HomeMy WebLinkAboutMiscellaneous - 12 WINTERGREEN DRIVE 4/30/2018Q
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Commonwealth of Massachusetts _
City/Town of No Andover RECEIVE®
a System Pumping Record
Form 4 `� i 2014
TOWN OF NORTH ANDOVI
DEP has provided this form for use by local Boards of Health. +raut the
information must be substantially the same as that provided here. BQfore using . I check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within, 14 days frcm the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1. System Location:
on the computer,
use only the tab 12 Wintergreen Or —
key to move your Address
cursor - do not No AndoverMA
use the return - -----_....---- —
key.
City;f'o�;�,� etate ---- - - Zip Code
2. System owner:
Varney_
Name _.--
Address (if different from location)
City/Town State
Telephone Numbar
Zip Code
B. Pumping Record
41. Date of Pumping—-- 2. Quantity Pumped: -
Date gallons
3. Type of system: F-1 Cesspool(s) J2/S"eptic Tank 0 Tight Tank El Grease Trap
Q Other (describe); —__ ---
4. Effluent Tee Filter present? [ Yes R No If yes, was it cleaned? Cl Yes [I No
5. Condition of System:
d
6. Skn
umpe By:
nZu
N Vehicle i_icensc Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Pre-treatment 91ant, 20 So. Mill Bradford, Ma 0
Date
t5form4.docq 03/06 Systerrr. Pumping Record a Page 1 of 1
FORM. U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT.. V A✓1.��. SI
LOCATION: Assessor's Map Number
SUBDIVISION
STREET Z� iyQ2J_JAJ
PHONE 9 jrF ( - 2-6 -'S/
PARCEL
LOT (S)
ST. NUMBER1��
*****************************************OFFICIAL USE
_ ONLI(***********************************
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMME
TOWN PLANNER DATE APPROVED
DATE.REJECTED
COMME
FOOD INSPECTOR -HEALTH DATE APPROVED
r DATE REJECTED
SE_VTIC INSPECTOR-HEALN DATE APPROVED
DATE REJECTED
o'� M
COMMENTS � � C> I cl A +� t ,
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9\97 jm
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NORTH ANDOVER
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t<'oI1SCH EHc�ir,ec . 0 6 -86 by
HOWARD
o CHANDLER
BUTTRIC'K J
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NORTH AuIpnUc-I-�, MA,
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4PPROOEP Qu(5, 7- ri) Apr'Iznvin)G
Db LA Z/,Iti� So tom- 6 _
AVPITJo�AL
DlS6�Pf �OvI:P Da i C-"
RE/jSo tis �,
FVAL APPFIjvAL D,oiE, �-3-� ,aPP► o��� ��;��
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Commonwealth of Mossochusetts
Executive Office of ErMronrriehtal�Af.alrs Q
e Imen
tnVii
onmental Protection
NY1111am F. Wald
t3vamor .
Trudy %e
sacro�ry, 50
Dayld "6; Struha TOWN OF N( H ANDOVER/
Commruion�r BOAWOF �IFALTH
;SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -�
PART. A
CERTIFICATION. 2 9
Property Address:., / (RDr'n% i2G,t°rzu'K r0�c; /U, �riCDuV�,'ddress of Owner;
Dale of inspection; a / `? /� �- (If diHuent)
Name of inspector;, 3r' ✓per'"
Cc.r,ipany. Nanie;:Address and Telephone Number l NEW ENGLAND ENGINEERING. SERVICES,
33 WALKER.ROAD
P.O. BOX' 536
i CERTIFICAT.ION N "
NORTH
ANDOVER, MA 01'$4.5 508-686
686 1768
inspected t hese�a 'disposal s temat thiddress:and That the Information reported below
s
true accurate
I ceriif�- thatI havepersenal h ge.
i r w erto�med based on m training and experience in the, pioper.function and.
and complete as',of-the. tame of inspectlon:.Tne inspect o t was Y, $ .
maintenahce of on•site'sewage disposal'systems." The'system:
Passes
Cpnditionaily Passes
a"
A
'.veed, � :F6nhe r. Evaluation 6y the Local Approving Authority
Fails
;Inspector's Signature: Date:
The System Inspector shall Submit a copy of this inspection report to the Approving Authority within t irty (30) days of"cgrripleting this
inspect oh If ihe.`sj'ste.m is.a shared system or has a
''design flow of 10,00.0 gpd:or greater; the inspector and the system"o%�'ner shall submit
I e rep,.^ to they ppropriate regional office of the Depanment of Envrronmentsl:Protection
Tr,,.o,;g nal shof;ld.o:e sena tc ;nF.s\stem owner. and copws sem; to Jw burei, if applicable and the approving authority,
1,',,SPECTIQN SUMh1ARY:
Check. A, B;: C; or D:
A; SYSTEMPASSES:
v I have�`not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15,303,
Any .failure criteria not evaluated are indicated below.
ei. SYSTEM CONDITIONALLY PASSES:
One or more system components need to .be replaced or repalred. The system, upon completlon of ;he replacement or repair,..
passes jnspection
Ir d .ale �zs, no; or not determined (Y; .N, or h0) Describe basis of. determination 1n all instances if "not determined explain why, not)
The septic tank is metal, cracked; structurally unsound, shows substantial infiltration or exflitration; or"tank (allure Is,
imminent. The system will pass inspection, If .the existing septic tank'fs replaced with a conforming. septic tank.as
approved, by the Board of Health.
(revised 8/15/.95! 7.
.�;. MY { t : 650.-1�49 Ttlephor a (617) 292-&W
t't�1i1111tH1�YFtil1�1 �� h�p4��clluaella
9y�lelq 1.ucAllurl -
1.1naJ�lily 1'umpeJ: ����--g���d�u
Selitic 'l enk: No .I Yes 1 -
Syelem 1111111110 uy: W iire &$ e#"0004
lle4101blifell 1t) : r,..;a*101101$guff d job 11
Dole: ---
4
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kt ,• tea, � �r 'i t
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TOWN.,OF NORTH ANDOVER
SYSTEM PUMPING RECORD
it+artiz�E�''•,iat���4�?,e
y z t w tr RA►T�•: �'v�
y{ ,'��r•lFt�� s° � b#a t � f h xM+Ci �!'.,s S rp.
{
t �� I I� k F �%°.'Ste .. �} .. , " . • - - -
SYSTEM OWNER &ADDRESS
; + _ SYSTEM LOCATION
(example: left front of house)
.•r vo(m
Lh�
-��ntz_&
Ia . e�
tt�E
rvc'1{ ''s't,•+i'�f� �t ` ✓r� ..
y t1hPr f.INt ,,fy,�,. ., r { til' tf r I rF *fes5 r i��t'� ,j xf b� �" ..r • Y
OF P�JMPING: -c:.
QUANTITY PUMPED" GALLONS
,'+{;�,SS'OOL: NO YES
{ .,... , .SEPTIC TANK: NO ._ YES
1
�'4
OF SERVICE:tOUTIIYE .: EMERGENCY
it ��rtiN�(f4f°r1N'lti}l.'
ry �r '1{. tat 2j i� � '.. ,. • .
,,SFRVATIONS,., f r
GOODCONDITION ' FULL TO COVER
GD
HEAVY EA�r
r ►,� , ,. I ,:, +7E . BAFFLES IN PLACE �—
;� ' r ROOTS
EXCESSIVE SOLIDS LEACHFIELD RUNBACK
, FLOODED
" ` I I SOLIDS CARRYOVER OTHER (EXPLAIN)
I� , 1 C ' 4 *�P�����.,��,�``F I�,+I� t����r ah�'�li�, •'(t r��i T';;.i I < f; ', 1 ,Fr I _ ..
�, + i�ra I§ i �At r2 "s, n+til !+'fit � �+�•1FJr �'Ij/ � i
�r�r5.§ i,i � ,n,� 1� Y•7�TF u� ' +I,y>zk. T`���
1 ,
ISI{"h i a
'TC 4VIN OF NORTH A�J®{7V _
/>
` 3r BOARD OF HEA' P,
4,t il, tti
,/�►� 62001
t A
7717i
M RAR �,; _'6'.. ° , tt+ : rte, -- _ -
To
^Al
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a} I
t 5
T.
+ tti 'M
Ft
of
'rowN OF NORTH ANDOVS,
UA I't SYSTFM PUMPING RECORD
f 31 GM VWNKK & ADDRESS
VCJ rn eq
a W i r) j�� ��
N. Orvdov-ee-, ry) a.
SYSTEM
DATE OF PUWNQ_QUANTITY P
:
UMPED:
sopic Tank: Nu
NA rURU OF SERVICE: Rou'rINE..._
RECEVLzf)
ObSURVA-non
R
0000 CONDITION .../FULL'ro covER U
ISAYY 01EmB BAMBS IN PLACL, JUN 0 3 2005
0
.KOOT13 SUN
F -Z A�
LEACMELD RUNBACK "OWN OF NO"?TH ANIIVER
ISMSSIVE SOL103 FLOODED HEALTH DpART,'vIENT
SOVI) CAKRYOYEX,—.-. OTHER EXPLAIN
sy atom PUM4Kd by
Po oCr`..
Ira.
CUMMhNTS.
wNrwrs rKANSYtRLUL) I'o
w
TOWN OF NORTH ANDOVER :�
SYSTEM PUMPINGa4��;r
l'Eh1 OWNER &A DDRE SS
v
SYSTEM LOC.ATIO,`` --
(mampit,�cf( iron( of h/ouL�t)
&I Z41 '54,c-
Ib rco� 6ov,14- n �� m�rJ�
OF PUMPINC: /e (QUANTITY PUMPCD�-
�)S1'UOL: NO ---L -ES SEPTIC TANK: NO YES V
\ A URE OF SERVICE: ROUTINE _��EMERCENCY
.�!I>�RV�TIONS�
GOOD CONDITION
HEAVY CREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
i )'I LM PUMPED BY
J, I M FLATS:
U'� I !:'N I'S TRANSFERRED TO-
V BULL TO COVE z
BAFFLLS IN
LEACH FIELD RUNBACK...
FLOODED
O, HFR (EXPLAIN)
�Al .r
r',�i<j (' I[. \ii�� �7, x,�^•M•1i�.N � l{i� Y\y}',,tF�'�,//'••1L/�,/. �a.J1j�.y; �i�l `/V �.i .. ' � •
`) v'�I'+t i•'�' �,!' 1} "�io't`� I .I�.1:r �I, T' VII•'y�n ' r''?'�11'r!li;l!I. i,•'�
:1•. •.�I{Cl. � V�,���Ii:b�• ,� q � 11(91 r1�:4: �• ' 1`Nr,
`DEP
,,has p'rovlded jttls (orm (or use b Iocal Boards
Y of Health, The Sys' em Pumping Recorc rr._:
be subml�ted tp the.looai'Board of Health or other pp
• :,�•� r,;,;,.::I,L'• :'11;::'1; :.,;,,.�.,:., a roving authority
:A, Facility,lnfort �tlor
i�:,; �� rein t.' ' � .::; .:1, •. .. ,::>:.,.' �'�:'� �, •'
JsrWhen NIN out' '.1::; System Location;
cy putar,
u,e t �y adores:
LQ move your :• —2Z9✓j�
'' •�`•' `uss't�•reEum �•Y,�„��; �; ty/Town ' :;;. •.��.,.:,: ' Stato .; ,,��,,rr
.t,.,y, lr�l l��vi �l��i�rJrrr,'.1,1t.t.r•�l,,y,J,✓IrnJ :''i:�'��,r•�V:I�•�:J:ii, , .,,'r - zip CWe
SSseem Owner* ,
.�•„ `}y �;14Jvj,1rif�!r�•'•• `I�, Ul�l,,yw�l.'if.�•'+tl't•'• /�
•'y= •,:1. rti?:'i��l?':!•'.S;'x;�S'i.ar.ir...,.t• ... ..d'i•.�,,:•', [/6%
.,r.
••1••' ':,'�r,/ \r �� 1"Nii�'.'J�.Q',IW'. I"•. ,.'1•.�)"Ir(,r .<.'t�p l...,
.•r u:• r 6�,e:.•a,.,i�, p pea' 'ii.,
' •' '• :�'• ';'h'.. r.��.41 k!'i l'`�•'•'r't'. �,'�'. 'r.4':,tl;i'.,,n :'.,;• .'r � /U`1 .'
�'' y �' i'','�;r, Addrett pf dlNennt rom tocaUon)
u',• ;, i ZIpC e
clophone
or
y ;::'�';; •;41.,;14 �.
'� fil. 1�1'.�Cp• t�t'l li '.Vrl'H I !Y r.l: -N V_�` - ..
-f:;l 14r plj�g Re.gord
t:g,x-Pum
;c,,'. ...• . ! v'. � r' hr,;,;. /,1(111tfAli;•1�'�I'1),(.•ll 1(•,�,. /'� p�
14
�;: '• 'Dale 2' 5�.0 n'Uh Pumped;10 6L
, � ,::',•;`:',�;';�'; ; ;;:' ` .. Gallons
pe\Pf system; ❑ Coss 001(s) eptic Tank ❑Tight
i'; .0:,
_ } 4; �Tank
a:;.',;,� JOther(desorlbe[/\ ,
,'t •'i�!,,�;i• •'7_„tt-{r!111�\9 N",i
t
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record .0
Form 4
DEP has provided this form for use by local Boards f He AY Thi Pu ping Record must
be submitted to the local Board of Health or other a proving authority.
TOWN OF NORTH ANDOVER
A. Facility Information
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor • do not
use the return
key......
HAW J1
1. System Location:
2. System Owner:
%,Wm
e
Name
Address (if different from location)
ka_
State
Cityrrown State
B. Pumping Record
1. Date of Pumping
I !Type of system: ❑
' ~{] Other (describe):
I elephone Number
pa 2. Quantity Pumped
Cesspool(s) Septic Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
Zip Code
Zip Code
Gallons
❑ Tight Tank
If yes,'Was it cleaned? ❑ Yes ❑ No
6. S stem Pumped :
/1C e cx K)
Name Vehicle License Number
Company
7.
contents were riicnncpri-
http://www, mass.gov/dep/water/approvals/t5forms: htm#inspect
t5forrn4.doc- 06/03 R
". System Pumping Record Page 1 of 1