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HomeMy WebLinkAboutMiscellaneous - 122 FOREST STREET 4/30/2018 (2) 122 FOREST STREET 210/1O6.A--0008-0000.0 } J� v V I i up•aoaueva leg OSB a ff RECEIVED COrnrn©nwealth of Massachusetts 1 1 201-5 C"fy1T®wn of North Andover OF �y. - o System Pumping Record -TOWN HEALTH GcPC)EPHANQOVER ART{NENT Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form,.check with your local Board of Health to determine the form they use. The System Pumping Record mustbe submittted to the local Board of Health or other approving authority within 14 days from the pumping,date in accordance with 310 CMR 15.351. A. Facility informati®n important,When 1Y . S stem Location: 511ing out forms U1 on the computer, ---' —'— use only the tab key to move your Address Ma 01886 cursor-do not North Andover Zip Code use the return State Ctylrown key. 2. System Owner: rm� Name Address(if different from location) State Zip Code Cilyrown Telephone Number B. Pumping Record = ._ C a �s r 2. uantlty Pumped: Gallons 1. Date of Pumping Dat 3. Type of system: ❑ Tight Tank E] Grease Trap Cesspool(s) Septic Tank ❑ g ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No .If.yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Vehicle License Number Nam tewart's Septic Service Company 7. Location where contents were disposed. Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facil'ty Date System Pumping Record-Page t5form4.doc•03/05 ((I ,•l�J� ��C� ISINy�i:r,�¢ yf,(,tt'',3. i ,,.•'1.;..;cy.;` )i'�5•1t�1I jr Jr,Q'•'1 ..'.. � '.Y:,`;. �i��•::fit:. ♦Y�' lif"•L+":.u ::777 "' f•: • .".:' .. ...'•t •.,'.,r,...^� �., :.r::l�.,./(;. ry1 ANDOVER^'•MAS : ..•TT SACHUS " 1 J S •i Y;S?{!.',1 ''' :.l' i• rO �� ' fit`'",:r��•1,�>r"�;� rA''GAY,. 1:1'/.:''• • '1•' •;'!'�.. Y'';� '• rl�y , tvll`:4: r ,`.1 , l�liY 1;1: .. •ai'(/,)rel,.I•"n,P'•1t4 a'��:,,.'',, yq, 'DEP.,has'provfde� 1.•u f.:r'. ,t— —�.'� d ktt form for use by local Boards of Healt`�, ,APs ba subinitted to the.local'Board of Health oro ygte Pumping Record m�S terapovingauthorltyl A ,Fpolli Infor'riiat(on � M ficA Tc'et ;ti (,�R,�O�rLallt:. :: ":'•..r.. '„'': '"r ur NORTH ANDN ,•Jr,T i!�Iv+,(>u►n9�out' .1,. •SyStem Location: i.TH DEPARTMENTER -COMPUterl U34. n w r...•..•. only the tab key Address to move your.. . ' .• � � �� .:;.arra,-do pot :r — us+'the, tum':% ',: ,1,,.Clty/Town t. Y.r. `'"� `'`s'J;::»i,.'•.i''i'Z 1 t.;.Sy ' ' State Tp —C Stem Ower•' ode r t ani{;t',`;l.:il..�i•;rnln�hri•v '�," .,,.oa�:..ny. .,i...li: :��.,i,/'•t. •'11;.:,4,. ,.; � (...•:t.r��r.., .. I. •r: .;, Name�'; ;,; �:'•. r;;..(;,:, . ,y' .;�; •.�r N:',., 1•i•e..�'.;'X) JitJt:'•.:':;,�i ^ Tr��///^r' (If different from tooatlon) . , ClgrrTovm•°w: Statezi' Tel p o um e h ne N ber 'UMPIr ^� ;r.•rr.•J! S>,�ta},'.c,t',r.C.fi(u,;i:J}1�'!�{I'1!.l.•i, ,� ... .•� 1`11. Dateof Pumpinq` ' Dat 2. Quantity Pum ped; . .., '3. �'.;., '; . .,•: ,.. aeons ,: ':TYpe Qt.5ystsm ❑ Cesspool(s) Septic Tank „. ❑ Tight Tank Other(describe): ';4,V'1:'EffluOt Tea Fllte rgsent?.❑ Yes No Iff•pyes, was It cleaned? ❑ ':'•t,.r:r Yes ❑ No 1�C T,,yrJ. �.R rS Ylwo,l;•;/�:i l;� I;r i � '.i' •:1�� � d{{�'�1`�i��'.I���.:1 iii.'��'',it�11ti':�c;,'ti:` '' .�� ',.,,.': �,:/i.,•.+.'!.:•({itT.;'.�YtYJbe:(f14ST�'i�'i;(�/lal.1'�•glts�' : %: �. 8•':';.Sy Pumped By �'r,.jf: ''A�w':S•'•:•4(,.Al/! amal.r V!i�•l,t.; '..' , +rP v ,, ,. ,•iC:'r.�.:�1�.n,,�l, � t�S'J��'f'?.1 N ',l'• , 1 ,(' � , i,•'f; � e uWnie Number ::�1:•ae 1,; '}T••.d1\�•.�'.�I�UF(i5:' i�,v .IyJ}; r �''• •!°6/a}.rrfil j�.;7`'�':; ':1'.�:� 'i.•a�• �'•;{,r it•+r1..,, �1 ,�'• 1'iA�!1`;C��•.•,' r.:� t' 11'�"•• r .. ,'.rq'•F.,<,;r,::j:7,. Locaflon.whera contents'Were I is::;' T �. ..,;.,.• We :d;3posed: • }t. silt. ��r�.i�','�:•'.�•'.l�iri.•�iS�:;at�•il„i��'f.:• '��:�:t�'`l .1�� ,T•ii � � f� �] ',.;: •�;::,;•r.:•h'j'':',;:�;�.�';�,;:;;Slpnature olHaulo µ • �. �� J/ww�v S;!':lrr<v.•;,... Date httP .mass.gov/dep%waterlapprQva�s/t5(orms,htm#Inspect ,tSfotrM•doc�,08rQ3 ��„•�� ,,r � � ' ;; Sy:tam Pumping Record Page 1 L Wealth Department Wputing SCp— Forwarded 6y Tamelu Flease return after review. dank Yom Date: SEP - S 2005 TOWN OF NORTH ANDOVER HEALTH DErAJ:i',;E^iT RE: ➢ Susan: ➢ Michele ➢ Debbie Health Calendar Updated? ❑ Yes ❑ No ❑ n/a RETURN TO PAMELA ❑ File: ❑ Dispose NOTE: BUTTERWORTH & O'TOOLE. Tr C. ` P.O.BOX 8294 SALEM,MA 01971-8294 ADJUSTERS/APPRAISERS FOR INSURANCE COMPANIES ONLY TELEPHONE(978)741-5731 FAX(978)740-9109 September 02 , 2005 RECE!V"'D FORM OF NOTICE OF CASUALTY LOSS TO BUILDING SEP - S 2005 WN OF NORTH ANDOVER UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B [1HEALTHDEPART-A'ENT TO: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectmen City/Town Hall City/Town Hall ADDRESSES North Andover, MA 01845 North Andover, MA 01845 RE: Insured: Dennis Bettersby Address : 122 Forest Street North Andover, MA 01845 Policy No. : OXH705-930552187 Loss of : 8/10/05 File or Claim No. : 58-1292 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1, 000 . 00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. Richard Peicott Adjuster iT3VY 1112. Member of National Association of Independent Insurance Adjusters BUTTERWORTH & O'TOOLE, INC. P.O.BOX 8294 SALEM,MA 01971-8294 ADJUSTERS/APPRAISERS FOR INSURANCE COMPANIES ONLY TELEPHONE(978)741-5731 FAX(978)740-9109 September 02, 2005 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B TO: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectmen City/Town Hall City/Town Hall ADDRESSES North Andover, MA 01845 North Andover, MA 01845 RE: Insured: Dennis Bettersby Address : 122 Forest Street North Andover, MA 01845 Policy No. : OXH705-930552187 Loss of : 8/10/05 File or Claim No. : 58-1292 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1, 000 . 00 or cause Mass. Gen: Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. Richard Peicott Adjuster Member of National Association of Independent Insurance Adjusters Commonwealth of Massachusetts o , Massachusetts i System Pumping Record System Owner System Location Date of Pumping: �1 /9) Quantity Pumped: jgallons Cesspool: No (. Yes Septic Tank: No Yes System Pumped by: Fare-dea rf&,761(da License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector- sg\, - TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD ;w DATE: prt r 7 4! , jra,I i ,i o-' • SYSTEM OWNER& ADDRESS SYSTEM LOCATION r ` �a (example: left front of house) �5 j lDdti�i� a..}��:,9'��®57.�e}:'t t{s�. �,1.. � �,s.�iti 1 ri+ek,� e,.r,..�..-e.,� E �.1;•;K i. i w>- . .� .... —.. :. , DATE OF PUMPING:` 3'U ( QUANTITY PUMPED_GALLONS ' CESSPOOL: NO YES SEPTIC TANK: NO YES..X ri r � JC �NATURE OF SERVICE: ROUTINE EMERGENCY rO1 ,SERVATIONS:.' ! GOOD CONDITION . � FULL TO COVER HEAVY GREASE BAFFLES IN PLACE _/ =' ROOTS LEACHFIELD RUNBACK >/ + EXCESSIVE SOLIDS KO FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) P _ F F tt l�., ' SXSTEM PUMPED BY: adv Iry Jaa .v y. 1 fig��jt,���$��rjys`+}rot 4 �• - _ `— _. _..w f,.. WENTS;.. . ,Il St i cF :<., d�cy�+z •t� lla i ,k _ ��r, g 44',''} ! ,, CONTENTS TRANSR FEDSD TO: i TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: �` 0 SYSTEM OWNER &ADDRESS SYSTEM LOCATION 6#�-S� (example: left frontofh ) T ` DATE OF PUMPING g QUANTITY PUMPED Ut v GALLONS CESSPOOL: NO AYES SEPTIC TANK: NO YES / NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: i F CONTENTS TRANSFERRED TO: t Commonwealth of assachusetts ti M sachusetts s tem m in Rec rd System Owner System Location ;60ZLUU� .0 41 Type: Emergency 0 routine (9--� DEC 0 7 2004 Cesspool: No e-' Yes 0 Septic Tank: No 0 Yes Q�• Date of Pumping 21, Quantity Pumped �'6 allons n : System Pumped by(Company) J T.1' L• n c. Permit #�// �j /3 /x i- Contents transferred to: Contents disposed at:. D Date Pumper Signature Condition of system/other comments: ,r f�' '\fl /1 � '�'1 N"+2':ty SIS Kw1 V b•',•.,�P� , r 114 1Q Yv h d ib IV ;C'� 'r.. iV[)K�r Qf?,hlr p/vvldrd )I�IrYlplm rol ry y ro.;of Boar I ".IDEF NANDOVER 01 r vbIllI ARNEW 7 got to Bcrr{: r c{ ' '•a „ �•' �OurinC/ Clnor iPacOrrrl �� S C 1 .InOrlry A. Faclllty I7777r1 I. U/ ,4/I,�!f`(„�r,il.�l r'IIC r�Vr�''+' y1�•��7, S�l�l ----__-.. V l• � rl� ' ' Ij' {i''{JI` ',i';I:1'rr'��;'�f' ” i•, 71-7-11 i 't'',It' i /+: •., 7• , 4 Ski ''' �•/Vdr r �- ' ''! H 1 d lrinl ran buVvnl • r {itl9npnl n,mvl, � �� mPnaqord Oele of Pum�InQ•' � J. rYflh41 MO 111 ! /p�!';lr�rr;�kll�;l� J�y{,,,,,,,,.• p �'o ll reg. e{ Ic c vaneo� ftop. '•',',!;•11VV /'I i,lr i% I wrw ' 1 +`IBJ,/,, • ,,.Q` { ' ala'''''i�'II/;{+r,:v�'i�� - - ;.,' SY Pvmpld ; +,,tl; ti;'f�' �►f i it Wo' t1 I I .►� • .._ '..,,. . :;,r',i, Cid on.when oo0linla;�o'ra dl� I�4V r' Posoa: l/„.V•.'I{,'�°Ilrl}''lt�,, ,' .�`r'�/I,rr,r l'r�r'i`',..i:'I � ' / ',,./t , 'p dep�ele(ls � DLII Commonwealth of Massachusetts w City/Town of North Andover fQ°J 21 Z01 System Pumping Record M TOWN OFIVOrM,AHAOVER Form 4 4"M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, 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 from 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 key to move your Address cursor-do not North Andover Ma 01845 use the return City/Town State Zip Code key. 2. System Owner: Name rerom Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping � / : /2. Quantity Pumped /600 Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. em PumpedA- 1_'_TGr-X l e Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 7Signatu:reof auler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1