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HomeMy WebLinkAboutMiscellaneous - 124 PENNI LANE 4/30/2018 (2) 124 PENNI LANE -- - -- - . i JL210/107.D-0031-0000.0 1� MAP # LOT # _-_ --- PARCEL # STREET_ C� .__.(� ...... CONSTRUCTI.ON_APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE to Al �I APP. BY_�� DESIGNER: PLAN DA1•E:------ CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMITS DRILLER._...�.-.--_--.____...__.._...._._ _._._..__._..........._._ WELL TESTS: CHEMICAL DAIE APPROVED._.___._.......... _ BfAC4,ERIA I DATE (IPPRUVED ....... BACTERIA I DATE APPROVED�`__�_ COMMENTS FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUED �3 ,�° BY CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID Y NO WELL CONSTRUCTION APPROVAL NU SEPTIC SYSTEM CONSTRUCTION APPROVAL NO OTHER YES NU ANY VARIANCE NEEDED YES NO BY: FINAL BOARD OF HEALTH APPROVAL: - .! i IS,THE INSTALLER yLICENSED? NO ► � '•1 1 - ,� .,.• ,. •,t� . .,. YES -. TYPE. OF- CONSTRUCTION: ��' _ .' NEW REPAIR" .'.NEW CONSTRUCTION: CERTIFIED PLOT -PLAN REVIEW YES NO r CONDITIONS OF.-APPROVAL YES NO t{ r (FROM FORM U) ISSUANCE^•OF DWC PERMIT. _ i ,' ` S NO • 2�DWC PERMIT N0. - .t INSTALLER•' 'I:- iw �v BEGIN INSPECTION YES N0: ' EXCAVATION . INSPECTION: : NEEDED: • 1 ,' Irk ..s. `si l` .i• _ _ `• t .,r� T ..•`_''- �-�• i`_. ♦ �' I•.\., :. - ..:jam:',''• - ../: .. - PASSED _ ' BY ::-..:CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES: . APPROVAL TO BACKFILL: DATE: BY !FINAL . GRADING APPROVAL: DATE 3 BY FINAL CONSTRUCTION APPROVAL: DATE: - BY FRECEI'VED'Commonwealth of MassachusettsCityjown of No Andover 2013 System Pumping Record H MPA—RTL**.. a` Form 4 HEALT 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 /Z� �n j jc)f1 P key to move your Address cursor-do not No andover Ma use the return Ci !Town key. State Zip Code &� 2. System Owner: lU rte!' n Name nes Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping —'�-� 5 2. Quantity Pumped: Q 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. System Pumped By: Name Vehicle license Number Stewart's Septic Service Company 7. Location where contents were disposed: 6 -s Pre-treatment Plant 20 So. Mill Bradford Ma 01835 qklc I Signa ure of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record-Pae 1 of 1 Y P 9 9 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD y' y PATE. I � I SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) ."1 r :lVb rd /p/ 7L J 1•, rid A/ D,A.TE OF PUMPING: QUANTITY PUMPED_GALLONS CESSPOOL. NO YES SEPTIC TANK: NO YES OF SERVICE: ROUTINE�„ EMERGENCY ..... _ ,� { r { OBSERVATIONS: r° GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY; �! •r,a t t ;! ! r y {1 , s Ml2s.�kk� I TNTS TRANSFERREP TO:: �'uti k ixl I +i HF 41 r e 14 t ��,�,, �`c �,�e�� , { � _ / ,.�Y ' 4 2001 • , � 1 1)1 r •'! y del 7 r �l�ji+C'I'1`�I,f '� it � ' ?% 7" N`Ork,• ver® No. 7. North Andover, Mass., M AeLO 2-4 19 9 S PEK �M� I �T� TO U 1L BOARD OF HEALTH Food/Kitchen j Septic System/��1� � / �� BUILDING INSPECTOR THISCERTIFIES THAT...R VKttr.PGr...........*AC..................................................................................................... Foundation 2f . 4 , has permission to erect.. .....ft?A CA buildings on ...I..................... ......r... l.i� ................................ o gl, �� ��f 4; Q> _ �l to be occupied as. .1. ...ho � �p "� Chim \' t ................ ... .. . . .. 11�... W*............................ ney b provided that the person accepting this permit shall in ever respect nform to the terms of the application on file in p P P 9 P Y P PP Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY PLUMBING IN PECTO REGULATED BY PARA. 114.8-S. B.C. /l VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PFIB' 1�-11 . ,a � �_ES IN 61viC�NVATQ Z� NJEE PAID ELECTRICAL INSPECT R UNI-ESS CONS FRAX <::EE TAI PERMIT FOR FRAME/BUILD .. Service vim/'/w� �. BUILDING I• PECTOR i DATE: A�A �TEE Final oCCilt j)a icy f�­r 7:iit Rt'C1ui1 ed t0 Occupy Bl_lildoig GAS INSPECTOR - ---- Rough i Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done i FIRE D PARTMENT Until Inspected and Approved by the Building Inspector. ' Burner ' j. Street No. FIN CONSERVATION 1l NA PLANNING Smoke Det. y /WATEZj INAL DRIVEWAY ENTRY PERMIT X, ���� i 0 ELEVA TIONS .a. DESIGN AS-BUILT INV. OF PIPE OUT OF HOUSE 105.55 *105.74 INV. OF PIPE AT SEPTIC TANK INLET 104.95 104.61 1 INV. OF PIPE AT SEPTIC TANK OUTLET 104.70 104.35 PARCEL B INV. OF PIPE AT D-BOX INLET 103.02 102.99 UD INV. OF PIPE AT D-BOX OUTLET 102.85 102.83 A REA = 3.02 A CRSS INV. AT END OF DISTRIBUTION PIPE 1 102.50 102.39 INV. AT END OF DISTRIBUTION PIPE 2 102.50 102.43 ,.::o * AS MARKED ON FOUNDATION BY INSTALLER. I HEREBY CERTIFY THAT I HAVE INSPECTED THE CONSTRUCTION OF THIS DISPOSAL SYSTEM AND THAT THE CONSTRUCTION AND TOP F.ND. = 108.43F/NAL GRADING HAS BEEN IN ACCORDANCE WITH THE DESIGNER'S INTENT AND THAT THE MATERIALS USED CONFORM TO THE PLAN 4 SPECIFICATIONS AND 310 CMR 15.00. / EXISTING / FOUNDATION i( D-BOX 1500 GALLON SEPTIC TANK , P-3 29 fESSIaNRI E� TP—CV-2® 12�' i 1 LEACHING — — — ft--- 3 TRENCHES 3' 52 TP-1 TP TP-2 TP PT TP—CV-1 60, EASEMENT 3® P-2 5�' NOTE. THIS PLAN IS NOT A WARRANTY OF THE SYSTEM BUT A VERIFICATION OF THE LOCATIONS OF THE EXISTING STRUCTURES. 25' AS BUILT PLAN 65, OF s 37SUBSURFACE DISPOSAL SYSTEM _ � AT PENNI 6" PVC DRAIN PIPE PARCEL "B" PENNI LANE, NORTH ANDOVER, MA PREPARED FOR: LANE FLINTLOCK INC. SCALE: 1" = 40' DATE: MAY 26, 1995 CHRISTIANSEN SERGI PROF�D SURVEYORS ERS 160 SUMMER ST. HAVERHX4MA. 01830 TEL 508-373-0310 CC) 1994 BY CHRISTIANSEN & SERGI INC. DRAWING NO. 94109003 Town of North Andover, Massachusetts Form No.s NORTH BOARD OF HEALTH « A . ,,,oDESIGN APPROVAL FOR SSACHUStt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant l ,Qom 1 � X04 Test No. Site Location— 01 1�) LALM.A ,AA J Reference Plans and Specs. ' +7' ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. /Zits • HAIRMAN,BOARD OF HEALTH • � l : Fee Site System Permit No. G _.C_\ Commonwealth of Massachusetts RECEIVE® : CiW1T®wn ®l North Andover MAY 1 1 2015 _ System Pumping Record TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Form 4 DEP has provided this form for use by local Boards of Health. Other forms y be this form,,ed, b t the with your information must be substantially the same as that provided here. B using 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. �aci9ity information important When System Location 1. S : ' Shing out forms Y 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 key. C'f�ylTown 2. System Owner: r im a Name MW Address(if dir'rerent from location) State Zip Code Ctyrov✓n Telephone Number B. Pumping R.ec®rd 0IsQuantity / 6 1. Date of Pumping ate Pumped: Gallons 0 Ti h' Tank ❑ Grease Trap 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ g - ❑ Other(describe): c. Effluent Tee Filter present? ❑ Yes ❑ No If.yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System P Y Vehicle License Number e wart'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 Facility Date System Pumping Record-Page t5mrm4.doc-03106 TO" OF NORTH ANDOVEP, UA 11 lVa� �Gv" SYSTEM PUMPING MCORD 'YST M OWNER ADDRESS SYSTEM LOCATION DATE OF PVMNNp;..._ _QUANTITY PUMPED: VSSPOOL: NO_...._ Septic 1'Lnk: NU ^.+ �q fT_ . �:EN,l NvC,j NA PUKE ON $ERYICB: KUU'fINB �6MMJENC,y MAY 0 6 2005 ObSERVA'11DN3: TOWN ter- iv'IRTH ANDOVER HEALTH DEPARTMENT (300D CONDI'rIUN uu. ,� COYER HEAVY OP-WB BAPPLSS IN PLACE. ROM _w LEACf�FIELD RUNBACK . S,XCR38YVE SOLIDS FLOODED -IOL DCARRYOYER,—._. OTHER EXPLAIN Sr.wm P"d by __ ? ...... T,/.G... .. �YQq�'�,Z7' VUMMENTS. CUN i'irN'I'S fKANSF'trRRfiU I'�� - - r ,fie-1 �� ?�auj�W 1 l''\t >K 4ti:,. .`1" \ •'s �.� ,y,,L a � - � >• it 11 tt � \ �i, �.:. '�� y t-��' � ~� � ,1 _ , `, It ., 1" s -r �. > ,\.., t l•: � tl� '\t �d7 l il• 1� `yi11���. .; C >N • _ d. _ '� 1 ,. t{ .eti� t-a t1.hr';)t r•. .1,_Jt�.,' ,`t� r, rrj, tt�'.:t� ,1 r Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH ) Q NORTH n �� 19 .'d oL 33II-- 0 DISPOSAL WORKS CONSTRUCTION PERMIT ,SS^CHUs�t Applicant /w �� — ^ADDRESS TELEPHONE NAME Site Location T �? '��l e ( r° �,e Q" Permission is hereby granted to Construct ( or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 1�—�L 1 CHAIRMAN,BOARD OF HEALTH �r D.W.C. No. Fee FORM U — IAT RE13Pn rm 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 local or state law, regulations or requirements. ****************Applicant fills out this section***********�***** APPLICANT: ��� �. - Phone4/1 LOCATION. Assessor' s Map Nu-.,,Lber Parcel S uiu ' On Lot (s� S tree= �f ���^ L�j�>P St. Nurhe= Use RECCY?K—ENDATIONS OF TOWN AGENTS: Daze Appro-ved Daze Re4,ec te_ Daze Appr:.ved Tc 4—. P_ar.^er Daze Re'eczac Dare Azzr:.ved FDaze Re-le=ad Daze dr_ve:aa%- pe.-- it F-re Dezarz-eTz Recti_•:ed by Bui'_dincr Inszeczor Daze Of p10R1F, 1ti 3 BOARD OF HEALTH o . p 120 MAIN STREET TEL. 682.6483 �9SSICMUSES�y NORTH ANDOVER, MASS. 01845 Ext23 PILE M E M O R A N D U M TO: Planning Board 1 FROM: Sandra Starr, R.S. ,,: Administrator RE: Penni Lane - Charles Nelson DATE: August 8 , 1994 The parcel of land on Penni Lane known as Lot B and owned by Charles Nelson, has had all soil tests done. There is a Board of Health approved plan for the site. cc: Karen Nelson, Director, Planning & Comm. Dev. File f '10prk 1 BOARD OF HEALTH i 120 MAIN STREET TEL. 682.6483 0*-110 SACNUSNORTH ANDOVER, MASS. 01845 Ext. 32 June 23 , 1994 Mr. Charles Nelson 31 Gray Street North Andover, MA 01845 Re: Lot B Penni Lane This is to inform you that the proposed plans for the site referenced above have been approved. If you have any questions in reference to this matter, please do not hesitate to call the office. Sincerely, J Sandra Starr, R.S. Health Administrator SS/cjp PLAN REVIEW CHECKLIST/y ADDRESS �/J//J// L� ENGINEER GENERAL / 3 COPIES STAMP � LOCUS NORTH ARROW �� SCALE �� CONTOURS E/ PROFILE SECTION BENCHMARK 4-� SOIL & PERC INFO ELEVATIONS WETS. DISCLAIMER WELLS & WETLANDSI,,--' WATERSHED? DRIVEWAY_L,,�(Elev) WATER LINEL/� FDN DRAIN r/ SCH4 0 cl TESTS CURRENT? /987 yP,/q86 SEPTIC TANK / MIN 1500G,/ . 17 INVERT DROP �� GARB. GRINDER/VO (+200% EDF) 25 ' TO CELLAR 1/ MANHOLE TO GRADE ELEV pt-- GW 0`c D-BOX SIZE # LINES -:-Al FIRST 2 ' LEVEL STATEMENT ;' INLET/63.6Q - OUTLET /QZ.85 = (2" OR . 17 FT) TEE REQ'D?/f/0 LEACHING MIN 660 GPD? -,"'� RESERVE AREA �4 ' FROM PRIMARY? ' 2% SLOPE 100 ' TO WETLANDS 100 ' TO WELLS Ll 4 ' TO S.H.GW 35 ' TO FND & INTRCPTR DRAINS L---- 325 ' TO SURFACE H2O SUPP �L 4 ' PERM. SOIL BELOW FACILITY J MIN 12" COVER C---- FILL? �(251 if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpd L"-� SLOPE (min . 005 or 6"/100 ' ) >3 'COVER?-VENTO"ZZ SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) L,,-' IS RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10 ' MINS 4" PEA STONE? 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VT-z `,fir�",c•, a"aE = j��^j��_iI{` - 1'•t �Y r {� F �TM• ._� .70, ��'�`.a sJ, r.., k+ ^; },t,.' -�[� �::•'� �. - t, ;.s !,•ads,.: r• .-sg: � - r. �;v _`.. :`>, .:ca �•'F,1$�i `v:' _ � '1.1•� .�,. ,,� -� .,.r: -;,,. :t. •T. _?° '•:,� � 2:.• a'�-.:�' .� s �--'.1 ..v pry.,, t. j, r:.1 rte% sr- _t:� .,_..M= t� 'j �:ar �x. _ 3�+r'• �:. ,�, + °•�"� �._� �..t - :F'�' L „�;a i. ;. Pi �j. :7;•" :i � r zc<. ,tui, ?� f' ���. -�^ .u`-:'+ � a res'=` - .F s•r. J -�. =,�. q 3-'y .('.'+�€,"_E)�: :.?';:�v��/>> '£ w<. :��""' - rnA :ti'• `��' ,y."" .ScY.:;.�, ,� �'_ >.„� �" �rk'9 ,#s-.�i,. ?• �! •'`` t"'q ..[z'It;�,, '-> u}� 2� �i�k�r 3" Y,.�+L�' h, a 'i..., ''a' - - -'3,y:� _ - - � •�''•;.;,.,.. a::` - .)+ ., aT,- .... +.•:.:,:+. r. -'�:'.:�C'+4'f. .r 4,a:a ', : 1t .t.^:<+:. -.�' #j:.e. ����� ��,�+FAe1L...>_- � `� t�ri..- 2 -..r+- :�+' q x:1F�'-,.. .... j.' 'w .I•!.- ...� -: � - •_'{y ,.. -'}..q. f _'r _ r ar�A � x,y� ;i I _ '�f'`r':- '3 ..n„ay e .,,,,,. r �` �: )ICA. .. -_ ,:,; •. �'•st?�. ,..' �+,..f� .. =I+-'=i '''�$tt•.,i a ... a . ^r.: :�'"�„•,'.•1 (�'.,�.,+T:' ,} aT< x -.y,<t , �.. / a .+ .• a.. 2a • '.Vim $A-v,L'.� y .r` 4t "• .z,. S- ..L ' 'a _ t �/ .fes h+[- Py. Kw,, •. . fi `' ` ,s F. r4 7'r •r, •i { v S'.w-a, s� 41. .: v2pTrn:.... '""rc• ..;�`:.s -..,• .7��"4 ,..._.. ____'� R.. _�t!•�l�t>~.•. .ti�. •"�:•-s� YSi vc!'._r �,3 1':��.� ,:b .....,,.r t' a •�.� n ;4S'''" _ d ' ~ ^ SUMMARY OF TEST PIT AND PERCOLATION TEST Performed on December 15, 1987 By: Christiansen & Sergi , Inc. Health Inspector: Mike Graf For: Charles Nelson , 31 Gray Street , North Andover TEST PIT #1 0- 18" Top & subsoil 18- 60" Light brown fine 'sand with a trace of silt and small broken ' rock 60" Water table � � 51 " No oxidation band , but isolated oxide deposit in corner of pit No refusal TEST PIT #2 0- 12" Top & subsoil 12- 36" Light brown fine to medium size sand 36-114" Very fine grey silty sand 90" Water table 42" Isolated oxide deposit on one side of the trench PERC TEST #1 Start � Soak 9: 45 � No drop in water elevation 10: 30 (Abandoned) PERC TEST #2 � ' Start ' 15 minute soak 10: 41 ' � 12" 10: 56 9" 11 : 05 � 6" 11 : 24 � � | Perc Rate = 19/3 ~ 7 min/in � PERC TEST #3 Start 15 minute soak 11: 15 12" 11 : 30 9" 11 : 46 � 6" 12: 12 Perc Rate = 26/3 ~ 9 min/in � d7 1 , o \ i es L o.r 1A STONE �✓GLL �f•tr�Cd�� GRF.b= I.ICo LaGRt'S 0° , 0 z2 r,-1 I ti o� cz= 5.>;�' ti . y ypc , 90 - Sc '� � Q Lo.00' p 17 0 ,� � �' -�. ,�� _..� �J F C N a tt L.>E S C,�. � ��N C a. N 1=>- ►-1 \, jl GRdY STaEaT � NOW-TN �11`4POvEQ, Mo.;' EvSaMeVvT iOR TtJT'ams ROOD a*Corm 3'N K:Goo 1{ ��ovMp) o c �So \• 3o;vu0, - 5 w:�' Aa R= C.o.00� \\�\� �� oory (,'oc'oo.,o�'c� D.N.(•FoaND) d= 143- 14- SL 1 \ to �\ h (1 s o 0 0 0 Lu \ L o T 11 % ===7A /V Q tZ�,C1 1.30 pa RYS oN _ Q IP Z � Ze '6 � a , 17 �N / S?' /�/T LOC�QT/py ® COL�2 LTi ' �9TiLvt/ ' Roca i s�P(Ow /��-C. /3/ X987 5 '' �� � K-CvT NJF �dNGEs D. Gvop NvE• � 54 �• ti p�-t4 �0�'' Rocx 91 (3o s i o N sr. j I �� �, ,,yy' Noa•c'u ANDD VERT Me. I i �i 'j :1 � � `T •*� w �5 t� 4 k .w. ;.SAY .113 r F m 4. • A t�' rf v� r7K 1 I ? .i iti ♦ k.,' J f 1 � (PH)PNEKALE. AJIA FOR ti DATE TIME .M. M PHONE© OF PHONE- AREA HONE AREA CODE NUMBER EXTENSION PLEASE GALL MESSAGE W(LLGALL flAME TO la �1 S��YDU i �� F101 p (,S ENTSY -I SIG TOP Ouva IYEZALL cel �1A �- � tf� A.M. FOR P.M. Mz4A z, flNED OF F#ETL1t�NEfl PHONE ''' D HALL" AREA CODE NUMBER EXT NSION PLl15E"CALL; MESSAGE WIWGALL;; AGAIN CAME'TCt:•; SEE YflLf :. WANTS Tt3; S1=E YI1LJ<. ........ ............................... SIGNED TOPS FORM 4003 NOTES NOTES ------ - -- _ 'd 50837-239�0 Pit I P-A SA- CHRISTIANSEN SERG19 INC. (So 372 3,;60 P FAGINEER5 AND LAND S"VEYORS NAL .. 373-0310 FAX� ROFESSIO r C"830 5tjM1,AErz STRIYT HpqERHIH!L may 24y 1994 6. c) ji e-,a th North And 2 0 i n Ardollerr A 01845 Dear hoard '415 -8 am red (,JjeTjt C�j'b �rle - F Xt meeting 0' rLLY - its *'18' Om bict'a, J -r d a, eak t,�,� the "OA-- i scuss tyle like to C, , ! purpose tO SP We Would tbe lot 2 6 F 1994 . pit data -S , 5t,m for T,hvrBdayr using existing te6t ;sav t - I ity Se tic j 0"3, 'ib of des-, 5r;lng S'j,b stir f.ace P on Lanet v uvft ! TOWN OFNORTHANDOVER SYSTEM PUMPING RECORD 2 2003 � 1 I'EM UWNER & ADDRESS SYSTEM LOCATION (example: left front of house) X;� 0 Ar U QTc OF PUMPING: �` , . QUANTITY PUMPCD a 0,, L.Lc» , NO YES SEPTI ' TANK:ANK: NO YES i ' -NUKE OF SERVICE: ROUTINE EM R E GENCY FRV.:TIONS; GOOD CONDITION. E~'ULL TO COVEIz HEAVY CREASE BAFFLES IN PLACb, ROOTS LEACHFIELD RUNBACK . EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER O HFR (EXPLAIN) PUMPED BY: -7 i CUM -'yl FNTS: UNI I:'NT' 1'RANSFERRED TO: ! 'a •`4r1. P `yrt ''• 4Ct,1� l.Ya•14t�.(ir t Y> t ` , Y'ti= � s t Q ,Q .;NORTANDOVER` MAS Lis- Pumping R666td MAY 1. 0 2007 �•!,l Jr , DEP has provided this form for use by local Boards of Hea t T S Record must be submitted to the local'Board of Health or other approvl "Ilftr WEPA TMEN •n, ,... tib ARTMtNT A Faclli`7 Information .• ' { �Rortint: r' Bung out 1•:. System Location ,/ *COMP ti the /�7` COrnpUtef,usey --[ only the tab.key Address to move your:.*;,...• : .-cursor-do'not use thCityrrown e retum to r Zip Code. : 1. ,..;�• 2 System Owner Name r Address(If different from location) Qty/Town State ZJp Code. Telephone Number . Pumping Record L of Pumping Da 2. Qu ntity Pumped: Gallons 3, .';Type of system ❑ Cesspool(s) eptic Tank ❑ Tight Tank 1 ;❑'Other(describej; 4. Effluent Tea Fiiter present?.❑ Yes If es was It cleaned? y ❑ Yes ❑ No 5 Cond(tlOn of Syst m ' 7777:7 4 It i ,••Y "x.1,;U' ''e �{'I'rl It l 1 .. �• Sy. em.Pumped By' ry �... �....: ,G q. y r Name _ r( Ir tts •✓ _' VehiGe Ucenee Number < r i l4 '�.' J: t - !! y �..;l•I•'3+Iii��F7 t,E`vJ�i',.Y��r l7t�i tY 1`r ,r 1',�! .. contents Were disposed: 5 .. a, , L Slpnature of Hauler,., �. Date httpJ/www.irtass. ov/de afe�/a r a 9 p/w Gv Is/t5forms,htm#in l?P sect t5form4.doa'08/03 System Pumping Record Page t of f �+E ,,;'f R ECEI �R�T1 AY1IDOVER ' ' Rec d Q.1 f � ',., . O r TOWN OF NORTH _;.I�.Q•J,��i,���;rl; ' „1;.','•.��r. ANDOVER ,,y., y, vi.,.,,' HEALTH DEPARTMENT OFP.hej provided Jhli rOiln lel X80 Jj' IO;of Q09rC1 01 ^U8 ^p $ 7:d 0o Iv�mlllod Io the loC�l 8^dre rl , Qj,(n Or C1/7 o+ IA? O;InC 1 inpri ' A' Facility In(orrTl�clon �+ �M n gym•7, C17�(� �Q ' 1 .,/ ';. 17 '+,�rs'�,��,�i''t 2'•d`r,Sy,alam,Owner .�,,,,, . ' ; . , , •A ''.r� �.1dl►-t•r (114Vfr,linl ICYn buVcn) ^� . T1�/9nOn1 rY,mpl, ' mpinl Rekord 10 I' 08119 0! PumInp / 6. (9) <50c Tan,. rl Eh1Vanl Too Flllo('P(.osenr? �`' Y09 ,.,/ a,``!'4;�;'� ' � (��1•,';'J`�,;,, t11�',.: f � Y09. ��e) �; :�9ana � n _ �' SY 4m od 8 P ' P 1 +i' 4c, 7,yr t , ''�!�J arl J,,i '.•; Vlnl U(; ,iv/ YY�,) f,,,II on.whers�Cor�!anU�.Ware d!ypo • •,i.•'�,:rl:Ir.� '•r..,r,lr ,ilt;,, •, 590: ��:.;�r;�.w.meSJ�govld9�/1Y8(9rlepprOYefJ/IblO�m�.r,!mAIn9�Ocl Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH OF�S�eD Ibq�O o —19 . F _ A R °° w°•�'' APPLICATION FOR SITE TESTING/INSPECTION ��ADRRTED PQp��y - . SSE ACHUS Applicant /l ,1'0 h � NAME ADDRESS TELEPHONE Site Location PIM AltA_, _4 Engineer NAME ADDRESS TELEPHONE �yj,�� Test/Inspection Date and Time /Y IV 10 H9'e1z' /:�:6z) CHAIRMAN,BOARD OF HEALTH FeeTest No. (0 30� S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. t Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH � ° � o APPLICATION FOR SITE TESTING/INSPECTION A�Rq TED PPP'\'�y 9SSACHUS�� Applicant NAME( ADDRESS TELEPHONE Site Location + ry Engineer ' .:. NAME ADDRESS TELEPHONE Test/Inspection Date and Time ,L CHAIRMAN,BOARD OF HEALTH Fee Test No tip, S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Pte® SE.CAL.L FOR DATE TIME M bAtA PHONEq: " OF TURNED PHONE (JAN YC3UA BALI AREA CODE NUMBER EXTENSION MESSAGE PLF ASE gWLC GAME 70 ;SEE YOUa q4 ' WANTS 7Cl SE> YOU SIGNED TOPS FORM 4003 NOTES _ _ _ Commonwealth of Massachusetts � GiV DO City/Town of No. Andover a System Pumping Record HAY 'I r� ZU II 4, Form 4 TOWN OF NORTH ANDOVER GSM By`e HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may 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 1. System Location: forms on the computer, use 124 Penni Lane only the tab key Address to move your No. Andover Ma 01845 cursor-do not City/Town use the return State Zip Code key. 2. System Owner: Nordstrom Name �0 Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 4/5/ Gallons 11 2. Quantity Pumped: 1500Date ns 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present. El Yes ❑ No If yes, was It cleaned? E] Yes ❑ No 5. Condition of System: Good Condition 6. stem F ped,-By: i Name Vehicle License Number Stewart's Septic Service Company III 7. Zation where contents were disposed: PW.—A's Pre-tre Plant, 20 So. Mill Bradford, Ma 01835 Si iture of Date y/ Signature of REivin-5tarcirity Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1