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HomeMy WebLinkAboutMiscellaneous - 126 LACY STREET 4/30/2018 (2) C Commonwealth of Massachusetts — - - .ir W City/Town of No.Andover System Pumping Record A -a toll Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. OthdrRT N he 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 Locatio forms on the U�' computer, use only the tab key Address to move your No.Andover Ma 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: VQ M-C-e 1 Name 'ef0 Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Is-pa Date Gallons 3. Type of system: ❑ Cesspool(s) 4?Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ YeqiP 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: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature Ha u Date Signature o eivin Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 • '� ��� ���77 TO: NORTH ANDOVER, MASS 8 19 77 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at L d T ClG tt c X 5 7`— North Andover, Mass. SITE LOCAT ON The grades and construction are as specified in my plans and specifications dated 19 . �-TTS Nb ' /db PIN-4 in$. `r. Rg. nitarian • w •' 4 SOIL PROFILE & PERCOLATION TEST DATA Town/ f No.&Street aLot N 0 0.� Loc./Subdiv. Plan ,12n Owner r" Investigator C=,za_ Observer SOIL PROFILES-DATE 3' Elev. 2. Elev. 3° Elev. 4'Elev. 0 2 0 0 lh 2 2 b' 3 3 3 4 J�4 4 4 S Q J � 5 5 \ -V6 6 6 6 � 7 7 7 7 8 8 8 B 9 9 9 10 10 10 10 Benchmark Location Elevation Datum Percolation Tests-Date Pit Number 1 2 3 4 5 Start Saturation Soak-Mins. Start-Test-Time Drop of 3"-Time Dro of 6"-Time Mins.lst Mins.2nd 3"Dro Notes & Ske ches on Ba k F ank C. Gerin//as & Assocpi s, North And. CY 1,' k"" �' 1 COL /V o 1141�rxA �- ���o�J�may.-,3 �/��•SZQ��-, .', ,- f �.._ . ,.. • Y � ,_ ... , WN � 36. `SS D N.CF-NIJ 0r 7 Of Uj >Na h� 1 • ofir � - PLA AJ sypWi�vC �0 AeoPO.SED SZ1&S!l,2F4GE SEWAC Cm h/SRas e- SYSTEM Z-07- arRAd 1AY* 19 77 �h7 0" OWa/E,e: Q.:COrr /-�2oAE�TiEs QQ � °�� 9L �.5 C'E�l%EF2 LST,QEET' (34- / ,. , LocA ro tii : A � J " �� �eA a�Aeck, -~94 / Lf�E. aw STI.t/A�2d C� GRCE. sA/o. MEADVNI, , MASS.�� ' TEL. -¢983 k lbAE.S�C�tJ DATA - U , TYPE OF 941/G,61AIe7: SZ (�l GARAGE O CELLAR P4U1VjB1A1C7 FACIL/T/ES: Q1 0 WELLr SE�U,4l E FLOW EST/MATE• o 4:�$.P.D, r cO — SEPT/G TAAAIK : a ALL ONS -- ABsoRR r-/oN AREA : go o so, Fr- �✓ Z' "� � PERCOLAT/Dc/ TESTs• �/ �Z �`3 #¢ ---�.__ ► //j DATE1 7k16 SEW<iGE D/SPOSAL .SYS EAf P ELEVAr/oN foo, o �OpF I 61-IOW&( OA( TH/S PLAA1 (S TTO/y EGE✓AT/::N 97. O l Alo,-- r0 43E CON6rRuGTE?) SATUWAT/OA/ /.S MAU. / a �RDP. GLE�IA THE /, 4Tia? TAG3C-E /Z"To 9" DROP 3 /til/N. M//tl AVA/1 M/N. N 4 a•RM. GA¢. N T/DA.( /,.S• ESTAousH no �" DROP ¢ M/,u. /it/IIAI M/A/• �gAJIAI. !)W E L EleCOLAT/oN RATE �Z M/N• /A/ /v//N. �N /I//N �N Af- 1". �°6AL. 0, /to G'A2l3<4 GE ,6/S%OGl5AL. Cl TEST PITS / Z 3 '�4 o rAatK-• /S TD [3E //vs .TAG, .�� roc/ DA rE /.Z-/-7C asoavrco THE P21,W� L)WE..LL TOP ELE!/AT/DN 900 S.F. EX P. ACE-A Q / 1 SO/G TYPES .5A/vU - 90o S•F. ANO vUU' WA TER TABLE SOU 7-/.0/V /!/O WATT i � - 5Z,oo• -- -- - X34-00, __ - -- =— -- �-"o' / BOTTOM ELEUA7-1OA1 _9/0 ioo g•M• `" / ,,rr�� TESTS coAlDac-r&n BY <7296EPAI S.. &4R,5AC AL L O , R.s• (VAI L IN PPL #M / � � (37, \ TESTS BY : Ale ANvOVE - NEAL rta DEPT- 16 0. EPT160. � / LAA! e DEsIGti( �R/rE-�e/A cS'HE'ET / of 2 Ca�PEo �'�vos Pe-rlQy Ea ,._ ' er ,y ti • ALS !�a=! �`•'�.. � ..,...,..,+�,_.,,.�...._.�.._.,.. ( -o sP C1,C1CA7-IOArS -- .sE,5- SCCr16A1 4r Zowaje ,e14Avr-) o 4'jeeA w 900s t .r,�...�..,...... /OOO e9.44. CO�t/Ceerw ,SEPT/C rAme- �.. l%C.,366,4460 .J►c I�V 4"� SRF. P.�°�'. � S•.� - ioa A107- Tia A11Y FIGI- A1usr 4w7j5 t0 ZS• FSM THE 6 47 EL. r©o.o �lNrJ 7`HE Ii SYoP6 TO 6RA0E. 1ON RAO � �.• � � • . Y EXisr. GavE Aurr' ,y •.�•>i �� • Gam' w • i �'1i * � �M�V��� wi•/K�� �. ' ~ M i� i . �trx s Z 0' p a IL e .. y. / „. .. . a t/ �ril/- u $ °Xo _ ti3 ro 1Mr4 5661► NUAT ' 1R . m n � -92 •�• �1 q F Zoo .9 �•4CY cST. 1 �l'Z�� �,�. ��� � � ��' i I i , , � s I WELL DATABASE ADDRESS: AGE OF _LL: WALL DRiI L 1 Zr W'ri r. PE_R1YET, : WE'LL LCCATiON: " ---SELL PERMIT]DATE:- of W-ELL: 2 k� —"_=HOF,WELL: DRIL.T.Em ~ b. DUG TYPE OF WATT BEARING ROCK: WA=ANALTKLS•DA=--- 'Y N ETIGHIRON: Y N OTE=C( ANN Asti : W_ELL T. DATAElksE ADDRESS: l Si AGE OF WELL: 'WELL DRILLER WELL PEF 11 WELL LOCATION: WELL PERLtiL!T DA=E: DE IN OF L. TYPE OF WELL: a_. DRILLED b. DUG ll,\F�L0 WN TYPE OF WA ER BEA,RIrtG ROCK: WATER ANALYSIS DATE: . HIG"r tiIANGA.3Y-ESE: Y N HIGH IRON: Y N OT= CONT.A!yflNA_iTS: Y N RECEIVED Sy PUMPING RECORD `O �0 ' NO [;fit A VE[ AUG 0 9 2004 UA€ _ TOWN OF NORTH ANDOVER + HEALTH DEPARTMENT SYN I hM OWNER& ADDR SS ' SYSTEM LOCATION /ad / DATE OF PUMP1N(l (.74SSKX)l_: NO �tE.S _ S€�a is Talc: NO y Es v NA t'VftE OF SERViC:E. KOUTINE...VV C; BSE'R.V A(T(>NS. GOOD CONDITION V..__ Fi LI- .W COVER HEAVY GREASE BAFFLES 1N PLACE ROOTS EXCESSIVE SOj__tj)5 �� 113 R�N3�A�.� ... SQUID CARRYOVER - OT1,4EIi EXPLAIN AEN Systom ("tom CON FLN FS lR_ANSYtARtf) 1-( a � S TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER ADDRESS SYSTEM LOCATION (example: left front of house) JOA 4 //v. DATE OF PUMPING: QUANTITY PUMPED ISO D GALLONS CESSPOOL: NO f YES 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: '�/� �C� — /juni3 C�� / ✓/ ?,7 CONTENTS TRANSFERRED TO: Rl , ' q ''Cornmonwelth cf Massachusetts ,`Cityrrown'of NORTH ANDOVER, MASSACHUSETTS System Pumping Record.. Form 4 DEP has provided this forTn for use by local Boards of Health. The System Pump�ng.Record must be submitted to the local Board of Health or other approving authority. X Facility Information Important: f gout 1. System Location: forms rms on on the ` computer,use only the tab key Address to move your cursor-do not ` ' CityRown State Z1p Code use the return key..... 2. System Owner. -/UC r-ip-l1 Q n Name 1 W Address(if different from location) Cltylrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Uste Id 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? El Yes [3 No 5. Condition of System: 6. System Pumped By: erne Vehicle License Number mpany 7. Locatio where contents were dispose BMd& ?Q C f-n III �t Signature of Hauler Date http:/iwww.mass.gov/deptwaterlapprovalstt5forms.htm#insped t5form4 doe 08103 System Pumping Record•Page t of t 4.