HomeMy WebLinkAboutMiscellaneous - 128 JOHNSON STREET 4/30/2018 128 JOHNSON STREET
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Commonwealth of Massachusetts
City/Town of IVO. And Ove
System Pumping Record
Form 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. op
A. Facility Information ,
y U'p
Important:When H .
filling out forms 1. System Location: E
on the computer, o r�•� s Y'1.� 1
use;only only the tab I V h
key to move your Address
cursor-do not �`rAy
use the return
key. City/Town State Zip Code
I
2. System Owner:
Name
rerun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record I
1. Date of Pumping
Date
` 2. Quantity Pumped:
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. S stem Pumpe 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 2LIgpetur Date
t5form4.doc-;06S� ature of Receivi acilit Datet5fomt4.doc• System Pumping Record•Page 1 of 1
iM£'Y;e
Commonwealth of.Massachusetts
"i
City/Town of No Andover -:Y 42013 �:
a
System Pumping Record To''.'�dOcP,:ORTHAMDOVER
r"
JT
wN
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 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
fining out norms 1. System Location:
on the computer, Johna)n
use only the tab
key to move your Address
cursor-do not No andover Ma
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
City/Town '` State Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingDat — / 3 2. Quantity Pumped: /000
alio
nsi
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: 7 /l
` ~
Name jr, Vehicle License Number
Stewart's Septic Service
Company
. 7. Location where contents were 'sposed:
Stewart's Pre-treatm t P 20 So. Mill Bradford, Ma Q1835
Signatu of Hauler Date
Sig>6VNbMTMg cility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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pEP•.has provided 4�{'.a.;r,.:,
rm fo
ih .for use b a he System Pumping Record ,r�,
be:ubmifted to the.local'Soard of Health
I VMg au horlty,
A •,Faclli Infgrr ' 'ation
tmrtant:,. ;..,: ,::;. �:`. DEC• 0..7 2007
J,,yYhen'(Ain9.out 1;. System Location;
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1
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to move yourdo pot
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uuthe"refum;, : ,.CltyJ'lown :.; ; State 7�
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:'Address(If different from'tocatlon) - -
. ' ;�:. •:•,'.GkgrlTowrti.:✓� :,,•'.,i ':I:'' r;,• .. State �\I
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Code
Telephone Number
10.
{ . pumplg;.Re.�;ord. :.,'
{f14il
:,•' Datoof Pumpin9l` 21
Dale Quantity Pumped:
.3. :••;.L; ..
?yPQ 9System::,: :
• •. Gallons
System:, ❑ Cesspooi(s) Septic Tank
❑ Tight Tank
( .f Other(describa);'
CCe�pp �r;'I;;t:';�•J;IS•,+• y}Ihn l�•..i'�' . .�
;'rr;>• 4 slit Tee Flite{pr�ssnt?.❑ Yes ❑ No I es was sit
`.;1:�;;,;.•; ;,✓.,•l,i�iti. cleaned? ❑ Yes No
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'�ry�;P,umped By,'''
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on.wher conte
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8-".gov/depAvaler/app.rQV8)s/t5forrns,htm#lnspect Date
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./' System Pumping Record Page l cl
TOWN OF NORTH ANDOVER
SYSTEM PUMPING PECOU
JAN - 6 2003
f V
i Eti1 UwNER & ADDRESS SYSTEM LUC.ATION - �
(example: Ief( (ronl �Qf nousrj
i
ia� u �a�rn C 60-1/z
Ala . Cne4)(tt1 ire.
a �
OF PUMPINC:
Q (QUANTITY POM 'L. D �
>>I'U0L: NO YES SEPTIC' TANK : NO YES c
ti
Al URE OF SERVICE: ROU'T'INE EMERCENCY
SII>rRv �TioNs:
LOUD CONDITION FULL TO COVE!!
HFAVY CREASE 13AFFLL:S IN I'LAC1
ROOTS LEACHFIELD RUNIUACK.,.
CXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER Oj�HER (EXPL.AhN)
I 'M PUMI'CD BY
, u ,lti-1rNTS:
U '� I.,:^,.I,S. TRANSFEIMLD TO
SEPTIC SYSTEM INSPECTION FORM
ADDRESS C 2 � i� s ►^
DATE INSPECTED ,&C-47
PROPERLY FUNCTIONING? N
WEATHER CONDITIONS
COMMENTS :
WA i ER QUALITY TES I tt n Ro50t_Z's
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
sf�
WATERSHED/RES I'S QUESTIONNAIRE
1. Name :
2. Street Address 2.
3. How many members are in your household?
4. What type of sewage disposal system do you have?
❑ cesspool
V septic tank and leaching area
❑ connection to municipal sewer
❑ other (describe)
❑ do not know
,.. 5. Are the plans (drawings) for}'our sewage disposal system on file with the Board of Health?
❑ yes ❑ no do not know
` 6. H w old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years
over 20 years ❑ do not know
7. Has your sewage disposal s stem been rebuilt or repaired?
Elyes ❑ no do not know
If yes, approximately how long ago? years. What was done?
8. How frequently is your sewage disposal system pumped out? ❑ annually
❑ every 2-4 years d every 5-10 year, ❑ over 10 years ❑ never
J
9. Have you had any problems with your sewage disposal system? ❑ yes 2/no
If yes, what problems?
❑ repeated pump-outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. How many of each appliance are connected to your sewage disposal system?
washing machine dishwasher garbage disposal
dehumidifier drain sump pump toilet
roof/pavement drains shower/bathtub
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher /!_ 'r
clotheswasher ff - id 5 <<
12. Does your property have a lawn? [►�° yes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/2 acre ®'K 3/4 acre ❑ 1 acre
❑ more than 1 acre (Specify) acres
13. How often do you fertilize your lawn?
1 No. of applications per year
Season(s) of the year
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
L9 Check here if your lawn is maintained by a professional landscape contractor.
Qp
/ 1 /' .
1. Name
2. Street Address
3. How many members are in your household?
4. 'V hzl type of sewage disposal system do you have?
cesspool
septic tank and leaching area
CI connection to municipal sewer
❑ other (describe)
❑ do not know
s, 5. Are the plans (drawings) for your sewage disposal system on file with the Board Of'Realth?,
❑ yes ❑ no p do not know
6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years
over 20 years ❑ do not know
7. Has your sewage disposal sstem been rebuilt or repaired?
❑ yes ❑ no do not know
If yes, approximately how long ago? years. What was,done?
6. How frequently is your sewage disposal system pumped out? Elannually
EJevery 2-4 years L every 5-10 years ❑ ,over 10 years ❑ never
9. Have you had any problems with your sewage disposal system? ❑ yes �no
If yes, what problems?
❑ repeated pump-outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. H o w many of each appliance are connected to your sewage disposal system?
washing machine dishwasher garbage disposal
dt.t:timidifier drain sump pump toilet
roof/pavement drains shower/bathtub
11. Please stat&the brand and type (li uido powder) of detergent you use for:
dishwasher 1 t&
clotheswasherbt-rmd 6&
12. Does your property have a lawn? R yes ❑ no
If yes, approximately what size? ^/
El less than 1/4 acre F1ElL
1/4 acre 1/2 acre � 3/4 acre ❑ 1 acre
❑ more than 1 acre (Specify) acres
13. How often do you fertilize your lawn?
{� No. of applications per year
�•• Season(s) of the year
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: v
Q` Check here if your lawn is maintained by a professional landscape contractor.
Town of North Andover f NORTH
OFFICE OF 3a o�`" ",�o0
COMMUNITY DEVELOPMENT AND SERVICES ° . p
27 Charles Street o "
North Andover, Massachusetts 01845 �y` "•° °" <y
WILLIAM J. SCOTT SSACHus�
Director
(978)688-9531 Fax (978)688-9542
March 24, 2000
Mr. &Mrs. Peter Rodrigues
128 Johnson Street
No. Andover,MA 01845
Re: Sewer Tie-in
Dear Mr. &Mrs. Rodrigues:
The Health Department has been supplied with a list of all residences, currently on septic,
which have access to the municipal sewer system. As previously published at a Public
Hearing on March 17, 1994, the Board of Health has adopted regulations concerning the
required sewer tie-in. The following timetable concerning your property status was
adopted:
4.1 All establishments that currently do not have municipal sewer available
to them must connect to the sewer as soon as it becomes available, with a
maximum time limit of six months.
The purpose of these regulations is to safeguard North Andover's drinking water, surface
waters, groundwater and surrounding environment. Sanitary sewer is believed to be the
most effective form of wastewater treatment. A copy of the entire regulation can be
obtained at our office.
Your property is in violation of this Board of Health regulation. Please contact the Health
Department regarding this matter immediately. If we do not hear from you by May 10,
2000 your name will be placed on the regularly scheduled Board of Health meeting agenda
and placed on public notice. The meeting will be held on May 25, 2000 for discussion of
legal action including court hearings.
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
M
Sewer Tie-In 128 Johnson Street Page 2
Any questions concerning this regulation should be directed to the Board of Health at
(978) 688-9540. Additional inquiries regarding the physical tie-in and permitting process
should be directed to the Department of Public Works at (978) 685-0950. Please be
advised this Board intends to persevere in this regulation.
Yours truly,
Gayton Osgood, 66uman
�Vj .
Francis P. MacMillan, M.D., Member
ohn S. Rizza, D.M.D., Member
SF/smc
- _ RECEIVED
TOWN N'OF ORTH ANDOV,E�
SYSTEM, P MPINO RECOIL) OCT 0 5 2004
uA rF q /. .7.0
TOUV 4TNORTH
D R�t�RT ANDOVER
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
r
DATE OF PCJMPfNt3:_._..._..... ... _..�J ..__...__QUANTITY PUMPED:...._..... ���_............. ._.. . . ..
CLSSPOOL: NO------., YES.. SOPtic 1•ank: NO
NAI URE OF SERVILE: KOU'rlNE _ _ EMER0EN()'
ObSERVA CIONS:
GOOD CONDITION FULL 'i'O COVER
HEAVY OREASE BAFFLES IN PLACE,
ROOTS LEACHFIELD RUNBACK
BXCI~SSIVE SOLIDS -- FLOODED
SOLID CARRYOVERT
_.. .__OTHER EXPLAIN
Syatem Pwnpcd by
..._ ..-LS6r0i6f-)
/ . , csf-, .C�Yaa�'r Via.
uMMr_N-rs.
WN I LN FS f KANSFlwRRED 11) ^� � Awlsi
I
Commonwealth of Massachusetts
RECE'v
City/Town of No.Andover
System Pumping Record o
TOWN OF NORTH ANp YER
,M Form 4 HEALTH DEPARTMENT
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 1. System Location:
forms on the
computer, use 128 Johnson St
only the tab key Address
to move your No.Andover Ma 01845
cursor-do not
use the return City/Town State Zip Code
key. 2 System Owner:
& Rodriguez
Name
fe"0/ Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
Crr1. Date of Pumping Dam ( 2. Quantity Pumped: I
Gallons
3. Type of system: ❑ Cesspool(s) [3,se-ptic 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. S stem Pumped By:
Name d 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 of Hauler Date 1\
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1