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HomeMy WebLinkAboutMiscellaneous - 15 BRADFORD STREET 4/30/2018 15 BRADFORD STREET 210/4061.0-0023-0000.0 _ MAP # LOT # PARCEL # STREET_..._1�.._�M k4k)�a.....S6........ CONSTRVCT_I ON__.APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO KLAN APPROVAL: DATE__ /(ate, ---- APP. BY...... ..... ............... _. ... DESIGNER: /UDrSf PLAI4 DA TE:__ CONDITIONS TQz 5G//4rZS -- -._.............._..._...............__............ WATER SUPPLY: TOWN WELL WELL PERMITD!y-I!-6L Eft � _..........._._...... ........._.. ............. ........... ..........__ .._ ......... WELL TESTS: C - ICA DA I E (=)l-'PRUVED BA ERI I DA I E OPPROVED '.CT II DAZE APPROVED _ _ COMMENTS: FORM U APPROVAL: APPROVAL TU ISSUE NU DATE ISSUED By _ .. ......._.._. _.........._....... CONDITIONS: ................ ........................ FINAL APPROVAL: . _ ALL PERMITS PAID WELL CONSTRUCTION APPROVAL -Y _ NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DA1'E: _. D Y . IS THE INSTALLER LICENSED? _ .YES NO _._. TYPE. OF CONSTRUCTION: NLW ZEPf�I R NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YEs 1,10 CONDITIONS OF APPROVAL YES flu. (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT N0. cs89 INSTALLER:,_ BEG I N INSPECTION YES O: - EXCAVAT I ON . INSPECTION: NEEDED: PASSED 9� /�7 BY r ----- _-------- CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: APPROVAL TO BACKFILL: DATE: HY__ _, FINAL GRADING APPROVAL: DATE17/ BY -� � FINAL CONSTRUCTION APPROVAL: Commonwealth of Massachusetts City/Town of � I �� ' System Pumping-Record SEP 3 p 201 4 Form 4 s' TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use=by local Boards of Health. 0 s may e'used, but the information must be substantially the same as that provided here. Before usin .this form check with our local Board of Health to determine the form theYus .The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of hous Le Righ rof hous Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/ I rear of building, Under. 9 g, a deck Address /Town 6ZA C" �y State Tr�Code 2. System Owner. Name' Address(if different from location) City/Town State zip o Telephone Number I B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) EPS-eptic Tank El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No: " 5. Condition of§ystem: � I 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location contents were disposed: �S: Lowell Waste Water Sign g Haule Data t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I Commonwealth of Massachusetts City/Town of W System Pumping Record 1 Z •~ Form 4 ti TI ANDOVER ; TOWN OF HEa�•T}l 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. A. Facility Information 1. System Locatio . eftight front of house, Left/Right a of house Left/right side of house, Left/ Right side of bui g, Left/Right front of building, Left/Right rear of building, Under deck Address case City/Town State Zip Code 2. System Owner: i Name Address(if different from location) City/Town State `'�-� Code Telephone Number B. Pumping Record f to �_�� t 1. Date of Pumping pate 2. Quantity Pumped: Gallons —� 3. Type of system- ❑ Cesspool(s) Septic Tank- ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes S No If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of System: 1 6. System Pumped By. Neil Bateson F5821 Name Vehicle License Number Bateson Enter rises Inc' rp Company 7. Locatio ere contents were disposed: �-S. Low ell Waste Water Sign a Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 'i Commonwealth of Massachusetts EIV D City/Town of System Pumping Record AUG 1 3 2008 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may used-,W-the— information W-thinformation 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. A. Facility Information Important: When filling out 1. Sy m LO n: �� forms on the computer,use only the tab key Address to move your . cursor-do not Cityfrown State Zip Code use the return key. 2. System Owner: dL -_ Name �I Address(if different from location) Cirylrovm State^ �� dip Conde Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Q--No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. SystemK7n ( �. Name � ® Vehicle License Number Company 7. Location re contewer�-di¢posed: Signature 1-14117 Date I t5fonn4.doc-06/03 System Pumping Record a Page 1 of 1 Commonwealth. of Massachusetts MEE CE 1,� ® City/Town of I System Pumping Record JUN 2 S 2006 w Form 4 TO`.w�;OF iV ?RTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. em umping Record must be submitted to the local Board of-Health or other approving authority. . . .A. Facility Information Important: When filling out 1. Sy tem Lo ation: �� C comps the y�� . computer,use only the tab key Address to move your L S_ cursor-do not c use the:retum Qrtylfown State Zip Code .key. 2.. System Owner: - Name Address(if different from location) City/Town State 7in ,ode -S ` 7( Telephone Number B. Pumping Record 1: Date.of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ❑optic Tanks ❑ Tight:Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [!� IlioIf yes, was it cleaned? E] Yes ElNo 5: Condition of Syste 6. System Pumped By Name Vehicle License Number Company 7. LocatiqWWhere contents ereed:. Sign ure. H ler Date http://www.mass.govidep/water/approvalt,/t5forms.htm#insPect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Address 15 62+b" oO-b sT Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date.of Refer to other Purpose of Documeint/Action and notes: action Document/ document/ Num. Action Department Board of Appeals - Board of Health - Planning Board - Conservation Commission - Building Department ('onunonweal tIt of Massachusetts crU.Q�, MassachuseUs System Pumping Record System Owner System Location Date of Pumping: as zUDO Quantity Pumped: 02 5aa gallons Cesspool: No �'vJ Yes LJ Se ptic Tank: No �_� Yes 1 i System Pumped by: Stewart License# Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector- i MY26 - , IN brceeb ST. AS-BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations As-Built Elevation 9 ?� House Q Tank IN Tank OUT /7 D-box IN C� 7 D-box OUT 9779 7 $ Trench Inverts Line 1 97 76 _ 973 �7.8 .5 - q7 Line 2 97, 7q Line 3 Line 4 Bottom of Exc. l Stone OK? L--1 D-box checked? Pipes cemented? y I l NORSE ENVIRONMENTAL SERVICES, INC. �, 3 Pondview Place Tyngsboro, Mass. 01879 TEL.649-9932 ie CERTIFICATION OF SUBSURFACE SEWAGE r DISPOSAL SYSTEM INSTALLATION rj. I, STEVEN ERIKSEN A Registered Sanitarian duly licensed by the Commonwealth of Massachusetts, License Number 886 , and working as an employee for Norse Environmental Services , Inc . certify that I have visually inspected the construction of the individual subsurface sewage disposal system at the referenced location and hereby certify that to the best of my knowledge and belief all work has been performed and completed in general compliance with the terms' of the permit and in general accordance with the plans approved by the local Board of Health. Furthermore , all construction appears to comply with the provisions of Title v of the Massachusetts Environmental Code (310 CMR 15 .00) and all applicable local regulations. �r LOT NUMBER: 15 yV. :.' STREET ADDRESS: BRADFORD STREET TOWN: NO. ANBOVER, MASS DATE: 10-1-.92 10-01 SEAL: SIGNATURE: — STEVEN ERIKSEN t' ►r J' NObfib ,t f���i-SAN��� 1LTURVEY Lot 1b Lk,RADFORD ST . N . ANDOVER 20 ' � � [ATE : 1O-1 -92 � Owner : MIKE MAKOR lns.ta / 1erEVE IACC.OZY Location E) evaf / on � Top Foundat / on . . . . . . YJ/& Foundation Outlet . . . 98 .8y - Tank In / et . . . . . . . . . . 98 . 34 Tank Uutlet . . . . . . . . . 98 . 15 D-Box lnlet . . . . . . . .. 98. O0 D-Box Outlet . . . . . . . . 97 .83 Bea. Trench #} , . . . . . 97 . 83 If If #2 , , . . . . 97. 7y End Trench #1 . . . . . 97 . 5O " If #2 , . . . . . 97. 54 Bot . Trench #1 . . . . . . 96. 50 , , / #2 - S WEN TV NO _ � � �p BRADFORD/l �� yl �� Tl �> ]r ���-J� 7- ' =� ' `,` ��' `^ , " +^ -, ' .^ "_ "_ ' ` RRECEIV D Commonwealth of Massachusetts j City/Town of EEC � 2012 i System Pumping Record TOW1 t4 ,�� A M v v Form 4 <r�; , , 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. A. Facility Information 1. System Location: Left/Right front of house R' t rear o ho , Left/right side of house, Left/ Right side of building, Left/Right front of buRingo. Left/Right rear of building, Under deck Address U-Q City/Town State Zip Code 2. System Owner. Name Address(if different from location) City/Town State(0 �Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filterresent? p El Yes Q'No If yes,was it cleaned? [I Yes ❑ No 5. Condit* n Syst m: � V11- 6. im6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loca' contents were disposed: G.L S. Lowell Waste Water Sign t e 4 Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I Nor-se Ent,, ironmerpt-al Ser-,.- 5086497562 F. 01 yJ SERVICES. INC. NORSE EIV VIRONMEN rA L 5 3 PondvIew Place Tyfigsboro, Mass. 01879 TE.I., 649-9932 FAX TR A N C VII T TA L FOPH TO , ATT tq RE: L c 1,,C). of f f t N or se Eriv f r oninent.a I Ser- 50 649 i 51'c F. 02 1 , NORSE ENVIRONMENTAL SERVICES, INC. 3 Pondvlew PlaCe 'y T'yngsboro, MASS. 01879 YEL.649-9932 s It CERTIFICATION OF SUBSURFACE SEWAGE DISPOSAL SYSTEM INS'T'ALLATION t A Registered Sanitarian duly licensed b°,+ the Commonwealth of Massachusetts , License Number and working as an employee for Norse Environmental Services , uric . certify that I have visually inspected the construction Of tY}E individual subsurface sewage disposal system at the refer.er,cecs location and. hereby certify that to the best of my knowledge and i. belief all work has been performed -and completed in general compliance with the termO'.Of the permit and in general accordance: with the plans approved by the local Board of Health. Furthervioce , all construction appears to comply with the provisions of Title V � of the Massachusetts Environmental Coad. (310 CMR 15 .00) and all applicable local regulations. LOT NUMBER; 3.5 STREET ADDRESS: BRADFORD STREET TOWN: NO. ANBOVER., MISS . w DATE: 10-1-.92 ' SEAL: s7FVEra SIGNATURE: --- f ERIK;t:N .,-'' l�.-�!j;•/`�r'� _'..� "�e����s"L.� '`. Nil biSEy FORM U - IAT 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 local or state law, regulations or requirements. ****************Applicant fills out this section***************** lwl'!re B Sax MA ��'a 8� 6 0-y 9/,;?l i3) APPLICANT: ejC( (iysvI 166, jA r'46y- /Clarl:�ar Phone /-`96--A63,2 LOCATION: Assessor's Map Number zliglD002 Parcel 3 — 00'nop Subdivision Lot(s) Street r'ctcY �� rrX SP� St. Number /.� ************************Official Use Only************************ RECOMMENDAT—IOON�S OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments �; ( 1 • Date Approved r�' 1 E� •� Tbwn Plaliner Date Rejected Comments iAZ74-: VAer1 J Date Approved Health Agent Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department ��rK� "Q ��rcn��.� � .,. &.Y b-)r Received by Building Inspector Date i Town of North Andover, Massachusetts Form No.3 NORTH BOARD OF HEALTH • f A DISPOSAL WORKS CONSTRUCTION PERMIT CHUSEt Applicant ME ADDRESS TELEPHONE Site Location : Permission is hereby granted to Construct.( ) or Repair (/an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. HAIRMAN,BOARD OF HEALTH Fee �' D.W.C. No. l 9 Town of North Andover, Massachusetts Form No.2 MORTI, BOARD OF HEALTH • •--.--� DESIGN APPROVAL FOR cu 0 Q • *' b•+ne'Aa p5`�� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM • )> W CD 8 • Al, ( l0'�� A) Test No. • Applicant Site Location �f'/9dEQn Reference Plans and Specs. ENGINEER DESIGN DATE a� Permission is granted for an individual soil absorption sewage disposal system to be installed j in accordance with regulations of Board of Health.. �� • (0 =r CHAIRMAN,BOARD OF HEALTH w w Fee Site System Permit No. ...�.._..� � =>e�-:k>tY-a-%,'w"GY'*'e7Fe�"`°"�""�'T.S..�.,". "��n.�"",,�'��".`..,-�+t-."-Y°'�'':5...r-� '�'� ,�"'^z+z";t+�%�c�+�^- +'.✓�=,:..:.`?'cfr.�'s�:"�'' __ PLAN REVIEW CHECKLIST �P/fR ADDRESS /� s'c��J=oi2�� ENGINEERR�CSI� GENERAL 3 COPIES Com' STAMP LOCUS [.i NORTH ARROW C/ SCALE CONTOURS L,-' PROFILE SECTIONBENCHMARK SOIL & PERC INFO ELEVATIONS WETS. DISCLAIMER WELLS & WETLANDS WATERSHED?J4--5 DRIVEWAY(Elev) WATER LINE Ot FDN DRAIN -- SCH40 TESTS CURRENT? SEPTIC TANK MIN 1500G. . 17 INVERT DROP -- GARB. GRINDER NO (+200% EDF) 25' TO CELLAR C,,-' MANHOLE TO GRADE ELEV GW D-BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET 97 5 - OUTLET 97 70 _ (2" OR . 17 FT) TEE REQ'D? LEACHING RESERVE AREA/ 4' FROM PRIMARY? c/ 100' TO WETLANDS 2% SLOPE 100' TO WELLS-- 35' TO FND & INTRCPTR DRAINS e,-' 4' TO S.H.GW L-----J' 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY MIN 12" COVER ✓ FILL?Ab,-- (25' if above natural elev;(10' f below) BREAKOUT MET?-Lz TRENCHES MIN 660 gpd G,"'� SLOPE (min . 005 or 6"/1001 ) >3 ' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D . (MIN 61 ) ,--. IS RESERVE BETWEEN TRENCHES?/�b IN FILL? - MUST BE 10' MIN. 4" PEA STONE?_(2& BOT -,70 X LDNG I ,b + SIDE 180 LDNG2'-L TOT (L x W x #) (G/ft2) (D Lx2x#) .h{ww a7y -.r u r ... .. �.`+�,'��_"'��"l�."eji?r..#�a�,. �.�"' ,�Cda�✓"'-�. +::�!'�4Y'arC;r�•gsn�„'c' ;�r�"'?"A?:'".1�� �y�k,,r.9:..�t-, .'„+«��'�,��a'�eu. {'�// "U —_ —� _ _ � _ - -- —.—� -- - — � - �� � - -� � ,� � � - � - � ,. t- � � - �_ _ �, -- - �---- ' _ ---� � -I- y- - - - .. I l l l l l l l i i i � � � � � � � � � � , . . - ,_ /� ��. I i i � �� _ ��I ' / I `� i � '' i i� I .. � 4 i i I Iii �� - � .._. .._ -- --- - -- -- ------ ��-,000;;;r- rv, 42-t19- 97 - - -- -- - - - - --- - - -- --- - - - - - - - - - - - -- ---- IStandard Const. Br :.dford St. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION I ,,,HEALTH 1EPPXTTD1ENT--NORTH AIMOVER, MASS. I hereby make application for a permit for a sewage disposal installation at Bradford St. T will install this system in accordance with all the lavas of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe' the minimum diameter being 4 inches, and will maintain a minimum grade of- 1 until. 10 feet preceding the septic tanks, where the grade shall not exceed 2%. 1 c,,,ill install a concrete septic tank, of _6po gal.- r in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with open joined bell and spigot Ackron pipe at least 4 inches in diameter and laid in a series of trenches, the bottom of which will provide a minimum of 1, O lineal ( ) feet of effective absorption area. The pipes will be laid, on a 6 inch layer of washed gravel or crushed stone ranging in size from 3A to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to IA" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of /+ to 6 inches/100 feet. No single the line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the in- stallation will be Less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further a rep not to cover any_nortion of this installation until approvnd by theinnnection officer, as provided below, and to incorporate any additional requirements that may be ''attached to the permit. Plot Plans must be submitted with application. DATE ,.' d, . y 1 g Signatu3# of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover=/`Massachusetts. DATE l !l d' Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Signature of Inspecting Officer �... Percolation Test • Garbage Grinder �,� BOARD OF HEALTH TORN OF NORV Al"MO-ER., MASS. 10 1. I hfJ NAME / -_�,G 1. DATE 2. ADDRESS z �'r :G'.. �/:� . _.'�'''. t LOTNO.�: :�' � : . TEL. 3. N0. OF HEDROON.S . . . DEN YES NO.. V .�. 4. GARBAGE GRIIMER YES N0..k. . 5. SHOW DIIhENSIOi!]S OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT S. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NIDE LOCATION AND DISTANCE OF WELL FRO114 SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAPIS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATION SHOULD BE READ CAREFULLY. i RECEIVE' Commonwealth of Massachusetts 4 2009 W City/Town of AUG 2 System Pumping Record TOWN of NORTH ANDOVER Form 4 HEALTH DEPARTMENT �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. A. Facility Information 1 SystLeft rear of o n: LR gh d ear of eft se of use,houRight side of house, Left front of house, Right front of house, e. Address .._ Cityrrown State Zip Code 2. System Owner: Name �J Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped. Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes �o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System- 6. System Pumped By: Neil Bateson Name Vehicle License Number F5821 Bateson Enterprises Inc Company 7. Loca ' contents were disposed: G.L. .D Lowell Waste Water I &- 1 a-0 S' n ur of Haul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 1'UI1.11 N - .�4 J�l...r t i..�if>►.��f K.._......:,.. 's Commom ealth of Plassachuselts Massachusetts ' TOW BOAR®E OF FIEALTHVEti/ Syster�t hU/llfl ,� eCU!' ecu ( No . A-71S Date of i,untping Quantlty Pumped! 1506 O✓Y4 0d Cesspool: No , 1'es I.Rrrntle Tnn," Yes System pumped by: License Contents transferred Io: �� LS D Date Inspector r Commonwealth of Massachusetts } Massachusetts System Pumping Record System Owner System Location Qal Date of Pumping: l � �^ c `� Quahtity Pumped: gallons No W-- Yes L] Septic "rank: No Yes Cesspool: i System Pumped by: vctreQoa, License# Contents transferrred to : Greater Lawrence Sanitary District Date: ___ Inspector: Tc IV, i r' OCT25 zoos TOWN OF NORTH ANDOVERW �-- --R SYSTEM PUMPING RECORD a- DATE: / 7 SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: 2�nIUANTITY PUMPED ���� GALLONS � v\ CESSPOOL: NO ZYES 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: CONTENTS TRANSFERRED TO: �se it , t'antntonweaitll of Massachusells f' , MassacttLisetss i stem I utnping Re-ord Syateln Uwhet System Location 0 Date of f'umpillg: � I `—C Quaitlily Pumped: '�' gallons t� I Yes � � Septic Tank: No �_.� Yes lam Cesspool: No � Syslettl lNilliped by: 014 rejeff EW41#14Qed License # _--- CpIllelils iraiisfelrred to : 01081er aWFSIICO YYcllIMry rlishlCI hate: Inspector: TOWN OF \x< SYSTEM PUMPING RECORD 3 2003 ` t pG� DATE: -- SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) ac C �06c 15 6raa DATE OF PUMPING: < QUANTITY PUMPED : GALLONS . CESSPOOL: NO 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 WMLAIlN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: h.- CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Commonwealth of Massachusetts City/Town of REI,EIVED System Pumping Record Form 4 �1 �TD O DEP has provided this form for use by local Boards of Healt ?Otlr�os� %�A, VER , but the information must be substantially the same as that provided here--Befare ctsing-thls oma,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. A. Facility Information Important: When onon tfilling out 1.. System i L©C^a On: forms the computer,use only the tab key Address to move your cursor-do not Cityfrown State Zip Code use the return key. 2. System Owner: VQ Name #fit Address(if different from location) Cityrrown. State Zp Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ts2c� ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes to If yes,was it cleaned? ❑ Yes ❑ No 5. Conditionof� �� r 6. Systegn P mped By: r Name Vehicle License Number Company 7. Locationre ntents re di ed: { — A.Ar AA:�< Sign auler U Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 l Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 NORTH ANppVER DEP has provided this form for use by local Boards of Health. Other fo sT information must be,substantially the same as that provided here. Befor orm, check with your local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health of-other approving authority. A. Facility Information 1. S teri*lDcati : Left side of house, Right side of house, Left front of house, Right front of house, eft rear of house fight rear of house. Left rear of building. Right rear of building. Address + v Cityrrown C Statue Zip Code 2. System Owner: CQ Name Address(if different from location) CityfTown4i5Fode Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [; o� If yes,was it cleaned? ❑ Yes ❑ No 5. Condit* � yAte/1�.,� 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati h contents were disposed: .L.S. a aste yyater Signa re H u er Date t5form4.doc•06/03 System Pumping Record.Page 1 of 1 Commonwealth of Massachusetts City/Town of RE ' E jED System Pumping Record e< 4 Form 4 G„ SyOy DEP has provided this form for use by local Boards of Health. Oth T ` 'A �� � N���.�t e information must be substantially the same as that provided here. _ef �'fr�g• �is k 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. A. Facility Information 1. System Location: Left/Right front of houseeft Righ ear of house eft/right side of house, Left/ Right side of building, Left/Right front of bul Ing, Left/Rlg t rear of building, Under deck Address City/Town State Zip Code 2. System Owner: (� Name Address(if different from location) City/Town State/-) Zip Code Telephone Number B. Pumping Record � v 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition ofSystem: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locat' he a contents were disposed: G.L S. Lowell Waste Water Sign to a Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1