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HomeMy WebLinkAboutMiscellaneous - 151 OLYMPIC LANE 4/30/2018 151 OLYMPIC LANE 210/106.B-0133-0000.0 FORM 4-SYSTEM PUMPING RECORD CURRIER SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON,MA 01949 (978)774-2772 COMMONWEALTH OF MASSACHUSETTS / r (VQ0 v C4 _,MASSACHUSETTS SYSTEM PUMPING RECORD 0 SYSTEM OWNER: SYSTEM LOCATION: P DATE OF PUMPING: /'�' QUANTITY PUMPED: 50 GALLONS CESSPOOL: NO0 0 YES SEPTIC TANK: NO YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: / INSPECTOR: A f FO 4-SYSTEM t 3 STEM PUMPING RECORD a SEPTIC & D�,A SERVICE 10.7.FOREST STREET;., ICE M. bDLETON,MA,b 1949 (978)774-2772; •tom. j N _ i r k '�OMMOTH OF. sR xrMASSACHUSETTS ,MASSACHUSETTS f y k SYSTEM P , U . MPI N I G a w� .RECORD SYST K.WINE Al s'(� SYSTEM LOCATION: �- i ,A. k n QUANTITYPUMPED: UMPED: /S 0.C) GALI:orrs ��x CESSP4�L • 0 YES SEPTIC TANK, rJp Y YES r ` - -- �dER SEP1`ICF&DRAIN SERVICE ,* C(JNTEIVTS:TRANSFE -------------- RRED TO L- � p bATEi ���,.7" .f• �. w f t v�" - ra INSPECTOR: Gr, r d• '`t 4 a _ ApR Form 4 -- System Pumping Record Commonwealth of Mossachusetss : Massachusetts System Pumping Record System Owner System Location P'C)LFJI TV-FV[+ki l W III MY'MPIC L.ANf I'I 01'rNFIC U'1,T I97ui �Fll-3'y34 Type: Emergency Routine Cesspool: No Yes Septic tank: No =Yes Date of Pumping: �f Quantity Pumped: GS�t� Gallons System Pumped By: Wim River Environmental, LLC Permit Jl: Contents transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments Dep Approved from - 12/07/95 Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS - System Pumping Record Form 4 ' 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving aut RECEIVED A. Facility Information Important: JAN 10 2008 When filling out 1. System Location: forms on the A TU.;,iW or I'URTH ANDOVER computer, use f ® i C HEALIt-I DEPARTMENT only the tab key Address ii to moveyour ,�� A A� o v 92 t cursorr-d do not use the return City/Town State Zip Code key. 2. Syst m Owner: Name rermn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: J-S®O Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Other(describe): — 4. Effluent Tee Filter present? ❑ Yes E; No If yes, was it cleaned? ❑ Yes ❑ No jj 5. Condition of System: C7 6. System Pumped By:_ Wr{�lsor �07��l M� Name 1� Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of NOM A�� •� System Pumping Record OCT o 4 2009 r` Form 4 TOHEA�TH DEPARTMEONTER DEP has provided this form for use by local Boards of Health. Other forms u e 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 �.5--/' ©l/. e computer,use !! L 14 only the tab key Ad re to move your cursor-donot 144 A use the return City/i own State Zip Code key. 2 System Owner'. f VQ Name ' Address(if different from location) City/Town State 8s3Y Zip Code Sig Telephone Number B. Pumping Record 1. Date of Pumping pate 2. Quantity Pumped: !s OQ 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 Puped By: G Ago 7 Name Vehicle License Number Comp ny 7. Location where contents were disposed: Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 I Commonwealth of Massachusetts City/Town of OCTw01(l System Pumping Record NORTH ANDOV R TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT 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 filling out 1. System Location: forms on the , computer,use only the tab key Address 1 to move your ovL� cursor-do not h(�r�_..�r� ----------- -- ---- — ---- --- City/Town State Zip Code use the return key. 2. System Owner: Name 'Af0 Address(if different from location) CitylTown — ---- — —..— State — ----- Zip Code ----- --„-- Telephone Number B. Pumping Record . 2Quantity OJ®0- 1. Date of Pumping Dat_ IQ Y Pum ed:P Gallons — -- --- 3. Type of system: ❑ Cesspool(s) [VSeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): ---- - — --- -- -- —.. ----- 4. Effluent Tee Filter present? ❑ Yes Y/No If yes, was it cleaned?. ❑ Yes /No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 a ^^A"^A^^^P nouninnnn Commonwealth of Massachusetts Form 4--System Pumping Record=% Massachusetts System Pumping Record System Owner__- System Location Trevisan Rolfe Primary Bome 151 Olympic Ln 151 Olympic Ln North Andover, MA, 01845 North Andover, MA, 01845 (978)-681-8934 x (978)-681-8934 x Trevisan Rolfe Type: Emerge nc Routine Cesspool: No Yes Septic Tank: No Yes Date of Pumping: Quantity Pumped: /rOG Gallons System Pumped By: Wind River Environmental,LLC i;CEI Contents Transferred to: 5 ;= 3 2013 AHE)eVER HEALTH DEPARTMENT Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments QL-S-D. over, AU is Printed on recycled paper Dep Approved Form-12/07/95 Commonwealth ofassac usetts City/Town of System Pumping Recor OCT - 7 2008 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 filling out 1. System Location: forms p the 1 5 ' p 1 y m P;e N computer,use only the tab key Address to move your /VOv}h ArdOvc < MG d 1 'RL4S cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Q -ko� �e, -TreY,i SQY� Name Address(if different from location) City/Town State Zip Code q-7g - bsI -g93L4 Telephone Number B. Pumping Record 1. Date of Pumping 4-032. Quantity Pumped: 5n() Date Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [ ""N0 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Good 6. System Pumped By: J►YY) GGI DY)� `7 �b�� Name (''' Vehicle License Number Win �i�/e,� CY11/i Covlsnr1en�cJ� Company 7. Location where contents were disposed: w t Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 1 • 4 r k n A C y� 7(y(y w y to • c> F� 'A r _ 40.11 r I NY, PIPE OUT OF DISE 141 ,3 I I'� L—r IKly P1PE INTDTO,I4y IbC�,cj�{- u t kk\/_PIPEOUTOF"j'"g�ti►� 100,31: C� INV_ PIPE INTO D 100,% (bP o. I I�1V. 1�I , QLJT soy, too ,Qo1 1NV E.�,tjZ OF' PI tj, �a+ r FRANKC. GrLINAS `�': YV I..;.1�,/� f �� Ila. 22728 • t��G;t��,.�� ter�� � •. .. , R 4 I � l � �" �� � �/C� � �I �I I f rd of Health BEPT'IC SLSM vrth An ver Haas. INSTALUTTCN CHIECK LIST LOT �-� a�Y �r, APPffOVID DATE D1 - PROVED X AVATICIN OK FAIL Rea F� ,knr 1. Distance Tot / r a. Wetlands r/ b. Drains c. Well 2. Water Line Location 3. No PPC Pipe Septic Tank _ --- -- . a. . _Tees Length & To Clean Out, Cowers. b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Boa a. Covers & Box - No Cracks b. A11 Lines Flowing Equal Amounts c. No Back Flow 6. . Leach Field or Trench a. Dimensions b. Stone Doth c: Capped Ends . d. Clean Double,Washed Stone 7. Leach Pits a. Dimensi s b. Stone epth C. Sp sh Pads d. s e. Cement Pipe to Pit - Both Sides. Clean Double Washed Stone 8. No Garbage Disposal 9. yinal Grading Inspection 10. Barricading Covered System 11. As Built Submitted.. a. Lot Location . b. Dimensions of System c c. Location -with Regard-to Perc Test d. Elevations e: Water Table i i - t t van,z iq1tvu, a PmM DEMO APPR WED DATE DISAPPRUM DATE Provided: Reasonst Title V FAIL OK Rog 2.5The vu'!_,f,Atted plan rant 010-tr .10 a aIrLoLM-9 k"', a) t%,e lot to lie lot #,abratters location and log observation hoico-distance to ties Z—� c location Pmd rets percolation testa-distwice to ties di design calmlations & calculations showing reTdred leaching (e) location and c1imensions of aystem-Licludimg veaerve area _7Z:(I existing and proposed contours location my wet areas -OUIAn 100 1 of sej age disposal systeirt or di check wetlands mapping (h) wirf nme Pmd subs fico drains -AtYln 3,00 1 of am-ne di. sal -3ys,40til or disclvim.sr loeaticn a.V, dreJnaga 1001 of acv-oaga di*-pospJ System or IMON'n zou��C,.Os of 't-n' 2CO, of Bovzga JAS"Roaal s7stmn or discladmar (k) location of wy proposed i;,00.1 to s� lot-1001 from leacb3mig fa, i�`J;y (1) location of meter Lines an from leaching facility location of benchmark (n) drive-ways to) garbage disposals no PVC to be used in construction p-,ofile of of basenszit, pIwzbq pipe., septic Ustrilbution box 5_,olets and out-lots., distvibution field pipLag z,,.,td bV%Or elcationa (r) [reoiind niter elevation in area sevage (s) PIMI "v-1,Cs"t be pmapared by a r-zofcusional Rm&ftoer or otber Id crA nc thin by law to prqf-te -- _h plans T. nk_s of flowp water tAble.. tees, depth of tc-S., accecs. jrwr,-,�.Ang X---(b) clout 0 101 from cellar yIl or inground mA=dmg pool d) 251 from subsurface drains 2 DistriLration Ee,%Xqs mope g6e4at to 0.08 b sump FA 11 OK L clKlap,Pits Leaching pits are przf ed. << :ere the Installation is po s b e Reg 11.2 a.) calculations ImId tg area-ridgy Soo aq ft 11.4 b) spacing Mace a 2� . . d) cove to al e) 6 . s, splash glad ) e at Olbo ' g no bwds in pipe from d-box to pipe c 61 Reg 15.1a) n g for an 20 mutes/Irkch . b) area-z" I1 900 aq ft 15.4 c) cons action of fid 1-5.8 d) a 'ace &vdmage 2 % 3.7 6 Of Avwa cellar u or inner d avimdng pool Leacgdng Trr; zches Reg 1:x.1 area-min 5bo sq ft !h.3 ) spaacirig®h ft Tdn 6 ft with rescarve beti1cen 1.x.6 coastra.ction Ih.7 ) stone E�.1O .f) surface 4raiange 2% Domhill Slope a) pe x Y- _Vto be shotwm) b) ylx X 150 = (to be sho-m) ER ms Reg 9.1a) approv-A 9.6 ..�. b) staid-by power SOIL PROFILE &PERCOLATION TEST DATA North Andover,l��ss. No.&StreetJL � Lot No. Loc./Subdiv. Plan Owner Investigator Observer SOIL PROFILES-DATE 1. Elev. 2. Elev. 3. _ -- Elev. 4�Elev. 0 0 0 0 1 1 1 1 Ties to Test .Pits 2 2 2 2 3 3 3 3 i 4 4 4 4 5 5 5 5 6 6 6 6 :7 7 _ 7 l — i 8 8 8 8 i 9 _ — 9 9 9 f w 0 10 10 10 { Benchmark Location Elevation Datum Percolation Tests-Date j Ldtek� Pit Number 2 3 4 5 . _ 4 Start Saturation_ Soak-Mins. Start Test-Time Drop of 311-Time . Drop of 6"-Time Mins. l st. 3"Dro ' Mins. 2nd 3"Dro j Percolation Rate Notes & Sketches on Back � SOIL PROF.f. -E & PERCOLA'.'ION `i�EST _DATA /F►/-7/11 ��� r- ,�- !t ter, !'V and Of271e h--Noz 1-h ,•.ndaver, 1.1assLot No Street �„ Subdivs_sion - Owner Investigator -_. Observer2._. SOIL PROFILES 1 . Date 7 �r� 2. Date 3. Date _ 4. Date Elev._F, Elev. w Elev.-,- Elev. et Inches 0 Ties to Test Pits 2A 2. 24 3. 36 60 � 5 25'r ]2 96 08 120 e : Top & subsoil depth; depths of other soil tees; depth of water table ; depth of refusal . P RI COLATTON TL'STS Date Date Date Date Date _=_i_t _Number_ _ 1 2 _ 4 5 q-tart Saturation - `Oa.K' Ili ns . j i,:31'L— Te St•-'1'irn � - -p of 6"-`1',-ale _. _ — - _---- - ---- - ---- - - - - - --- - ' :i.ns. 'Ist 3" Dr. op r�s. Pnd 3" D, on _ to _ i;.n �7_n --