HomeMy WebLinkAboutMiscellaneous - 155 DUNCAN DRIVE 4/30/2018 (2) I 155 DUNCAN DRIVE
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Commonwealth of Massachusetts
_ City/Town of
System Pumping Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be used but the
Y Y ,
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, Left/Right rear of house, Left - �hou Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address Ss
City/Town State Zip Code
2. System Owner.
Name
Address(if differnt from location)--.
11 '.�
Citylrown State
D`-c 0 12014
�.
Telephone Number
TOWN OF r ,tat r AN' _+_R
HEA -
B. Pumping Record
1. Date of PumpingDate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ateptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition of System: ` � ,{ • ��� ,, ��)� -�{�6 ,_ d ,�,�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatio `ere contents were disposed:
S. Lowell Waste Water
S'ZH� aul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
I
-CN- Commonwealth of Massachusetts RECE MMMM �
City/Town of JUN U 5 2012
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
s " 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.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left/ . t side of hour, Left/
Right side of building, Left/Right front of building, Left/Right rear of building,—U-nder deck
Address D,/-- Y v c "C ` 6-1'�
Cityrrown State Zip Code
2. System Owner.
Name
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) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? ❑ Yes ❑ No
5. Conditipn,often
v
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. iSigtufe
re contents were disposed:
S. Lowell Waste Water
Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
TOWN OF \Je4--
SYSTEM PUMPING RECORD_. -'-- -
DATE•
Nov 2 6 TIM
i
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
Yc
1
DATE OF PUMPING: (q-0 QUANTITY PUMPED : �i� GALLONS
CESSPOOL: NO YESS PTIC 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: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: Z3��
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
i (example: left front of house)
�s
DATE OF PUMPING: _ d QUANTITY PUMPED GALLONS
CESSPOOL: NO I. 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: 8Z�Q-: '
COMMENTS:
Lws.
CONTENTS TRANSFERRED TO: `
i
i
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SEWER vccT-.4ar 122 .33
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Address Title of File Page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Documernt/Action and notes
action Document/ document/
Num. Action Department
Board of Appeals — Board of Health — Planning Board — Conservation Commission— Building Department
t� G.
FORM - U - LOT RELEASE FORM
INSTRUCTIONS- This form is used to verify that all-necessary approval/permits from
Boards and Departments having jurisdiction have been obtained.This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
..■r.■t...................................e.■..........................a...
APPLICANT i l l VIP + VA SC�,J
OO PHONE � Q a' � a '7
ASSESSORS MAP NUMBER LOT NUMBER s
SUBDIVISION LOT NUMBER
STREET �U A .4 n� S4 STREET NUMBER
........................................ass.■.ago..Bonn.....amasses.....WON
OFFICIAL USE ONLY
RECONEvIENDATIONS OF TOWN AGENTS
,............................................■.......r......................
DATE APPROVED
CONSERVATION ADMINISTRATOR
DATE REJECTED
COMMENTS
DATE APPROVED
TOWN PLANNER
DATE REJECTED
COMMENTS
DATE APPROVED
FOOD INS E" R-'HEALTH DATE REJECTED
r
r_= DATE APPROVED I
C TOR-HEAL
/y DATE REJECTED_r
w COMIVIEN'TS �i
PUBLIC WORKS-SE4R WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTNIENT
DATE REJECTED
CONO ENTS
RECEIVED BY BUILDING INSPECTOR DATE
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DIMEJI_.tt�G.
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01 12 :33 PM DAVID L ROBERTS 60367980662 P. 02
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HALL - '
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-01 12 :33 PM DAVID L ROBERTS 60367980662 P. 03
. -. o F� Q� # s vQ uFa 7-0
&F Tffe- !�ALLtaAy 7`D T01: r •
STA3Z G a2 IS RE-�QTrD
1 N Ttt E A-TTtt.
oPO -
f5 DOAJZ li A)_D PIV IN6-
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[A YITI-ffEW
»a~a or 11'nni t'
Borth Andarer,r:_aza• 1.1=1 C Si Tiya —
INST!.I_AA'1a% -CE]',-'K LIST LOT S
Ornu? DATE DISAiPPROi ED XCAVATIC94 OK. FAIL
WO
of
easnznst
i
All
FAIL OK
�-- 1. Distance Tot
a. Wetlands
b. Drains
c. Well
2. Water Line Location
3. - No PPC Pipe -
$. Septic Tank _ --- - - •
a. _Tees --Length & To Clean Out Covers
b. Cement Pipe to Tank -- On Both Sides of Tank
5• Distribution Box
a. Covers & Box - No Cracks
b. - All Lines Flowing Equal Amounts
C. No Back Flow
6. beach Field or Trench
a. Dimensions
b. Stone Depth
c: Capped lhds
d. Clean Double Washed Stone
7. L /7�Ston
a. ons
b. epth
c. Pads
d.e. Pipe toPit - Both Sides
f. ouble Washed Stone
8. No Garbage .Disposal
9. -Final Grading Inspection
10. Barricading Covered System
10 ll. As Built Snbmitted
a. Lot Location
b. Dimensions of System
C. Location Stith Regard-to Pere Test
d. Elevations r
e: Water Table
TO: NORTH ANDOVER, MASS 19 e.3
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
7- 14 _D (4 IVQ9N _P 4 North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in woy plans and specifications dated
Std' t 4 19 2- 13 Y )C�e/q A/ 6'FL ov 4 a 7'F110
'F S
IA
ZH 0 F lYigss�\
Re" Pr r n „e'& Reg. S: taria
,A No. 464 ,
G�STER !�
ss%NAL s����.
L.tasG nA /�/eb�ac--�//o
N6
J _2^
ELEYAT/oNS /N(/ER�S
SEWE/� vu r.4 c.r 12 2 3$
TFIMk
t q MK u KT /21- 7/
/3 Qx //L/
/310x our r � 9•tl- rr9�ii. //9•//
"V D.L111/__ _1_I. 8_.�-.11.x .1-ir8.ge
G a T 7.4
��8.80 -lt883
,S
� I� .� , �y /,5'0o G,q/• SEPrt.c TAN,
i• �
Paa'rd of H.. 'th
?'c. -th ►- !nv .r,'i as
WBSURFACE DTc,?OSkL DESIGN CHECK LIST
LOT
APPROVED DATE DISLPFRGvED DATE
Provided: Reasons:
Title V FAIL
Reg 2.5 a submitted plan must show as a minimum:
the lot to be sorvvd-area,dimensions lot # abutters
location and log daep observation hoes-distance to ties
location and results percolation tests-distance to ties
design calculations & calculations showing required leaching area
e location and dimensions of system-including reserve area
t existing and proposed contours
g) location any writ areas within 1001 of sewage disposal system or
E disclaimer-check -wetlands mapping
surface and subsurface drains within 100' of sewage disposal
system or disclaimer
(i) location any d{ainage easem-nts within 1001 of sevnge di€posal
system or disclairar-Planning Board files
0) knom sources of vntor supply within 2001 of sovage disposal
system or disclaimer
t��ky location of rmy proposed well to serve lot-1001 from leaching facility
location of water lines on property-10I from leaching facility
`i m) location of benchmark
s driveways
) garbage disposals
no PVC to be used in construction
(q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
r) maximam ground grater elevation in area sewage disposal system
(s) plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 S tep is wanks
(a) capac t os-150 of flow, water tgble, teas, depth of tees,
access, pumping
) cleanout
( ) 101 from cellar wall or ingrouad su.u3.ng pool
d) �5, from subsurface drains
Reg 10.2 ✓ Distribution Bores
slope greater MW 0.08
Reg 10.4 / b) sump
1
3nbsuria6e :?5im Check Litt _ _ P-taa 2
FAL QAC ---
s
.:aching Pits
Leaching pits ate erred mere the installation is possible
Reg 11.2 jb)
) calculations of leaching area-mtniz= 500 uq ft
11.4 spacing.
11.10c
surface drainage 2%
11.11 cover material
) AlxvxV splash pad
)'tee at elbow
no bends in pipe from d-box to pipe
Leaching Fields
Reg 15.1 ) no greater than 20 zdmtes/inch
b) area-minimum 9Q0 sq ft
15.4 ) construction of field
15.8 ) surface drainage 2 %
3.7 e) 201 from cellar xall or inground mdm dng pool
Leachin TVI Chas
Reg 14.1 a) calcula s o eaching area-idn 500 sq ft
14.3 b) EOW�ction
- ft min 6 ft with reserve between
14.4 c)
14.6 d)
14.7 e) sto
14.10 f) ace drainage 2%
Do=hill SI e
L a) slope 7/x�to be shote)
b) y/x X 150 - (to be shown)
Reg 9.1 a DipVVal
9.6 b) shad-by power
WELL DATABASE
ADDRESS:
AGE OF WELL: 1+ X WELL DRILLER:
WELL PERMIT : ` WELL LQCATION:
WELL PERMIT DATE: DE OF WE .
TYPE OF WELL: a.. DRILLED Z�. b. DUTG tTiN-KNOWN
TYPE OF WATER BEARING ROCK:
WATER ANALYSIS DATE: HIGH MANGANESE: Y N
HIGH IRON: Y N OTHER CONTAMINANTS: Y N
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: - _d
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
NLA coo, b r
DATE OF PUMPING: `I_3`6�)- QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINEI 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: ` `�(nbA `7r�
COMMENTS:
CONTENTS TRANSFERRED TO: �9 -
Commonwealth of Massachusetts
11
City/Town of
System Pumping Record
LR
UG 1 3 2007Form 4
�1'ce'. JcRHDEPARTMENTDEP has provided this form for use by local Boards of Health. Other foV--6e used,-but"t
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
Important:
When filling out 1. SysteLocation:
forms on the 1 `a
computer,use
only the tab key Address , V i/ ,
to move your �
cursor-do not
use the return Cityfrown State Zip Code
key. 2. System Owner:
rab
Name
mown -` 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) fy Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition em: p TkA-.,l � C
6. System J By: 01
Name Vehicle License Number
Company
7. Locatigere VS wer, isposed:
A.
(JV/ s-q oil/
Signature of auler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
t
IL
Commonwealth of Massachusetts
City/Town of -7EiVED
_'
a' System Pumping Record
Form 4 NOV 1 3 2008
DEP has provided this form for use by local Board i Health..O.ther4tiFxa'g y be used, but the
information must be substantially the same as that 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. System Location: Left front, left rear, left side of house. Right front, right re , right side of house.
forms on the
computer,use
only the tab key Address
to move your
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
-- Name
Address(if different from location)
City/Town State 0 &� ip Code
Telepphhvhoon',e Number J
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 Filter present? 0 Yes If yes, was it cleaned? 0 Yes No
5. Conditigtl of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S.D Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
a System Pumping Record RECEIVED
Form 4
MAR '19 2010
DEP has provided this form for use by local Boards of Health. Other fc rms may be used, but the
information must be substantially the same as that provided here. Bef rVM9A6§rfQ.flMtvsIJQ6K ith your
local Board of Health to determine the form they use. The System PurteiRgftl*ffiWiN�ub itted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of houseCe eft front of house, Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Addresst V C,� A 1 A— Xj-,\ ��
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
�77
Telephone Number
B. Pumping Record
1. Date of Pumping Dam 2. Quantity Pumped: 11
aos
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Eq-14-o� If yes, was it cleaned? ❑ Yes ❑ No
5. Condi ion of Syste : '
1
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
LAS.D Lowell Waste Water
A/1 9:d\ h
�-- v
g to a of Haul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of Y - .
System Pumping Record ' s
Y p 9
�M Form 4
r1`1A� �� Q�,
DEP has provided this form for use by local Boards of Health. Other ttf�tWMayrt -,4pe��
information must be substantially the same as that provided here. Be . th mbac with your
local Board of Health to determine the form they use. The System Pumping Record mus a su mitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of house, left side of hous right side of house Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State
�3 rde
Telephone Number �J
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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location- re contents were disposed:
G.L.S.D. Lo ell Was ter
A0
l I
l 1
Signature f u Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1