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HomeMy WebLinkAboutMiscellaneous - 155 GREAT POND ROAD 4/30/2018 155 GREAT POND ROAD �d 29 01037.C-0022-0000.0 ! .,V X14 1`• l,. t Commonwealth of Massachusetts 4/Town of NORTH OVER MASSACHUSETTS ' system,Pumping Record , Form 4 OCT 12 2006 t. �. ANDOVER DEP has provided this form for use by local Boards of HealtTh System Pu_m-Pin _g 2ecor mu; be submitted to the local Board of Health or other approving authority, A. Facility Information - Important: When filling out 1. System Location: forms on the computer,use only the tab key Address •-- - - --- ---- - -- .. - . to move your cursor-do not Clty/Town ---- State use the return - Zip Code key. 2. System Owner: Name Address(if different from location) , City/Town Zip Code Telephone Number B. Pumping Record - - Date of Pumping 2. Quantity Pumped: a ons— ----._.. .-. 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank L4., Other(describe):ffluent Tee Filter present? ❑ esoIf yes, was it cleaned? ❑ Yes ❑ No ondition of System: 6. Sy em Pumped By: I .Name Vt a Vehicle ice se Number Company - - 7. Location where contents were disposed: -------------- Si ature of Hsu _._._..._.._.. _..__._.._. Date -- --------•--------- -- - http://www.masg,gov/dep/water/ proyals/t5forms.htm#inspect t5form4.doc,06103 System Pumping Record•Page t of I; RECEIVED TOWN OF NORTH ANDOVER OCT 0 5 2004 SYSTEM PUMPINQ RECORJ,, UA t k. � qIa �[/ TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER dk ADDRESS SYS LOCATION G�U • t, DATE OF PLJMPING: G�o2 D Q!.)ANTITY AUMAED: 0®0) T L tiSSPWL NO YES . - ,. - Septic Tank: NO YEC NA FUt;E OF SERVICE: UU"CIN _ f~MER(UIrNC'1' Ota S ER V AT10N S_-------- D CONDFJ`.ON FULL. 'W COVER y _ BAFFLES IN PLACE ROOTS _ LEACFiRELD RUNBACK EXCF,SSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN System Punmpad by __... lcSt< rna. 0UMMENTS. _................. l CUN I EN FS I'KANS.FhRREL) 1-0 � f Av . . . TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD u.a IT'.: S1 STEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) ,/o U:\TC OF PUMPINC: QUANTITY PUMPEDc�2et-D CALL0N ,, (. I:SSI'UU.L: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE MERGENCY Uli.>FRV.:\TIONS. CUUD CONDITION FULL TO COVER HEAVY CREASE BAFFLLS IN PLACE ROOTS LEACHFIELD RUNBACK CXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER V,JHER (EXPLAIN) i i M PUMPED BY; c,umNIENTS: UN"I'ENTI TIZANSFEIZRED TO: d <0 w N i,-, t---,a y celnce�R vv' co �ce�� ct�.a�es kVA (hCyv��tc7f�11l3 o (-- ��ease- riceef L Tine �ol�nw�h cs o�ieS © C �'ICceCt\,xO'A ���\$ -eol kms bee,\ Ma�,rifiAtKed QUA c�\ec�<ed` a C,\ B0,C- S lv`ce ` S l�S�al`ar� Cc'ho� cS C'xce�lerv"� Co 'o vu yo 0 tS Cry\ �1 Cl r �...c S i,h^'k �"l *� r♦ < ;"r 4 i{a't,r�'r°��,jR 1t8i ��Y�d�"", 4Sa�.'�� �Y tt'1`�r„,rtr x,� �D`" Raga ' 1 alnt. l^ A OVERS EPTIC : ASP i. YANDOVERSEPTICr�PUMPERS 3 r. Tel 475 2593 :=Dale.$treet"Shop. , !Locally Owned . F P.:"0'Box'4173°B:Station and.Operated ` .�, � � ��`' =EST•1957 Andover P'01810 Oi Kw 76, e , �.rta`«��r�,,;,.,���,M,., x -1..4 '��" -.,.x � `-, s�.. -+w,.(S` d ` :.��.*•. �....•,.....�., � S-. �ATEa ss SCRIPTION q^ . �r r j d� eY[ rPu peddrywell° �H Se agedumping,fee SDI jg~It1"char. - . 00 `Endca i S `` 3• {'� �f` _ `1 rY°iYM -. 1 ,yyf� J 5 fru ' kINVO1C `PINY FEtOM THI'$;BILI: TERMS*OFiP/YMENT.�NET 10<DAYS EA'FIN'ANCE CHARGE OF 1 1/2%PER•' ILL BE t CES.THIS GANNUAL RAT'le".1, -.^„.,t i` ,::'�'t b «:,y Std .'n r=-•i� � 1' 7+e' I i *. A ':.'s gx y�, iia, a�y.��,c+xu- _ S ; .A ':•.�w sM�, }�u'} ASP, ' < 2�4a X9.{{2. .:�'�C� n -#"..�� +, ..�,c,tr� s t .�''�.,���_�w''� r �w� r ���.'.- �..�}r,g�'z�c«.�5� • "w`Yi.:'r• cr .s v i:4. �: 3 5Y9`�r'. � # �'4.:#yr�"."'�^'t"Y"'�Y" -3a• *� Y e'€ 4 "S `ANDOVER SEPjTtIC PUMPERS CTef;+475 2.�i93,, ; s 10dallylo, e12Dae Street Shop ` T n+` i id t n,+ '9 q x P 0,Box 4179 B Stat on, ,,, h,t? r °.� , ; s K and`Operated Andover,.MA 01810b��K ' U. ' r SS, X1957¢ � 8i•r9.o-mnr6.;+�,a-afar• `+� r _. .,...m t {w .�� T�«4�r-. ax a..-� a.�.�x .G S S� e.;•Y.nr�f' ,a �.,� . ^ syy, '"`"{.�`"`ft,"°.a$. `t4.,`3; ", f..1`.� :.� s ' { .. :. i.•� �`s�+ 3�t 1 �1 � �� `�" aC.g�"`w, '� '!4 '*c%.�,,,,��„�.sr ���' � Y�• '4i t'*°`�, � a � �� a�'! F ..�� *41 O.154 N,, z A� ��� �.� � v r ,fiS ��r`Ft-irk 'r+T•. Y ws X'��wg i.hs' r�'.' ?'fir'*. '�%Y*�� y a �° �a`7' 'k �''rei`, IN ,.k.G i f -e`a *,' Fz Y 'ems f y k°fd' fy+��n ✓ ai A� ro y a rf �d4� �C� Yfi A ys' su 'tom§f }t'��n�'h3' l5Y '�' �y " ,�'4.yiy+n biy,• g 5.�3 f5.t �S'^ r^��...q�* �� .g�arywyq... 3 •-�w "bit $ 'r. a DTEy L1 DESCRlFTlO. +� rp .y� 1^'�F" `� 'Y�u`s `�' i9,. ."an'.i"R0. +ixn�4�-r_. 4 ? � P,um_ped,,septic,� z 3 . G.itta '�.-�' `"' e � •r" - �s'sem '°X"'m - e r•+" �;. 'Y`x +''�.. '�.�y M a RIMP ... f">*� ,�' -, ,1� .�1r � -rat s• 3 a.,: t� ag% mping�fee� seg Yom;.; �z. t Y�ve'4 d 4 'w,.�� g91ng ch ar�g:es � .�iaaf3'*S"�+K'.� +'i^'. Ft �. xl'£ �- !Reamed plpeF .1. t�'', � yr i �v,;,�_ e m� �w r ra•s '`- `�� �g,A 7 :rn yty ol + a R. 47 ,da dp`�` nv �.3. any ial � p j lq 9�,,a p7.,'.tV mw e �"ei- .�.,,z< '" �."`•�y ` �T y. "T- �u t �ro.k �PYiv .'`+tV ,c' ..f � ,,,�'< K4 .{Via �,. I 'kklk 6m id ;> r` = INVOICiMx Yll E PAY�FROM THIS-BILL, OF PAYMENT NET+30 pAYS� A FINANCE CF�ARGE OE 1I/246 PER MONTH WILBE k� � A----TO ALL PAST,QwUE€BALANCES THIS ISkAI "a N n..3,,��r �M R:. � +drtK� .s� r�a.3'•p4'..iL..r��t,i.,l:Fi 2` Tv'G.. .."..r+'� r'w-i:Iev'^ :�C.:.�.'.w�`<',ii."t„a..'F.fia.1:S-4".�.<:...�.i"b..."...•i,'�.:..�Mi�..s��:t,�.x�-si�' �....,�.�..z:..�..b"� �..-..Yaa_..::fi....«:t' F + A-SP LL'm ,� ���, 1ps�rr p. ae '! •(� .efd -*,. ,.'AND`OVERSEPTIC `PU'MPaRS .` -• 4 Tel 475=2583° 12 D'ale'cSfreet'Sl op.: s� *' Locally.Owm'e P O,Box 4173 6 StationV } : tis and dpbtatbd° 'Andover','MA 0181.0" , S7 1957 �R � .. � t _«; ,r �;r+ r. Nota x*� "' �p •»•s{ � '�f ,� r?a. .Wn'�7 ; � :`'h •.....+c .s. ."aw•. ^aJ'rbt+w.' r teb P g, 's. { �;t ,�'^ rh r �..•+.. ¢ s.,� �` ^t"M:. ,. 9' �st,,;,T � y�Via}�� ., rt 41�'� ` -: Jti,r''" � f gym..� �.,'S a s`-y'+' �y,:•h� �� i 7 -. � y, `a' u�r n a -.dot�s��•u.�'.S �.. '.. v.,.•T��.c:ys`.,+,L,Y.s � � ...� °' ,..:�.f »."w�'�ra,s.-;,`.;�:,s�..�n' Se a •.-.-.•ifs J'��Aa,''�' i �...Ma...•c ski. .�., _ "�".`.-P.a.rr4 ..�. re v,,:s� dk�� $ .• .i�+.ro `.kw, 1, DATE.; ,.:I PT1 z fir f 4 t A f =. ..:. D ESCF3IPTION '� �v�..�a..+�+�+�•r.M= � .+"""`to..a- '�.' ,„.,�, p'ulsnp'e"d�gept I an " _ j j� ;IT"1 .'�{•�4 v s " t-7 •,S•r 'f 4 . Pumped dr` well . Sew;ageWdumpng,feek x DIggIng ch.arges� .. t ,Reamedplpe fEndcapQ = N 19, g - y VVOfCEa�P `•FROM T•iIS'BILL d e �TERMS'QF>,PHYMENT NET 30 D w ti + p `ANdANEE~ ADDED TO"ALL'�PASTxDUE BALJANCtS THIS IS AIV; � I:. r' `lANNUAL°RATE"OF 180A R ..:+,-'T+rx')?JJ �.-•..ems�,w.tii.,.+iM h�'� .n'.-.'^�*v�.ix'x.^+-.+w�.s+_ +{�M- •h WATERSHED RESIDENTS QUESTIONNAIRE 1. Name 5dc ew - C0INVJ4U 2. Street Address 155 ceaZ �.r' - 3. How many members are in your household? c 4. What type of sewage disposal system do you have? ❑ cesspool &?' septic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no F] do not know 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years R" 11-20 years ❑ over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes (r no ❑ do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? CN' annually(Plndovea Sepal ❑ every 2-4 years ❑ 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. How many of each appliance are connected to your sewage disposal system? washing machine U dishwasher I garbage disposal dehumidifier drain G sump pump 0 toilet 4 roof/pavement drains D shower/bathtub L%- 11. 11. Please state the brand and type (liquid or powder) of detergent you use for: dishwasher S ut\"sLPj ,T clotheswasher (►kk 12. Does your property have a lawn? 0" yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/2 acre ❑ 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) 01 acres 13. How often do you fertilize your lawn? No. of applications per year L Season(s) of the year Soe� S% n,r+_ �a1� 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: Aon��ed (e v► �recct \ A E �eRv�c�S — TS1. ����to�.MASS- V Check here if your lawn is maintained by a professional landscape contractor. SEPTIC SYSTEM INSPECTION FORM ADDRESS l S� ►-P P6� DATE INSPECTED PROPERLY FUNCTIONING? N WEATHER CONDITIONS COMMENTS: WATER QUALITY TESTED? RESULTS? DYE TEST PERFORMED? Y N DATE? SKETCH: 1. IJ a nne 2. Street Address 15� 3. How many members are in your household? C41 4. What type of sewage disposal system do you have? ❑ cesspool septic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no P1 do not know 6. blow old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years Q� 11-20 years ❑ over 20 years ❑ do not know i. Has your sewage disposal system been rebuilt or repaired? ❑ yes C�1' no ❑ do not know yes, approximately how long ago? years. What was done? { S. low frequently is your sewage disposal system pumped out? {B' annually OAp~- Sc� .- ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years O never S. 1-lave 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. How many of each appliance are connected to your sewage disposal system? washing machine dishwasher 1 garbage disposal &Jtumidifier drain G sump pump 0 toilet i ago;ipavement drains shower/bathtub 4- 11. Pz ease state the brand and type (liquid or powder) of detergent you use for: d)shwasher clotheswasher A\� 12. Does your property have a lawn? 0/ yes ❑ no rf yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/2 acre ❑ 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) OL acres 13. Howe often do you fertilize your lawn? Na. of applications per year l cl- Season(s) of the year Sot:we S U Or. Pal 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: vt E cz,_IeRViCes r,i Check here if your lawn is maintained by a professional landscape contractor. -- i1ti;iC�.l,.'��'(S J'fi1}:�''I�y lv2 v����l�r l,."��1� ,.'�•�1�y�'fll .. --- t �!Y'J,', y•P,+$b ri c lltd'J. , 6 tt i \l � �_.� , ' ' '�'`', •"' ---,__._.__ _ i y f(I \ ��i ti � �� �j f�'�l`CI �J���li(`• l'•.�11,� 1 ' <'.� 1� •"(w I ''!If' 1"C"2l 11����1 ✓ �.•2� S�.v't�l�il�l l'.li I 1 OA' j nM SCJ ;x t Wl. Np 0-,k�kj,3* a�/ 1'7-1 1'1'`11a.4 ✓ - O� �I 1\.1 ��rtl �t)C� �. � til���/�'I l'I / ��,�.t/^�� /f"'� � -_ _.-_._.... '. QUANTITY r 14,r�1�1�11.jIS '11��IC�.1'fl� 1 �:(�S ' ..���• I�; (DYrS SEP71C' T�,r��l� n � p I II v ✓ I( ` Lm ERC � ,•,� % :FULL Tv c� �rcls L C A C H F I C L --- �SQII IUB C y'IRf�YOY R 'r Q m H R Z .(�'Xf ._.- �' "p U M p C I O Y I t� ti, , ,,I' �Ilr v �,. t'i •. t IV f lilS C, 1 Iil Commonwealth of Massachusetts RECEIVED City/Town of kqjSystem Pumping Record DEC 1 1 2007 Form 4 TOWN OF NORTH ANDOVER 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 Important: When filling out 1. System LOg_atIOf): �C forms on the (/ computer,use only the tab key Address ) -� to move your !j �� 4-L—A�� cursor-do not Cityfrown State Zip Code use the return key. 2 System Owner: Name ICI Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping v l2. QuantityPumped: p g Datep Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): ,-3�� 4. Effluent Tee Filter present? ElE Yes Ivo If yes,was it cleaned? ❑ Yes ❑ No 5. Condition 6. Systeme Name Vehicle License Number 1 Company 7. Location7�e con tents ver osed: Signature of b(hu# Date t5form4.doc•06/03 System Pumping Record a Page 1 of 1