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Commonwealth of Massachusetts RECEIVED
City/Town of North Andover
System Pumping Record MAY 19 2014
Form 4 TOWN OF NORTH ANDOVER
w" 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.
6. Q11stem
l Pumped By:
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Vehicle License Number
rt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Receiving Facility
Date
Date
�t5form4,doc• 03/06 System Pumping Record • Page 1 of 1
A. Facility Information
Important: When
filling out forms
the
1. System Location: .-
5
computer,
use only the tab on
1
key to move your
Address
cursor - do not
N. Andover
Ma
use the return
key.
City/Town
State
Zip Code
r�
2. System Owner:
G R
ien®n
Name
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
%
00
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:
0 oo
6. Q11stem
l Pumped By:
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Vehicle License Number
rt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Receiving Facility
Date
Date
�t5form4,doc• 03/06 System Pumping Record • Page 1 of 1
I 1
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
. I will install this system in ac-
cord c mit �Y�%aus 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 pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of in size. A manhole (s) permitting easy cleaning
will be provided with r966 ab]:" cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of lineal (square) feet of effective absorption area.
The pipes will be laid & e6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 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 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile 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 installation 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 agree not to cover any portion of this installation until approved by the
inspection 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
t e ant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE
I have inspected the uncovered
as described.
DATE
i alp,
t o ea Agent
system indicated above and find everything done
Percolation Test / // , J f�fj
Gaz-oage Grinder f
wA-
��.,.
Signature of I specting Officer
ff FE 1141
NCX 7-- Tr Aivm 8r_= If
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
1 �r " q
/'ro L) '
1. NAME7 (fes�I DATE;�,Cv cJ G
r '� -�'
2. ADDRESS � % /� /� � � LOT N0. TEL . 3 20 �! y
3. NO. OF BEDROOMS �, DEN YES NO
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
NAME OF APPLICAN
LOCATION
SEWAGE DISPOSAL
nATE p
BUILDING: Dwelling X Other
SYSTEM: New Repair
GENERAL DESCRIPTION OF LAND
SUBSOIL: Clay__,) vel Sand
PERCOLATION TEST !�L minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK gallon capacity.
LEACH FIELD— --lineal feet of drain pipe.
�))J)I .
illiam J. D i coil, Engineer
Board of Health
Commonwealth of Massachusetts
W City/Town of No Andover
System Pumping Record
Form 4
M
R "EiVED
MAY 14 2013
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
tGa L
System Location
1555 Turnpike St
Address
No Andover
City/Town `
System Owner:
Jovice & Wavne Marceau
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system:
❑ Other (describe)
Ma
State c—
State
relephone Number
2. Quantity Pumped
❑ Cesspool(s) )211eptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ��IoCd
5. Condition of System:
Zip Code
Zip Code
Cv
Gallons
❑ Grease Trap
If yes, was it cleaned? Yes ❑ No
6. stem Pumped By:
�,l l
ame 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
Signature of wing Facility
Date
Date
t5form4.doc• 03%06 System Pumping Record • Page 1 of 1
TOWN OF/,ANDOVER
SEPTIC SYSTEM SERVICING
REPORT
Date • (D A 00
Homeowner: A0
Street
Phone
Nature of Service:
Observations:
:
Descri.pt__on of Work;
Vcao 2 4 P� �ko )j
Comments:
Routine ✓
Emergency
Pumper : R�Ae-r--
Address: �3
Phone
Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy, Grease
Roots
Other (Explain)
10
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD -, C
DATE: Li J3o CD 3
SYSTEM OWNER & ADDRESS
555" - � „p►k e- i
SYSTEM LOCATION
(example: left front of house)
�,y 2 2003
DATE OF PUMPING: S (33 QUANTITY PUMPED 15an GALLONS
CESSPOOL: NO YES
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SEPTIC TANK: NO YES 1
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Ro a -4-Q r - k,I.1-�
COMMENTS:
CONTENTS TRANSFERRED TO:
Commonwealth of Massachusetts
CityfTown of
System Pumping Record
Form 4
'*Y
DEP has provided this form for use by local Boards of Health.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
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-:
111-55 �7
cftyt 1 own
2. System Owner:
Address Cd different from location)
City/Town
State
State
Telephone Number
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping Dat 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5_ Condition of System:
6. System Pumped By:
Nv'm Vehicle License Number
C6m any
7. Location where contents were disposed:
Signature of Hauler
Date
t5form4.docc 06/03 System Pumping Record • Page 1 of 1
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°r Date°of P ' ` 7
r }; , Do2, Quantity Pumped:
y• :.1 ;,:. 1ump gin GaUons
:';:8,.' `.Type pf,ayatem ❑ Cesspool(s)9
eeptic Tank ❑ Tf ht Tank
[�' Other
' y '{f,, 1 t+. 1!j �V.� .t'.�q 411(Y1�'jyli •Y e:J11,' }•� .':�' � � y',1'
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FYL/.It�TFiYf/ r�i�I�'
Date
System Pumping Record • Page t of t
Commonwealth of Massachusetts
City/Town of N o W 1 Py&vt
System Pumping Record
Facility Information:
System Location
I - I
RECEIVED 11
JUL 14 2009
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Address .. 1555 _Iurnpl� cof
- 6vol
City/Town State Zip Code
System Owner:
Cau
Adress (if different from location of pump)
City/Town State Zip Code
_q -7S_-__ & ga - c5Idq
Telephone Number
Pumping Record
Date of Pumping ja J9 —Quantity Pumped 00 gallons
Type of System Septic Tank Grease Trap Other (what)
System Pumped by:_. )-)rA a T
r)
Company- ROOTER -MAN 12 East Dracut Rd., Methuen, MA 01844
Location where contents were disposed:
Signature of Hauler
Date � 1A ( 19
wtlw alth
of Massarcl-husetts
7 Q f :S Recc-T�d
mrtion:
A Cl
Cation of
�
Record
,s4.
S -,a, -e
State
EIVED
AUG '15 Z011
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
rM
Quamkl�f Pump
Cob
Cx-eaas-c Trap
RzOAD —R -MAN 46) Ponia.-Id ZStu" t
7j
's we
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