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HomeMy WebLinkAboutMiscellaneous - 160 FARNUM STREET 4/30/2018 160 FAR NUM STREET 211)/107.A-0021-0".0 r Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER Farm 4 t the DEP lya i provided this bstantiially the sameor use by l00ards of Health. Other forms may be used.as that provided here. Before using his fora►,check with your information of H be s soca!Beard of Health to determine the form they use.The System Pumping Record must be sUbdAted to the local Board of Health or other approving authority within 14 days from the pumping date in acco�Fa ance with 310 CMR 15.351. A. ci Information impotent: ell APR 1 .i 1012 Wien filling out 1. System Location: forms on the _ _ "_ _TQW..I4AFMORTH AN OVER – GPmpUter,use .._�_.._..._... .. "' -- HEALTH DEPARTMENT only the tab key Addr to move your . - • p e _• _ State Zi Cad cursor•do not CI yR¢„yn use the return key. 2. System Owrter: Name ._ ..... A.�• Address(if different from location) Zip Code Yetepr+ane nturnber .,,.,, B. Pumping Record .--f 2 _....--... . .... 1, date of Pumping 9- aN ...,._.......,.--..r 2. Quantity Pumped: Daltons ate 3. Type of system: ❑ Cesspool{s) Septic Tank © Tight Tank ❑ Grease Trap Q Other(describe): 4. EEffluent Tee Filter present? C Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Sxstern Pumped By: ry NumUer Name k ompany 7. Location where contents were disposed: x signature 01 Hauler Signalw8 of Receiving FBGtiiiy_.----.,^----{--••-� - Date• -••�,M—_„� v __�..,. System Pumping Record•Page I of i Wc=4.doc•03106 Commonwealth of Massachusetts City/Town of system Pumping Record NORTH ANDOVER 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 ruing out 1. System Location: �,. forms on the ��/� computer.use IRS_ klUWA - only the tab key Ad res to move your �. O�Q_ ]2- _...__._-... State _ .LHEALTij cursor-do not City/Town oe, use the return key. 2. System Owner: :: '. e.r: Name Address(if different from location) City,rTown State Zip Code Tefbphon6 Number B. Pumping Record 1. Date of Pumping --- �.� 2. Quantity Pumped: -- Date / � Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yebzto If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By. snp Name Vehicle License Nu er Company 7. Location where contents were disposed: QLLA D, <Sign4atre;�of Hauler Date Signature of Receiving Facility Date t5form4.doc•03x06 System Pumping Record•Page i of 1 FAUG E® c €�onwealth of Massachusetts 014 C;l,,y/Town of TOWN OF NORTH ANDOVER item pumping Record NORTH ANDC3VER ,EALTHpEpARTMENT Forn-► 4 forms may be used.but theDEP has provided this form for use local Boards that prow dad he e- Before using this form,check with your irformation must be substantially the he stem Pumping Record must be submitted to locai Board of Health to determine the form#author authority W thin 14 days from the pumping date in the local Board of Health or other app ng accordance with 310 CMR 15.351. A. Facility information importaw: 1 system Location: When LIGne avi v _ _ 1u a - - forms on the --"-- - - computer,use Zip Code Address oniv the tab key to move your _ State cursor-do nat City/Town use the return key. Systpm Owner: - r sl Name w A.ddress(if different from location) Cityfrown 10prhlne km'? — p, pumping Record 2. Quantity Pumped: Gallons s. Date of Pumping Dai Tight Tank ❑ Grease Trap Ty Cesspool(s) �j Septic Tank E] 9 pe of system: ❑ (J�� ❑ Other(describe): - — a. Effluent Tee Filter present. C] Yes No if yes, was it cleaned? Yes ❑ No 5. Condition of System: 6. System Pumped By: �p�Q -- - — Gz-1-1�— _ -- Vehicle License um Name company 7. Location where contents were disposed: N t tgnature of Hauler --- --- -- Date Signature of Receiving Facility System Pumping Record•Page i of t �51form4.doc•03106 (R of I ��� N�c�TN� /�tipnU�I�IM�1, ('` �r_G A-SOPt ty p F(5(A 0 WELL APN�ouCD lY�Te i�PPi ovr v �Qr�� APROUiNG /UTFIO>'?iTy D 15A PPKU VEp COn.►�(��J�15 ', OgiE \ DLO(-- ScP��c c SYS t EM i j SIA t-t..,QTI OAJ cYCAV4Tc©1J �,v�� c��oti G/Jr� Q i��SS ❑ ���� (tiSPE�i"lo� PAPE -�vcJ o TJ0K Ll PrySS T� Ro)L 1 PPRUVEP U4TC Apl-'(��vrn�G 14VP(T(OMAL., 1 A) i10,05 X 11-,�►�Y) D,4 i C RE/J50 NS"� FVA L APPI-jVAL DOC UF— e , 61LNAN ST: _ i Q i _ CHIMNEY I �OOO GAC, � f TAN K �e"DF>=P) I -a00' - I LL- J). BOX`S (2' PEEP) I I N 4 0' s I PLAN 5h'0l1v' 1NJ NE1 ,! SUBSORAC-E SFPAGE UfSPS ` BATESON ENTERPRISES, INC. ARGILLA RD. LOCAT101y ' 4160 FARNHAM ST, ANDOVER, MA 01810 NO. A N D O V E R , MA . OWNEP\ , MR . PAUL OLSEN DATE : TUNE ' , 1188 No+ +o scale. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at dZe . I will install this system in ac- cordance with all the laws 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 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 removable 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 of1z' lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging g g 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 Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE �' V Signature of I pecting Officer Percolation Test Garbage Grinder I �r BOARD OF HEALTH OF NORTH ANDOVER , MASSACHUSETTS SEWAGE DISPOSAL DATE g NAME OF APPLICANT LOCATION -ff- 4Q�-Z, Address of lot no, BUILDING: Dwelling x Other SYSTEM: New Repair GENERAL DESCRIPTION OF LAND SUBSOIL: Clay X Gravel X- Sand PERCOLATION TEST 4- minutes per inch. . MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK B-" gallon capacity. LEACH FIELD `2. o-O lineal feet of drain pipe, William J, scoll , Engine r Board of Hea h r roti !t BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. r do ,l- 1. DL SaA l DATE OC71 4' 2. ADDRESS -f-p,e7iS/ LOT NO. Gni TEL. 3. NO. OF BEDROOMS �iie�---- DEN YES NO l/ 4. GARBAGE GRINDER YES L/ NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES ']. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL t. 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. I { TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD f DATE: I —O SYSTEM OWNER &ADDRESS SYSTEM LOCATION f 5�� (example: left front of house) 01 Vo l DATE OF PUMPING: oZ QUANTITY PUMPED ©D GALLONS CESSPOOL: NO /YES SEP IC 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) i SYSTEM PUMPED BY: i COMMENTS: CONTENTS TRANSFERRED TO: L- �7 TOWN OF NORTH ANEYJVSYSTEM PUMPINQ ,"CC)' 4; JA rt f7 19 c,K --------------- DATE OF QUA N? TY PLypr) C tlisL: Ott , NA rVRJ� old ,� ' ...._.. !v cow 12 ®p LEACKRELp RUNBACK C VlVB SOLIDS' _ E F R LID CAKA`0 a QEXPLAIN TINE°ZH��PP �� .... T-4. Address tb� Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action—and notes action Document/ document/ Num• Action Department Board of Appeals — Board of.Health — Planning Board — Conservatiion Commission — Building Department--- G i Commonwealth of Massachusetts �► d aye,f , Massachusetts System Pumping Record System Owner System Location OISOR :t Date of Pumping: �/301o1) Quantity Pumped:1000 gallons Cesspool: No Yes Septic Tank: No I] Yes V System Pumped by: Fctre4ortitL`e2f'tided License# Contents transferrred to : Greater Lawrence Sanitary Vlstrlct Date: Inspector- i i w -tc 4�. ?�OARi:. Ok hS R.�T:a Conu►►onwealth of Massachusetts - -�'yMassachusettsL7LJ System Pumping Record System Owner System Location a S � v�u a � 0 Date of Pumping: . ( — (o—q7 Quantity Pumped: (�� gallons Cesspool: No Yes ❑ Septic Tank: No ❑ Yes System Pumped by: 64&JOst Sati''evI4w License# Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector: i Commonwealth of Massachusetts City/TownRECEIVED E�Dof NORTH ANDOVER - _ System Pumping Record Form 4 APR -6 N10 DEP has provided this form for use by local Boards of Health. Other formsa K)l;ejtt 0W61thRD0VER information must be substantially the same as that provided here. Before using k060"KPTslMi T o r 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 /(�/6 .�. computer,use lJ only the tab key Address to move your cursor-do not City/Town State Zip Code use the return key. 2. System Owner: OL f Name — --- '""° Address(if different from location) City[Town State Zip Code Telephone Number B. Pumping Record /` o f 2. Quantity Pumped: 1. Date of Pumping Date y P Gall ns 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - 4. Effluent Tee FilterP resent? ❑ Yes Et o If yes, was it cleaned? ❑ Yes ElNo 5. Condition of System: 6. System limped Bly: �V\G+�. cam► _ — — Name Vehicle License Number Company I 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