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HomeMy WebLinkAboutMiscellaneous - 17 SUGARCANE LANE 4/30/2018 (2) 17SUGARCANE LANE , - L-f�Ji i��i__a_Q_=y;3_Qtrlvt�J.O 1� i� MAP # LOT # PARCEL # STREET CONSTRUCTIQN__ARPROVAL HAS PLAN REVIEW FEEL EN PAID? YES NO PLAN APPROVAL: DATE /��z�g APR. BY,_.. �2 DESIGNER: 41Z556G� TGsS 7/lAPLAN CONDITIONS __-. _._---............ i WATER SUPPLY: TOWN WELL WELLPERMIT _ DRILLER.-__.._.__.__......................_......._....._..... ...._...._._... ......._...... . � WELL TESTS CHEMICAL VA*lE APPRUVEU BACTERIA I UA I E (1PPRUVEU BA RIA II DATE APPROVED.........._____..__.__..__ COMMENTS: FORM U APPROVAL: APPROVAL 1-0 ISSUE YES NO _BY DATE ISSUED CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL �'�� NO SEPTIC SYSTEM CONSTRUCTION APPROVAL NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL (BOARD OF HEALTH APPROVAL.: DATE:........._......._..._..._.IIY: __. . _ Commonwealth ®f Massachusetts CityfTown of North Andover . em Pumping Re cord - Y Form 4 'w I DEP has rovided this form for use by local Boards of Health. Other forms may be used, but the p check with 'Pumping your information must be substantially the same as that provided here.' slRecord must be submitted to local Board of Health to determine the form they use. The System in date in the local Board of Health or other approving authority within 14 days from the pumping g accordance with 310 CMR 15.351. A. Facility information Important When Sllmg out forms 1. System Location: on the computer, use only the tab - 17 key to move your Address Ma 01886 cursor-do not North Andover State Zip Code use the return CiliTown key. 2. System Owner: T Name rmrm Address(if different from location) State Zip Code City/Town Iii- _ .. _ Telephone Number B. Pumping Record 2. Quantity Pumped: 11611ons 1. Date of Pumping dte Ti ht Tank Grease Trap 3. Type of system: ❑ Cesspool(s) E] Septic Tank ❑ 9 ❑ Other(describe): r a. Effluent Tee Filter present? ❑ Yes No . -If Yes,was it cleaned? Yes ❑ No 5. Condition ofSystem- 6. System*P d By: �3 Vehicle License Number Name Stewart's tic Service Company 7. Location where contents were disposed: Ste rt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835•.- ��� Djte ig ture of H Dat "` Sign t eceiving Facility System Pumping Record-Page t5form4.doc-03/06 Commonwealth of Massachusetts H City/Town of No Andover System Pumping Record 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 forms 1. System Location: ana on the computer, C(:)I use only the tab key to move your Address cursor-do not No Andover Ma use the return key. Citylrown State Zip Code 2. System Owner: �11uG Name enmr Address(if different from location) City/Town State q Zip Code Telephone Number B. Pumping Record f _ / C>� 1. Date of Pumping Date Il / 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap t ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: + COVE Name Vehicle License Number a Stewart's Septic Service L' CompanyNORTH ANpOVER T H AOr� EPME NT 7. Location where contents were disposed: 7. Stewa Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 // A, z Sig r f Hauler Date -' Sin ure of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record SEP 14 2006 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTP TENT DEP has provided this form for use by local Boards of Health.. The-System-Pumping-Real must be submitted to the:local Board of Health or other approving authority. . X Facility Information .important: When tilling out 1. System L catio forms on the computer,use only the tab key Address 0 to move your t cursor-do not ` use the return Cityfrown ate Zip Code key. 2. System Owner: V ' � Name Address(if different from location) CityfTown State C e: Telephone Number B. Pumping Record 1. .Date.of Pu.mping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank- ❑ Tight.Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes No 5. Condition Systerrt: "' 6. System4wmped By P)a, 42 F! Name Vehicle Liceme Number Company WAX 7. Locatio here contents ere osed: Signal a of a er Date http://www.mass.gov/dep/water/approvals/`t5forms htm#inspect t5fonn4.doc-06103 - System Pumping Record-Page 1 of 1 J w CERTIFIEdS PLOT PLAN LOCATES�A NO. ANDOVER, MASS. SCALE;1'=60' 4/28/95 Scott L. Giles R.P.L.S. 50 Deer Meadow Road o N North Andover, Mass. N) rn o � 0 ^M r LOT 38A GAR. FLOS.D.=153.0 13g6 co = 153.9 3INV. S.S.D.S.=151. 2 s � T.O.W 161 49 �6 x. E � s 31' o �� LOT 36/37 a2' �2x� 53.68 43560 S.F. 01 x 62� S.S.D.S. ELEV. 7/13/95 w tib OUT OF HSE.154.49 IN TANK 152.98 LOT 35B OUT TANK 152.73 IN BOX 151.54 OUT BOX 151.26 END PIPES 150.69 I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE or 6 THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION OF ZONING BY LAWS OF NO. ANDOVER CONFORMITY OR NON-CONFORMITY / �p WHEN BUILT WHEN CONSTRUCTED. 1 7��3�95 CERTIFIED PLOT PLAN LOCATED IN N0. ANDOVER, MASS. SCALE;1'=60' 4/28/95 Scott L. Giles R.P.L.S. 50 Deer Meadow Road o N North Andover, Mass. o G 7 �n 7 o Cn 0 �M LOT 38A GAR. FLOOt3,kl 153.9 213' o o �T.O.W=161.49 S.D.=153.0 6 INV. S.S.D.S.=151.5 a- \JJ9 LOT 36/37 53.68 43560 S.F. k cr+ 2g w 2roro. LOT 35B I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE "6 WITH THE ZONING DETERMINATION OF ZONINGBY . .. NOLANDOVER AWS OF CONFORMITY OR NON-CONFORMITY3 ` WHEN BUILT WHEN CONSTRUCTED. ". CERTIFIED PL('.i !AN ° 8 LOCATED IN NO. At4€ OVER, MASS. SCALE;V=60' 4/28/95 f Scott L. Giles R.P.L.S. 50 Deer Meadow Road o North Andover, Mass. o G rn o � 0 r LOT 38A rn 0 i �T LOT 36/37 43560 S.F. ��>, / 53.68 x 1 .o X66. LOT 35B I CERTIFY THAT titA or OFFSETS SHOWN ARE FOR THE USE J THE OFFSETS OF THE BUILDING INSPECTOR ONLY ..' SHOWN COMPLY AND SUCH USE IS FOR THE 1 WITH THE ZONING DETERMINATION OF ZONING BY LAWS OF N0. ANDOVER CONFORMITY OR NON-CONFORMITY WHEN BUILT WHEN CONSTRUCTED. Town of North Andover, Massachusetts Form No.2 Of NORTH BOARD OF HEALTH : •-ef••`'° '••"�o November 21 , 19 9 4 • • - DESIGN APPROVAL FOR ,SSACMUSEt'� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Robert Janusz Test No. Site Location Lots 36/37 Sugarcane T ne Y Reference Plans and Specs. Thomas F NPvP ENGINEER DESIGN DATE s. Permission is granted for an individual soil absorption sewage disposal system to be installed r.• in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH 1' _ Fee,.S60- 00 Site System Permit No. .{- `L *'ami rvr 1^ r' :+n t i X T + - - �a_I�_e_� 1 1 I�IIJ . r vi1�lil� 1 'u - �1 �1��i1 �;.1 1 11 0! 111�1 i� 1 , =e�JQ��I�I I 1 111 1111 1 1 1 111111 111'�'111� ® 111 1111111 o Ihe� 11 11 ® 1 1 111 1 1 1 1��I[N1 .91 �, _ 1 111 1 1 1 111l19e A9�7�• � �I 11�?�l�1�l1 , ��* " �' .�; Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH pF t�eo '9 b`16�O L �� 19 1 Z O e u ur t^ * _ * " ' APPLICATION FOR SITE TESTING/INSPECTION �9SSACHUSh Applicant 0 t O"Vt1 AME I ADDRESS TELEPHONE Site Location 3� Engineer--F6vv1 WA—�J--L NAME ' APDRES5 TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. � S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH 320y"'E. '6lq - � I --:?, 19 APPLICATION FOR SITE TESTING/INSPECTION �iy'°RATE°PPa��S SSACHU5� Applicant'-LL� 40 NAME ADDRESS t f TELEPHONE Site Location -u Engineer--76v\^ NAME AIDDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee -57) Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. 796 a 3Z- e>11 f twc 5th ' W R., eb Town of�North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH 1'/{\/�[/'�[]�n/ OR /6� Sj LED s O'YO _ �'Y -' "—' 19 3� 5¢ L F eW106 ^' ' APPLICATION FOR SITE TESTING/INSPECTION A�qA TED �SSACHUS�� Applicant NE `vs ADDRESS TELEPHONE Site Location WT 'a,�' Q/�C /t/•�. � _� Engineer aA-V--, JSP � Ck I NAME �T ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. 7� S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH ,�{t fA` y� 1 /�]^�J �2 Oy�tLE° ib��OL !i' AW.IF Cn t� 1 g f 4�/" °R APPLICATION FOR SITE TESTING/INSPECTION �I TED US���h Applicant"'—&6 C JVD(_) `Z yo S-jrc - L NAME �� ADDRESS / TELEPHONE Site Location Engineer � �'� �-P,t-�-P_ + C, � , NAME YADDRESS k TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee i 5) Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. •;f• � ,' �� .,:ii��Yx�",x'�rL� v�?a2*�, :�uta_,' C'yt+'•�S,t�S.ia}� 3� 1`= Alda !`-'X`Iiri`i`; \ �S ; fit. + ` T -•` `' `.ls tea +ti y T t Z l`y y, i %\�\ ''4 .. �T h t, � ,• k_t . \�ti ,';."Y `a Tri i ry tv �i ,\ \ -+ nt•� } 1 y4`1 c Z i..h � 7 r. 'a�, ♦ vii . \ 1 , t.tT, - Jk Form No.3 " Town of North Andover, Massachusetts . BOARD OF HEALTH NORTH - 9 _v+ Ot ta�•c ;s gMO LF O 9 qc DISPOSAL WORKS CONSTRUCTION PERMIT 9SSACHUSEt Applicant \061-tc-�✓ c� ? TELEPHONE NAME ADDREbS • Site Location Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH °n� D.W.C. No. �1 Fee `{ • Q� Town of �!` 1 1 � 7 �� ) over No. I CC d _ M f orth dover, Mass., ; �,: c ` .,,":; 19 F .,� B 1 BOARD OF HEALTH PERMIT T Food/Kitchen I LD Septic System�; 3� BUILDING INSPECTOR THIS CERTIFIES THAT..�. ::.'.. :. has permission to erect. -�'a": 4:?......�.4t !f; .. buildings on ........�.....�...:��-a�'ac �' I ou , olc.I �tz� to be occupied as 4 t. :Ktki•...f��` !#.�.tl,a .��:'�a'::.9:'►tt.►; .......'.: ........ .:;.... ........................................ c 4Z t'2 provided that the person accepting this permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection Alteration and Construction of Final /-27—r Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY PLUMBING INSPECT0 REGULATED BY PARA. 114.8-S. B.C. VIOLATION of the Zoning or Building Regulations Voids this Permit. DATE FEE PAID a� l 1::1N/1I` I . 1.';�.1'IL�1..:,> IT`�I ,t� �/1( �� � � . � �_.)-N �" ) l,l(.:'�'It_) ELECTRICAL IN,SP T R PERMIT FOR FRAMUBUILDING c............:'.....................�................I: ; g. Service .:....:.: ..:.:...:.:.. BUILDING INSPECTOR in DATE: FEE/P�ID• �7w VCCI-l. )CII l(, E'1"11`l"l1 ��C( l.(.11('[.� [[? (_)c CII )y C31alI["�l1"l�(7 GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove P Y P •in Iv � � �� No Lathing or Dry Wall To Be Done FIR . DEPARTMENT Until Inspected and Approved by the Building Inspector. l I22lgb .� , ` `4 X36 PLANNING FINAL CONSERVATION �� N �� street N°•� � A ''` �` Smoke Det. 6 i K /'-/?- SEWER/WATER ._/9-SEWER/WATER I FINAL DRIVEWAY ENTRY PERMIT � '.Yor. i;.. _ Y _ i ;5. `V,i? ipi f.y�il`b�L� :.+.��:il`A•^i ` 'y'!a7'._ Y `�c. ... �'C\a `'i` Vii, e\ .\.. � y � 7 `s._,1 �•l t.�•_ �l\l-. \i il����i.�5'���i41 ��R�.ilSj_�?-y�i ��ti`i^'l ,a r� i�i�`^v�.\ � -1,. ..� y.. .� ._y S • �` �. � , •�, ,:� t t..a\�i`«� �. S�ay�.i� �r}���� s SLC �';`� i � `,���_ti�::�z ��t��•'Y'y c . } , � t �i t \• i i flit �� i�31 t���X����\�����:i�a�,�; :���� ili t � � .,11.1 tp,,\I.� Town of North Andover, Massachusetts Form No.3 • f HOR7h'1 BOARD OF HEALTH 9 C 3: a �, •° OL • F 9 1 3'"°•,..o��"� DISPOSAL WORKS CONSTRUCTION PERMIT 9SSAC HUSEt Applicant NAME � AJRESS TELEPHONE Site Location ( n' —C I Permission is ereby grante IoConstruct �r epair ( ) an Individual Soil Absorption Sewage Disposal ste as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH r Fee 0 D.W.C. No. I THOMAS E. NEVE ASSOCIATES, INC. ������ O� �QQ���D��Q� Engineers - Land Surveyors - Land Use Planners 447 Boston Street US Route #1 TOPSFIELD, MASSACHUSETTS 01983 DATE JOB NO. FAX O7-3(508) 887.8586 3`7 FA (508) 88480 ATTENTION A J , ,jr>l STARK RE: TO 3A,00y STARR R.S. REvtiS►o'-jS -ro 5e. l'+1C. Desi n l_O'T'" 3Co �j J SV rCc.n� l...AnQ 130ARP OF H EALT 1-1 IZo MAttJ STRIFE- Notz-rt-i Aaapov E2 > M A 01045 > WE ARE SENDING YOU )<Attached ❑ Under separate cover via the following items: ❑ Shop drawings Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION RE\/: �f19f95 305- ' SEP-rIG v�S�c,-a F'or< t_,oT 24/3"7 S,.)vARC.ANE l..Ar-)e F'1h. 'o C-0fX o1F LOT Z S.j,,se* Rock Roaet THESE ARE TRANSMITTED as checked below: For approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution > ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS P► r,6, en`lased resvlsed tl-.e a4�\re rv�en�'ioneGl filar,• n A no�C Inas bec., ade�ee2 '+o +►tee Sys+ens ec'o4�, le 5 aa�irw all o"F& +r> be. 4" PjC (Sc-f-t 40), A no+c 1-,as been oOuca '1;0 +-h lc.n r ovr 0\-SLvSSIOn ran to SeaSor\ 'l`es't bfforr^rd A+ +1rC - + cL;g c-r e-+ton o-IF J-�,e s cwxol o-� Hta l Jl-) ,,s e el Qr�or 'l'o cor,S'Fruci-%oma•. (� . The diS+r i ba•1-�or� 1.�.�e I s p1"' O.00S'/ �c� I -l- wws r+o+ S1•own on tl-e {�lgr� 4 01 + ?SGS been Aaldeol `!o ike !;rJ%Je- A be,C'1n17,a.rK hAs been Aoldec( +4 rolw-, C-)wber -}o +}.e Sys•-fh' (tiGor.•er ©�' e,Lec+r;c �aa�>, Tee r>> S 3ra-1 3�0-Z ace 10C-a.ted or, LOT Z SQMS.C+ tZoc.l< rZor- , This ac-a JSeA +o b< t'l-e r->eac- ol� LoT Uo. See P}.o�v c.o(ay� Z•F' yoj 1�avt a;LnY �.�es+�o� IfAC .S cell.ll. COPY TO SIGNED: 5 i��ft'y) PRODUCT 240.2 a Im.,Grata,Man man. If enclosures are not as noted, kindly notify us at once. DATE Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE *0 PERMIT # CO DATE RECEIVED APPLICANToP r Apt/ S ASSESSOR'S . MAP ADDRESS PARCEL # LOT # STREET ENGINEER TOM A16-Uc- ADDRESS PLAN DATE ///,7 144 REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED >o JULy /91?,;?- % �,v�mvM Sco�G OF 7 9 2lC p. to i �.- �, 1-119 f NORTNI , �oto °4,° BOARD OF HEALTH F140 9 ♦ i i ` 9120 MAIN STREET TEL. 682-6483 "SSAC.HUS Et`h NORTH ANDOVER, MASS. 01845 Exc23 January 9, 1995 Mr. Thomas Neve 447 Old Boston Road Topsfield, MA 01983 Re: Lot 36/37 Sugarcane Lane Dear Tom: This is to inform you that the proposed plans for site referenced above have been disapproved for the following reasons: 1) Note: All piping to be SCH 40. 2) Soil tests out of date - April and July 1992 . 3) Minimum slope of distribution line to be . 005. 4) Benchmark not within 50 feet of system. 5) What is the location of soil tests 36-1 and 36-2? If you have any questions, please do not hesitate to call the Board of Health Office at the number above. Sincerely, Sandra Starr, R.S. Health Administrator SS/cj p I PLAN REVIEW CHECKLIST ADDRESS j Q% /-97 �U61?,eCAW ENGINEER /70- ,W &cv6- GENERAL 3 COPIES I/ STAMP L/ LOCUS C/ NORTH ARROW SCALE CONTOURS PROFILE SECTION (/ BENCHMARK 0050y� SOIL & PERC INFO ELEVATIONS ✓ WETS. DISCLAIMER WELLS & WETLANDSWATERSHED?_YL DRIVEWAY �(Elev) WATER LINE FDN DRAINSCH40 TESTS CURRENT? 199A SEPTIC TANK I/ MIN 150OGy . 17 INVERT DROPy GARB. GRINDER/1/O (+200% EDF) 25 ' TO CELLARMANHOLE TO GRADE ELEV GW D-BOX SIZE # LINES FIRST 2 ' LEVEL STATEMENT INLET 10-147 - OUTLET /6� _ SAO (2" OR . 17 FT) TEE REQ'D? /VD LEACHING / / MIN 660 GPD? `' RESERVE AREA 4 ' FROM PRIMARY? y 2% SLOPE 100 ' TO WETLANDS ✓ 100 ' TO WELLS " 4 ' TO S.H.GW 35 ' TO FND & INTRCPTR DRAINS 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER L--"FILL? (25 ' if above natural elev; 101if below) BREAKOUT MET? TRENCHES �/ tt t %6016- t MIN 660 d SLOPE min . 005 or 6 100 >3 COVER. VENT gP ( / ) SIDEWALL DIST. 2.X EFF. W OR DD (MIN 61 ) C/ IS RESERVE BETWEEN TRENCHES? �� IN FILL? -,-------MUST BE 10MIN.L-4" PEA STONE? BOT EOO X LDNG W�-+ SIDE O,�-) X LDNG40 = TOT (L x W x #) (G/ft2) (DxLx2x#) (G/ft2) I� Copyright 0 1993 by S.L.Stare FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section****************** APPLICANT: / Phone LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street L St. Number �� ************************Official Use Only************************ RECOMMEND T ONS F T WN A NTS: , L , Date Approved /712y Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food�J Inspector-Health Date Rejected Jit Date Approved Septic Inspector-Health Date Rejected Comments Public Works -_aaA4er/water connections lli7A J4�lfv - driveway permit S`�(�o -7 ''l� (WIP __U I Fire Department Received by Building Inspector Date �_' � _ � MASSACHUSETTS MASSACHUSETT , FIRE INCIDENT REPORT STATE FIRE MAHSHAL V | | \ situation found | | action taken i | mutual aid ! B | ................... _----_ | fixed property | | ignition factnr | ! C | _ _-___ D3D���'` ��A��. | �1 | correct address | zip code | census | D | | \ occup' name� last, first , mi | telephone | room nr apt | E | | | | owner name last, first , if)i i address | tplephone | F | _1��1-'�wIl=L]�8,--Sl1=VA_'___-___--____l _17_S{JGA.R1,`ANE -LN�_-N 557�5728 | | i method of alarm i | district | shift } no. alarIII s i G | _- -_|____'_!D___--| | | #fire service | #tankers | #engines | #aerial app | # other vehicles | H 1 _--|___�� 0_ | | hazardous material | substance | c,i. equip used | ' | ___ _____________ _| | numbers of injuries | number of fatalities | rescues | I | _f,iZ��-§'e[..vj���_- _�_-__gt1���L�___-0-_|--f.i���'��e)��i�.......... -__-�8_011�{�R | mobile property | | vehicle stolen ? | estimated total dollar | J | 'lJ)VD1�T1�RMI�N{ ['�-N{}|'!D!0|--__--'-�'-'-�---' --�'-� --'-'1'_LOSS--_.-_'-' _-. ---'-.-$�. @0' -- ! | insurance company | total insurance { claim paid | | '-_-__'-_-__---'_--_--______-___--_- _--'--------__-----'_-_!-----_----__-_-$��0��-'�--------'--$!D�'�!!D'' | | | year | make � model | color | lic no | vin# | | ... ......... ............._-_......1.................. -...._... __'-..........._L_____-L-_...................................... .............. ....................... __'......... _-----_--......... -/ | | if equip involved | year | III ake | III odel \ serial no | | _4�.|jIL-i _-__--___' -- _'-_i____-___-... ..................... ...'.............. __._-| | complex | | area cif origin | equip inv in ignition | K | -���X'< �����|���_I�N��I� | | form of heat ignition | material ignited ) form | type | | L \ _l.JR11_QF.1��EAT_-I'G|V_l_'.D0... -'_---.... ...... ....._...___1 ]R1M_1IMT1.'-|_..Of l.YPf''DF--MA].'L||_��Z | | method of extinguishment } | level of fire origin | | M | _M.]l��D-�1�X.].x'CDN].-U1�I>f�l.ERxl�D.T--RE1z--_-|�-�D--i--L,EVEl=-'{��-DRIS]]�-lJ1NDETE��RMJNEl ----'i -�y- | | numbers of stories | | construction type | | | -1VOc_ I�ES-UNIU�ll�RM/ND.�-'1R1�����--_--' fi-NDT-'REPD�TED�' -� 'i-��L-| | extent of flame damage | ) extent of smoke damage | | N | L� J�D�R l}__ �DT����'_ i0_\ | detector performance | | sprinkler performance | | | _U1�IX�RTERY1]�NED/1, ].T--REPD�RTED--�- -� -'-1-'!D-1--UNDER.l'{ RM'INED-'{}R-lVDT. -RB-DR.Tl:]D.... -|--{Q_.| | if smoke spread | material generating | forIII | | type | | | beyond rnom | most smoke : \ | 00 \ | 00 | Q | _�f'_q��iqiIL___----__i__-__�__'____-_'__--_---_� R| | R | weather condit ions I _aV C--s/Ipk��--t����j�l-�_UNDERTERM. REPDRTE| {D '| | -------------------- | entries contained in this report are intended for | | 30 DEGREES F. | The sole use of the state fire marshal. Estimat- | � | CLEAR AND COLD | ions & evaluations made herin represent "MOST ( � | | LIKELY'' & ''MOST PROBABLE'' cause & effect. Any | | _____ | representat ion as to the condit ions outside th | e | | State Fire Marshals Office is neither intended nor \ | member making report. ( implied | | --E�_'MD�RGAN--_.-_----'---_--_-_-''_--_'-. --1�.�1��-����.�������.��.������.��.__1_-[--I_.}L���'-. -2-.-[_I_IL�...............------� R,0 IEA ' Or-HE ' � C4 INCIDENT REPORT NARRATIVE 01 /27/98 22:22 PAGE 2 CASE#: 4961 SEQ: 81 CHECKED ENTIRE HOME FOUND 0 PPM , OWNER HAD OPENED THE GARAGE DOOR PRIOR TO OUR ARRIVAL. WE ADVISED THE OWNER NOT TO HAVE DOOR OPENED TO HOUSE WHEN VEHICLES ARE RUNNING. ` �f} n"r'MI' r1'�1 x.' �1 r., t, -r: '_,' J r . � t.' • • Ct - { �J TOWN-OF•NORTH ANDOVER SYSTEM PUMPING RECORD — AP �� (S// - 1�1.,. ' •� SYSTEM OWNER&.ADDRESS SYSTEM LOCATION (example:.left frontof 4ouse) OP 4",` 2 � � h� Ir31�'� 1"xr q? L�2rli�`�ty S"aRkJ tj fAa-tt`• j+ y - � f>s ` ' ` 's OA�IT OF PTJMPING: l l`a'l QUANTITY PUMPED GALLONS 1�r� r 10 N YES SEPTIC T : NO YES ,A a1.,y 1 g'Mfr+ f.ir< "! �tt fr a�• gat ', «t � •���p� t 1 '��j 'f ', > j.<' , - ' :'t + r � . . jt�►TURE OF SERVICE: ROUTINE 'EMERGENCY It ..:1/� v _�l rI '•.or r.�'. ,ATIONA7: ,1�`F4v"�'l�yli�lt�pt Jalfrt Ea �n r. OOD CONDITION FULL TO COVER HEAVY GREASE. —�� ' 1 _.� BAFFLES IN PLACE ROOTS LEACIDULD RUNBACK EXCESSIVE SOLIDS FLOODED r SOLIDS CARRYOVER _ OTHER 1 � tF r rf{ ts�lwt 'S 1S,r�.'�f'+rK�f D � ,rk`I''r}1,R'.'F'�SiPR.!►1r/i.4 r�1. . By t a tt'q u 4 i)0r 204 . ( 54 ,i a ,� S��A►�T FE n ,, � xs BRED TO. �o � t r . j' r�.ty ' L riM ,r a jiAr#cti'}1hc/j� H^'.I�y I� '{x^l(�i) r}� in 'jf,.• 1� ,'•Si.r �r �r•��� d r a `•alis k i. t daF' tf!1�"t��S) r Commonwealth of Massachusetts RECEIVED City/Town of a System Pumping Record NOV 2 5 2008 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other orms may a use t 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 Locatio ' Le fro , left rear, left Sid tygRight front, right rear, right side of house. forms on the computer,use only the tab key Address to move your l 1-� cursor-do not City/Town J State Zip Code use the return key. 2. System Owner: --- Name Address(if different from location) City/Town State � Zip Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: Cesspool(s) eptic Tank Ej Tight Tank Other(describe): ! 4. Effluent Tee Filter present? Yes Q-<O-� If yes, was it cleaned? D'Yes No 5. Condit' o�m�� 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L. .D Lowell Waste Water M0 igna ure of H u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 TOWN OF A- AtAfjbJr(— SYSTEM PUMPING RECORD DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION. (example:left front of house) co, 6 DATE OF PUMPING: QUANTITY PUMPED : 1 D c7 GALLONS CESSPOOL: NO ✓ YES SEPTIC TANK: NO YES SZ NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER I 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: Commonwealth of Massachusetts City/Town of a System Pumping Record RSG-IV Form 4 ' ["OV 1 2090 DEP has provided this form for use by local Boards of Health. Other f ms may be used, but I information must be substantially the same as that provided here. Bef FtNi r�@bth your local Board of Health to determine the form they use. The System Pu i �A itted to the local Board of Health or other approving authority. A. Facility Information 1. System Locat :�Leftfront of right front of house, left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. CitylTown State Zip Code 2. System Owner: Name Address(if different from location) City/Town Stat755 .� i Co¢� JJ Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: gallons 3. Type of system: ElCesspool(s) © ept�5 is Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condit'o of S stem V & System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Loc i re contents were disposed: .L.S.D. Aqell Wast W r Signatu of a ler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I Commonwealth of Massachusetts City/Town of System Pumping Record F 7AU0 '17Hil Form 4 TOWN OF NORTH ANDOVER M Svy`• DEP has provided this form for use by local Boards of Health. Other fo HEALT DEPA 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 1. System LocationLe front of of hgo�,ss- right front of house, left side of house, 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: S� U Name Address(if different from location) City/Town State S^ _ 4P Code Telephone Number 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 2-140 If yes, was it cleaned? ❑ Yes ❑ No 5. Conditi'�yst�' 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location where contents were disposed: G.L. .D. w II Waste/Wates, Signature f ul r Date t5form4.doc•06/03 'System Pumping Record•Page 1 of 1 t