HomeMy WebLinkAboutMiscellaneous - 174 INGALLS STREET 4/30/2018Common ivealth of Massachusetts
W City/Town of No andover
a System Pumping Record
Form 4
M
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:
on the computer,-/
use only the tab
key to move your Address /
cursor - do not
No Andover.
use the return - —= �' --—.------•--_ _—.-
key. City/Town -- State
2, System Owner:
Name
ieru�n
j Address (if different from location)
City/Town
B. Pumping Record
Zip Code
State Zip Code
Telephone Number
1. Date of Pumping
Dat6 2. Quantity Pumped:
GaGaallons'
3. Type of system: ❑ Cesspool(s) ! Septic Tank ❑ Tight Tank ❑ Grease Trap
El Other (describe):
4. Effluent Tee Filter present? [] Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradfor
Signature of Hauler
Signature of Receiving Facility
Vehicle License Number y, V�® %
Q 5 tq!3
Ma 01835 c7F NO
Date ANDcNT�
Date
Date
t5form4.doc• 03/06 System Pumping Record . Page 1 of 1
011.36010usetts
DEP he . 9 .. provided this form for use by local Boards of Health. The
be submitted to the IOC41 Board of Health or other approving authc
Impontnt:•
"w"w 1. System Location,— - 714
bm on the .1
computer. use
oNy the tab key Addres
to move YOW
qWw - do not
the rahim
—a CWTO
key,_,
2. System OWnOr.
Arm
IS
State
Zip Code
Nam
Address V different imm locaton)
City/Town - state Zip Code 1.
Telephone Number
Be Pumping Record
��I f v ODD -
1 Date of Pumping a 2. Quantity Pumped: Gallons
Type 0 . f system: Q Cesspool(s) k(Septic Tank ❑ Tight Ta . nk
Other (descgibe):
4, Effluent Too Filter present? ❑ Yes Cj No if yes, was it cleaned? ❑ Yes ❑ No
S: Coriditlon of System:
QTMW
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M
System Pumping Record - Page 1 of 1
j Commonwealth of M.
ssachusetts
C�ty/Town of NORTH ANDOVE
System ,Pumpin Record R MASSACHUSETTS
Form 4....
g
DEP has provided this form for use by local Boards of Health, The s e
be submitted to the local Board of Health or other approving � ping Record mu;
pp uthority.
A. Facility Information I
Important:
When filling out 1. System Location: ` ` T01AN OF NORTH ANDOVER
forms on the . ; i t.=At: H DEPARTMENT
computer, use s, 7 -
only the tab key Address
to move your .
cursor - do not
use the return City own ------
key.. State
2• System Owner: Zip Code
Name
Address (if different from location)-- --•-
City/Town - - - --- -----
.. State -—/--------_____ -- -
. _.____•—/ Y� Zip Code -
Telephone Number
B. Pumping Record
1, Date. of Pumping .:
e', v�_
.Date 2. Quantity Pumped:
ll •____._._.._
3• Type of system: C] Ga Cesspool(s) Ga
60c Tank
C3 Tight Tank
❑ Other(describe): ---- __-•---- __-__.__,_.____--._-- .__ _.
4. Effluent Tee Filter present? ❑ Yes o
If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst m: \
6. sv-gfem Pumped By
Vehicle License Number
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t5form4.doc• 06/03
,htm#inspect
System Pumping Record • Page 1 of 1
North Andover Board of Health
120 Main St.
North Andover Ma.01845
Haul Lic. #151 -OOH
Install Llc. # 128-0
Date Address
11/1/2000 303 Chester St
11/1/2000 50 Willow Rd
11/1/2000 160 Carelton Ln
11/1/2000 165 Bridal Path
74
11/4/2000 1_In6ais_St_ _7
11/4/2000 1062 Salem St
11/6/2000 373 Raligh Tavern Ln
11/6/2000.252 Boxford St
11/6/2000 150 Liberty St
11/6/2000 149 Osgood St
11/7/2000 255 Haymeadow
11/7/2000 850 Winter St
11/8/2000 25 Windsor Ln
11/9/2000 249 Carlton Ln
11/9/2000 767 Johnson St
11/10/2000 56 Academy Rd
11/14/2000 Sugar Cane Ln
11/14/2000 250 Abbott St
11/15/2000 195 Winter St
11/1512000 187 Winter St.
11/16/2000 85 Laconia Cir
11/16/2000 86 Willow Ridge
11/17/2000 2135 Turnpike St
11/20/2000 203 Grandville Ln
11/20/2000 391 Pleasant St
11/20/2000 124 Tucker Farm Rd
11/22/2000 394 Boston Rd
11/22/2000 728 Forest St
11/22/2000 18 Johnney Cake St
11/24/2000 106 Rockey Brook Rd
11/24/2000 258 Rea St
11/28/2000 1815 Great Pond Rd
11/28/2000 1420 Great Pond Rd
11/29/2000 266 Lacy St
11/29/2000 155 Laconia Cir
Andover Septic
47 Railroad St.
Bradford Ma. 01835
Gallons Comments
1000
1000
1500
1500
1000
1250
1000
1000 Leachfield Run Back/ Ex. Solids
1500
1000
1500
1250
1500
1500
1500
1500
1500
1000 Extra Solids
1500
1500
1500
1000
1500
1000 Flooded
1500
1500
1500
1500
1500
1500
1000
1000
1500
1000
1500
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: / �IC7ILI,l
SYSTEM OWNER & ADDRESS
"SYSTEM LOCATION
(example: left front of house)
l
DATE OF PUMPING: QUANTITY PUMPED WO' GALLONS
CESSPOOL: NO ✓YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ^v EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO:
'_ v .�`��4�1i `iii•} Ik�l�r'�r-A� ,,._m.�
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UEP I has pQ(j to e local d ;hl';` loan
cv . !or neo ; ;o; a, Boa rcr or ri
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oalcnorcIf, �ppro;rr,� rnoriry.
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ocaUon:
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'
RECEIVE®
JAN 0 6 2005
V .� t't M P N U TOWN OF NORTH ANDOVER
. ,.t _ C OKL HEALTH DEPARTMENT
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::,'.r.•r:'•'' .;<; EP• has provided this •.:r'.;,:,,..,:• ..• • ,. ,
ba mi ed form for use b loca
:ub to the.iocai'Boar Health �,' .... ..,: ! , 1, d of o
A; Fac- l(t}r information
f'nfl out : .1; . System l.ocatlon;'
<: contDutBr, use.;, TO"I
0,* the tab key Address H
to move your.:.. .
auw • do not
U
te the rottim''�' '';:.Clty/Town
`rrr. ;; :;I ,� t ?,r , ..System Owner'
;
IlLno
Address (If different from location)
r
Pumplhg RdFord
�'l'r'f�yi' :%/ � .' f • ,
Dat�'of Pumping
Date 2.
3 TYpe f s t
tem Pumping Recorc m;,'s:
. r
State
$tate' . ZI Code
Telephone Number
Quantity Pumped;
Gallons
P ys am, , [i Cesspools) [Septic k
;:. Tan
C (Other (describe
), .
4• Effluent Tee Fiiter
` present?' EjYes o
.� • '% r. ,ni Fr=� il„f .'..7fti. ,,,r i, y��(H,r =It
Co�ditJon 711 ii.• N'1"•5✓' ri ,
Pumped a
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. •I•'ii�' p'�i, i,�•t' Cv'� %", I '..tli'= ' v:y�.
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7; Locabon.where. era
contents yr . d#osed,
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rms,htm# nspect
t5fomm 400' o8/Q3
❑ Tight Tank
If yes, was It cleaned?
11110
Date
❑ Yesl No
System Pumping Record ' Page 1 cl 1
'LxCommonwealth of Massachusetts
I E)
W City/Town of North Andover f - 5 2013
a System Pumping Record TOWN OF NORTHANNDOVeR
Form 4 HEALTH DEPARThTINrr
�G
M
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
vQ
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
1. System Location: I�
Address
North Andover
City/Town
2. System Owner:
C
Name
Address (if different from location)
City/Town
11S
Ma
State
State
Telephone Number
01845
Zip Code
Zip Code
B. Pumping Record k 6
1. Date of Pumping Date 2. Quantity Pumped: Gallon )
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
El Other (describe):
4. Effluent Tee Filter present? ❑ Yes V No
5. Condition of System:
6. System �Pumped By:
Na
Stewart's Septic Service
Company
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
7. Location where contents were disposed:
Stewart's Pre-treatment Plant120 So. Mill Bradford Ma 01835
nature of Haul i - Date
Signature o ceiving Facility C Date
t5form4.doc• 03/06 1
System Pumping Record • Page 1 of 1
.. E
Commonwealth of Massachusetts
City/Town of No Andover
System Pumping Record
Form 4
M
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
System Location:
_I
Address
key. City/Town
2. System Owner:
yy-
Name
tam
Address (if different from location)
City/Town
a
State t
M
State
Zip Code
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Aons2. Quantity Pumped:
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ YesX No
5. Observed condition of Qomponerit pumped:
6. System Pump
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
Signature of Hauler
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
^t"
D ate
Signature of Receiving Facility (or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING .
(Print or Type)
Mass.� ate �— 19 ?6
City, Town Permit IJ _
Building /"/- `�� Owner's y %
AT: Location % / -Fit_-► NameS',-�
Type of Occupancy:
New❑ Renovation 4 Replacement ❑
FIXTURES
Plans Submitted Yes[] NoZ
(Print or Type)
Installing Company Name -- - --
Check One: Certificate
K Corp. C ��
O Partnership
1.1 Firm/Company
Business Telephone � Name of Licensed Plumber or Gasfitter
-
I hereby certify that all of the detail and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions
of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
Signature of Owner/Agent
I have a current liability insurancep licy to include completed operations coverage.
❑— -/�
SiMaster ❑Journeyman �Gasfitter
122-2, Z
on�tur. of Licensed Plumber or C a fittnr License Numbnr
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SUB-BSMT.
BASEMENT
1 ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
.5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
(Print or Type)
Installing Company Name -- - --
Check One: Certificate
K Corp. C ��
O Partnership
1.1 Firm/Company
Business Telephone � Name of Licensed Plumber or Gasfitter
-
I hereby certify that all of the detail and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions
of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
Signature of Owner/Agent
I have a current liability insurancep licy to include completed operations coverage.
❑— -/�
SiMaster ❑Journeyman �Gasfitter
122-2, Z
on�tur. of Licensed Plumber or C a fittnr License Numbnr
2802
Date....
1
HORTh TOWN OF NORTH ANDOVER
0 PERMIT FOR GAS INSTALLATION
°•...., .� 4, M
This certifies that . '/l.. c
a..
has permission for gas installation ..C�f 5..... .........�
in the buildings of1r. .......... o..
at ! . 7..� �r �..� ....... , North Andover, as.
Fe3�..... Lic. No.. ......................... .
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer