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HomeMy WebLinkAboutMiscellaneous - 184 CARLTON LANE 4/30/2018 (2)Commonwealth of Massachusetts -- City/Town of kECENSD System Pumping- Record ti7 1 2014 Form 4 TOWN OF NORTH ANDOVFX DEP has provided this form for use -,by local Boards of Health. Oth HEA0 F.I pAfii iii 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: Left / Right front of houseytGjRI r oi�df , Left/ right side of house, Left / Right side of building, Left /Right front of bdiM"ing, Left / ig r buildin , Under deck 9 Address CWTown State Trp Code 2. System Owner. Name Address (if different from location) Cihr/Town g� �C� QZIp Cgde Telephone Number u B. Pumping Record 1. Date of Pumping gate 2. Quantity Pumped: Gallons a 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank 4. ❑ Other (describe): Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition o�tem: 6. System Pumped By. Neil Batesbn Name i Bateson Enterprises Inc Company contents were disposed: tMrm4.docP 06/03 F5821 Vehicle License Number —[ 6—/y System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record �,�� C 4 X013 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other orms 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 1. System Location: Left / Right front of house,Q) Right r of hou Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Addresst v uv Cityrrown Q `State Zip Code 2. System Owner. ©VI\ Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State` _a G z Telephone Number Ji (m -31-c3 ... _ Date Cesspoo(s) — Z. Quant) Pumped eptic Tank Gallons —Y ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ['No If yes, was it cleaned? ❑ Yes ❑ No. 5. Condibicin gf System: f v�'A 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: Waste Water F5821 Vehicle License Number Date t5form4.doc• 06103 1 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of W' System Pumping Record Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. few 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 1. System Location: 11'.&� 4:::,n) 4�— h&U&'e Address ((a— \4 �_ W l /// CitytTown State 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping Zip Code Stat 25 geCode Telephone Number Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) E-]--5eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: In C)� 6. Syste Pt4mimed By: /I -- e' icle I--eVehicle License Number Company 7. Location,w ere contents re Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachu City/Town of System Pumping Record Form 4 RECEIVED NOV 13 2008 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards 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 1. System Location: Left front,eft rear left sid of ous . Right front, right rear, right side of house. Address , ` (//� City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping State Zip Code StatL�a Zip Code <:S—<::77�©Y Telephone Number 2 Quantity Pum ed' l S� Date p Gallons 3. Type of system: 0 Cesspool(s) eptic Tank 0 Tight Tank 0 Other (describe): 4. Effluent Tee Filter present? 0 Yes 01lO 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: L.S. Lowell Waste Water of If yes, was it cleaned? [j Yes p No F 5821 Vehicle License Number ( C 0 -a- i - c� �- Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 _C�x Commonwealth of Massachusetts City/Town of System Pumping Record w Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When fining out 1. System Location: -C� forms on the computer, use only the tab key Address Q to move your v cursor - do not use theretum Qity/T°wn State Zip Code key. 2. System Owner: TOWN OF A). A 6 Le -L SYSTEM PUMPING RECORD SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: 10 QUANTITY PUMPED: 1.506 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: TOWN OF P - SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: �UANTTTY PUMPED: RECEIVED NOV 18 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMCE NT CESSPOOL: NO YES SEPTIC TAW: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste GALLONS DATE:�1-Q'0`� SYSTEM TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD kt(� P c YTCfO✓\\ NOV 19 2004 TOWN OF NORTH A"!OVER HEALTH DE"'A',T%.,_NT (example: left front of house) Lck � �Ous-c- DATE OF PUMPING: QUANTITY PUMPED / -� CESSPOOL: NO J" YES S PTIC TANK: NO NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: GALLONS YES FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: 6—, � - �) ` N n r I 0 M 0 Oh El -v L I FORM U - LOT 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 or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT�/ Vi/�?° PHONE i7yfF>— er LOCATION: Assessor's Map Number PARCEL_ f �� SUBDIVISION / LOT (S) STREETY/�DJ? �Jg� ST. NUMBER 18 **********OFFICIAL USE ONLY********************** RECOMMENDATIONS OF TOWN AGENTS: /°� I�`+ - ,v/w C- CONSERVATION ADMINISTRATOR DATE APPROVED I� y� DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD I 1!11:1 PECTOR-HEALTH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER..CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9197 jm BUILDING DEp,, --J Ali ti rtnzA 1.46 S Ar,' bw 7z GkoolvD zo//�/ 74-- 7/LO Zo f SS AW L5AO-6 f/'7 10/25/1999 10:30. 5084607009 outs-+KrE, o 15xtS-f DECK.. MIN -0.. FQOf-A �c�r�c T�rrc . s LIRA ARCHITECTS PAGE 02 1Ci 90 00 lb �0 L� LjA T•. WX v p�osr og + _x, sore i ,o !Z" .G' Dim oto s OF 1 r 10 2�t 4 Lal4' L J c t ZxiO'S� IZ diiC• � Jt�pt o Ll It N I $` PEWCOWr. 4`-0' 1 • SKI�T • I I V, EX Gid•(AT 95MT• Lry 9: L, 0 N N Q y Liz LLJa N Ul c.; 3 221 {949 Commonwealth of Massachusetts Massachusetts A stem Pumping Record System Owner Date of Pumping: 1�ITI J � Cesspool: No Yes System Location�t/, (adkk-� 1, Quantity Pumped: �.0 gallons Septic Tank: No U Yes L -K System Pumped by: vare44-v 50.&Vo a License # Contents transferrred to : Greater 6wrence Sanitary District Date: — Inspector: TO: NORTH ANDOVER, MASS _ b C T- 07 19 F4/ BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at C'/4 L f0 V L/i/t/E North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 t-�, & 13 19� 4�- Board of•Realth i. North AndovzHaas. BEPTIC SISTF�i e.rt. INSTALLATIC.K CHECK LIST LOT" SS ro. ►VED DATE DI PR S AVATIC�t Ob FAIL C -- sasunst FAIL OK io-I���� 1. Distance Tot a. Wetlands b. Drains c.. Well 2. Water Line Location 3. No PVC Pipe - %. Septic Tank a. Tess _Length do To Clean 'Out Covers b.• C'einent Pipe to Tank on Both Sides of Tank .5. Distribution Box a. Covers k .Box - No Cracks Lines Flowing Equal Amounts c.. No Back Flox , 6 Leach Field dr Tr'en'ch":,:, a. 'Dimensions b. Stone Depth c. Capped Ends d. •.Clean Double Washed Stone 7. Leach Pits' a. Dimensions b. Stone Depth c. -splash Pads ` d: Tees e. Cement Pipe to Pit - Both Sides £. Clean Double Washed Stone 8. No Garbage Disposal - - - 9. Anal Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b Dimensions of System c. Location -,4th Regard -to Perc Test d. Elevations e: Water Table r . hoard of Health • -- ti wart}:: dovor,Mots SQgSQgFACE DISPOSAL MSTGN CHECK LIST % : �•�� r LOT CAR LOAJ LA, APPR.CNID DATB - ' " � �..(W5�?�1J DISAPPROVID DATE _ " Provided*- . Reasons: 6A - Title V FAILCK.. . Reg 2.5 The submitted plan must show as a gni: lot J,abutters +. the lot to be served-area,dimensions hoes-distance to ties location and log deep observation Location and results percolation tests-distance to ties Ra design calculations k calculations shaming required leaching area location and dimensions of system -including reserve area existing and proposed contours sal systemor location any wet areas Athin 100 of sewage disposal (h) disclaimer-check wetlands napping surface and subsurface drains vithin 100' of sewage disposal (i) system or disclai.msr location any drainage easements v&thin 100' of swage disposal (j) system or disclairer-Planning Board files known sources of sorter supply within 204' of serge disposal e _ -- ---- --- - ) S((1) system or disclaimer - -ocation-ef -sem proposed -vel—Ito serve lot-10:?r<l�� g fav: from leaching Sacili— location of eater lines on propez'ty-10' # (m) location of benchmark l/ (n) driveways' o) She disposals _ (q) no PVC to be-used in construction luab i e septic tari of system-elevations of basement, p P P _ Profile distribution box inlets and outlets, distribution field piping an 0tLer elevations - ,�,�Yia�m ground cater elevation in area. swage disposal system s) plan roast be prepared by a Professional Rngineer or other professional authorized by lair to prepare such plans f .i Reg 6 C/ (a) Septic Tanks capacities-i50%• of flow, :,ate'. table, tees, depth of tees, access, pumping r/ b) (c) cleanout 10' from cellar van or inground sig Pool (d) 25' from subsurface drams Reg 10.2 Distribution Boxes t n 0.08 l/ (a) slope greater Reg 10.4 I b) �'� D i TOWN F A IVJRTH NDOV ��utuuutlrl+Null ur AINrr,lrbustllr ��OARO�FTH ��EA - ER/ ' . 1 �11IUg8UU�lUl;t��It� � . Jul_ 9199 ' )'tllftt t�tctto�- I ' .^ ev �_.S•/� ` 1, ' t, t t i TOWN F A IVJRTH NDOV ��utuuutlrl+Null ur AINrr,lrbustllr ��OARO�FTH ��EA - ER/ ' . 1 �11IUg8UU�lUl;t��It� � . Jul_ 9199 ' )'tllftt t�tctto�- I ' .^ ev �_.S•/� ` 1, ' t, ('oi monwealth of Massachusetts v- Massachusetts System Pumping Record System Owner System Location 6g— t+",Y\ Ll� Date of Pumping: ( l Quantity Pumped: �- �8allons Cesspool: No 1 Yes L.) Septic Tank: No L Yes L System Pumped by: Fat`eQ4rt 51&T,64meQ License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: 17 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: x:411: DATE OF PUMPING: to l—bZA SYSTEM LOCATION (example: left front of house) Dc i 2 5 2001 PUMPED I � GALLONS CESSPOOL. NO YES SEPTIC TANK: NO NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: YES ---' FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: (& is` c).0 RECEIVED -C-\ Commonwealth of Massachusetts DEC 15 2009 City/Town of WN OF NORTH ANDO System Pumping Record TO HEALTHDEPARTM NT R Form 4 N svJ 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 tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health ol"©thOr approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house, Right front of house, ear of house, dight rear of house. Left rear of building. Right rear of building. Address Cityrrown 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code State Zip Code Telephone Number Date ` a 4-6 0( �2.uantity Pumped: Gad ons%c� Cesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location whe>:espntents were disposed: G.L.,S. D/ Lowell Waste Water If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Signature of ria u er Date t5form4.doc• 06/03 System Pumping Record . f TOWN OF ^N • VaoJer SYSTEM PUMPING RECORD DATE:ii-q-03 SYSTEM OWNER & ADDRESS CCN -- 0A1' IS q Ca(- H-0 K- L'� - NOV Z 20? E SYSTEM LOCATION (example: left front of house) i�ei'I- �ack est l�au� DATE OF PUMPING: - QUANTITY PUMPED: _ 1 500 — GALLONS CESSPOOL: NO YES EPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Commonwealth of Massachusetts -- _ City/Town of L a System Pumping Record NOV 10 2010 Form 4 JTOt"Nj�O�F NORTH ANDO DEP has provided this form for use by local Boards of Health. Ot C, the information must be substantially the same as that provided here. Before using this o , eck 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 L_ ion: Left front of house, right front of house, left side of house, right side of house ea of hour, right rear of house, left side of building, right rear of building, under deck. " ` ANJO y -e City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record State Zip Code State Zip Code Telephone Number 1. Date of Pumping 1,( d—' L(�) 2. Quantity Pumped: 1 Date Gallons 3. Type of system: ❑ Cesspool(s) ES1 Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [° No If es was it cleaned? Yes No Y ❑ ❑ 5. Condition of System: 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Location where contents were disposed: G.L.S. Lowell Waste Water Signature of Hau F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts Rid = City/Town of System Pumping Record Nov 30'1011 .pForm 4 �M TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms m , 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: Left / Right front of houseL `Right ear of house Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address C f R City/Town State Zip Code 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Telephone Number ?(6 11 Date 2. Quantity Pumped'. Cesspool(s) Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes l.j'No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditior System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Loc ' nt G.L Sign toe Haule t5form4.doc• 06/03 were disposed: )well Waste Water F5821 Vehicle License Number �( -�r) -(r Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record I:�'d 2u U12S Y p 9 s Form 4 TOWN OF NORI H ANDOVER HEALTH DEPARTMENT 1 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 1. System Location: Left / Right front of house / Righ r f ahouse )Left/ right side of house, Left / Right side of building, Left /Right front of bul ding, Left / Right rear of building, Under deck Address 66' � � City/Town State 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) Zip Code state*---- Zip- 7� Telephone Number (C� — Z. Quantity Pumped; [�Jeptic Tank C� Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition ofJ UK��`� C`p�J ) V�%, 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Loc here contents were disposed: GL. Sj Lowell Waste Water F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1