HomeMy WebLinkAboutMiscellaneous - 188 HAY MEADOW ROAD 4/30/2018A-1
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INSMWCTIONS: 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: _ __ _:e Phone
LOCATION: Assessor's Map Number Parcel
Subdivision Lots) b
Street ` e�`� ���1��, St. Number �.
************************Official Use Only************************
RECOMME.*iDATIONS OF TOWN AGrE iTS :
Date Approved
Conservation Administrator Date Rejected
Comments
i Data Anzroved
Town`Planner�j Date Rejected
Comments
Healt : Aaenz
Comments %!�ti•ic c%C
Pubiic WOr'{s - sewer/ waLar canne=tions
- driveway peri-.
Fire De=ar_=en-_
Date Approved
Data Rejected
Received by Building Inspectcr Date
Town of North Andover, Massachusetts Form No. 3
NORTq
BOARD OF HEALTH
Of 1ti
,.� 19
O 9
'°•,..o.�"� DISPOSAL WORKS CONSTRUCTION PERMIT
,SSACNUSES
Applicant /1-' GA/ k�fw
NAME >� ADDRESS TELEPHONE
Site Location /,68 Hi�Y/rlc�%Gc�b
Permission is hereby granted to Construct ( ) or Repair �)d an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
Fee IKL
CHAIRMAN, BOARD OF HEALTH
D.W.C. No. 4a ��
�L\ Commonwealth of Massachusetts
_ W City/Town of NORTH ANDOVER, lilt.
� System Pumping Record
Form 4
M
DEP has provided this form for use by local Boards of
be submitted to the local Board of Health or other apps
A. Facility Information
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
^0",
ierun. ,
1. System Location:
Address
City/Town
2. Svstem Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
NOV 14 2007
Record must
MA aWC3
State Zip Code
Stat ode
IT
Telephone
Telephone Number
Date O I , 2. Quantity Pumped: Gallons
�(
Cesspool(s) 1�6 Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes IdNo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Sjstem Pumped By:
ft W4
�Vme(Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
101 ice I zoo -1
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
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S EWART' S SEPTIC TANK SERVICE
47 RAILROAD STREET
BRADFORD, th 01835
978-372-7471
M01MI OF
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