HomeMy WebLinkAboutMiscellaneous - 189 CARLTON LANE 4/30/2018 (2) NO• 189 CARLTON LANE
210/107.A-0206-0000.0
ADDRESS DATE
Commonwealth of Massachusetts
City/Town of
System Pumping-Record
Form 4 ORZN MAID ER
10WF GSH p>✓PP�SM�NT
DEP has provided this form for use=by local Boards of Health. Ottorms 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 Locatio�e /Righ hou /Right rear of house, Left/right side of house, Left/
Right side of buifdi'n Left/Right front of t din Left/Right re
9 99 9. g rear of building, Under deck
Address
Cityrrown State Zip Coale
2. System Owner.
d)1-A AK
Name
Address(if different from location)
Citylrown ' Stater? Zip Code ;
v
Telephone Number i
B. Pumping k-ecord
1. Date of PumpingDate 2. Quantity Pumped: Gallons
El Cesspool(s)3. Type of system. Se tic Tank Tight Tank `
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yeas No If es,was it cleaned? Yes Na
y ❑ ❑
5. Condition of som: ��
4�CJ�
6: System Pumped By.-
Nell
y:Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
• j
7. Locati contents were disposed:
GL-L S. Lowell Waste Water
Sig HauleV Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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.
A. Facility. Information
1. System Locatiofe / ig ;lnt of hous eft/Right rear of house, Left/right side of house, LeftRight side of buildi�Left/ Igrout of building, Left/Right rear of building, Under deck
Address A � �Uk'Z-�_ r A
City/Town I1 �`/Svtaatte` CJ Zip Code
2. System Owner. (J\V\
Name' � J
Address(if different from location)
City/Town ' State/'7 l � Z•��er.
Telephone Number d
B. Pumping Record
1. Date of Pumping " —
p g Date 2. Quantity Pumped:
Gallons
3. Type of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yeas 9-1No If yes,was.it cleaned? ❑ Yes ❑ No:
" 5. Condition o S ysteM.
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati whe contents were disposed:
O.I•.S. Lowell Waste Water
Sign Haule Date
t5fonn4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts I AECEI E-0
lugCity/Town of AUG 0 5 2013
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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: eft/ fron of hou igh Left/Right rear 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
City/Town State \lam Zip Code
2. System Owner. C v V\
Name
Address(if different from location)
City/Town Stat Co
�0
Telephone Number
B. Pumping Record
` r 03 f W
1. Date of Pumping 2. QuantityPum " ns
Date ped: Gallons
3. Type of system: ❑ Cesspool(s) a<eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition o Sy tem, �Q
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
SigWHaule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
1
L Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
M v
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 Locatio igh oof house Left/Right rear of house, Left/right side of house, LeftRight side of bul , Left/Rlgo building, Left/Right rear of building, Under deck
Address Lv\` K-)d---RS0MRQ1'- ,
City/Town State Zip Code
2. System Owner. AUG 14 2012
L)LT TOWN OF NORTH ANDOVER
Name
Address(if different from location)
City/rown State Zip Code
C '7--q'?�%� d�a
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quan •ty Pumped: Gallons
3. Type of system: E] Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? M Yes No
5. Conditi n of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio ere contents were disposed:
L S. Lowell Waste Water
9SignVeHagule ���� Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth. of Massachusetts
City/Town of
System Pumping Record
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 filling out 1. System Location: C)
forms on the
computer,use
only the tab key Address 44.,
to move your cursor-do not " T
use the:retum CdytIown State
key. yN�O d p� de
2. System Owner: mmb� (t�
9
Name
Address(if different from location)
City.fTown staRZip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �l r �
Date . Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ff No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: '
L
6. System6Pumld��
Name Vehicle License Number
Company -- .
7. Location ere c stents we Isp
A�j A
Ct
signature f t4 I Date
hftp://www.niass.gov/dep/`Water/.approvalg/t5forins.htm#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of 1
i
TOWN OF t V
u
SYSTEM PUMPING RECON ;�7-= r--
DATE: SEP - 7 2005
��j
TOWN Or NORTH ANDOVER
rEALTH DE 'ARTMENT
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front ofhouse)
ut[ KVA—
Lyv
DATE OF PUMPING: (g, b QUANTITY PUMPED : GALLONS
CESSPOOL: NO YES SEPTIC 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)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED To: G.L.S.G Lowell Waste
i'
-73
i
lob 38
154 GRi
i
�— ~FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and ^Apartments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
FILLS OUT THIS SECTION
APPLICANT V o_5g�h_ v, T n ze PHONE 1 7�
..
LOCATION: Assessors Map Number PARCEL_
r
SUBDIVISION LOT (S)
STREETCcr 1*k �Q hy ST. NUMBER
""""'"OFFICIAL USE ONLY
REC ENDATIONS 0 TOWN AGENTS:
CONSERVATION ADMINIS RATOR DATE APPROVED
DATE REJECTED
COMMENTS W�
AICA ii
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
r
�r
FOOD INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
INSPECT06111- faCtH DATE APPROVED
DATE REJECTED
i
COMMENTS
PUBLIC WORKS -SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
ov� V\\/\
DATE OF PUMPING:
QUANTITYPUMPED `GALLONS
CESSPOOL: NO YESSEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE e EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: -v Q
r
' •'irl
too
2 Li
a
z.
lot
BOARD OF HEALTH
No.Andover, Mass .
SUBSURFACE DISPOSAL DESIGN CHECK LIST
LOT
APPROVED - DATE DISAPPROVED DATE
Providcds Reasons:
J rr
Title V FAIL CK
Reg 2.5 The submitted plan must show as a minimuAs
a) the lot to be served-area,dimensions ' i�
of ,abutters
b location and log deep observation hoe s-distance to ties
c location and results percolation test.-distance to ties
d design calculations & calculations sly King required leaching area
(e) location and dimensions of system-"ne' uding reserve area
f) existing and proposed contours
(g) location any wet areas i4thin 100' of .wage disposal system or
disclaimer-check Wetlands mapping
(h) surface and subsurface drains within 1XI of sewage disposal
system or disclaimer
(i) location any drainage easements within 100' of sewage disposal
system or disclaimer-Planning Board files
(3) known sources of water supply within 2001 of sewage disposal a
system or disclaimer
(k) location of any proposed well to serve lot-1000 from leaching facility
(1) location of water lines on property-101 from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system-elevations of basea:-mt, plumb, pipe, septic tank,
distribution box inlets and outlets, 2istribution field piping and
Omer elevations
(r) maximum ground water elevation in are_ sewage disposal system
(s) plan must be prepared by a Profession l Engineer or other
professional authorized by law to pre•,are such plans
Reg 6 Septic Tanks
(a) capac t es- 50;6 of flow, water W .es tees, depth of tees,
-— - - access, pumping
(b) cleanout
(c) lot from cellar wall or inground swiw'.ng pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
(a) slope greater 0.08
Reg 10.4 b} . P ...
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1 Iil
;OARD OF HEALTH `
Io.Andover, Mass . ,
SUBSURFACE DISPOSAL DESIGN CHECK LIST
LOT # 3� GDS-,1✓�/�
?pRWIZ-J j ID - DM IZ- DISAPPRODATE_2(�� 3 3 -
rovideds �'' VED Reasons: 3 3�
Me V FAIL CK
eg 2.5 The aub4-tted,plan must show as a minimum-
a) the otube served-area,dimensions lot #"abutters
b location and log deep observation hoes-distance to ties
c location and results percolation tests-distance to ties
d design calculations & calculations showing required leaching area
(e) location and dimensions of system-including reserve area
f) existing and proposed contours
(g) location any Bret areas within 100' of sewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within 100' of sewage disposal
system or disclaimer
0.) . yjWft ease , , _age disposal
pal e
i2ity
P-URD Op LOT 39 VT�LTIO)j LA
NaI�T'N &L,)OUE)-�I M,4.
�J�Pu CAti I_ 1't4luc-ti_
D WELL- ,�P ouCD IYJ�C
SS 3 �� SCPCic SYS
1JPi3ZoVIN6 /urhoi IITY
CotiDITIoN5=
DI,iQPPRo VED IA e
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ADDITILOMAL- II15�rzTIDti5 ���A►�Y)
DISA PPJ�O\JFID D,aTC
,. APP►3a,11A)6
Address 109? C,4-2J.Tb&t 1L�t( Title of File
Page of
Date File Open:
Date file closed:
[C1oc Doc�rment/Action Title Date of Refer to other Purpose of I�ocumecnt Actio --�
action Document/ document/ / nand notes
Nurn. Action Department
-----------
---------
-______
Board of Appeals — Board of Health Planning_Board - Conseruatiion ----- sio
n —
BUildinq l?epartm, eat
Con nonw allh of Massachusetts
_ I j• A"Massachusetts
System Pumping Record
System Owner System Location
U CA lz V\ Ley
cam,
Date of Pumping: �� -- Quairtity Pumped: gallons
Cesspool: No Yes L.) Septic Tank: No Yes ( —
System Pumped by: 94WOO 464e7Wded License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: _ Inspector:
- 2 g 153
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: U—ZM dr—v)
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
(j
DATE OF PUMPING: �`� Q�ANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
Nov 3 0 200 '
OBSERVATIONS:
4+-
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
CUIIIIIIIIIIII IM�1�1 br A�plMtlt�llillllls „„��' ��
Vlal
9
>is7lelrrc,tlrner , � ,
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n LlCellse Mt
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t'anunonwe Ill, of Massachusetts � �
Z°`l��6assachuselts
SvstOm i7urnpingrRecord
Systcn, U4v,iel System Location
( q-,q Cak.
I)ate of 1'umI ging: / tloaiitity Pimped: L Gallons
Cesspool: No Yes L J Septic Tank: No
(-_J Yes J�
Syslri,► I'u,liped by: Vae'doo .61frovmMea License #
Co,iie.,ils lransfeured to : riledler LAWrallce Ranitaru PisLrl��
Uxle: _ lnspeclor:
TOWN OF 0
SYSTEM P PING RECORD
T( ., Or i�!OR FH A,, /
FOS ` Cr :4r-1'1;'-1
DATE: DI
25
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:left front of house)
ow 01
�'_R
I6
(af t�vl-- Lv�
DATE OF PUMPING: 2 QUANTITY PUMPED : GALL NS
CESSPOOL: NO YES SEPTIC 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)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D1 Lowell Waste
Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JUN 2 5 2007
;f Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health.aher 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
Important:
When filling out 1. Sys m�Location_ (�
forms on the •�%� ,
computer,use
only the tab key Address
to move your C � A4 ��Iq_Al�
Com`^
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner.
Name
Address(if different from location)
City/Town Stat '75—'-7,�,p ode
zi
Telephone Number
B. Pumping Record
l
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 to If yes,was it cleaned? ❑ Yes ❑ No
5. Condition ofSystem:
Q
6. System fumped.13y:
Name Vehicle License Number
Company
7. Locatio re ron7tep"re Is sed:
S' Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts LHEAL
"IVEp
City/Town of
Zit System Pumping Record JUL 7 Zoos
Form 4 ANDOVER
'-'rMENT
DEP has provided this form for use by local Boards of Health. Othbe u he
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 Location:
forms the
computer,use � J
only the tab key Address
to move your
cursor-do not GityfTown Ste Zip Code
use the return
key. 2. System Owner:
VQ
Name
Address(if different from location)
City/Town State L —� Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes-E3*No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition (Syste� m- ' V\\
6. Syste-r���By.
Name Vehicle License Number
Company
7. Location where contents re disposed:
�,
-'�>—
Signq(uro Asuler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
�L\ Commonwealth of Massachusetts
City/Town of
System Pumping Record JUL 2 ? 2010
Form 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of 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 or-outer approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left frontbf ho ight front of house,
Left rear of house, Right rear of house. Left rear of building. Ig rear of building.
Address 8`�T Lv\ ` 4a
Cdy(rown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Sta c Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) D-�S`eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed.
G.L.S.DA A L w Waste Water
�-- iy
Signature f au Date
t5form4.doc•06103 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
City/Town ofWE�EIVE®
System Pumping Record
Form 4 AUG
DEP has provided this form for use by local Boards of Health. Othe fall T e
information must be substantially the same as that provided here. B 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 of house, 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.
1 ,31 I+�n l� �J- �da.r�
City/Town cam— State Zip Code
2. System Owner:
UL'A A ✓\
Name
Address(if different from location)
City/Town State Zip Code
-15 - -1I '�p
Telephone Number
B. Pumping Record
1. Date of Pumping t k 2. Quantity Pumped: 1 56 C-)
Date Gam
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E4o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Locatio ere contents were disposed:
S. Lowell YVaste Water
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1