HomeMy WebLinkAboutMiscellaneous - 19 BRADFORD STREET 4/30/2018 (2) 19 Bradford Street
I
Commonwealth ®f Massachusetts
City/Town of N®rth Andover
System Pumping Record
9 2094
®@ iB4 I H ANDOVER
PARTIVIENout the
DEP has provided this form for use by local Boards of Health. Ot --;
information must be substantially the same as that provided here. Before using this form, check with your
he System Pumping Record must be submitted to
local Board of Health to determine the form they use. T
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 informati®n
Important When
System Location:
1. S
filling out forms Y
on the computer,
use only the tab
key to move your Address 01886
cursor-do not North Andover Ma
use the return State Zip Code
City/Town
key.
2. System Owner:
Name
Address(if different from location)
CitylTown
State Zip Code
_ Telephone Number
B. Pumping Record
1. Date of PumpingDate 2. Quantity Pumped: Gallons
Tight Tank El Grease Trap
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Ti 9
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes,�54No .. if.yes, was it clearied? ❑ Yes ❑ No
5. Condition of System:
6. Syste Pumped By:
Name Vehicle Lice e Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-tr ,ment Plant, 20 So. Mill Bradford, Ma 01835
f
a e of H r Date
/*
gnature o acility Date
t5form4.doc•03106 l.� System Pumping Record•Page 1 c
Commonwealth of Massachusetts
EIVED
FforMs,may%e-
W
City/Town of No Andover
System Pumping Record 3Form 4 OVER
USTDEP has provided this form for use by local Boards of Health. Other ed,buti 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, c-11
j c�
use only the tab 1 -/ �I�i �1?�
key to move your Address
cursor-do not No Andover Ma
use the return
key. City/Town State Zip Code
2. System Owner:
Name
ream
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
in `da
1. Date of Pumping g 2. Quantity Pumped:
Date
Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No Ifes was it cleaned?
y ❑ Yes ❑ No
5. Condition of System: �G,2
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date ~
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts Me
F W
City/Town of No Andover _ RE
a System Pumping Record OCT
Form 4 TOWN OF NHEALTH DEP has provided this form for use by local Boards of Health. Other forms may be used,
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, --T— /
use only the tab
/9 0 rod
&jy It;
key to move your Address
cursor-do not E`
use the return No andover _Ma
key. City/,town ---- — State —- — -- ----- -----
Zip Code
r� 2. System Owner:
CTI
ds�
Name
2nun
Address(if different from location)
City7own State
Zip Code
B. Pumping Record Telephone Number
1. Date of Pumping w / 7
Date 2. Quantity Pumped.
Gallons
3. Type of system: ❑ Cesspool(s) .Septic Tank ❑ Tight Tank
9 ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o Ifes was it cleaned? ❑ Yes
y � ❑ No
5. Condition of System:
6. System Pumped By:
Name
Stewart's Septic Service Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signatu a of H e Date
i n e of Rece Eacilit Date
t5form4.doc•03/
System Pumping Record•Page 1 of 1
��� � dOVE•��' .MAS
SACH'USS 1 ?
RECEIVED
or P. ➢!oYldrd 1111, loll,n !�d �;, � VI Boa+�
vnll
119d110 V11 !OC 11 80,Ic
A. Faclll o o,
ry Inlorm��lon.
" '�:: •', TOWN OF NO
HEALTH DEPARTMENT
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..: Commonwealth of Massachusetts RECEIVED :
rz}
x lir:r
- t'/Town`o,-f-`NORTH �AI DOVER MASS CHUSETTS
SystemPumping Record NOV 13 2006 .
Form 4' `
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP,has provided this form for use by local Boards of Health. The System 7umpTffg Ke!6ord must
be submitted to the local Board of-Health or other approving authority.
k Facility Information
._.important:
..when filling out 1 System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not City/Town State Zip Code
use the return .. `
key i
2. : System,Owner:
Name
AQrO Address(if different from location)
CitylTown. State ip�o2C�d�
Telephone Number
B. Pumping Record
e'
1. Date of Pumping e, 2. Quantity Pumped:
Date 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 of System:
i
em Pumped By
,G
Name jVehicle License Number
'Ma.
Company
7. Location where contents were disposed:
a 0 -11y. A4 or9 lei
Signature of Hauler . Date
http://www.mass.gov/dep/water/approvals/t5fo.rms.htm#inspect
t5fonn4.doc•06/03 System Pumping Record•Page 1 of 1
� Q 0YIJDry
r R'7� A 0 ESR
OCT 9 2008
DFP hoij
provided 1Shli loan !
o,
00 1_Dml{IOd to thlo,al
e �, Y '
Ecu/�: ^.o8:;n or Cl1 0 raVI�OF � ANIDOgVER
Sig s'd
�. Faculty InforrrlacI
zv.
Owner
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p��roia (Ild cull rcvnlouUcn;
Pumping Rekord —
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,J,
V9NGl9 'iCT{ N 8
on whar8 COrll9nl9'were c 9poseo
oil#
provaJ&0(orm9
�• I
ego RE MVIED
( c�wry0� NO R I•Il .�r�ch., OCT 0 7 2005
SYs'T`EN'l PUMPINU RFC,OkI.
TOWN OF�110], HANDOVER
HEALTH DEPARTMENT
irl
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Sl STEM
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4L CD CA KAYpYgK'"'"" FLOODED
.�.., 01'NLR EXP L,AIH
un I tN I'� f11.1 N�th,KK.'�U .'i
RECEIVED
r� OCT 0 5 2004
WN OF NOR1ANDOVER
UA l
SYSTEM PUMplAo REC'ORI.) TOWN OF NOH ANDOVER
k RTHEALTH DEPARTMENT
SYSTEM OWNERBt/A�DDRESS SYSTEM LOCATTC)N
DATE OF PUMPING;
_...__QUANTITY PUMPED:..._.7��... _�.5.. . ..... .'.. .
YES
SaPtiC 1'snk: NO_ Y ES Y
NA PUKE OF SERVICE: ROU fINE, EMERUEN(')'
013SERVA CIONS;
GOOD CONDITION PULL 'W COVER y,
HEAVY GREASE BAF.FLBS IN PLACEROOTS LEACHFIPLD RUNBACK
EXCESSIVE SOLIDS
.-__-- lM LOODED
SOLID CARRYOVER.-.. OTHER EXPLAIN
Syetvm Rumpcd by
CSf,._
177a.
CUMMhNTS.
CUNI EN I'S f KANSFhKK6D i-s_) a� ✓Av
I
TGWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
q j
�1 TEM OWNER & ADDRESS SYSTEM LOCATION
// (example: left front of house)
l+
U I'E OF PUMPING: 3—(�r-D '-) QUANTITY PUMPCD GALLO ,s .
C. S1'00L: NO '- YES SEPTIC TANK: NO _ .YES
NATURE OF.SERVICE: ROUTINE �ERGENCY
tJ I3.S f:R VATIONS:
CUOD CONDITION- FULL TO COVER
HEAVY CREASE BAFFLES IN PLACE '
ROOTS LEACHFIELD RUNBACK
CXCESSI-VE SOLIDS FLOODED
SOLIDS CARRYOVER CQ�HER (EXPLAIN)
>1 "1'LM PUMPCD. BY:
cu)i�I'Fl-NTS;
l:U�'.1i:��"r� �'JtANSFC1tRLD 'r�:
i
Address G RA U ro Q o ST Title of File Page of .
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes
action Document/ document/
Num. Action Department
Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Departrment
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.
*****************************APPLICA-NT fiLLS OUT THIS SECTION******************* i`**
� ,..
APPLICANT %JJf"� PHONE
�( LOCATION: Assessor's Map Number PARCEL
SUBDIVISION LOT (S)
STREET ST. NUMBER /?
USE O N LY tt **** * * ***** ** *
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
I
COMMENTS
FOOD INS TOR-HEALTH DATE APPROVED
DATE REJECTED
SEP C IWBfsECTOR-HEALT —_... DATE APPROVED
- DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
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WN OF NORTH .MovIv
. , STS PUMPING
RECORD
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I SYSTEM LOC. ..
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n '
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j
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• �+1�ar ED 5 GALLONS
tt /` pp"�^��Q'�*����J�`AeF'�f�.�t,� ,"N, et•b 'dl Yy dp (�
yf �AQ�'f�Rl�' a"' TT��•,OIf t� � � \t ll` •• r,1 ar�,i. �lf6,�r(1h.1,.'„i,r ,.
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Y �,. FULL TO COVER
RO —. BAFES INpLACE
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CC VSOS . " FLOODED
!1 CAR,R,Y .• OTHER
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ORTH ANDOVER' M 4U`SETTS } .
yI:Se, °pumping
-Re
cord T K o07
�MM*•1/I(` l�Jf �,+l4rJ�t'��r'el,(.k�l k`'�,L ! {rr. .A1C 1 V Z
i�4�,fJ i •a i �,� Ir. ! i.•u p{..,, ' ' W pF.t 10RTH.ANDOVER
DEP..ha:provided thia form for use by local Boards of Health. ��ita,��ste iprilT ecord must
be submitted to tJte.local•Board of Health or other approving a r tY,
. acllity Infornl�atlon
T�^1mRortantt,: ' ' �• '
:f rWhen filllnp out: .1 System Ocatlon
only the tab key Address
to move your=;
air:or•do not
use the rotum / Clty/Town
' State
Zip Code.
Syste r .
Im Owner, r r
,'\7I. .'i,• � t4 r. ` IM. rf'1 I ...1'� 1!. , ''{1 I
TS �
yr Name {.
Address(It different from location)
Clty/Town State Ca Zip Code
Telephone Number
tt,. ti
i ,•pumping 6cord:
Datiof Pump ing pate 2r Quantity Pumped:
Gallons
' 3, TYPa Pf system, ❑ Cesspool(s) Septic Tank
i ❑ Tight Tank
Other(descrlbe),
(fluent Tee Fllter present? Yes o
❑ If yes, was It cleaned? ❑ Yes ❑ No
4L
Condition ofSystJQB,m'';
.. �.. t `\ ,,. \ � rf, 4 V1,��,rY r,r•/-.a rlgr�r,.l';'�,J I � �
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.rl�..l�y'{�iAr!�11,�+�1w�
t ••'r; ,.7,. Locatlon.Where contents ;
r Were disposed:
,rt �. r:� t,. ..,y..../:`.fir.'..:,.�\�• /,a'
na
.r' Date
http:!/www.mass,gov/d vwafer/approvaislt5fofms,htm#inspect
1 t5
08/93 r ..
forrn4•doa' " System Pumping Record•Page 1 of t
Commonwealth of Massachusetts
man, Ef
City/Town of NORTH ANDOVER MASSACHU E
EIVED
System Pumping Recordu spry
Form 4 ,
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. The Sys m i aff fust
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms the 1 G
computer,use
only the tab key Address
a
to move your
rsor-do no
usse the retut
umCityfrown Sta a Zip Code
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record Q//7
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) XSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
i 5. Condition of System:
6. System Pum By:
Q __
me Vehicle License Number
1
ompany
7. 1 Locatio here contents were disposed:
UIC-)
VG
ignature of Hauler
Date
http:/ .mass.gov/dep/water/approvalstt5f,rms.htm#inspect
t5form4.docr 06!03 System Pumping Record•Page 1 of 1
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