HomeMy WebLinkAboutMiscellaneous - 191 JOHNNY CAKE STREET 4/30/2018 191 JOHNNY CAKE STREET treet
2101107.A-0191-0000.0
Commonwealth of Mass chusetts
u C ity/Town of N U 0 r
o
W" System Pumping Record
Form 4
G7 SV'y`Ov
DEP has provided this form for use by local Boards of Health. Other_forms.Tay-pe.used I but the
information must he substantially the same as that provided here. 1306, a 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 1�4 day ,f c� ttwe ing date in
accordance with 310 CMR 15.351. �,f
li.
A. Facility Information
Important:When
filling out forms 1. System Loon:
on the computer,
use only the tab
key to move your Addr ss
cursor-do not
use the return — —Y— T
key. City/Town State Zip Code
- J.
r�
2. System Own
))Dma&...
Name
ietmn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dated 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ['Septic Tank ❑ Tight Tank [] Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes [] No If yes, was it cleaned? Q Yes ❑ No
5. Condition of System:
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 �._T. Date _
Signature of Receiving Facility
t5form4,doc•03/06 System Pumping Record•Page 1 of 1
7
r Health
►daverzHaae. SEPTIC SISTEH
INSTAI ATICK CHBCK LIST LOT `����`��
OVED DATE DISA.PPHOJED X AVATIGN OK FAILr
86
erns!
-FAIL OK
1. Distance Tot � .-Tow� �
a. Wetlands
b. Drains REST 01�_
C.. Well
2. Water Line Location
3• No PPC Pipe
4. Septic Tank
a. Tees -_Length k To Clem Out Covers u
b. Cement Pipe to Tank On Both Sides of Tank
5. Distribution Box
a. Covers k Box - No Cracks
b. All Lines Flowing Equal Amounts
C. No Back Flow
6. - Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Ends
d. Clean Double Washed Stone
_. _ 7. Leach Pits
a. Dinansions
b. Stone Depth
c. Splash Pads
d. Tees
e. Cement Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
C* Location with Regard-to Perc Test
d. Elevations
e: Water Table
Health
,.. Audover,Masa
SUBSURFACE DISPOSAL DESIGN CHECK LI' ,T
---- LOT
APPROM DATE t-2,q- 5 DISAPPROVED DATE
Provii)Ms Reasons:
S= 32-0
Title V FAIL (K
Reg 2.5 The submitted plan must show as a minimums
a) the lot to be served-area,dimensions lot #,abutters
b location and log deep observation hoes-distance to ties
I(c location and results percolation testa-distance to ties
d design calculations & calculations shooing required leaching area
e) location and dimensions of system-inclu-ing reserve area
f) existing and proposed contours
g) location any wet areas within 100, of sF wage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within 10L of sewage disposal
system or disclaimer
(i) location any drainage easements within 5 )0' of sewage disposal
system or disclaimer-Planning Board Ub3
(J) ma known sources of water supply withiL 20L of sewage disposal 6
system or disclaimer
(k) location of arq proposed well to serve lit-1001 from leaching facility
(1) location of water lines on property-10l from leaching facility
(m) location of benchmark
(n) driveways
Wgarbage disposals
no PVC to be used in construction
(q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
other elevations
(r) maximum ground water elevation in area°sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 Septic Tanks
Nk (a) capacities-15D% of flow, water table, U es, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground swimmir S pool
(d) 25, from subsurface drains
Reg 10.2 Distribution Boxes
(a) slope greater 0.08
Reg 10.4 b) sump
r-)a�A i,vl L40
" _ �,z' �'.- 'r! L�r�, t 1 ✓ C�C���/I,.�YJ .✓tom v"`�nU
` 1 L-41 =� 1-DL p I �`CJ"JMs Cj
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i
TOWN OF NORTH ANDOV-P- ' ~ '
SYSTEM PUMPINC P-ECQ @-
�1 Eti'i OWNER & ADDRESS SYSTEM LOU �TI0,�
(nampit: le(( (ron�
0 C OF PUMPINC: QUANTITY PUNIPID
v
00L. NO YES SEPTICTANK NO YE
URE OF SERVICE. ROUTINE ENIERCENC1
_ Y
C,'OOD CONDITION FULL TO COvC
HFAVY CREASE !3 EFLL;S IN -----
ROOTS EACHFIELD k - N�ACK..
EXCESSIVE SOLIDS FLOODED -_--
SOLIDS CARRYOVER O,;HER (EXPLAIN)
LPUMPED BY
J �I �IrNTS:
I:�' I'S TIZANSFCRIZED TO
-43
l4 33.2
f
THo,ly\S !
h1U;:"rAY
r , —
V y"�y'
-AT FOU LA T I ON
_A' TIli IET, r
A T TANK 0t )LE- '
a _
it i� fel T /Al LE T ` - /77;;x,
COMMONWEALTH OF MASSACHUSETTS - DEPARTMENT OF PUBL?C HEALTH
DIVISION OF TUBERCULOSIS CONTROL
600 W?,',hINGTON STREET, ROOM 360 - BOSTON 02111
Questionnaire on Status of TW)erculosis Patient
NAME: Please record change of address here :
Address:
Date of
City: Birth:
Please check beside appropriate words:
1. This patient is is not under my care.
If yes, please give date of last visit 19
2. Date and results of most recent sputum:
a. Date : 19 Positive Negative Pending
b. By smear Culture Other
c. Laboratory performing test:
3. Date of last x-ray: 19
Progression Unchanged Regression
4. Present Diagnosis: (Please complete both columns) .
( ) Primary ( ) Active
( ) Minimal ( ) Active Impr. Mos.
( ) Moderately Adv. ( ) Ouiescent (Cavitary) Mos.
( ) Far Adv. ( ) Quiescent (Non Cay. ) Mos.
( ) Extra Pulmonary ( ) Inactive (Cavitary) Mos.
( ) Inactive (Non Cay.) Mos.
( ) Undetermined
(Specify)
5. Drugs Administered: Yes: Date Started: 19 No:
DOSAGE SPECIFY DOSAGE:
INH
PAS
STREP
MYAMBUTOL
PZA
Other
Signed: M.D.
PH-TG-21-10/71 Date: