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HomeMy WebLinkAboutMiscellaneous - 195 CANDLESTICK ROAD 4/30/2018 195 CANDLESTICK ROAD 210/106.A-0206-0000.0 )ad L I i I / J Commonwealth of Massachusetts —� City/Town of . System Pumping,Record JAN 14 2015 Form 4 III z•• TM 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, Left i t r of hous Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Cdy/Town Lp C•C/ State Zip Code 2. System Owner. 16A Name Address Cd different from location) Citylrown State Zip Code Telephone Number B. Pumping Record 5 �I 5 1. Date of Pumping gate 2. Quantity Pumped: Canons 3. Type of system. ❑ Cesspool(s) aleptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No, 1% ' 5. Condition of System: 6.- System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lo a contents-were disposed: Cx L S: Lowell Waste Water Sig Haul Date h t5fbrm4.doc•06/03 System Pumping Record•Page 1 of 1 . I RECEIVED Commonwealth of Massachusetts t-JAY 2 0 2013 City/Town Own Of TOWN OF NORTH ANDOVER System Pumping Record HEALTH DEPARTMENT Form 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 Location: Left/Right front of house, Left/ rear of Nous Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Rig t rear of building, Under deck Address City/Town State Zip Code 2. System Owner. Name Address(if different from location) City/Town State ^� � Zip Code Telephone Number Oy` B. Pumping Record • 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 No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditi n of System: 6. System Pumped By: Neil Bateson F5821 4 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location ere contents were disposed: L S. Lowell Waste Water CC✓ - U,3 signitufe cfHaule Date I t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record V V Form 4 JUN 11 9 2012 DEP has provided this form'for use by local Boards of Heal -MherCfor 8-Mair, , but the information must be substantially the same as that providede[l i T , 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. i A. Facility Information 1. System Location: Left/Right front of house, Left Right rear of hou Left/right side of house, Left/ Right side of buildM, eftRight front of building, Left/Rig rear of building, Under deck Address Cityrrown State Zip Code A 2. System Owner. Name Address(if different from location) City/Town State Zip Code (4sc Telephone Number B. Pumping Record 1. Date of Pumping Dater C (oZ 2. uantity Pumped: Gallons sa 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 i 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati a contents were disposed: G.LS. Lowell Waste Water Signitufe cfHau6U Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 INSURANCE ADJUSTMENT SERVICE 94 West Canal Street,Unit 2 Winooski,VT 05404 (802)654 - 7900 Fax (802)654 - 7990 UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 3B Date: March 27,2010 TO: Board of Health/Building Inspector RE: Insured: Donald Pickrell Property Address: 195 Candlestick RD North Andover,MA Date of Loss: 3/14/2010 I:: Policy Number: BCGCJJ Type of Loss: Water Damage File or Claim Number: 61481 Claim has been made involving loss,damage or destruction of the above captioned property,which may either exceed$1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6,to be applicable. f If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate,please direct it to the attention of the I writer and include a reference to the captioned insured,locations,policy number,date of loss and claim or file number. i Thank you for your cooperation. Very Truly yours, Paul Barrett Adjuster Ext. 107 i Commonwealth. of Massachusetts Afflfs City%Town of I -------- - System Pumping Record Form 4 , MAY 0 3 2007 rn DEP has provided this form for use by local Boards of Health.. ThejSystem Pumping�Record must be submitted to the local Board of Health or other approving authority. " `F "�:N' A. Facility Information Important: When filling out 1. System ocation: forms on theS computer,use tl p 6 ._ . only the tab key Address ^ r / to move youra(� cursor-do not use the�return Cityrrown State Zip Code key_ 2. System Owner: Name Address(if different from location) City/Town State ip Code Telephone Number i B. PuMplr g Record �=c : l'S� 1. Date of Pumping nate 2. Quantity Pumped: Gallons I Type e of system: ❑ Cesspool(s) G _emetic Tank- YP Y L73 p ❑ Tight.Tank Other(describe)` 4. Effluent Tee Filter present? ❑ Yes LNo Ifes was it cleaned? Y ❑ Yes`❑ No � 5. Condition f System: t Ut6. System Pcn�ed By Name. Vehic e License Number Company .. 7_ location ere contents: ere osed:. Signat a aler Date http://www.mass.gp% wa er/approvalt/t5forms.htm#inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts FT0jWN0F City/Town ofSystem Pumping Record 9naForm 4 H Cc'�. N 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: j fom the computer, r,use only the tab key Address to move your cursor-do not —46 -' "''j use the�retum Cityrrown State Zip Code .key. 2. System Owner: Name 'r°fA Address(if different from location) City/Town State Telephone Number B. Pumping :Record 1. Date of Pumping pate 2. Quantity Pumped: I Gallons .3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight.Tank ❑ Other(describe): 4: Effluent Tee Filter present? ❑ Yes Ly'No Ifes was i y t cleaned? ❑ Yes ❑ No 5. Condition of System: ✓tic �W-10 . 6. System Pumped By;" 4)7 Name J `Vehicle License Number Company -- .7. Location here clIontents were dispps�d:: Sig at of uler Date hftp://www.iiiass.govidep/water/approvalt/t5foans.htm#inspect t5forrn4.doc•06103 System Pumping Record•Page 1 of 1 N s ' u v 2 � y` N ell, VI r to t` \ . �- - - - - - - �, � � •, - � � '.`fit �� in Oo 14 U � w q OF �yqs �o JOSEPH i. J. v BARBAGALLO cn ! 464 ! t {! e 9�'`E��O L 1 � 10 � O s TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: J QUANTITY PUMPEDCY-�- 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) &Le�s SYSTEM PUMPED BY: i COMMENTS: CONTENTS TRANSFERRED TO: - - Commonwealth of Massachusetts Massachusetts System nuin in Record _.Y p g i System Owner System Location c kyo- Date of Pumping: /W Quantity Pumped: gallons Cesspool: No Yes- L_) Septic Tank: No U Yes � I System Pumped by: FefWea 5044 ftae4 License# Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector i i ,__..^-- -ER TCS OFA�`� y AALSN� i r^� � 1 i g /fid�► s � Title of Fine Page of Date File Open:_ Gate File Closed: . Doc Document/Action Title Date of Refer to other Purpose of©ocument/Action and notes action Document/ document/ tes Num. Action Department ------------ Board of Appeals — Board of Health Planning Board _ Conservation Commission — Bui[ding De partmen,t ---_—___ 4R� OF' HEAL-1-H � , l.aT 13 C,&jac,STiGK 2 NdI�TN AtiI�VEI�, M,4, , � Phi CAfv I, �J/yv�cZ _ c,�arER S ��O PPLY - 'Tbwt l 0 WELL- ApPRO uCj�wc- SS � St Ic 51r S T --- EAA k-- APNNOVW6 Aun-1oi?iry G� &A.)CK PUX) DATA gfj CO�pIT(O�JS : ' 0Y - T-U SHIF1 L R SONS " 1YAA)/4,) D 7 StPT"f� SYSTEM 1jSTAi.( '�oAJ 1c�NAL I�15p�rlon� APP(�d�EJ� /JTC APPi)vItiG AVr+to���ry I NkLA APPITI0IJAL_ 1� �.i 5 (pN5 �1FA►�Y) - - DtSAP1'�ovED D,arC Fw4L OPI�vAL f APn3ovN6 4u i Hopi �j � Commonwealth of Massachusetts MAR i 1 ;997 � Massachusetts System Pumping Repord i System Owner System Location s C� �j Date of Pumping: — — Quantity Pumped: f v gallons Cesspool: No Yes U Septic Tank: No Yes System Pumped by: gctwart grac't wa License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: i r.. ._ ..�` y O andover consultants 213 BROADWAY inc. METHUEN, MASSACHUSETTS 01844 (617) 687-3828 c � a DATE 4416- . /d /79 TO : NORTH ANDOVER HEALTH DEPARTIVILNT TOV�N HALL, NO. ANDOVER, MASS . RE : SUBSURFACE SEWAGE DISPOSAL SYSTEM 66 /-� e.4_a1/JLgE5176V- A20., NO. ANDOVER, MAaS . I hereby certify that I have inspected the construction of .the disposal system at e_�T /3 r/C. A• North Andover, Iviass . and that the location and elevations are shown on the its-Built Drawing dated #4416. /.0 /179 AIN.DOV.'t� CONaULTLiI,TS , INC. b5gg1-4 William 6 . kacLeod Registered :sanitarian This certification is not to be construed as a guarantee of the system. 1` 4.1 IAJUER T E LEVAT/OAJS 9 ' . . . . . . . . . kT NOUSE i/2. 3q -rAkjK /AJLCT 112. 16 -rA AJK D J7LFT • l 11, ?O LDS !3 130 x /FILET '4� 3�7 S.� •°. 36X NUTLET !O . . . . EAR) OF /39D //0.66 8 -ID 0 h w ;' :�. a a N a ' cSUBsue�,4CE c5:EwA6E DISPOSAL- SYs7-E/v1 � � (� _ �_] (J �q;' VCALE l " ZD hAT� �I�� . /, /5 73 h O O W1vE,e: -rgiOAAALS klILL/A M S 4 S UA S 9-r AVE. zs.5 'DI.5T BOX M,�7'1 LA5&1, AAASS. i50D &AL." LOCA r10A1 LDT /3, CA�111�LE5T/GCS RI�. � dll�. �4�lIDDVGs�2 SEPTIC TANK andover ���� WILLIAM consultants S. �" MAC D i nc. 1 2 ���Fs9Ec,sn?, *Pz N L 213 Broadway , Methuen , Mass. Tel. 687- 3828 7-/-//5 DA-,A W/il/C7- , W17-Al A7-7-4CN6�D CE,e7 /CAT/DN /S AVD T A �U.4.E'A/V TEE 7-/-1A T 7111E SYS TEM W l,,L FUiVCT/O/V P�2aPERLY TOWN OF Avi b SYSTEM PUMPING RECORD,,, DATE: t, - la-6 SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front 4 house) t*4ml f I I : kl � CaVIA411 DATE OF PUMPING: 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.D Lowell Waste `�e,o lL FORM U - VERIFICATION F ex I S - „� o'ec�INSTRUCTIONS: This form is used to verify th all n approvals/permits from Boards and Departments have 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***************** t ' � hone - .� arrLl CANT: n� r c ! r TZ- LOCATION: LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street 1 roile-iSkcrz' _ / St. Number l j � ************************Official Use Only************************ RECO ATIO AGENTS: " Date Approved Conservation Administrato , Date Rejected lob Comments S i i Date Approved Town Planner Date Rejected Comments Date Approved Food. Inspector-Health Date Rejected � ^� XJ 'Date Approved tic Inspector-Health Date Rejected �P P J Comments T6r1A.11 IV6U57_ —3E /2T 6E�915_17_ %D 141119Y TIS Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date i TOWN OF SYSTEM PUMPING , � 1lED i DATE: ,QS APR 1-3 2005 TV, NORTH ANDOVER HE/-,L FH DEPARTMENT I i SYSTEM OWNER& ADDRESS SYS LOCATION (examW:left front of house) 1t 1 lR5 DATE OF PUMPING: QUANTITY PUMPED : 15CLb GALLONS i CESSPOOL: NO YES EPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACIMELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D t Lowell Waste Commonwealth of Massachusetts City/Town of s T �NED System Pumping Record 008 Form 4 At'R 0 9 2 DEP has provided this form for use by local Boards of Health.Other forms mil 0 t e information must be substantially the same as that provided here. Before usi eck with your local Board of Health to detemune 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 on the computer,use only the tab key Address � / to move your �� _ !/ cursor-do not use the return City/Town State Zip Code key. 2. System Owner. Name Address(if different from location) City/Town State& � �� � ZCode Telephone Number G/1 B. Pumping p g Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) p Ic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: V � � C 6. SystemPump": Name ehicle License Number Company 7. Locations where contents were disposed: Sign re of Hauler Date t5fonn4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts FTOWN ECEIV City/Town of R 2 3 200 System Pumping Record 9 Form 4 F NORTH ANDOVER V• 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 all 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: Left front, left rear, left side of house. Right fro , right rear, r ht sid of house forms on the computer,use only the tab key Address I to move your. cursor-do not Ci /Town use the return ty State Zip Code key. _ 2 System Owner: Name Address(if different from location) City/Town State � Zip Code Telephone Number B. Pumping Record �.S 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? (l Yes If yes, was it cleaned? L3 Yes No 5. Condition of System:� 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 1 7. Locati aiwhntents were disposed: L.S.D Lowell Waste Water Lf (��D igna ure of H u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 i Commonwealth of Massachusetts City/Town of RECEIVED } System Pumping Record 7.1i SVev Form 4 HAY 18 Z011 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other f rmsuAay-p*---ne#Mtpjth information must be substantially the same as that provided here. Betore using is torm, c ec 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. City/Town State Zip Code 2. System Owner: Name Address(if different from location) Cityrrown S tem _ �� ip Code Telephone Number B. Pumping Record 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 LSO If yes, was it cleaned? ❑ Yes ❑ No 5. Conditi no 7Sstem- 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location where contents were disposed: J 4G.L.S.D. well Was earSignat a Hauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1