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HomeMy WebLinkAboutMiscellaneous - 200 COACHMANS LANE 4/30/2018 (3)R'WO Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER 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 rovidedhere—. Before-ustn his ofm check with our local Board of Health to determine the form they use. The Sys m PrmpiFieruste 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 h" ., A. Facility Information=A 1. System Location: Address 0 FYI, ��.-- -- �'� - -- -- CityrTown State Zip Code 2. System Qwner: Name Address (if different from location) CityrTown St eta\ Zip Code ----- lepho a Number B. Pumping Record 1. Date of PumpingDate — 2• Quantity Pumped: c�ailo--"�� 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes Cj--kslo 5. Condition of System: 6. System Pumped By: Name ff, oR-r< Company 7. Location where contents were disposed: Signature of Receiving Facility If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Numb QL.S.D. Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 I .\ Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS - System Pumping Record Form 4 Fstemj,�Wnpi!ngj8%qTrd C�V� DEP has provided this form for use b local Boards of Health. The S must be submied to the local Board of Health or other approving authority. =DEPARTMEANT A. Facility Information HE Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. inwn ' 1. System Location: 2 Addy ss ''' 6"WOOEA City/Tow ' System Owner.- 1'-1 wner:1' I K -C_ C� Name Address (if different from location) State IN". Zip Code City/Town - _ S4�ate Zip Code 9'—�) bSa- FOoq Telephone Number B. Pumping Record 1. Date of Pumping Dai_ t 0-) 0 2. Quantity Pumped: Gan n500 3. Type of system: ❑ Cesspool(s) ZSeptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 2'lklo If yes, was it cleaned? ❑ Yes 2"'No 5. Condition of System Goo J 6. System Pumped By: Jim GQ I cin L Nan4 /I Vehicle License Number Company .L.&D. 7. Location where contents were disposed: wrr'rce, MA. j., Signature of H ler Date http://www.mass.gov/dep/water/ pprovals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 --C\- Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER 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 within 14 days from the pumping date in accordance with 314 CMR 15.351, A. Facility Information lmporti mt: When ill ling out 1. System Location, forma tr7s t 1 T . cortrputote<, use _ ,._ ..... •- -- -. _... ,,. _ ..... . _ _ .. .._ .. � - Onlythe tab key reto move yourW.cursor - da not use Itu return pAdMd ty °N'n State Zip Code key' 2. System Owner: Name _.._ now Address (tf differ2nt from focat�or+j Citylrovvn $tdtas Zip Code Telephone N%jfnber B. Pumping Record 1. Date of Pumping ;el --- 2. Quantity Pumped: Gc eons— �- 3. Type of system: p Cesspool(s)%P�epfic Tank [] Tight Tank © Grease Trap [] other (describe): 4. Effluent Tee Filter present? ❑ Yes if yes, was it cleaned? Q Yes 5. Condition of System: G-D5� --,. .... _.._ _.... T _.. 5. SystW Pumped By: Nance corwny 7. Location where contents were disposed: .dam ��-•--.._.._.......__. - Venlde License Number Gr.L.S.D. North Anidouei; MA. 5igndture of Hauler oats -- -- -- Signature of Receiving Facility 1516ma4,0v 03106 System Pumping RecoM • Page t of f �..• h - - ..v"I"I V1 VU1.UF ajiprvving autnority. A Facility. Information lmortant. fUune out 1 . System Location =npu use 620 ony the tab.keY : Addres .. to move your:.",../ - arrsor 7 do not use the return City/Town State P key Zip Code 2. System Owner. r O Name------------- Ago Address pf dNferent from location) 9 City/Totwn State 9-A P.2 a p umber T le hone N , I .. .. yrB.'Pumping Record '• Ja Date of Pum in P 9 Date 2. Quantity Pumped: 3 � GaUona YPe of system ❑ Cesspool(s) tsd'Septic Tank ❑Tight Tank []' Other (describe); . Effluent Tee F(Iter present? ❑Yes lo' If yes, was It cleaned? ❑Yes ❑ No 5 Condition of System 7 t. Sy em Pumped sy� Nama i „Vehicle Ucenae Number .ir �*u°�T ir�'sr�yi'�y�rL�`..� 'alk i<4. � �C�CrV �.+�: ,'�'�'u•�/ �j')� J + :, . y JJ r . , ,A hl Hfj�`f• N�A�M1 r r 1'17., J [ ��.: 4 A4 J �1•. , " r 7 Location where contents Were disposed; � �`r � � �.i r V 'tilt j t •;' , _ ,.7 ly..,1. ,,. � � . . t I v Haular;1, �• Date tittp,//wtivw mass gov/depJwater/approVals/t5fomis,htm#inspect 6form4 doe 06/03 System Pumping • Y Record Page 1 of t S7ZMT I S SEPTIC TANK . SERVICE 47 RAILROAD STREW BRADFORD, MA 01835 978-372-7471 KM OF o Zt 654) 6�6 1506 1400 1066 We) - odd ADDRESS -PY-1 on A, I I paj 163 Uj fire 7 ------------- 0-ir ck. L153 Flq Ism r s 77 654) 6�6 1506 1400 1066 We) - odd It �m 541 X 10 Board of Health North W_O_V8_r,*B5O OVED DATE Cl � 11 SEPTIC SISTER INSTAILATICK CMr-K LIST LOT DISUPROM AVATI CN OK Reauonst 1. Distance To: a. Wetlands b. Drains NeeD5 A5 Q c..' Well 2. Water Line Location 3- No PVC Pipe 4., Septic Tank a. -Tees -_Length k To Clean Out Covers b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a., Covers,& Box No Cracks b. All Lines Flowing Equal Amounts e. No. Back Flow 60,- Leach Field or Trench a. Dimensions b. Stone Depth ce, Capped 'Ends d. Clean DoubleWashedStone* 7., Leach Pits a. Dimensions b. Stone Depth c., Splash Pads d. Tees e. Cment Pipe to Pit Both Sides f, Clean Double Washed Stone 8. No Garbage Disposal 9. -Yinal Grading Inspection 1d. Barricading Covered System 11. As Built Submitted, a. lot Location b. Dixensions of System c. Location with Regard -to Pere Test - d. Elevations e. Water Table 30ARD OF HEALTH 'io.Andover, Nass. DATE s SUBSURFACE DISPOSAL DESIGN CHECK LIST DISAPPROVED DATE Reasons: LOT # Title V !eg 2.5 Reg 6 teg 10.2 teg 10.11 FAIL OK The submitted plan must show as a minimum: a) the lot to be.served-area,dimensions lot #,abutters lblocation 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 wet areas within 100 o of sewage disposal system r disclaimer -check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer. (i) location any drainage easements within 1DO' of sewage disposal system or disclaimer -Planning Board files (j) knosn sources of water supply within 200' of sewage disposal « system or disclaimer (k) location of any. proposed well to serve lot -100' from leaching facility (1) location of water lines on property -10' 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 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 mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks (a) capacities -150% of flow, water table, tees, depth of tees,`} access, pumping (b) cleanout (c) 10' from cellar wall or inground swimming pool (d) 25' from subsurface drains ` 7 Distribution Boxes (a) s ope greater than 0.08 b) BURP 4 BOARD OF HEALTH No.Andover, Mass. APPROVED DATE Provided: 611 SUBSURFACE DISPOSAL DESIGN CHEQK LIST LOT # DISAPPROVED DATE________ 1�41 Reasons: �� Title V FAIL 09 Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served -area dimensions lot #,abutters b location and log deep observation holes -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 M existing and proposed contours (g) location any vet areas Athin 1.00' of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements within 1001 of serge disposal system or disclaimer -Planning Board files (j) known sources of water supply within 2001 of sewage disposal d system or disclaimer (k) location of any proposed well to serve lot -100 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 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 mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 I Septic Tanks (a) capacit es- 50% of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 10, from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) —sl ope greater than 0.08 Reg 10.4 �(b) SUMP 14 a dry '•.k wry �'xi i Y Y } S� a;! .b d pY, i N t � z { dry '•.k wry �'xi i Y Y } S� a;! .b d pY, \lP � 2� I 01' / +3'{