HomeMy WebLinkAboutMiscellaneous - 204 MILL ROAD 4/30/2018 (2)Commonwealth of Massachusetts
RECEIVED
lug
City/Town of
System Pumping- Record APR 2 7 2015
Form 4 TOWN OF NQRTH ANDOVER
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: Left / Right front of houseRight _ f house; eft /right side of house, LeftRight side of building, Left / Right front of b, Left / Right rear of building, Under deck
Address a 0-
City/Town state
2. System Owner.
Name' C J
Zip Code
Address (if different from location)
Citylrown Stater—� ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system-. ❑
❑ Other (describe):
Date
Cesspool(s)
— 2. Quantity Pumped
Septic Tank
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yeas DATO If yes, was it cleaned? ❑ Yes ❑ No:
5. Condition ofSystem: U',J� LA1_
6: System Pumped By.
7.
Neil. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
contents were disposed:
t5fbrm 4.doo• 06/03 System Pumping Record • Page 1 of 1
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Q
ILS
REGI
Commonwealth of Massachusetts
CJUN 0 2 2008
City/Town of
System Pumping Record 1'OW LTFi DEPARTM OT R
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. Sy�tem Location:
001-4 "10
City/Town
2. System Owner.
Name
Address (if different from location)
Citylrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
f — (- .
State
U Z, -,�, I q
Zip Code
State &aa— —,4P Code
Telephone Number
b ---2y / (f
Date 2. Quantity Pumped: Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes EJ-1qo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition
V-\ C) -(-System:
("', V--42�q &31)A3
6. Syste Pupped By :
Name x�l I����
�' �N
Company
7.
pontent
(!�enrposed:
T—S&C)-(
Vehicle License Number
Date
t5form4.doc- 06/03 System Pumping Record a Page 1 of 1
Pools.& Septic Systems # HD -02
Why do I need this approval? Unless the
Board of Health approves the location of the
proposed pool, the Building Department will not
issue a building permit. The Board of Health
reviews all applications for residential pools that
are proposed for sites with septic systems to
make sure that the pool is not being placed on
top of the septic system components, on or in
the leach area or on or in the reserve area. In
addition there are certain setbacks to the septic
system and any well on site that must be
maintained.
These setbacks include all parts of the pool, such
as fences, decks, cement walkways and grading.
How do I do this? To start the process you
must first go to the Building Department and
apply for a permit to install a pool. You will pay
a fee and receive some paperwork. You will
have to go through the Conservation
Commission if you have wetlands on or near
your property. It is always wise to check with
the Conservation Department whenever you
are planning an outside project that will result
in excavation of soil or removal of trees. You
can,
What do I need? For the Health Department Cr—
review you will need the following document•
• Scaled plot plan with hf-
system accurate"
• Pian location o
the correct scale O
If you do not have this
files, the Board of Health
at the same time you are working with
tion, submit your paperwork to the
apartment for review and approval. If
problem with the application or if
-i is missing, you will be contacted
to supply additional paperwork or
thing on your application. A final
J issuance of a building permit will
the approval of all pertinent
by providing a copy of yo
Who do I see? To obtain n '^
(the plan that shows your
system as it was buil4, you r
be made at the Health Dep
file. If you cannot obtain a st /� U
want to request that your s
come out and locate tf
components. A Civil Enginee
the system and can then prep
plan. Once you have the plot p e ready
to site the pool, there are a few rules you need to
keep in mind. They are:
• In -ground pools must be at least 20 feet
from the septic system leach area and at
least 10 feet from the septic tank.
• Aboveground pools must be at least 10
feet from both the leach area and the
septic tank.
If there is a well on the property, regardless of
the well's use, then:
• Both types of pools must be at least 15
feet from the well.
eferences:
15.000 of the State
ental Code, Title 5
a copy online at
vvww.state. ma. uVdep/brp/ww m/t
5pubs.htm)
• Town of North Andover Minimum
Requirements for the Subsurface
Disposal of Sanitary Sewage
• #CD- 01 Notice of Intent (NOI)
brochure
• #PD -01 Watershed Permit brochure
Town of North Andover Health Department - Community Development & Services Division
This brochure is intended as education of the local permitting process only. It does not cover al1jurisdictions or
scenarios that your permit application maybe subject to. Permit applications are site specific.
Jit << :. R r ^'••�A,r�
r e Pools & y
Septic S stems
Why do 1 need this approval? Unless the
Board of Health approves the location of the
proposed pool, the Building Department will not
issue a building permit. The Board of Health
reviews all applications for residential pools that
are proposed for sites with septic systems to
make sure that the pool is not being placed on
top of the septic system components, on or in
the leach area or on or in the reserve area. In
addition there are certain setbacks to the septic
system and any well on site that must be
maintained.
What do I need? For the Health Department
review you will need the following documents:
• Scaled plot plan with house and septic
system accurately located;
• Plan location of your proposed pool at
the correct scale added to the plot plan
If you do not have this information in your own
files, the Board of Health may be able to help you
by providing a copy of your septic As -Built plan.
Who do I see? To obtain a copy of your As -Built
(the plan that shows your lot, house and septic
system as it was built), you may request a copy to
be made at the Health Department if one is on
file. If you cannot obtain a scaled copy, you may
want to request that your septic tank pumper
come out and locate the septic system
components. A Civil Engineer may also locate
the system and can then prepare a certified plot
plan. Once you have the plot plan and are ready
to site the pool, there are a few rules you need to
keep in mind. They are:
• In -ground pools must be at least 20 feet
from the septic system leach area and at
least 10 feet from the septic tank.
• Aboveground pools must be at least 10
feet from both the leach area and the
septic tank.
If there is a well on the property, regardless of
the well's use, then:
• Both types of pools must be at least 15
feet from the well.
# HD -OZ
These setbacks include all parts of the pool, such
as fences, decks, cement walkways and grading.
How do I do this? To start the process you
must first go to the Building Department and
apply for a permit to install a pool. You will pay
a fee and receive some paperwork. You will
have to go through the Conservation
Commission if you have wetlands on or near
your property. It is always wise to check with
the Conservation Department whenever you
are planning an outside project that will result
in excavation of soil or removal of trees. You
can, at the same time you are working with
Conservation, submit your paperwork to the
Health Department for review and approval. If
there is a problem with the application or if
information is missing, you will be contacted
and asked to supply additional paperwork or
clarify something on your application. A final
approval and issuance of a building permit will
depend on the approval of all pertinent
departments.
Other References:
• 310 CMR 15.000 of the State
Environmental Code, Title 5
(Download a copy online at
www.state.ma.ugdep/brp/wwm
5pubs.htm)
• Town of North Andover Minimum
Requirements for the Subsurface
Disposal of Sanitary Sewage
• #CD- 01 Notice of Intent (NOI)
brochure
• #PD -01 Watershed Permit brochure
Town of North Andover Health Department - Community Development & Services Division
This brochure is intended as education of the local permitting process only. It does not cover al1jurisdictions or
scenarios that your permit application maybe subject to. Permit applications are site specific.
('oninion weal tIt of Massachusetts
Ne_ , Massachusetts
System Pumping Record
System Owner
Vim"f6tc—
Systent
Location
-zo � R1 I � Wd-
Date of Pumping: aOD 0 Qttaittity Pumped: i) a D C-) gallons
Cesspool: No IV Yes U Septic Tank: No �._� Yes
System Pumped by: Fare44rt gi rer,6taa License #
Contents hansferrred to : re
Date: _ Inspectors
C\ Commonwealth of Massachusetts 10121 -
= City/Town of
a
W° System Pumping Record ��701p
wM Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, oute
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. S n: Left side of house, Right side of house, Left front of house, Right front of house,
eft rear of u;;e, Right rear of house. Left rear of building. Right rear of building.
Address T`� }}
C -OL'c
City/Town
2. System Owner:
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
State
V � l
L4--ao-lo
— 2. Quantity Pumped
eptic Tank
Date
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
5. Conditiop of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
�� n Lowell Waste Water
�Igr;bture of
t5form4.doc• 06/03
Zip Code
State Zip Code
Telephone Number c_tL
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
Date
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. Other forms maybe 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 hous Le ig rear o hou , Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Ig
t rear of building, Under deck
Address 1 p PA /
Cityrrown l Vl State Zip Code
2. System Owner
del f
Name
Address (if different from location)
Citylrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
State�] (� % p Z' Code
l � G ! —S-A 6 Z
Telephone Number
Date 2. Quantity Pumped.
D-ge—ptic Tank
Cesspool(s)
Gallons
❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes o
If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of tem:
6. System Pumped By:
NO17
Neil Bateson
F5821
Name
Vehicle License NUrh6dr:DF NUI? 1 H i\NUUVtK
Bateson Enterprises Inc
HEALTH DEPARTMENT
Company
7. Localt*M whe a contents were disposed:
C .. S. Lowell Waste Water
SignAtufe qt Hauleq J
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1