HomeMy WebLinkAboutMiscellaneous - 234 HAY MEADOW ROAD 4/30/2018 (2) _ 234 HAY MEADOW ROAD -�
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Commonwealth of Massachusetts RECEIVED
City/.Town of No Andover JUN 102013
System Pumping Record TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Form 4
M
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 310 CMR 15.351.
A. Facility Information
Important:When '
filling out forms 1. System Location:
on the computer, f
use only the tab 64
key to move your Address
cursor-do not No andover Ma
use the return City/Town State Zip Code
key.
2. System Owner: {
VQ
Name
rnnm
Address(if different from location)
City/Town State Zip Code
Telephone.-Number
B. Pumping Record
� O
1. Date of PumpingDate 2. Uantity Pumped: aeons
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? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: /
Z
Name Vehicle Li ense Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature Date
Signat e o ceiving F ility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from'
i
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
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APPLICANT � '� �\ Q �C c��z�,. ( `C.c.s- /"l HONE �,
LOCATION: Assessor's Nlap Number PARCEL
SUBDIVISION rh LOT (S)
STREET 1-44 p� i w lL�y� ST. NUMBER=-
USE
UMBER=USE
RECOMMENDATIONS OF TOWN AGENTS:
a Soh 5
CONSERVATION ADMINISTRATOR DATE APPROVED �6
DATE REJECTED
COMMENTS {J �r��1r �„/��.IN 0-0
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
i
FOOD INSPECTOR-HEALTH DATE JAPPROVED
/7 I
DATE REJECTED
SZ
T 1 ECTOR-H DATE APPROVED
40, DATE REJECTED
COMMENTS 5,e lea :L Ys7��r-ti
'a
PUBLIC WORKS -SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
G►� ` AE ..
RECEIVED BY BUILDING ii 1SPECTOR �" DATE
Revised 9\97jm
i
TOWN OF /
SYSTEM PUMPING RECORD
DATE: 1 DEC 2 %.
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
DATE OF PUMPING: QUANTITY PUMPED : JGALLONS
CESSPOOL: NO S SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ✓ EMERGENCY
I
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
REGISTRY: E55cJ' NDf�TS/
d
TITLE REFERENCE: 6e 177Z /fE ZY
PLAN REFERENCE -a-2' 9Z9/
LOT /meq
0-
37"
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a
CERTIFIED PLOT PLAN
LOCATION '3�f i/4y ME9Gt7w f'D
/YGRTf/ AN.GCYEiY' �M.9
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SCALE .1 i_ DATE: 6 3c-88 This plan was not prepared from an.itstruttuKtt survey.
Offsets aad distances shown should am be used to establish
CERTIFIED TO: property 13 3es.
I
tN!ff This plan intended for mortgage purposes only.
u I certify tj at the structure shown on this Plan
'n conformamx with zoning setbacks
sy in effect the time of coostruction- __.
Wta [certify I v2t the parcel shown is i12T located within
JOB NO. a flood rd area as depicted on HUD Floor!lasarancc Rate
CAMERON BROS., INC. Maps for Community No'_2SOb%d- —
MALDEN,MASSACHUSETTS