HomeMy WebLinkAboutMiscellaneous - 25 JERAD PLACE 4/30/2018 (2),O- e'�4
IL
MAP # LOT4
_
PARCEL # STREET �
HAS PLA
PLAN AP
DESIGNE
CONDITI
WATER SUPPLY:
-�
WELL PERMIT. -
WELL TESTS:
COMMENTS:
TOW WELL
DRILLER______
CHEMICAL DAlE API-RUVED_______
ER I"IDA|E (\|'PRUVED
�9ACTERIA`�_� DA[E APPROVED_______
FORM U APPROVAL: APPROVAL TU ISSUE(&) NO
DATE ISSUE BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID --qD NO
WELL CONSTRUCTION APPROVAL NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL NO
OTHER YES NO
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DA7EBY:_,
9ER_[k.Q F STEM -).Tf
JP THE INSTALLER LICENSED?
TYPE OF CONSTRUCTION:
NEW CONSTRUCTION: CERTIFIED PLOT PLAN NEVIEW
CONDITIONS OF APPROVAL
(FROM FORM U)
cy E__ _s- NO
NLW [REPAIR
Y E S NU
ISSUANCE OF'DWC PERMIT C - –Y E S NO
'DWC'PERM I T NO.INSTALLER:---
-B, TVVIS
BEGIN INSPECTION (Yiio:
CONSTRUCTION INSPECTION:
AJ I
NEEDED:
AS BUILT PLAN SATISFACTORY:
APPROVAL TO BACKFILL: DATE. BY
FINAL GRADING APPROVAL: DATE LZ zo
—BY ---
FINAL CONSTRUCTION APPROVAL: DATE:-
Oki -
0 /7 7-
//0
�-L--\ Commonwealth of Massachusetts
CitylTown 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 310 CMR 15.351.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
A. Facility Information
1. System Location:
Address 4
.- Xn.
CilyrTown
2. System Owner:
Narne��--
Address (if different from location)
CityrTown
B. Pumping Record
r 4�`J�� �rJ15
Slat _ . Zip Code
State Zip Code
__ =655'.g--
Teiephone Number
1. Date of Pumping—1ate 1.-_. — 2. Quantity Pumped:
OGalton..
3. Type of system: ❑ Cesspool(s)eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [4-i4o - if yes, was it cleaned? ❑ Yes ❑ No
5. Condition/of System,
6. System/Pumped By:
Name vehicle License Number
/L ---- . ........__.__...._. _._...._.
Company
7. Location where contents were disposed:
Signature of Hauler
--- --.— -._..
Signature of ReceivinggFacility
Date
Date
l,w.w;1.P
11poich� Mp.
15form4.doc- 03106 System Pumping Record • Page 1 of 1
REC VIE; U
Commonwealth of MassachusettsNDOVER
LHEALTH
WN RORTHAMENT DEPARTMENT
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
` H ith Other forms may be used, but the
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
k_ey.
v�
I.AV
DEP has provided this form for use by local Boards of ea
information must be substantially thheform theame as that
use. Thed here. SystemPumping Record form,
m must be submitted to
local Board of Health to determine t Y in date in
the local Board of Health or other approving authority within 14 days from the pumping
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
Address
City/Town
2 System Owner:
Name
Address (if different from location)
�e Zip Code
-- State
Cityrrown
Telephone Number —
s. Pumping Record
�.1�. --� ---- 2. QuantityPumped: ns
1. Date of Pumping Date Gall
Cesspool(s)eptic Tank [] Tight Tank E]Grease Trap
3. Type of system: El
❑ Other (describe): __ _
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? yes L
5. Condition of System:
10
6. Sy tem Pumped By:
Nam
Company
7. Location where contents were disposed:
Sig t e o aider
Signature of Receiving f=acility
Vehicle ucen Number __.....
idvve� MA
Date
Date
System Pumping Record • Page 1 of 1
t5form4.doc• 03/06
Owner' , .. , t : - , . � . .
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Location
r
Type: Emergency Routine
Cesspool: No
Yes
Date of Pumping:
System Pumped By: Wind River Environmental, LLC
Contents Transferred to;
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
E
Dep Approved Form - 12/07/95
Form 4 -- System Pumping Record
RECEIVED
N0V 1 3 200
TOWN OF NORTH AND VER
HEALTH DEPARTME T
Septic Tank: No = Yes
Quantity Pumped:_ Gallo s
Permit #:
FORM 4 - SYSTEM P G RECORD
CURRIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978)774-2772
OMMON/�WEALTH OF MASSACHUSETTS
/'rC/O i/ei' , MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNER: cm( le
a S J P rc:�(c,0 �L .
L
SYSTEM LOCATION: leR Side
0 c 30 F,(om C0�(yier
(Lel, I occf 10' -F(on�l
Fa % r -e 'r i ),A Fro N 1,
DATE OF PUMPING: 9� 7 QUANTITY PUMPED: /5'�� GALLONS
CESSPOOL: NO F-� YES F7 SEPTIC TANK: NO F7 YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE: 7- �� INSPECTOR:
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FORM U - IAT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
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*****************
A /'
PPLICANT: (ayilIW?v� u �' �£n Phone 1_6?
LOCATION: Assessor's Map Number _104M_ Parcel
Subdivision _ ; x?Al) Lot(s) y4111�
Street R,4-- Off/" St. Number 25
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Ylb l AuTells
Town Planner
Comments
Food Inspect -or -Health
Septic Inspector -Health
Comments
Date Approved
Date Rejected
Date Approved 2
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Public Works - sewer/ water connections
- driveway permit
Fire Department
Received by Building Inspector Date
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Sheet j-- of i
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
$ice SUBSURFACE DISPOSAL DESIGN REVIEW
FEE PERMIT
APPLICANT Zb*30 S'
ADDRESS
ENGINEER " -
ADDRESS
.,• .
► �c ,
PLAN DATE
CONDITIONS OF APPROVAL:
APPROVED APPROVED
# DATE RECEIVED
ASSESSOR'S MAP
PARCEL #
LOT # 3 � &-A1c�C. i?�O
STREET
REVISION DATE !DA 7 -
DISAPPROVED x
A\� N?.p�r1c:� 5��\1 �� �uF�C-p r� �'iE �r �O � �1 �. Cy►�z- �`iv�.
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�+ Hca i tial % �, 4a
bfi L:C-7�'�" 2 � ec7a2,
PUMP GLjRVE FOiR PUMP
ON L.. 0-r 44 IJERAV Pt_Ac. F— ROAD
Model
SE411
AMPERAGE
MAX.
LOCKED
RUN.
ROTOR
AMPS
AMPS
9.0
15.5
db
Peabody Barnes
lb
Form No. 1196-280
s
May 24, 1.990
Thomas E. Neve Associates, Inc.
447 Old Boston Road
Topsfield, MA 01983
Re: Lot 44, Jerad Place
North Andover
Dear Tom,
I have reviewed the April 17, 1990 resubmission plans. The plans for the
installation of the subsurface disposal system cannot be approved at this time.
Of most concern is the depth to ledge or watertable below the easterly end of
the proposed leaching trenches. The plan shows the original topography in this
area to be EL 170.0. Your design is based on a watertable observed in a test
hole 8 1/2 ft. lower in elevation than this area (EL = 154.0). This assumption
is of some concern since this would mean that watertable or ledge are not
present within 16 feet of the original ground surface at the easterly end of the
trenches. Therefore, before approval can be given, I would request a deep
observation hole be dug in at the easterly end of the proposed leaching trenches
to demonstrate that water and ledge are not present 4' below the proposed
leaching elevation. If this test is conducted in the next two weeks, I will
have no problem considering that it was conducted "in Season". Please make
arrangements with the Board of Health office to have this test witnessed.
Also, please show the following on the plans:
1. A Benchmark in the vicinity of the proposed leaching trenches (rim
of C.B. at Sta. 4 + 00 will be close enough).
2. The topsoil and subsoil excavation limits shown on the plan view
since it will vary from 25 feet along the road and Lot 43 side of
the trenches.
Thank you for your cooperation in this matter.
NEVE.LE5
Very truly yours,
MARCHIONDA &
Town of North Andover
•• +
p II
in,,ii3',_.md
May 24, 1.990
Thomas E. Neve Associates, Inc.
447 Old Boston Road
Topsfield, MA 01983
Re: Lot 44, Jerad Place
North Andover
Dear Tom,
I have reviewed the April 17, 1990 resubmission plans. The plans for the
installation of the subsurface disposal system cannot be approved at this time.
Of most concern is the depth to ledge or watertable below the easterly end of
the proposed leaching trenches. The plan shows the original topography in this
area to be EL 170.0. Your design is based on a watertable observed in a test
hole 8 1/2 ft. lower in elevation than this area (EL = 154.0). This assumption
is of some concern since this would mean that watertable or ledge are not
present within 16 feet of the original ground surface at the easterly end of the
trenches. Therefore, before approval can be given, I would request a deep
observation hole be dug in at the easterly end of the proposed leaching trenches
to demonstrate that water and ledge are not present 4' below the proposed
leaching elevation. If this test is conducted in the next two weeks, I will
have no problem considering that it was conducted "in Season". Please make
arrangements with the Board of Health office to have this test witnessed.
Also, please show the following on the plans:
1. A Benchmark in the vicinity of the proposed leaching trenches (rim
of C.B. at Sta. 4 + 00 will be close enough).
2. The topsoil and subsoil excavation limits shown on the plan view
since it will vary from 25 feet along the road and Lot 43 side of
the trenches.
Thank you for your cooperation in this matter.
NEVE.LE5
Very truly yours,
MARCHIONDA &
Town of North Andover
SOIL PROPILE & PF:,RCOl,A"F10N TFST DATA
Town/City k'14A.qCVa Ind o.&Street_ j,�40 Lot No. 444
Loc. Plan Owner
:Investigator Observer
Soil, PROFIIJES --DATE
El'ev. 2' Elev. 3. Elev. 4 Elev.
0 0 0 0
if
2 2
3: 3 3 3
4
,',cls �7 4 4
1. 5 5 5
6 1�jk 6 6
.7, 7. 7
8 8
9 9
10 10
Benchmark Location_
„Elevation Datum
Percolation Tests -Date
Pit Number l 2
4
5
6
7
8
9
10
-Notes & Sketches on Back
3
4
5
Start Saturation
Soak -iqlns.
Start Test -Time
Dr2_p of 3" -Time
t
Mins -.12nd 3"Drop
-Notes & Sketches on Back
April 17, 1990
THO
Board of Health
120 Main Street
North Andover, MA 01945
Re: Lot 44 Jerad Place
Dear Sirs
EVE
INC.
I have reviewed the changes you have requested, and all adjustments
have been made. However, I do not understand which catch basin you
are referring to that is 7 feet from the leach area. Enclosed is
a copy of the Interim "As -Built" Plan of Jerad Place II, on which
I have sketched the leach area.
Also, the rear area of the trenches has been regraded so that the
system will no longer be located in the hillside. Therefore, I
feel that the deep hole that you requested is no longer necessary.
Thank you for your time.
Very truly yours,
THOMAS E. E ASSOCIATES, INC.
Thomas E. Neve, P.E., P.L.S.
President
• ENGINEERS • • LAND SURVEYORS • • LAND USE PLANNERS •
447 Old Boston Road U.S. Route #1 Topsfield, MA 01983
(508) 887-8586 FAX (508) 887-3480
.. 1 m
BOARD OF HEALTH
120 MAIN STREET TEL: 682-6483
NORTH ANDOVER, MASS. 01845 April 3, 1990
tj32 or 33
Thomas E. Neve Associates, Inc.
447 Old Boston Rd.
Topsfield, MA.
RE: Lot 44 Jerad Place
Dear Sirs,
We have reviewed your plans and feel that the following
comments must be addressed before an approval can be granted:
— The slope shown does not meet title b
— The Leach area is 7 ft. from the catch basin (note: the
catch basin is at a lower elevation.
— Inforwat.ion needed:
a) The 0 ft excavation around the leach area should be
shown . zS
b/ b) Plan shwa;d show how o1 tpn the pump will go on, each day.
I must also request that you do a deep hole on the high side of
the hill to determine where the ground water is. phis in a
concern because of where the trenches will be placed in the
hillside.
A
RECE vEU Ajt 1.1 SM
IL
9
BOARD OF HEALTH
120 MAIN STREET TEL: 682-6483
NORTH ANDOVER, MASS. 01845 Apri 1 3, 1 Ext. 32 or 33
Thomas E. Neve Associates, Inc.
447 Old Boston Rd.
Topsfield, MA.
RE: Lot 44 Jerad Place
Dear, Sirs,
We have reviewed your plans and feel tI)at the iolicwir•qg
comments must be addressed befurr-� -in approval carr be granted:
- The slope shown does not meet title -J�
- The Leach area is 7 ft. from the catch basin (note: tyre
catch basin is at a lower, C�levaticlrr.
- Infor(,ja::+c.:t,-lr, needed.-
a)
eeded:a) The lf� ft excavation aroured the lf-�ach area should be
shown. ZS
b/ b) Plan show hQw of to -Il the pL11111.) ani 11 go on each day.
I must also request that you do a deep Bole on the high side of
the hill to determine where the gt%ound water- i=_;. 111is is-; .i
concern because of where t I ire t r•enches will be Placed ire the
ie
hillside.
n
---
RECEJVZ�U Ajt 1.1 SW
April 3, 1990
Thomas E. Neve Associates, Inc.
447 Old Boston Rd.
Topsfield, MA.
RE: Lot 44 Jerad Place
Dear Sirs,
We have reviewed your plans and feel that the following
comments must be addressed before an approval can be granted:
- The slope shown does not meet title 5.
- The Leach area is 7 ft. from the catch basin (note: the
catch basin is at a lower elavation.
Information needed:
a) The 10 ft excavation around the leach area should be
shown.
b) Plan should show how oftOn the pump will go on each day.
I must also request that you do a deep hole on the high side of
the hill to determine where the ground water is.
concern because of where the trenches will be placed sin1the
hillside.
Commonwealth of Mossachusetss
Massachusetts
System Pumping Record
Location
Type: Emergency � Routine
Cesspool: No (/ Yes
Date of Pumping:
System Pumped By: Wind Over Env w)mentoi, LLC
Form 4 -- System Pumping Record
Septic tank: Wo =Yes E /
Quantity Pumped: i 5;()�3 Gallons
Permit 7t:
Contents transferred to:
r � r
Contents Disposed at:
f LAoq
Date:
of System/Other Comments
Pumper Signature:
Dep Approved Form - 12/07/95
Type: Em
Cesspool: No
Date of Pumping:
System Pumped By:
Contents transferred to:
Commonwealth of Massaehusetss
Routine
Yes
Wind River Environmental, LLC
Massachusetts
System Pumping Record
Location
Form 4 -- System Pumping Record
/f
Septic tank: No =Yes
Quan" Pumped: ao 0j"j Gallons
Permit #:
Contents Disposed at:
E"C?s -f"-774
Date: /— ?-6 Pumper Signature:
Condition of System/Other Comments
Dep Approved Form - 12/07/95
CURRIEA
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978) 774-2772
Y
FORM 4 - SYSTEM PUMPING RECORD
COMMONWEALTH OF MASSACHUSETTS
--ZiL Aldo ./ e /-- , MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNER:
v- c0 we (C
�s )AVed P(
da ve
SYSTEM LOCATION:
Cl LA s -C
C)
DATE OF PUMPING: j D v QUANTITY PUMPED
CESSPOOL: NO YES [_�] SEPTIC TANK:
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO: � S
a S GALLONS
NO 0 YES [ -
DATE: ,S / � p v
INSPECTOR: � ,,t
107 Forest St. �N FORM 4 - SYSTEM PLTN PNG UC
Middleton, MA 01949 SRP'
(508) 774-2772
Commonwealth
of Massachusetts
Massachusetts
SH&W Pumping Record
ystem Wmer
�9��.�1
(A
�0� y
oybmai i ocation
o, Y,:1R 0( /0 ' d
tin e�
Date of Pumping: 37^ 2 5� 23' a
p Quantity Pumped' allons
Cesspool: No ❑ Yes ❑ Septic Tank,: No ❑ Yes
System Pumped by: C &A k.
Contents transferred to: --!_
License #:::
Commonwealth of Massachusetss
Massachusetts
System Pumping Record
Type: Emergency Routine
Cesspool: w Yes
Date of Pumping:
System Pumped By: Wind River Environmental, LLC
Contents transferred to:
tocatfon
L
Form 4 -- System Pumping Record
("I /JP/ �f
�r
Septic tank: No MYes F7EI/
Quantity Pumped: Z 5n Gallons
Permit it:
Contents Disposed at:
Date: Pumper Signature:
a �
Condition of System/Other Comments
RECEIVED
AUG 0 4 2004
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Dep Approved Form - 12/07/95
Type: Em
Cesspool: No
Date of Pumping:
System Pumped By:
Contents transferred to:
Contents Disposed at:
Date:
Commonwealth of Massachusetss
: Massachusetts
System Pumoina Record
Location
Form 4 -System Pumping Record
v .
Routine
Yes Septic tank: No Ycs
Quantity Pumped: Ions
Wind River Environnrento% LLC
of System/Other Comments
Dep Approved FmM - 12/07/95
Permit #:
_.� Commonwealth of Massachusetts
City/Town of NORTH ANDOVE ,
- System Pumping Record
(\�Form 4
DEP has provided this form for use by local Boa a�
be submitted to the local Board of Health or oth -f
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
4(„a
A. Facility Information
1
System Location:
Addr W
6 A & Clot) 111111
Cityrrow
2. System Owner:
Name
i j We n
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
�17UETTS \1
v
OCT 0 4 2009
State
Pumping Record must
a s.
Zip Code
State Zip Code
_q.�i�- X85 -900`f
Telephone Number
Date _ l - 2. Quantity Pumped
500
Gallons
Cesspool(s) [' Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes dNo If yes, was it cleaned? ❑ Yes [2/No
5. Condition of System:
G o c)�
6. System Pumped By:
Na e Vehicle License Number
Company
7. Location where contents were disposed: Ipswich Wate ,
Treatment Pla
-- Ipswich, ISA 01 ,,oj —
Signature of Hauler Date
http://www.mass.gov/`dep/water/approvals/t5forms.htm#inspect
t5form4.doc• 06/03 System Pumping Record - Page 1 of 1
� Commonwealth of Massachusetts
MOM _ City/Town of
System Pumping Record NORTH ANDD
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 310 CMR 15.351.
rZ1.10 -0 Zola
NORTH ANDOVER
IMPARTMENT
Stat ------- -- - Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumpingf�l 2. Quantity Pumped: Gallons
� - ---
Date
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? es ❑ No
5. Condition of S tem:
6. System Pumped By:
Name
Company
7. Location where contents were disposed:
1
Signature of Hauler
Signature of Receiving Facility
If yes, was it cleaned? es ❑ No
Vehicle License Number
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
A. Facility Information
Important:
When filling out
forms on the
1. System Location:
computer, useonly
the tab key
to move your
cursor - do not
Address
use the return
ity/Town
key.
2 System Owner: _
Name
Address (if different from location) ---
City/Town - ------ — ---
Stat ------- -- - Zip Code
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumpingf�l 2. Quantity Pumped: Gallons
� - ---
Date
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? es ❑ No
5. Condition of S tem:
6. System Pumped By:
Name
Company
7. Location where contents were disposed:
1
Signature of Hauler
Signature of Receiving Facility
If yes, was it cleaned? es ❑ No
Vehicle License Number
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
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. More using this form, check with your
local Board of Health to determine the form they use. The System Pumping Reoord must be submitted to
the kxA1 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:
"w filling out
1.
System Location:forms _?1CACC_
r
on
I
computer, use
Only Me tab key
to ff W#* your
Address
jot-A�) And crvu
OPNOWH MDOVGR
=HL' A L(;T H9PARTMENT (
cursor - do nol
use the return
Cityrrown
Stale zip Code
key.
2.
System owner -
Li
Name
Address (if diffoent from location)
(5t_y1TGVM
State Zip Coe
Telephone Number
B. Pumping Record
1.
Date of Pumping2.
Date
Quantity Pumped:
Gallons
3.
Type of system: El Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
El Other (describe):
4
Effluent Tee Filter present? L] Yes SyNo
it yes, was it cleaned? Q Yes @/No
5.
Condition of System:
S. System -Pumped By -
Name
Vehicle Licenset4umuer
W1 11 j — -_ .- _. . - — - —
-dompany
7. Location Where contents were disposed:
NW* AMovtr, M A -
!�1—goOr"f Hauler Date
-6g—natu—teof _Receiv_ingFaciU't_VDate
15fortnCdoc- 03106 System Pumping Re;o(d - Page 1 of I
Commonwealth of Massachusetts;;•,',:V U
City/To
wn of
System Pumping Record NORTH ANDOVER CE" X012
Form 4 TOWN OF NORTH ANDOVER
ti �MEALTH DEPARTVENT
DEP has provided this form fqr use by local Boards of Health. Other forms may be -used, but ttie
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 on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
-1�
1. System Location: ::�� Po
Address
CityrFown - ---
2. System Owner:
Name----- ----..._— ---- --
Address (if different iron location)
City/Town
?�/5"-
Zip Code
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gaiions
,.,�
3 Type of system: ElCesspool(s) [ Septic.Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - — — -
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
If yes, was it cleaned? ❑ Yes ❑ No
6. System Pumped By:
/4;7G C C -
Name Vehicle License Number
Company
7. Location where contents were disposed:
Si__gnature_ of _HaulNo�tAndover MA --- -- __ - -.
er
-------- _---- --
Signature of Receiving Facility Date
t5form4.doc• 03/06 System Pumping Record - Page 1 of 1