HomeMy WebLinkAboutMiscellaneous - 259 CAMPBELL ROAD 4/30/2018m
r _-
Commonweaith of Massa c uset s
City/Town of /v� , a
System Pumping Record
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
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
nb
rerun
1
la�
City/Town
tate
Zip Code
2. Syste Owner:
&v -i-,1
el
Name
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 2 e y 2. Quantity Pumped:
dMons
3. Type of system: ' ❑ Cesspool(s) P, Septic Tank
❑ Tight Tank
❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [/No
5. Co Ilion of'System: c
ke4fIt' ;0lj
6. System Pumped
Name
Stewart's Septic Servi
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill
Signature of Hauler
Signature of Receiving Facility
t5form4.doc• 03/06
If yes, was it cleaned? ❑ Yes ❑ No
i' ryr�
Vehicle License Number
Ma 01835
Date
Date `
Syste 'Pumping Record • Page 1 of 1
y`
f' L
achusetts
rd.
DEP has provided this form for use by local Boards of Health.
be submitted to the local Board of Health or other approving I
A: Facility Information
important: --
1. System Location:
faints on ft
oWy Ow tab Use
Address
to move Your
cufior • db not -Ck/Town
use the few
key'...• 2. System Owner
State
C
DEC I � 2010
m Pumpjng Record ust
N OF NORTH ANDOVER
Zlp Code
Name -- V
Address (If different from IocaUon)
Ci0vrrl State Zip Code
Telephone Number
B. Pumping Record (5
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ other (describe):
4. Effluent Teo Filter present? ❑ Yes (D NoIf Yes, was it cleaned? ❑Yes ❑ No
5. Condition of System:
6. 8YAtem Pumped By: /
Vehicle Ucense Number
7. Lo tlofil tt@re contents were disposed:
A, n v
Date
m.ms.gov/deroval orms.htm#inspect
t5fomA.dw 06103 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
- System Pumping Record
4
Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
DEP has provided this form for use by local Boards of Health. The Sy tem Mping Record m
be submitted to the local Board of Health or other approving authority
A. Facility Information
1. System Location:
1.1:215
Address
City/Town
2. System Owner:
Name
tuutcss to onrerem Trom iocatlon)
City/Town
State
TOWN HEALTH DEPARTMENTER
Zip Code
State Zip Code
97
Telephone Number
3. Pumping Record
Date of Pumping Date 2. Quantity Pumped
Type of system: ❑ Cesspool(s) eptic Tank
❑ Other (describe):
Effluent Tee Filter present? ❑ Yes*—o
Condition of System:
Ilons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
6. System Pumped By:
�n �,o�c �A.01
NameCC- � / Vehicle License Number
CAI
Company
7. Location where contents were di
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
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9
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make applic��tion for a permit for a sewage disposal installation at
. I will install this system in ac-
cordance with 1 the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%6. I will install a con-
crete septic tank of Ze-c- v in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of ';Z C-0 lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that ma be attached to the permit. Plot Plans must be submitted with application.
DATE 4L - oZ S-- -7 d
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE ?7,)
7,) - -7 d
Signa ure of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE t
Signature of Inspecting Officer
Percolation Test
Garbage Grinder
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
1. NAME J o s c p � R. C'+ 'A f DATE � � � 0 � J U
2. ADDRESS 'L v M C^c' y i I j� F' ` 'LOT NO. TEL.
3. NO. OF BEDROOMS DEN YES NO '<
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE 8425/70
NAME OF APPLICANT Joseph Gaudet
LOCATION Lot #1 Campbell Road
Address of lot no,
BUILDING: Dwelling X Other
SYSTEM: New X Repair
GENERAL DESCRIPTION OF LAND high
SUBSOIL: Clay Gravel SandaOlay X`
PERCOLATION TEST 6 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK I nno gallon capacity.
LEACH FIELD 20D lineal feet of drain pipe.
William J, Driscoll, Engineer
Board of Health
Board of Health
:forth ADi 0V82'i�iBaD.
smic STSTEK
INSTA=TICK CMDA LIST
easonst
LOT -�-
TLrffa
MX AVVATICH Og FAIL
1. Distance Toi
a. Wetlands
b. Drains
c.. Well
2. Water Line Location
3. No PVC Pipe
4. Septic Tank
a. _Tees -_Length & To Clean Out Coversb. Cement Pipe to Tank - On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
c. No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth.
c: Capped Ends
d. Clean Double Washed Stone
7. Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tees
e. Cant Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. -nnal Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b'. Dimensions of System
C'. Location with Regard -to Pere Test
d. Elevations
e.' Water Table
%-z:::)�
11
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SOIL"£89 3NOHd3l31
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BOARD Or NF.Ai,Tli
No . Andoue r , 'viaU s .
SUBSURFACE DISPOSAL DESIGN CHECK LIST
APPROVED DATE
Provided:
I. goad wr 5olt 4� i��PGpc o�
10 14 jgn%/VT TR ENGtj6_5
Z, TJ NCAXH S MvST TSE $ ' 4jW
101-teN CO 51 RU
Title V FAIL
Reg 2.5
Reg 6
Reg 10.2
Reg 10.4
N F
DISAPPROVED
Reasons:
DATE 1
SCC
LOT # I C%M PLa
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 do 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' 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 100' of sesage disposal
system or disclaimer -Planning Hoard files
known sources of water supply within 2001 of sewage disposal «
system or disclaimer
;k) location of any proposed well to serve lot -1001 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
Septic Tanks
a) capacities -15U of flow, water table, tees: depth of tees,
access, pupping
b) cleanout
c) 10, from cellar wall or inground swima3ng pool
d) 251 from subsurface drains
Distribution Boxes
a) -slope greater than.0.08
b) sump
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BOARD OF HEALTH ^
No.Andover, Mass. y
APPROVED - DATE__
Provided:
SUBSURFACE DISPOSAL DESIGN CHECK LIST
DISAPPROVED DATE_, _
Reasons:
LOT J
Title V FAIL OK - - - -
Reg 2.5 [The submitted plan must show as a minimum.
a) the lot to be served -area, dimensions lot #,abutters
blocation and log deep observation hole:,, -distance to ties
c location and results percolation testa- distanceAo 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 1001 of sewage disposal system or
disclaimer -check wetlands mapping
(h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i) location any drainage easements within 1001 of sewage disposal
en
system or disclaimer. -Planning Board files
(j) known sources of Water supply within 2001 of sewage disposal e .
system or disclaimer
(k) location of any proposed well to sere: lot -1001 from leaching facility
(1) location of water lines on property -1•j1 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 basem nt, plumb, pipe, septic tank,
distribution box inlets and outlet_ -t, 'istribution field piping and
Other elevations
(r) maximum ground water elevation in area zewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare'such plans
Reg 6 Septic Tanks
(a) capacities -1507, of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground swimming pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
1(a) slope greater Man 0.08
Reg 10.11 L b) ,P
jjj? Y R i
I .r • ,
14
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Commonwealth of Massachusetts
W City/Town of No.Andover
a System Pumping Record
4,,M SV 9 y`v
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.
A. Facility Information " UMVED
Important:
When filling out 1. System L fon: C`,%' 1 Q 2011
forms on the 0-b-2 P I A / U
computer, use Vim- TOW r
only the tab key Address I HEALTH DEPARTMENT
to move your
cursor - do not No.Andover Ma 018
use the return Cityrrown State Zip Code
key. 2 System Owner:
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record v -)�'S-08l
1. Date of Pumping ate 2. Quantity Pumped: Gallons
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: 67�ef) J
6. S m Pumped By:
Na e
Stewart's Septic Service
Company
7. Location where contents were disposed:
Vehicle License Number
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date 0
/ 2
Signature of Receivin acili Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
N City/Town of North Andover
a w° System Pumping Record
,1jy SV B p
Form 4
f
21 2012
N
TO'f'N OF NORT4 ANDOVER
HEALTH DEPt'RT70ENT
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
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
L
�enrm
System Location:
umpWV,
Address
North Andover Ma
City/Town State
System Owner:
Name
Address (if different from location)
01845
Zip Code
City/Town State
Telephone Number
Zip Code
B. Pumping Record
/ a
v
/
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Grease Trap
El Other (describe):
4. Effluent Tee Filter present? ❑ Yes 2*'No If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System: X
6. tem Pumped By:
11) Ue ur�e
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
(Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
J
Signature Haul
Signat of Receiving Facility
161d;lL /id,
Date 16Z;hd
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
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ING RECORD
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