HomeMy WebLinkAboutMiscellaneous - 266 LACY STREET 4/30/2018Cl)
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Commonwealth of Ma,,§sachusetts
City/Town of North Andover
System Pumping Record
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.
City/'Town
State
RECEIVED
JUL 13 2015
Zip,.Code
TOWN OF NORTH p! 4 L�UV�R
HEALTH OEPART�,;EIINIT
Telephone Number
Zip Code
B. Pumping Record,
1. Date of Pumping 2 Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) [VISeptic Tank Ej Tight Tank F1 Grease Trap
[I Other (describe) -
4. Effluent Tee Filter present? F1 Yes F] No If yes, was i -t cleaned? 0 Yes R No
5. Condition of System: R
6. SyztenTPU`Mn-e-ff
Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Date
Signature of Receiving Facility Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
A. Facility Information
Important: When
filling out forms
on the computer,
use only the tab
I System Location:
CL
key to move your
Address
cursor - do not
use the return
North Andover
key.
City[Town State
2. System Owner:
Name
Address (if different from location)
City/'Town
State
RECEIVED
JUL 13 2015
Zip,.Code
TOWN OF NORTH p! 4 L�UV�R
HEALTH OEPART�,;EIINIT
Telephone Number
Zip Code
B. Pumping Record,
1. Date of Pumping 2 Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) [VISeptic Tank Ej Tight Tank F1 Grease Trap
[I Other (describe) -
4. Effluent Tee Filter present? F1 Yes F] No If yes, was i -t cleaned? 0 Yes R No
5. Condition of System: R
6. SyztenTPU`Mn-e-ff
Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Date
Signature of Receiving Facility Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts
CityfTown of No Andover
System Pumping Record
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. — _"wO7
F _R_F__C E I _V E 0
A. Facility Information
Important: When
filling out forms
on the computer,
use only the tab
key to move your
ettrzor - do not
use the return
key.
2
System Location:
,-,3 60 6 LP - q 57"
APR r) 9 2014
V
TOWN OF: NORTH ANDOVER
HFALTH DEPARTMENT
Address
No Andover Ma
Cityrrown State
System Owner:
Name
Address (if different from location)
Cityrrown
State
Telephone Number
B. Pumping Record
1. Date of Pumping (�)La�) /1 2. Quantity Pumped:
Date
3. Type of system: El Cesspool(s) [;�-5eptic Tank El Tight Tank
Ej Other (describe):
4. Effluent Tee Filter present? n Yes Ej No
5. Condition of System:
6. Sy�t�m Pumped By
Name�
Stewart's Ser)tic Service
Company
7. Location where contents were disposed
Zip Code
Zip Code
wi
Gallons
El Grease Trap
If yes, was it cleaned? n Yes 0 No
Vehicle License Number
Stewart's PreAreatment Pl�j��ill Bradford, Ma 01835
6 nalu �eH
'g
'tu
2:: S �_ign re of R,�ceVing =F�aility
t5form4.doc- 03/06
Date
Date
System Pumping Record - Page 1 of 1
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<�\_ Commonwealth of Massachusetts
City/Town of No.Andover
System Pumping Record
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 CIVIR 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.
VE]
A. Facility Information
1 . System Location:
;7_1 tit
Address
No.Andover
City/Town
2. System Owner:
Name
"_�Cnr�j
Address (if different from location)
City/Town
Ma
State
TOWN OF NORTH ANDOVER
State Zip Code
Telephone Number
B. Pumping Record,
1. Date of Pumping I Date antity Pumped: Oallons
3. Type of system: El Cesspool(s) �Septic Tank 0 Tight Tank D Grease Trap
F-1 Other (describe):
4. Effluent Tee Filter present? Yes 0 If yes, was it cleaned? El Yes El No
5. Con it' n of S em:
6. Syst2alF5,VMped By:
Service
P 7—
Vela6cle License Number
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
A
Signatu rf
_§ignaturVRe*iving Facility
Dat 73 - /3
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
T 11
SACHUSETTS
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:,:c DEP,hai OrdVidid Olfform'foru'sb by local Boards of He' MprWQ-R"
alth. he S stem
t� the.106al'Board of Health or other approving &L orl )rd must
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ks
O�;
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(if Offeront from loc"on)
Qltyffowiv
State nA
zi
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Telephone Number
—Ord
00�
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3,21
Dat
Wofftrn nq 2. Opi
antIty Pumped:
Gallons,
'Pate
f
9 Cess000l(s) n—leptic Tank Tight Tank
Other (desc.rIb.#':,.`.i
T.' '-I"4'!ie`:sent?-;13 - Ye S. B IN _� If yes, was It cleaned? Yes No
..ht eeFlIterp...,
e
VenIC44 uGen44 Number
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OCS QkWhore. WOr,� pposed:
NIP,
up
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Date
System Pumping Record , Page i of I
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Fortri 4
DEP has provided this form for use by local Boards: of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility InformAtion
Important:
When filling out 1. Syste L cation -
forms on the
computer, use
only the tab key Address
to move your
cursor - do not
use the return City/Town State
key. Zip Code
2.. System, Owner:
Name
Address (if different from location)
City/Town 1p Code'
Sta Zi
(0 L4 —3 a
Telephone Number
13. Pumping Redord
1. Dateof Pumping -6ate 2. Quantity: Pumped:
Gallons
3. Type of system: Cesspool(s)
.9-9-eptic Tank 11 TightTank
El Other (describe):
4. Effluent Tee. Filter present? El Yes If yet, was it cleaned? E] Yet- El No
.5. Con 'ti of System:
Ise)
UA I
A D
RECEI
To ty DEC 0 6 2005
OF NORTI
LT P�
�YST,Bm pumplNu "
OF NORTH ANDOVER
HEALTH DEPARTMENT
3s -
TITY
A:20
rvxu op
YvLl (,Q cc)
M000ac)
K4,jpij�j
rm tyo
N"
T _N OF NORTH ANDOVER
OW 'x
SYSTEM PUMPING R-ECORD" 10>
DATE:
STEM OWNER & ADDRESS
D..�TE 0 F PUMPING:
SYSTEM LOCATION
(example: left front of house)
in 6
QUANTITY PUMPED/&o,-d' GALLONS
PO 0 L: N 0 YES SEPTIC TANK: NO
NATURE OF SERVICE: ROUTINE—// EMERGENCY
B.S F R V *ATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
'-.)'TE.M P U M P E D B Y:
CUNI.�/l E N T S:
(.UNTENTS TRANSFERREDTO:
Y E S
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OAHER (EXPLAIN)
�/"Y,�, L� - vv //."
North Andover Board of Health
120 Main St.
North Andover Ma.01845
Haul Lic. #151 -OOH
Install Lic. # 128-0
Date Address
11/1/2000 303 Chester St
11/1/2000 50 Willow Rd
11/1/2000 160 Carelton Ln
11/1/2000 165 Bridal Path
11/4/2000 174 Ingals St
11/4/2000 1062 Salem St
11/6/2000 373 Raligh Tavern Ln
11/6/2000 252 Boxford St
11/6/2000 150 Liberty St
11/6/2000 149 Osgood St
11/7/2000 255 Haymeadow
11/7/2000 850 Winter St
11/8/2000 25 Windsor Ln
11/9/2000 249 Carlton Ln
11/9/2000 767 Johnson St
11/10/2000 56 Academy Rd
11/14/2000 Sugar Cane Ln
11/14/2000 250 Abbott St
11/15/2000 195 Winter St
11 /15/2000 187 Winter St
11/16/2000 85 Laconia Cir
11/16/2000 86 Willow Ridge
11/17/2000 2135 Turnpike St
11/20/2000 203 Grandville Ln
11/20/2000 391 Pleasant St
11/20/2000 124 Tucker Farm Rd
11/22/2000 394 Boston Rd
11/22/2000 728 Forest St
11/22/2000 18 Johnney Cake St
11/24/2000 106 Rockey Brook Rd
11/24/2000 258 Rea St
11/28/2000 1815 Great Pond Rd
11/28/2000 1420 Great Pond Rd
11/29/2000 266 Lacy St
11129/2000 155 Laconia Cir
Andover Septic
47 Railroad St.
Bradford Ma. 01835
Gallons Comments
1000
1000
1500
1500
1000
1250
1000
1000 Leachfield Run Back Ex. Solids
1500
1000
1500
1250
1500
1500
1500
1500
1500
1000 Extra Solids
1500
1500
1500
1000
1500
1000 Flooded
1500
1500
1500
1500
1500
1500
1000
1000
1500
1000
1500
sit
-APPR OV FM
Date:
1.
N OR TH A-1,TDOV-PM BOARD OF IFAL TH
CHELK LIST
DISAPPROV7M
Date: s Oof7g_
Reason-!-',
1 Lot location., dimensions of system location in regard to
u .
percolation tests., depth of system3 water table
EXCAVATIOIN OK
2. Dista7Z Wetland Areas, Drains., Street & House, Drainage Easement and Wells.
3. Wat/Line Location
4.
No ip e
/P
'A,IAI
5.
Sep
Tees,, Cem
e to Tank -Joints on both side of Tank.
6.
Dis t;pelion
Box No'cracks
in box or cover., all lines flow erually from box.
7. Leach/elds - Dimensions th Cajoped ends., Clean double -i-!-__-h-_d stone
Stone Dept s.,
8. Leach Pits - Dimensions., Depth of Stone, Splash pad�tees., Cement -pipe to tank -
joints. on both sides of tank -2 Clean double-irashed stone
10.
No �/age Disposals
Fin/Grading *"�'barricading of sub -surface system'�
th, rq
by A tta , �r- - . AzIme
/h. "e'�'P-eea, Se-,P-tftbe,, 7,
'Scott Fo e g,d 'te"'4t f "A2te4 797.-
ttanz bee. 01
tvet4
WELL DRILLING
REPAIRING
REDEVELOPING
03-893-6793
MUNICIPAL
INDUSTRIAL
DOMESTIC
617-452-3682 *
November 25, 1977
Scott Proper -ties, Inc.
35 Center Street
Burlington, Massachusetts 01803
Gentlemen:
The following is a report of water wells completed and water analysis reports
on these wells on Lacey Street, No. Andover, Mass.:
e4 to t.
B. & H. Drilling Company
Jack Halliday
Water
Iron
tem
Lot#
Depth
ScreenSize
G.P.M.
Vacuum
L—evel
Content
PH
Coliform
1.
1
141
25 Slot
40
22"
41
.02 ppm
6.2
0
2.
2
2 1'
30 Slot
16
2311
61
.02ppm
6.2
0
3.
3
2 V
20 Slot
13
2011
61
.02pp.m
6.2
0
4.
4
22'
30 Slot
15
12"
61
.02ppm
6.2
0
5.
5
19,
30.Slot
12
16"
69
.02ppm
6.2
0
6.
6
21'
20 Slot
10
2011
61
.02ppm
6.2
0
7.
10
281
15 Slot
10
2311
91
.02ppm
6.2
0
e4 to t.
B. & H. Drilling Company
Jack Halliday
NORTH AIWVM BOARD OF IMLTH
—INSTALLATION CHMK : LIST
APPROUD DI SAPPROVED
Date: Z5:/
Reason:
1. As Biiilt Mitted
Cht /k:-. Lot location, dimensions ' of system, location in regard to
percolation tests, depth of system,, water table
5
EXCAVATION OK
2. Distance to Wetland Areas, Drains, Street & H�use., Drainage Easement and Wells.
3. W er Line Location
4. No P ip e
P
_>ai-_ik vo
5. (`Se;__c___Tarnk, Te Cement-Pil� �OT -Joints on both side of Tank.
on both s
d 0 ��n
k*
— / et
6. Distribution" Box cracks n cover, lines flow e ua from
Cl a
7 elds Di� on s Stone Dep� �s Clean dou e- bed stone
C app)��
d t
8. Leach Pits Dimensions, Depth of Stone, Splash pad� tees., Cement -pipe to tank -
joints on both sides of tank., Clean double-was'ned stone
Ga
9. No . /age' Disposal.s
10. CFQ1 Gra�(�ng �',bar�ric ystem),
C'3 .1?L1
_J '�
h—
TO: NORTH ANDOVER, MASS 7 19 7
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
A e Y S7— North Andover, Mass.
SITE KOCATION
The grades and construction are as specified in my plans and specifications dated
19—
OF P44,
0 s.o
6!
JOSEPH
A
i1krian
G�
"CIVAL S'�'
46
4,Z
�S Ilk 7 17 7
77 N G
I
ZA CY S Tiq 1",t'T
JOSEPH
i I
A L 1- 0
1,54
Is
ox //V
/0/
Jcl-ao
46
4,Z
�S Ilk 7 17 7
77 N G
I
ZA CY S Tiq 1",t'T
JOSEPH
i I
A L 1- 0
1,54
Is
SOIL PROFILE & PERCOLATION TEST DATA
olo ae,—
Town/City,_ No.&Street Z0rt.4 Lot No._/8
Loc./Subdiv. Plan Owner or
Investigator Observer
\j SOIL PROFILES -DATE
N
1 . Elev.
0 �// 9�7 7 0
3
4
6
7
E
P'�4
3
4
5
6
7
8
9
2. Elev.
A
11—
2
3
4
5
6
7
8
9
3. Elev.
0
1 i I �_
2
3
4
5
6
7
8
9
10 L__
--A 10 10 10
Benchmark Location
Elevation Da.tum
Percolation Tests -Date
:77, 1.?7,7,7
4. -Elev.
Pit Number 2 3 4 5
Start Saturation
Soak -Mins.
Start Test -Time
Drop of 311 -Time
Drop of 611 -Time
Mins.lst 3"Drop
Mins.2nd 3"Drop
ijores & -�iKetcnes on Back Frank C. Gelinas & Associates, North And.
Z- / A/ Z --
--------------
Ir
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WELL DATABASE
AJDDRESS:
AGE OF
WELL DRILLE:R.- /00
"WELL LCCA71ON:
�WELL PER�.ETDATE:- DE -27111 OF WST
--=EOFIW-ELL-- a- DRIl= b. DUG
I MJE:oFWA=BEA2,ING ROCK -
WA= ANNA= DA=- LT
SE. y
y y N
W—HI-L IDA=,�LBASE
ADDRESS: --L-2L(- /- Y��
U
AGE OF IN= V�=L DP=ElL-
WELL PERM71 r4: WELL LCCATTC�
NE DEP7H 01
WELL PE� 1 T
TYPE OF WELL: a- DRJLLED b. UG
TYPE OF WATE.RBEAR2qG ROCK.
WATERAINALYSIS DATE: -ES': Y N
I-HGH MANGAN
IEGH IRON: Y N OT= CONTA-NMNA-NTS: y IN
I
TOWN OFNOP4,TH ANDOVER
SYSTEM PUMPING RECORD
DATE
SYSTEM OWNER & ADDRESS
6 ecv-1
62 �6
SYSTEM LOCATION
DATE OF PUMPING -3 QUANTTTY PUNTED IQVI<5�
-AIM116
CESSPOOL NO YES SEPTICTANK No YES
NATURE OF SERVICE;-, I EMERGENCY
OBSERVATIONS:
GOOD CONDITION __.qL FULL TO COVER
BFAVY GREASE BAFFLES IN LACE
ROOTS LEACBFIELD RUNBACK
EXCESSIVE SOLIDS -FLOODED
SOLID CARRYOVER
OTBER, EXPLAIN
SYSTEM PUNTED BY
—7"
COMMENTS:
i
F40WN OF NORTH ANDOVER
S4 y
L)All- 11�7-,I/JA STEM FUMPINQ R.ECOR-1.)
�YS 'M OWNER & Ar
(3t
-j�o
DATE OF PU4
a y a I r.M LOCAT-ION
so 0 1 /;�7n -�-
-Q(-)ANTITY PUMPED:..—
C I v
NOV - 3 2004
TOWN OF NORTH ANDO�
HEALTH DEPARTMEN
CLSSPOOL: NO SOPtic 1'ank: NO_ YES L --
NA rURE OF SERVICE: K0U'rINE
ObSERVATIONS:
000D CONDI'FION �e� -ro COVER
HEAVY OREASE BAFRES IN PLACL
ROOTS LEA-CHFIFLD RUNBACK
8XCESSIVE SOLIDS'-- FLOODED
SOLID CAKRYOVER, ...... OTWER EXPLAIN
SysLoM pwnp'c'j
Z?l
C�o
�:UMMENTS.
L�UN I't�N I'S r'KAN8k'bKR.6D FU
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in
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to Moye YQUI
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MAY 0 9 2008
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System PUMPIng Rscor� - P;�e 1
AMA
xe
4
DER
.hai Provide
d 01*'for
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be SubMI(te'd to thOJOCA!'Board of Health or other approYing
�A C I I I ty.
Infofifttlon
in
M4n* NLIQ out I SYSterin L6UUon:'-':_
the tab ke y Moms
to Moye YQUI
0.4w, do not
owner.,
4=
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-Ad
drou (If dIfferont from
loc4uo)
4`
Mn1n&;P' 'n r
State
MAY 0 9 2008
OFNORTH
"M ------------
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To 1-0 p —ho—n, s N w m b —or
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0.4
x
iQ
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3 Cos p 0
s 0 1(s) optic Tank T19
htTank
jOther(de d
.,K:,-
prgs Y
Tioi Flite' on t?". 0 as If yes, Was It 6ileanied?
40 'Y" CD Yes C1 No
Oe
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4
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n
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t6fWM.dOv OtVQ3
Miff Nufter
OlVehId
corc rn_�
System PUMPIng Rscor� - P;�e 1
Important
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Ion
Commonwealth of Massachusetts
City/Town of rE—CEFVED
System Pumping Record ',.% � %d
'_ t4 1 1) all
Form 4 TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of HealthjgjhhtkakgF4�� 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
1. Systern Location:
North Andover
Cityrrown
2. System Owner. r-)
Name
Address (if different from
Cityrrown
ma 01886
state Zip Code
State
Telephone Number
Zip Code
B. Pumping Record 13. C"� - /0 &Y Y--)
1. Date of Pumping Date 2. Quantity Pumped: Gailrons-
3. Type of system: cesspooi(s) septc Tank [I Tight Tank El Grease Trap
[I Other (describe):
4. Effluent Tee Filter present? [I Yes 0 No If yes, was it cleaned? 0 Yes 0 No
5. Condition of System:
6. Syqtem Pumped gy:
Name
Stewart SeDtic Service
Company
7. Location where contents were disposed:
Vehicle Uoense Number
St.hArts Pre treatment/Oant 20 So. Mill St, Bradford Ma 01835
/A - /jj k I a, (�)- - / 0
SWItdr9of Flauler— / r - Date
Signature of Receiving Facility
Date
t5foffn4.doc- 03/06 System Pumping Record - Page 1 of 1