HomeMy WebLinkAboutMiscellaneous - 285 CANDLESTICK ROAD 4/30/2018 (2)ki
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M Ap # LOT # V c/
. . ........ a . ..... . . ...........
PARCEL 4 STREET .. ........
. . . . . . . . ................ ......... .
HAS PLAN REVIEW FEE BEEN PAID? Ily �s NO
/0 - / "4��
PLAN APPROVAL: DATE , 2
14SZ4C43 APP. BY..
DESIGNER: PLAN DATE P0611 frl4tj
CONDITIONS
WATER SUPPLY: WELL
WELL PERMIT-- DRILLE
WELL TESTS: CHEMICAL
BACTERIA I
BACTERIA II
COMMENTS:
FORM U APPROVALs
DATE ISSUED
CONDITIONS:
DATE APPROVED. -
DATE APPROVED..
DATE APPROVED
APPROVAL TO ISSUE <�p NO
FINAL APPROVAL:
ALL PERMITS PAID
WELL CONSTRUCTION APPROVAL
SEPTIC SYSTEM CONSTRUCTION APPROVAL
OTHER
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
DATE: .... . .......
................... _BY
IS THE INSTALLER LICENSED? YES NO
TYPE OF CONSTRUCTION: NEW REPAIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT YES NO
DWC PERMIT NO. INSTALLER: ... -- --- ----------
BEGIN INSPECTION 0:
(2P
EXCAVATION INSPECTION: NEEDED: . . ......................... ..
. .............. . . .....
PASSED BY. -
CONSTRUCTION INSPECTI ... . ....... . ......... .... ............... .. . ......... ....... ._ . ......... .............
AS BUILT PLAN SATISFACTORY:
APPROVAL TO BACKFILL: DATE:
FINAL GRADING APPROVAL: DATE_
FINAL CONSTRUCTION APPROVAL:
YES:
DATE:
Commonwealth of Massachusetts
City/Town of ORTHANDOVER
System pumping Record N
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
e substantially the same as that provided here. Before using this form, check with your
information must b stem pumping Record must be submitted to
local Board of Health to determine the form they use. The Sy tle in
the local Board of Health or other approving authority within 14 days from the pumping da
accordance with 310 CMR 15.351.
A. Facility Information
important:
When filling out
I , System Location:
forms on the
5— 'J/e 57 /C
-------
computer, use
only the tab key
Address
to move your
X,�r Jet, -7
State
zip code
cursor - do not
use the return
key.
2, System owner:
ARres (if different from location)
State
zip Code
-7
Telephone Number
B. Pumping Record
2. Quantity Pijmped�
daiions_
1. Date of Pumping Date
Cesspool(s) Eq�_Septjc
Tank F� Tight Tank
El :Grease Trap
3, Type of system:
Other (describe)�
Filter Yes R -NO
if yes, was it cleaned?
0 yes No
4, Effluent Tee present?
5. Condition of System-.
6. System Pumped By. rz
11&4 h4 -
Vehicle License Number
Name Pi Z014
G.L.S.D. TOWN OF NCRTH ANuOVER
1AR"' . EN7
7. Location where contents were disj4" AmdoveL MA. HEALL5H DEPARTMENT
- - ---------
Date
Signature of Hauler
Date
!�1gnai_u_re'o"f Receiving Facility
System Pumpin6 Record , Page I of I
15form4.doc- 03106
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;ystem Owner
Conwnwealth of Mossachusetss
; Massachusetts
System Pumpina Record
System Location
h t I
Form 4 -- System Pumping Record
Type: Emergency Routine
sanons
Cesspool: No Yes Septic tank: w -=Yes In
Daft of Pumping: t - 27,;j Quantity Pumped:
System Pumped By: Wind River Env"nonental, UC Permit #:
Contents transferred to:
Contents Disposed at:
Date.
of Systern/Other Comments
Y
Pumper Signature:
Dep Appmved From - 12107195
IMMEMIN
FOI?11 U
TOWN OF NORTH ANDOVER
LOT RELEASE FOM
SUBDIVISION P
ASSESSORS MAP
SUBDIVISION LOT(S) C� uc /?Oct
PERMANENTeDDRESS (ASSIGNE,,p P6Y D.P.
t
STREET r�
APPLICANT PHONE
DATE OF APPLICATION
TOWN USE BELOW -THISLINE
PLANNING BOARD
I'Ulffl PLANNER
CONSERVATIONCOMMISSION
CONSERVATION ADMIN—.
HEACE11- SAN'ITARIAIr
DEPARTMENT OF PUBLIC WORKS
DRIVEWAY PERMIT
SEWER/WATER CONNECTIONS
FIRE DEPT.
RECEIVED BY BUILDING INSPECTION
DATE
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
---
DATE REJECTED
This form shall be signed by the agents of the Planning and Health Boards,
the Conservation Coirunission prior-, to the issuance of any building permits
for the subject lot. This form shall not releive the applicant from the
compliance of any applicable Town requirement or'Bylaw.
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DISAW)�O\JFIP DA T-C--
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Fk)4L APPROVAL
PAT -C" — APF)�W�&)6 lmllnj"Irl
S-\ Commonwealth of Massachusefts JAN 3
City[Town of
System Pumping Record NORTH ANDOVER
Form 4
QEP 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,
4. Effluent Tee f��jjter- present? C] YeS �0
5. Condition of Svstern:
6. Systern umped By:
7. Locafion where contents were disposed:
If yes. was it cleaned? C1 Yes
Vehicle License Number
'r— ---' ' - — -^ - ' — -- -- '- - - * - - --- - — -- 4
Signalure 7f -Heule, Date
Signature of Riereiving Facility Date
15form,l.doc- 03M
Systern PumpirIg Recorcl - Page 1 of I
A. Facility Information
Important.
When filling out
forms on th�!
1. System Location:
CCAA nAq
computer, use
only the tab key
to fAove your
Add
. .... ..
cursor - do not
use the return
Cityrrown
State
Zip Code
key.
2. System Owner:
fF., A D
Name
Address (if different *om location)
Slate
zip Code
Telepone Number
B. Pumping Record
10 /�
1. Date of Pumping '551i�
2. QUantity Pumped:
3. Type of system: El Cesspool(s) li;��Pflc Tank El Tight Tank
0 Crease Trap
E] Other (describe);
4. Effluent Tee f��jjter- present? C] YeS �0
5. Condition of Svstern:
6. Systern umped By:
7. Locafion where contents were disposed:
If yes. was it cleaned? C1 Yes
Vehicle License Number
'r— ---' ' - — -^ - ' — -- -- '- - - * - - --- - — -- 4
Signalure 7f -Heule, Date
Signature of Riereiving Facility Date
15form,l.doc- 03M
Systern PumpirIg Recorcl - Page 1 of I