HomeMy WebLinkAboutMiscellaneous - 313 SUMMER STREET 4/30/2018 (2) 0,000049i 0 0! J
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.0 Commonwealth of Massachusetts
City/Town of .
System Pumping-Record
Form 4
8 '
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.
A. Facility.11lnformation
1. System Location: Left/Right front of house, Left i t rear of hour , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
' Name i`
Address(if diffe i nt from location)
MAY 18 jj S
Cilylrown State^ t.: 71
l ` . LTH,
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity_ Pumped: Gallons
SII [S
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
4
❑ Other(describe):
4. Effluent Tee Fil Iter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition f System:
D � CU
6.- System Pumped,LBy:
Neil.Bateson i F5821
Name I Vehicle License Number
Bateson Enterprises Inc'
Company `
7. 7Loca :.,where contents were disposed:
Lowell Waste Water
c4fTOA, Bz6z--,��
Sign ItHaul Date
t5forrn4.doc•06/03 `-
System Pumping Record•Pa'
e 1 of 1
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FORM U - LOT 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 or requirements.
AFFLICA,NT FILLS OUT TN15
-APPLICANT R1cw:< .2i 0 PHCNE
LOCATICN: Assessors Map Number PARCEL
SUEDIVISION LCT (S)
ST. NUMEER
OFFICIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS: C-�ns�- . C L �`�'
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR-HEALTH DATFEAPPROVED
DATE REJECTED
S> TIC INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
AT N
PUELIC NARKS -SE'vYERM! ER CONNECTIONS
CR1VE-NAY PERMIT
FIRE DEPARTMENT
RECEIVED EY EUILDITIG iiISPECTCR DATE 2 9
Revised aha—irtiw:..;`,
9... 7 6' 5�.�cel�.. tr e...•....r,
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RECEIVED
Commonwealth of Massachusetts
L City/Town of t,l GO 'Zu 11
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
Y•v`
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.
A. Facility Information
1. System Location: Left/Right front of house ar of h tts , Left/right side of house, Left/
Right side of building, Left/Right front of bul Ing, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown Stat de
_C:;,�� r L�
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Qu tity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' here contents were disposed:
Lowell Waste Water
Signitufe HaulerU Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 1
NORTH ANDOVER BOARD OF HEALTH �!
INSTALLATION CHECK LIST
}
APPROVED DATE DISAPPROVED DATE hXCAVATION OK
REAS S• I -
-7 a�
FAIL OKd. 9 " I-78
1 . Dis ce To:
Wetlands
Drains
Well
Water Line Location
3. o PVC Pipe
4. Septiank
ees - Length & To Clean Out -Covers
Cement Pipe to Tank - On Both Sides of Tank
5. Distri ion Box
er & Box - No Cracks j
All Lines Flowing Equal Amounts I'
,r
No Back Flow
6. Leach F' or Trench
ime io
St e De
Cappe,d,ends
Cle Double Washed Stone
7. Leach Pits
Dimensions
Stone Depth
Splash Pads
Tees
Cement Pipe to Pit - Both Sides
Clean Double Washed Stone
o Garbage Disposal
. Final Grading Inspection
Barracading Covered System
r
I::I As Built Submiitted�
0 0
Dimensions of System
Location with Regard to Pere Test
Elevations
Water Table
i
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NORTH ANDOVER
SUBSURFACE DISPOSAL SYSTEM CHECK LIST
a�
I. General Information ""► �I'r ,• , ,
Reg. 2. 5 The subm' tted plan must show as a minimum:
(a) t lot to be served
(b) location and dimensions of the system (including
I�
Aes
erve area)
(c) ' n calculations
(d) lculations showing required leaching area
(e) fisting and proposed contours
(f) ocation and log of deep observation holes -
dU ance to ties
(g)/location and results of percolation tests -
distance to ties
(h)/l cation of any wet areas within 100 ' of the
�segedisposal system or disclaimer
and subsurface drains within 100 ' of
th ewage disposal system or disclaimer
(j ) ocation of any drainage easements within
100 ' of the sewage disposal system or disclaimer
(k) nown sources of water supply within 200 ' of
�th sewage disposal system or disclaimer
(1 ) ."- O_ tion of any proposed well to serve the lot
(m) ocation of water lines on the property
(n) ,,wraximum ground water elevation in the area of
the. sewage disposal system
(o) � rofile of the system
(p) Olio PVC is to be used in construction
(q) ocion of benchmark
(r) >-an must be prepared by a Professional Engineer r
or other professional authorized by law to prepare
such plans.
II. rbage Disposers
III. Septic Tanks
- 0 of flow
Reg. 6. 1 (a) .�-a acities 1 5 �
Reg. 6. 7 (_b) er table
Reg. 6.8 (c) s
Reg. 6.9 (d) �pth of tees
Reg. 6. 12 (e)�cess
Reg. 6. 18 (f) C_ ping
W Cleanout
IV. Pumps
i
Reg. 9. 1 (a) Approval
Reg. 9.6 (b) Stand-by power °
I
V. Distribution Boxes
Reg. 10.2 (a) Z e greater than 0.08
Reg. 10.4 (b) �p
VI. Leaching Pits
Leaching pits are preferred where the installation is
possible.
Reg. 11.2 (a) Calculations of leaching area (minimum 500 S.F. )
Reg. 11.4 (b) Spacing
Reg. 11.10 (c) - Surface drainage 2%
Reg. 11.11 (d) Cover material
VII. Leaching Fields
Reg. 15.1 (a G - ester than 20 minutes/inch
Reg. 15.1 (b)�Area (minimum 900 S.F. )
Reg. 15.4 (c),�&I� struction of field
Reg. 15.8 (dl�urface drainage 2%
IX. Do nhill Sl e
•
(a) Slope y/x = (to be shown)
(b) Y/x X 150 = (to be shown)
SOIL PROFILE & PERCOLATION TEST DATA
Town/City No.&Streeter Lot No.
Loc./Subdiv. Plan Owner_ 0_ 0 p,
InvestigatorX�, ���a Observer
SOIL PROFILES-DATE
E ev. 3.
0 lev. 2. Elev. Elev. i---Elev.
- 4-1717,70 ........... .�.�._
0 0
o'
i 1 1 1
2 _, 2
2 2
3 3 3 3
4 4 4 4
5 5 5 5
6 6 6 6
7 7 7 ?
8 8 8 8
9 9 9 9
10 10 10 . 10
Benchmark Location
Elevation Datum
Percolati n Tests-Date
Pit Number 1 2 3 4 5
Start Saturation
Soak-Mins.
Start Test-Time
Drop of 3"-Time
Drop of 6"-Time
Mins.lst 3"Dro
Mins. 2nd 3"Dro
Notes & Sketches on Back Frank C. Gelinas & Associates, North And.
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