HomeMy WebLinkAboutMiscellaneous - 336 CANDLESTICK ROAD 4/30/2018A
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MAP #
LOT #____
PARCEL #
STREET
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APPROVAL
,
HAS PLAN REVIEW FEE
BEEN PAID? YES
NO
.. `
`
`
PLAN APPROVAL:
DATE APP. BY
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DESIGNER:
-
PLAN DATE
»
CONDITION
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_-__-__--.... ...... -.........
,
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WATERSUPPLY�
WELL
WELL PERMIT
DRILLER__---'-_
__----.
'
WELL TESTS:
CHEMICAL
DAlE APPRUVED________
`
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BACTERIA I
DAlE AopHUVED _
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BACTERIA II
DAlE APPROVED --
FORM U APPROVAL: APPROVAL TO ISSUE NO
DATE ISSUED Y ............ . ,������..... ... __
CONDITIONS:
_...... ... ...... ..����
.
FINAL APPROVAL:
` ALL PERMITS PAID
' WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL-=;;?� NO
OTHER YES NO
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES NO
DATE: _BY: _
'• .,; ..•
SE,PT I C _�_Y_SZE.?�__� N.�.�8.4.L.A.:L.I..4.N. •
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 NO
DWC PERMIT NO. 6- INSTALLERr/
BEGIN INSPECTION AYE 0:
EXCAVATION.INSPECTION: NEEDED:
"
PASSED .�h5 BY -
CONSTRUCTION I NSPECT I ON r NEEDED:. ................ ... _�._..._.........
AS BUILT PLAN SATISFACTORY:
8�a� 9 3 HY-_�Q...._._______.___.._.
: w_r_
APPROVAL TO BACKFILL: DATE.
DATE 7/z,69`3
FINAL GRADING APPROVAL: -BY,��-
DATE: BY_AJ'
FIN L CONSTRUCTION APPROVAL: ----
North Andover Board of Assessors Public Access
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Summary
Residence
Detached Structure
Condo
Commercial
1Z 111 1 11111
Page 1 of 1
Ot
MOV
44� property Record Card
Location: 336 CANDLESTICK ROAD
CURRENT YEAR
Owner Name: PORCARO, MARY ELLEN
Total Value:
JOHN MADDEN
742,400
Owner Address: 336 CANDLESTICK ROAD
490,300
City: NORTH ANDOVER State: MA
Zip: 01845
Neighborhood: 8 - 8 Land Area:
1.00 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area:
2925 sgft
ASSESSMENTS
CURRENT YEAR
PREVIOUS YEAR
Total Value:
717,200
742,400
Building Value:
490,300
515,500
Land Value:
226,900
226,900
Market Land Value:
226,900
Chapter Land Value:
1.1
http://csc-ma.us/PROPAPP/display.do?linkId=1465197&town=NandoverPubAcc 6/16/2009
: Commonwealth of Massachusetts
. City/Town of RECEIVED
System Pumping- Record
Form 4 JUL 2 8 2015
Y� V
TOWN OF NORTH ANDOVER
DEP has provided this form for use -by local Boards of Health. Other foniiW*Pbb�6fdd� 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 Location4CeVRig ron of house eft / Right rear of house, Left/ right side of house, Left/
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/rown State
2. System Owner.
Name aid &A
Address (0 different from location)
Cityrrown
B. Pumping
1. Date of Pumping
rd
3. Type of system: ❑
❑ Other (describe):
9
Zip Code
State Zip Code
Telephone Number
Date l S 2 Quantity Pumped:
Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yeas
5. Condition of System:
6.- System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc -
Company
No If yes, was it cleaned? ❑ Yes ❑ No,
7. Location where contents -were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Date
t5form4.doe- 06103 System Pumping Record • Page 1 of 1
'O Box 55098
3oston, MA 02205-5088
07-951-0600
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845
RE: Insured: JOHN MADDEN and MARY ELLEN MADDEN
Property Address: 336 CANDLESTICK RD, NORTH ANDOVER, MA
Policy Number: HMA 0375081
Claim Number: BOS00048747
Date of Loss: 2/15/2015
Company: Safety Indemnity Insurance Company
Claim has been made involving loss, damage or destruction of the above -captioned property,
which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be
applicable. If any'notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please
direct it to the attention of the writer and include a reference to the captioned insured, location,
policy number, date of loss and claim number.
Lisa Monette Claim Examiner
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098
Phone: (857) 233-8618
Fax:. (617).535-5833
Email: lisamonette.@safetyinsurance. corgi
2/17/2015
Commonwealth of Massachusetts
_ City/Town of
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.
A. Facility Information
1. System Locatio : Le V Rig of hous , Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
M\4:a�-&A
L4 ( - [-3
— 2. Quantity Pumped:
0-tLeptic Tank
Date
Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes aNo
State' �ip,Cgde
L ._ 'v l,,
Telephone Number
Js�
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sy � PU—e-k � V1-
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locah�'oa_w�here contents were disposed:
Waste Water
F5821
Vehicle License Number
Date
�-f--1-13
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
0
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
RECEIVED
JUN - 8 2009
TOWN OF NORTH ANDOVER I
HEALTH DEPARTMENT
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 front ft rear, left sidf of house Right front, right rear, right side of house.
Address
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: 8
Q Other (describe):
C-/.6-� /j- 4
State
Zip Code
Staf�� Code
Telephone Number)
Date 2. Quantity Pumped: Gallons
Cesspool(s) Septic Tank Tight Tank
4. Effluent Tee Filter present? [j Yes
5. Con pion of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
If yes, was it cleaned? Ll Yes El No
telu-o�r �" 'N'
7. Location wbg
re contents were disposed:
.L.S.D Lowell Waste Water
of
F 5821
Vehicle License Number
Date
r— —0
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
I
41 b3
O` MORT .,h
O
Town of North Andover
,;,o HEALTH DEPARTMENT
,sSACNus�� ll//
CHECK #: 7*, D' TE:11
LOCATION: "cin GiC
H/O NAME:
CONTRACTOR NAME:
Type
of Permit or License: (Check box)
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
I
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Systems:
❑
Septic - Soil Testing
$
0
SS tic - Design Approval
$
I
Septic Disposal Works Construction
�}
$
(DWC)
❑
Septic Disposal Works Installers (DWI)
$
❑
Title 5 Inspector
$
❑
Title 5 Report
$
❑ Other. (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Application for Septic Disposal System
p Construction Permit - TOWN OF
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
Important: Application is hereby made for a permit to:
When filling -out ❑ Construct a new on-site sewage disposal system* .
forms on the
computer, use ❑ Repair or replace an existing onsite sewage disposal system* _
only the tab key /
to move your epair or replace an existing system component — What?
cursor - do not
use the return
key. A. Facility Information
-
�f Address or Lot#
CitylTownAl" .
2.- *TYPE OF S PTIC SYSTEM*:
❑ Pump ravity (choose one)
***if pump system, attach copy of electrical permit to application***
Eq-do�nventional System (pipe and stone system)
Q infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D -Box Present) S.A.S.
2. Owner Information
Name
Address (if different from above)
Citylrown State Zip Code
Telephone Number
3. Installer Information
ij�TxSoi✓ sl 25,1
Name Na of Company
Address Q
City/Town ,k State Zip Code
Telephone Number (Cell Phone # Wpossible please)
4. Designer Information !
Name Name of Company
Address
Citylrown State Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction permit - Page 1 of 2
ORTNI. Application for Septic Disposal System
p.a yeti
10
AConstrlucton Permit — TO��UN OF
TH ANDOVER, MA
PAGE 2OF2
A. Facility Information continued....
5. Type of Buildinq:Residential Dwelling or ❑Commercial
B. Agreement
'�e — /"/ --a 9
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover nd not to place the system in operation until a Certificate of Compliance has
been issuey his Board of Health.
i
Nam Date -
Applicata LAPprovedo:d of Health Representative)
Representative)
Nafine//Date - - - - - -
F�ppcation Disap roved fort following reasons:
For Office Use Only:
Application for Disposal System Construction Permit • Page 2 of 2
co
MZ
L
Fee Attached.
Yes `'
No
2.
Project Manager Obligation Form Attached.
Yes
No
3.
Pump S sy tem? Ifso, Attach copy ofElectrrcal Permit
Yes I
No
4.
Foundation As -Built? (new construction ronly).
Yes
No
(Same scale as approved plan)
5.
Floor Plans? (new construction only).
Yes
No
Application for Disposal System Construction Permit • Page 2 of 2
co
MZ
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
33,-, ��-��l��C d-, T_ --j
(Address of septic system) nn nn For plans by
Relative to the application of
(Installer's name) And dated
Dated ! /G
o ay s ate With revisioi
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection, without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
MY company
a. Bottom of Bed — Generally, this is the first (1'� inspection unless there is a retaining wall, which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: healthdeptQtownofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system, all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade — Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than .rim*le excavation) and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover. significant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Feral inspection by Board ofHealth staff or consultant.
d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: e
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Commonwealth of Massachusetts
Massachusetts
Sstem Pumping Record
System Owner
System Location
Date of Pumping: �'—� `99 Quantity Pumped
Cesspool: No Yes U Septic Tank: No U
System Pumped by: iarwart License #
Contents transferrred to : Greater Lawrence Sanitary District
Date:
Inspector:
�. gallons
Yes Ll"
FORM U - VERIFICATION 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*****************
APPLICANT: Slq e K e fiz W /V% DDf,t/ Phone 4,7/
LOCATION: Assessor's Map Number Parcel
Subdivision
Lot (s)
Street Cy4OGF J RD , St. Number 33
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
v Conservation Administrator
Comments
Town Planner
Comments
Food Inspector -Health
✓ Septic Inspector -Health
Comments Aj 6.2ouup
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date
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CERT/F/ED FOUIVDA RON PLAN
LOCATED /N No. AspoyER,V«• -
SCALE: /"= 40' DA7:7: s�2o�93
Scott L. Gi/es R. L. S.33
50 Deer Meadow Road
North Andover, Mass.
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/ CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE
THE OFFSETS OF THE BUIL DING /NSPEC TOR ONLY'``��
SHOWN COMPLY AND SUCH USE /S FOR THE
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WITH THE ZONING DETERM/NATION OF ZONINGS
BYLAWS OF CONFORMITY OR NON- CONFORM/TY`
ti10. Mk• WHEN CONSTRUCTED.
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IV
BUILT
TOWN OF ° " "`�'
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
p6i--A.�
,3 �-. �
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: QUANTITY PUMPED:
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE '^! EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
6 ?0T6
GALLONS
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
Location 407r
/ Q 7q
Permit # CO 4 -0 -
Food Service
Retail Food,
$
Limited Retail 4
$
Seasonal
Disposal Works Installers
$
O �
Disposal Works Construction
$
Soil Testing
$
Design Approval Permit
$
Dumpster Permit
$
Burial Permit
$
Swimming Pool Permit
$
Animal Permit
$
Recreational Camp Permit
$
Well Construction Permit
$
Funeral Directors Permit
$
Massage Establishment License
$
Massage Practice License
$
Suntanning Establishment
$
Offal/Trash Hauler
$
Other
$
0854
Health Agent
White - Applicant Yellow - Dept. Pink - Treasurer
r-tr
-, - 1,yA
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 3
DISPOSAL WORKS CONSTRUCTION PERMIT
Applicant / /E•C 1//N
NAME// ADDRESS TELEPHONE
Site Location OT 4,-3
Permission is hereby granted to Construct .(-�Y or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No. &6¢
CHAIRMAN, BOARD OF HEALTH
Fee('��6• oa D.W.C. No. Co
Town of North Andover, Massachusetts F°'"''
f N°R,►, BOARD OF HEALTH ,kk, (�
DESIGN APPROVAL FOR-,
SOIL ABSORPTION SEWAGEDISPOSAL. SYSTEM
Applicant UD �aAik S? Test No..
Site Location
Reference Plans and Specs.
e'YV� r
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage 'dlsposal syste o be in ed
in accordance with regulations of Board of Healt�h�..,,aw'Y''
f t pal '
T,- b� C AIRMAN, BOARD OF HEALTH
'i6vc- Cor 44
Fee Site System Permit No.
SD
FORM U - LOT RELEASE FORK
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*****************
APPLICANT: ,��,�F'y /,��� ���� Phone
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s) IVY
Street �fc�l/Z/ ,- AW St. Number
************************Official use Only************************
RECOM+iENDATIONS OF TOWN AGENTS:
Conservation Administrator
• Comments
Town Planner
Comments
Health Agent
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department '
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved ZZ/Z
Date Rejected
Received by Building Inspector Date
TOWN OF
SYSTEM
DATE: a - At 01
SYSTEM OWNER & ADDRESS
f �tadde�
CWAJ(cA ClL
G RECO
SYSTEM LOCATION
(example: left front of house)
RECEIVED
OCT 19 2004
TOWN OF NORTH
HEALTH D PART
ANDOVER
DATE OF PUMPING: QUANTITY PUMPED : GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
G.L.S.D
Lowell Waste
FORM 4 - SYSTEM PL-.NWL\G RECORD
Commonwealth of Massachusetts
, Massachusetts
System Pumping Record
ystem uwner bystern Location
Date of Pumping
Quantity
Pumped: t
Cesspool: No , 'es ❑ CPntir Tnnl.. �„ �] Yes
System Pumped by- License #:
Contents transferred to:
Date
Inspector
Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
p` APR 2 3 2008
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. er T T 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
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
OQ
1. Sy tem L
Address
Citylrowm
2. System Owner:
Address (if different from location)
City/Town
B. Pumping Record 4
1. Date of Pumping
3. Type of system: ❑
Date
Loa
State Zip Code
State e
C-01_ � I — — . .-�P
Telephone Number
(0 -<!:�
2. Quantity Pumped
Cesspool(s) Septic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
5. Condi 'o�qs�terr.
, Name
�� '
Company
7. Locati
f J2�
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
t5form4.doc^ 06/03 System Pumping Record • Page 1 of 1
Commonwealth. of Massachusetts
City/Town of 1 _ -
System Pumping Record MAY 0 1 2007
Form 4
v;ER
DEP has provided this form for use by local Boards of Health.. The System_ e,._ p1lg uSt
cortl--
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When filling out 1. System L �ti /
forms on the
computer, use �,
only the tab key Address
to move your
cursor- do not
use theretum Cityrrown State Zip Code
key.
2. System Owner.
ray
-Na--me.. .
tC�l Address (if different from location
Cityfrown State
Zip Code
Telephone umber
B. Pumping Record ` D
T. Dat 1711 Qu.mDate antity` Pum ed:
Gallons
I Type of system ❑ Cesspool(s) eptic Tank ❑ Tight:Tank
❑ Other(d'escrlbej.
4. Effluent TeeFdtec present? ❑Yes If yes, was it cleaned? ElYes E] No
5. Condition of System:
6: Syste&,,p Y;
Name Vehicle License Number
Company
T Locatio here contents re disp d::
Signa _re user Date
http;//wWw.mass.gov/dep/wa ed. pprovals/t5forms.htrn#inspect
t5fonn4
.d
oc- 06103
System Pumping Record Page 1 of 1
N Commonwealth of Massachusetts LK'��tlD'~City/Town of .11lU11
System Pumping Record NORTH ANDOVERForm 4 H DEPARTMENT
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 front of house, right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
13
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town State Zip Code
�c
Telephone Number
B. Pumping Record l I)
1. Date of Pumping � ty ed: 2. Quantity Pumped:
p
3. Type of system: ❑ Cesspool(s)eptic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [3"No
5. Conditio of ystem:
Vvs� 2�v�
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Loc R� �Uo contents were sed:
G. L. S. D. w�N Waste er
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1