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Miscellaneous - 356 RALEIGH TAVERN LANE 4/30/2018
r a Commonwealth ®f Massachusetts = City1T®wn ®f North Andover RECEIVED System Pumping Rec®rd MAY 112015 Form 4 e 'w TH ANDOVER , DEP has provided this form for use by local Boards of Health. OtherT{�WjUb't. thiso�bhek with your he p ame as that provided here. Bef9 information must be substantially the s Record must be submitted to local Board of Health to determine the form they use. The System Pumping um in date in the local Board of Health or other approving authority within 14 days from the p ping accordance with 310 CMR 15.351. A. Facility Information Important When a, 1. System Location: tilling out forms Y � 1 on the computer, use only the tab key to move your Address. Ma 01886 cursor- do not North Andover Zip Code use the return State City/Town key. 2. System Owner: Name raven Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping Date 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): -- 4. Effluent Tee Filter present? ❑ Yes ❑ No State Zip Code Telephone Number 2. Quantity Pumped: Septic Tank ❑ Tight Tank 5. Condition of System: i, 000 Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No 6. System Pumped By: ��-Ck�'V, �� Vehicle License Number Name Stewart's Septic Service Company 7. Location wh ontents were disposed: eatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Receiving Facility t5form4.doc• 03106 Date Date System Pumping Record • Page 1 � n � } � � ' ` l . i. _ _ _ .. _�, �• - Vim l ��^ /' � .._ � ., ... .'� -� {- ., z lei � ,� ' .. r Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of NORTH ANDOVER MASSACHUSETTS System Pumping Record Form 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 1. System Location: �j `-i � Z Address �/O. &V 6517a� City/Town 2. System Owner: Name Address (if different from location) City/Town MAY 11 2006 B. Pumping 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): QEPARTIENT State Zip Code State ip Code Telephone Number e 2. Quantity Pumped Cesspool(s) Septic Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 1066 Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No r 6. System Pumped By: Name Vehicle License Number Company 7. Location where contents �were �disposed: Q Q y as ignature o auler Date hftp://www.mass-gov/dep/water/approvaIs/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 J APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I h reby make ap lication for_a permit for a sewage disposal installation at I will install this system in ac- cordance with all the laws f 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%. I will install a con- crete septic tank of 5-,o �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 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 may be attached to the permit. Plot Plans must be sub_m}tted with application. DATE gnature of Applic I hereby issue the above permit for the Board f Health of the Town of North Andover, Massachusetts. DATE / / / '- --7/ Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Percolation Test' -A"", Garbage Grinder Signature of Inspecting Officer y74 BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS.. %5' 1. NAME (!2L �& o�,1 DATE 2. ADDRESS�,��e� `G � v c „e S• i- oL4 LOT NO. -115 TEL. 3. NO. OF BEDROOMS S� DEN YES NO 4. GARBAGE GRINDER YES NO r 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. SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT A STREET (Q FORM U TOWN OF NORTH ANDOVER LOT RELEASE FORM S (ASSIGNEQ BY D.P.W. APPLICANT 1N 7 ii9t612fGK PHONE _ A-a(o(2 DATE OF APPLICATION TOWN USE BELOW THIS LINE PLANNING BOARD DA'T'E APPROVED TOWN PLANNER DATE REJECTED CONSERVATION COMKISSION CONSERVATION ADMIN. BOARD OF HEALTH DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS FIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED This form shall be signed by the agents of the Planning and health boards, the Conservation Commission 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. will o , I 19 :o IN vixy t- SOrTI r I 0 p6 S/- cox S�-�-��N�- I/ �� t, as �. ICRAf-i` IuiToIS-r / asVtom,T'-;otit "Cox Sunil-hN(v IINYL Slow(v 31" S4a ; svw-) un 1)1. Sft-E-iK6LK p ' j I O x I® MORTGAGE INSPECTION PLOT PLAN NORTHERN ASSOCIATES, INC. 630 TURNPIKE STREET N. ANDOVER MA. 01645 7 -EL. 509-975-7117 NORTSABAR' THOMAS 6 DOf" DISTEFANO DEED FIEF. 1290 / 62 LOCAT10tV 966 RALEr W TAVEW LANE PLAN REF. 5919 'ITY, STATE' N. AAVOVER . NA SCALE: 1— 60' DA Te A UO/ 24 / 91 U06 /.• 91/ 4776 MA RALEIGH TAVERN LANE C -"--'R r-rFrEi0 Ta riNi�Ov'C i? S "'$V r N p� f��i ivK NOTE: This mortgage inspection was prepared I FURTHER STATE THAT IN MY PROFESSIONAL specifically for mortgage purposes and is not to be relied OPINION the principle structures and accessory upon as a survey. Northern Associates, Inc. accepts no outbuildings,_ CONFORM _ responslblfiry' Ior damages resulting from said reliance by �1}� with the setback requirements of the local zoning anyone other than the said mortgagoe and its assigns InS M N ordinances, and that there are no encroachments of major connection with its proposed mortgage financing to said improvements either way across property linos except as rnort a or. C S g g N shown. el 1 0.z5�v , _W/t 1)1!1 0 ALSO: �`�He l,r l IV a 1. Property is not in a Flood Hazard Area. This mortgage inspection was prepared in accordance ({ Or i T G ��Of ❑ 2. Property is in a Flood Hazard Arca. with the Technical Standards for Mortgage Loan Ko y y t.'t❑ 3. Information is insufficient to determine Flood Hazard Inspections as adopted by the Massachusotts Associotion Flood Hazard doterminod from latest Federal Flood of Land Surveyors and Civil Engineers, Inc. Insurance Rate Irtao Pannil MORTGAGE INSPECTION PLOT PLAN NORTHERN ASSOCIATES, INC. 6.30 TURNPIKE STREET N. ANDOVER A(A . 01845 TEL . 508-975-7117 NOR TBA &act THOMAS G DL1M1M DISTEFANO DEED REF, 1290 / 62 LOCA TIONS 955 RALEIGH TA MEW LANE PLAN REF. x919 'r Ty, STATE N. AAVOVEq . KA DA TE AUG/ 24 / 91 SCA LE• 1- 50' 'JOB r!' 91/ 4776 N Cc'RTrFrZD Ta AN1)t)t1ER Jijll- NOTE: This mortgage inspection was prepared specifically for mortgage purposes and is not to be relied upon as a survey, Northern Associates, Inc, accepts no respon"firy for damages resulting from said reliance by anyone other than the said mortgagee and its assigns In connection with Its proposed mortgage financing to said mortgagor. This mortgage inspection was prepared in accordance with the Technical Standards for Mortgage Loan Inipections as adopted by the Wlassachusotts Association of Land Surveyors and Cl" Engineers, Inc. RALEIGH TAVERN LANE I FURTHER STATE THAT IN MY PROFESSIONAL OPINION the principle structure/: and accessory Outbuildings, CONFORM with the setback requirements of the local zoning ordinances, and that there are no encroachments of major improvements either way across property lines except as shown. ? ALSO 1 i. Property is not in a Flood Hazard Area. ❑ 2. Property is in a Flood Hazard Area. ❑ 3. Inlormation is insufficiont to determine Flood Hazard Flood Hazoro doierminod Irom latest Federal Flood Insurance Rate Map Pannll TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD ADDRESS SYSTEM LOCATION ! DATE - oo4- BcC (C r 1,,, • , SYSTEM ADDRESS SYSTEM LOCATION (r S no (example: left front of house) oo4- BcC (C r 1,,, • , 7 DATE OF PUMPING: �-�-{61 QUANTITY PUMPED O GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES 1111'4 "_ 3 7'. • , 7 . NATURE OF SERVICE: ROUTINE . EMERGENCY OBSERVATIONS: GOOD CONDITION FULL ' HEAVY GREASE TO COVER ROOTS -- BAFFLES IN PLACE —� ! EXCESSIVE SOLIDS -"- LEACHFIELD RUNBACK SOLIDS CARRYOVER FLOODED OTHER (EXPLAIN) —''— 07 1 f SYSTEMPUMPER BY: Al1)a ver o� 4, ,,COMMENTS: 1 1 1 COAT ENTS RANSFE i� T BOARD OF 'r.�r+LTrl t/42Q01 I- 7 11 2 AAo T &;. r -,,L4. ZSR B,E.p TN cet NO 4!9 z'E1}6 6 LE/7aa � C� �f�� ...r'.v�9FS' f L r=e� c..:� �t-� 7',E j' ► �E =ITS' t . CA Si �v 74► i�d . .�.: �ev14:�., pct Z • . a� ula►.aQ� sAQ ha c�C%/ I k of C 'N '4 - ro, A Iv CM cro C da, k6 ra .fin 4JO.. 501 lr_ 41:7 5D, t� a i r P(-4CC-' 4117-1,4 E1,r _940. 02 lrT r/ 0 :7 ,rz. UMc 00. p C) lot Z 10 LL T/I 1'-'W -IN sr V 0 '4 - ro, A Iv CM cro C da, k6 ra .fin 4JO.. 501 lr_ 41:7 5D, t� a i r P(-4CC-' 4117-1,4 E1,r _940. 02 lrT r/ 0 :7 ,rz. UMc 00. p C) lot Z 10 LL T/I t ,o i TOWN OF ORTH ANDOVER UA 11 -7 SYSTEM P MPINQ RECORI,) SYSTEM OWNER & —ADDRESS lea/ 7a-il N.iNc4D✓ere `Ylq. RECEIVED NOV - 3 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT : DATE OF pIaANTITY PUMPED: CLSSPOOL: NO—--.. YES.. S00c Tank: NO. YES NA rUKE OF SERVICE: OBSERVATIONS: (100D CONDITION FULL'Iyj COVER HEAVY OREASEBAMIN PLACLoy ES L r ROOTS LEACKFIELD RUNBACK BXCF,SSIVE SOLIDS FLOODED SOLID CARRYOVER,_~ OTHER EXPLAIN system pwnpcd vAf f) CPO -7 lgra-a�g)' /2 a. CUN I EN I'S I"KANSYbRUL) 11) 3 0 r 0l r m u WNtR & ADDRESS i fan6© .Qle'l ` h Ve✓�/' � Lance AIDGlu a o vel. /�'I�, SYSTEM LOCATION DATE OF PUMPING} QUANTITY•PUMPED CESSPOOL NO 1"EST � SEPTIC TANK NO YES NATURE OF SERVICE;;•R.QiTjNE ' EMERGENCY OBSERVATIONS; . :. . GOOD CONDITION FULL TO COVER HV CREASE �;, : BAFFLES IN LACE LEACHFIELD RUNBACK EXCESSIVB SOLIDS T_ -FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY Tt" 4 OF NORTH AlMDO`.' R/ Fr/''RE' OF HEALTH TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD NOV - 4 ; .3? STE-M OWNER & ADDRESS SYSTEM LOCATION /S� I (example: left front of house) G p Ck, U \"l E OF PUMPINC: l QUANTITY PUMPED DDD LLU�> .!.,)SPOOL: NO Y i/ ES SEPTIC TANK; NO YES "'ATURE OF SERVICE: ROUTINE uf! FRVATIONS: GOOD CONDITION V HEAVY CREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER EMERGENCY FULL TO COVE, k BAFFLES IN PLACE LEACHFIELD RUNBACK . FLOODED Oj�HEIZ (EXPLAIN) >l >1'LM PUMPED BY: `U�IMENTS: U'�''I I:'.N I'S' TIZANSFEIZIZED TO: N;J 1 O W, ORTH;ANDOVER MASSACfHUSE S Reco rY�?J'>',.:.' is ^. � .5 2��7 NL,,i ;b{CA Vv '1:1.}.: ►� I li'1 �,; :q:.Y,. ., t'�iC;IJ .•Y .I f',: "TL,,LriI':•4'irvY!;• r DEP has provided 61* form,for•use by local Boards of Health. The Sysce"m`�Fum In Recora mss: ba submitted to the.local'Board of Health or other a pr 9 pproying authority,' "'v' ry� A:..Faclli lnformtlon . fy J; ,When f�un� .out" .1.. System l.ocatlon;` }:r ;,.::•.:.:. `fir W4 tris tib key ..' Address to move your:, /�� — '. : ,.alrsor • do dot . us+ the 11rofum ,i ,CltY/i own J : state 4.''•I n . :r••,ti r:l:i'�'.....5 •, ' is , .:.. ,� ', ,' ZIP �/ Cod@' . .System Owner, :�,�, • ,. } '..`: � Y,�t r �..!tVl .•t'a.e';"'I �,.5.,. , 1 1 i. � /IA�H, �ij, a%y -0001 Nam (If different from location) ,Y Clty/TowM1, Stat@' ...,. ��J _� Code �. TelephoneNumber ':tt.• it ;..i w`11 r {r'' '" '� , I�::: = � � � � .. U1 P1n0:Rd.Q'ord: i,ri,:.(t�,1J''j;�:i:�'{;�:,r.r�J(u.•rayll%j'N ri'tli.';'•�r c �' `:` :,,, ,; Y: ,.. .:;.•. .�„� r„`;; �.,r..• I,y, CC.,// /ice ,•� Dat0;of Pumping ; ' Z� �/� oat Quantity Pumped: Gallons ❑ C,esspool(s) S tic Tank ❑ Tight Tank J J other (describe); Effluent Tea F11W present? ..❑ Yes o If yes, was It cleaned? ❑ Yes ❑ No ... �i:r-. r.,��:,�P, � .t, �t,�•1h!:�nf.�"r:,ii': ,'{i;a;v`h j4r>:. ;•,' / Co�ditlon'.o(Sysf :,.., ' gl• Jr,Yl:�n .. ;:�`• r'.., �. ,. ��4i'!1(�'�t I' •eai;,'r,'1,�l,%i' �'jti � ".rl.'•, •.r� �.r•wr�.'.Y`.;:�c�; .'1'.11. , '11% Y. jta.l'\••"''. ''I, • `. �•'��:.i••+r.1 :.`Y,'�a;l', ama:j'ti �,ip'•j Vii'. : :ri,�r. -''. i';`'r .+,t� i;�:w'`Yi:+ir'I �r��. ;�,,. ;;✓�' 1.:l�'!<< V@hi cen#e Number :E�Y>:�?•r.;•r.'jr``,X"r;�',rF.�tYlt'�.f+'�11..1e:;�.' �;,C' i;<f� �` •,�l ,�Y�� � . .'t,:r,�. .'J' ;a;}t�•���j.J�•4t;:,. Y;,,(;,uJ,},� �,�,,•l},..,1',,�ilJj':I` ,,gin J ' ✓: � .. �+� >: •: !i,,.p , 7.,•Iq•i�7:it '• r IIYr ti+f �:51r �r. a� ` il� .I ,J.'''.: • .i 'N'),. �Y.J'I%'!r F",:,/., .A 'M I 11>,ir �� , 1.' • 1 Imo,'. ,.. :� • r'�i.y;,t: i.r, t 1'I :,•.va' 7;'': location.where contents yrere dipposed: -'� � - � f � , ,,' . I � , r 1 � tliy�lt'` r,. r"tt'�,• �r{,. , t r r d J ti l r'I:'+t^rr4,.:!•', ,.. 7 2 .'�.'•{'. ! ,t i.' 1}' {'„ yv\.'I. Y.Fr�• yr �l, , �r �. 1_ .,� r N.t.:, �,r, r,t'.y.."' / `�/+ • ,',�..'' r,:.. Slpnatur of ier;i,. i';;,,; �.,,,..•" Data httpJ/rvww,maSs. gov/dep/watar/approvalsJt5forms, htm#Inspect torrn4.d ' System Pumping Record Page I of ueN.hai provided lhliYlorm Ior Sao �;• ;oCo, 60 00 +'.drr.11lod l0 u1e loC+1 8carc: cr ^oa,,n or cin A, Facility In(ortT Hon `4 •^'tib' �-' � . �� rlq•!;��^ SS•"� YL oca Uon: ..� Sim Owner, ' " is ;::'',-.• , , -',':'•: ;'." . 6 �d,►i� gl90"Inl ,c(n buUcn) _1920 �� } r1 °2rnQr)l h.moll P..umpin8 Record I. Oa,� o! PumIn 9: 0+:r ? o. d�= TYpa PI ry�lem;.. Ce99p� NX Q O'her (describe/1 i 4' vEMvon)( Too Flllo(P�p�ent? [' Yo9 ... . ' . �•� % 'r ':Coridlyon 0(;9yj;�m,,.�.,. , . . Y Py'mpod 8y:• lo ;r; r ' '' �r.,� �•'�.':; y Y';��`,'��•�' '� r �y1':w Irl., , �•'.r,',i�',l `. ..,.,. )ik I�'l,�l•.'�„�dj, �'/,1J�I�IIVi,,l,i�l��,' . on. �rher�••Cor�lanla',were dl p .,..:,:�'.1�! ••r•,.;r,,,•• :iii}„ 9 OSeO: S nitw ,r.mesa.80Y/de101/epp(oY8) sllblorm�.n mul�9�eC1 sepft Ten,, On, Commonwealth of Massachusetts 0 NIP" City/Town of NORTH ANDOVER MASSACHUSET System Pumping Record Form 4 5 Z010 DEP has provided this form for use by local Boards of Health. T System Pumping Recor must be submitted to the local Board of Health or other approving aut OnN Op NORTH ANDOVER HEAM DEPARTMENT 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.. tC� http:/Avww 1. System Location: ISG nQn ane Address I ,-A ��c�U�rACK Cityrrown State Zip Code 2. System Owner: T1n T n n Name Address (if different from location) City/Town State Zip Code B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe): Telephone Number 44 /W Date 2. Quantity Pumped: &x) Gallons Cesspool(s) �eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: If yes, was it cleaned? ❑ Yes ❑ No 6. S stem Pump d By: G Z e Vehicle License Number Company cnntpntc wprp rlisnnsari- htm#inspect t5form4.doa 06/03 1. System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record Form 4 GSM Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rerun HAY 'I � � (311 TOWN OF NORTH ANDOVER 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 356 Releigh Tavern Lane Address No. Andover Ma 01845 City/Town State Zip Code 2. System Owner: Destafano Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 4/15/11 Date 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): State Telephone Number 2. Quantity Pumped: Gallons ® Septic Tank ❑ Tight Tank ❑ Grease Trap Zip Code 1000 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: Good Condition 6. Sys em Pumped By 7. W / Kf n cl-� Name Stewart's Septic Service Company were disposed: If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 'CN Commonwealth of Massachusetts I RECEIVED w City/Town of No.Andover h1AY118 Uf2 a System Pumping Record TOWN OF NO. VDOVE Form 4 HEALTH DEPARTMENT '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. City/Town Ma State State Telephone Number B. Pumping Record 1. Date of Pumpingate I 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) 00septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of 01886 Zip Code Zip Code G lions ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No 6. SyT mped By: Namg 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 Signature of Ha er Signature of RecA in Fa ility Date � C2 Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. Sy n: forms on the computer, use only the tab key A ress to move your ' No.Andoyer cursor - do not City/Town use the return key. 2 System Owner: raS 'eR Name Address (if different from location) City/Town Ma State State Telephone Number B. Pumping Record 1. Date of Pumpingate I 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) 00septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of 01886 Zip Code Zip Code G lions ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No 6. SyT mped By: Namg 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 Signature of Ha er Signature of RecA in Fa ility Date � C2 Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 No Andover J&S Development dba 1600 Osgood St Stewart's Septic Building 20 Suite 2-36 Andover Septic No. Andover, Ma 01845 58 South Kimball Street Bradford, MA 01835 Date Name & Address Gallons Comments 5 -Apr Andriolo 37 Birch Lane 1500 Good Sullivan 47 Boxford St 750 Good 6 -Apr Saplenza 40 Sterling Ave 1500 Heavy bottom 9 -Apr Disalvo 400 Winter St 1500 Good 10 -Apr Sarano 265 Hay meadow Rd 1500 Xxxsolids 12 -Apr Lind 575 Winter S�,., 3.54, 16 -Apr Distefano,?6& Raleigh Tavern Lane 1500 Good 1000 HG Walsh 58 Paddock Lane 1500 Good 18 -Apr Schrader 35 Woodberry Lane 1000 Good Ahlhdm 48 Hawkins Lane 1000 Good 19 -Apr Barrett 235 Candel Stick Rd 1500 Good 20 -Apr Harold 453 Forest St 1500 Good Duffy 67 Shirwood Dr 1500 Good Zoll 333 raeligh Tavern Lane 1500 Good 23 -Apr Haffeners Car wash 564 Chickering Rd 2000 red tank 25 -Apr Valle 58 Evergreen Dr 1000 Good 27 -Apr Lucas 39 deer meadow Rd 1500 Good 30 -Apr Meaney 745 Foster St 1000 Good MAY 18- 2012 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT