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HomeMy WebLinkAboutMiscellaneous - 44 SHERWOOD DRIVE 4/30/2018 (2) 44 SHERWOOD DRIVE !rive 21Oil 05.C-0059-0000.0 J i 1 i F 4 ' .. h ' S,� {{ f r ~� -'+»J��+' S• ��.���L# �L'� � �i c�r�}�''�i13.f I-gyp' �/ Y{�i �4/ MAR14.1 # PARCEL # STREET OONSTRUC.TI0..N_APPROVAL HAS PLAN REVIEW FEE .DEEN PAI.)? YES NO PLAN APPROVAL: DATE 47 1'��6 APP. BY DESIGNER: PLAN DA,rE. CONDITIONS WAT SUPPLY: WELL WELL PERM WELL TESTS: CHEMICAL DA-TE APPRUVEU BA RIA I D14 T E (IPPRUVED BACTERIA iI DAT'E APPROVED COMMENTS: FORM U APPROVAL: APPROVAL TO ISS -E YES NO DATE ISSUED CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NU SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: gm G�SY�LM�NSSflt� t QN .�X, 1� i•° ` r- :!• ♦ L:?Y-:..1 ...J , 7x IS,THE INSTALLER LICENSED? + ` ��� YE NO -TYPE. OF- CONSTRUCTION: - REPAIR NEW CONSTRUCTION: CERTIFIED PLOT -PLAN REVIEW YES NO CONDITIONS OF:.APPROVAL. YES NO (FROM FORM U) ,• � �+ _ • ^fes �; .l ... ...:• • - r - r -ISSUANCE NO DWC PERMIT ` YES NO DWC PERMIT N0. "` INSTALLER: C? -Z/�/U�� BEGIN ..INSPECTION .`..*,'. ` NO .t :.:' =::EXCAVATION INSPECTION: ; NEEDED: ;.6 � BY •PASSED " .:-`....CONSTRUCTION INSPECTIONS ; NEEDED: AS BUILT PLAN SATISFACT{]RY - APPROVAL TO BACKFILL: DATE. BY F'INAL. GRADING APPROVAL: DATE BY� ,�i' I BY FINAL CONSTRUCTION APPROVAL: DATE:.` / •,•, lye ,. 1��:' � .. ' . - , ' • ` .. 7.11'1.•••, ,' , :.. .�L- .. '` _ - .. .- . Form No.,4 Town of North Andover, Massachusetts BOARD OF HEALTH Februarv�11 19 98 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed (X ) or repaired ( ) by Robert Innes INSTALLER at-Lot Lot 7 Sherwood Dr. r North An r7���er,m SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. dated May 8 , 19 97 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH FORM U - VERIFICATIOV 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: �ewr7- Phone Svc 37 LOCATION: Assessor' s Map Number /DSC Parcel Iy Subdivision E'er _!-tom Lot (s) a Street S _/t L_-4,o to St. Number. y - ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS t� Date Approved Conservation. Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health , Date Rejected q Jf /ij U Date Approved Septic Inspector-Health Date Rejected Comments Public Works. - sewer/water connections driveway permit Fire Department Received by Building Inspector Date THOMAS E. NEVE ASSOCIATES INC. Engineers • Land Surveyors • Land Use Planners 447 Boston Street US #1 TOPSFIELD, MASSACHUSETTS 01983 I DATE JOB NO. (508) 887.8586 FAX (5508) 887-3480 ATTENTION TO P*-3 POA ��1Z RE: PIE— Vv s 'h1K/� dol OW OF— l 1 EPf_—'(�4 WE ARE SENDING YOU [Attached ❑ Under separate cover via the following items: ❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION v pk_;r2.► PrLE a6pl, —Mom A-&- e. 1a Fuc- 1S 1449-Z THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted Resubmit I copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS '�Z-- yiC�-C - L- X1 t-r] (5a- U W— Old 8 k!S JQ4,., (:'Zi t k - l �t�11 COPY TO RECYCLED PAPER: SIGN^—� Contents:40%Pre-Consumer•10%Post-Consumer if enclosures are not as noted,kind y notisat once. UlU 04� PLAN REVIEW CHECKLIST ADDRES S�C EL - �� cS �L.LY�� ENGINEER GENERAL 3 COPIES STAMPy LOCUS !/ NORTH ARROW L---' SCALE CONTOURS PROFILEc/' SECTION �� BENCHMARK `�� SOIL & PERCS ELEVATIONS ✓ WETS . DISCLAIMER WELLS & WETS �✓ WATERSHED?� DRIVEWAYS Elev) WATER LINE FDN DRRINL�� SCH40 ✓� TESTS CURRENT-? SOIL EVAL �5 D SEPTIC TANK / MIN 1500G !// . 17 INVERT DROP y GARB . GRINDER(+200% EDF) 25 ' TO CELLAR t--' MANHOLE ELEV GW # COMPS . D-BOX SIZE # LINES FIRST 2 ' LEVEL STATEMENT 4 /16 INLET 37 D - OUTLET ) •R (2" OR . 17 FT) TEE REQ ' D? LEACHING . / VY �/ 4 ' FROM PRINLARY? L�2% SLOPE-L--- MIN 660 GPD . . RESERVE AREA ' 100 ' TO WETLANDS �� 100 ' TO WELLS c/ 4 ' TO S . H . GWl/ - 5 >2M IN) 35 ' TO FND & INTRCPTR DRAINS 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY C,,-" MIN 12" COVER-FILL? 6- (15 ' v- if above natural elev; 10 ' if below) BREAKOUT MET? TRENCHES fSIDEWALL DIST. 3X EFF. MIN 660 gpd �cX SLOPE (min . 005 or 6"/ 100 ' ) W OR D (MIN 61 ) RESERVE BETWEEN TRENCHES? C-----'TN FILL? L----MUST BE 10 ' MIN . 4" PEA STONE? L/ VENT? (>3 ' COVER; LINES >50 ' ) A� BOT '7�� + SIDE �©(.� X L DNG TOT ft2) (L x W x #) (DxLx2x#) (G/ E VG ,&/Av� Copyright I9 1995 by S.L. Starr FO Irl 1 SS L-mak`.aLL;ATOR FOR:-M TOWN OF NORTH ANDOVE Pave 1 of 3 BOARD OF HEALTH AUG 4 1996 Date: 09�� of l�lassachusetts 5e_, Massachusetts Soil Suitability Assessment for On-site Sewa-ge Disposal r� �..... Date: � le, QS� Performed By: Witnessed By: _. .......................... ^� AC4JUs:lame. �,®! ``G�J'K.! � �r t Lt�cauon Address a (� !/! ncEras.i•+a , i r-�i ��s r tw S, r p 7.r- New construcr-ion R Qair Office Review ' lished Soil Survey Available: No ❑ yes // ��d ( ®� , Published . ..,.. / �3 So ll'slap Unit year Published Publication Scale -•• //a: ....................................... . ......................... Drainage Class ��QrClr�/ - „oil Limitations ............................ Surficial Geologic Report Available: No X Yes ❑ Year Published Publication Scale GeologicMaterial (Map Unit) .............................................................................................................................._ ......._... Landform Flood Insurance Rate Map: Above 500 year flood boundary No Yes ❑ Within 500 year flood boundary No Yes ❑ Within 100 year flood boundary No Yes ❑ Wetland Area: .................................................._---... National Wetland Inventory Map (map unit) .................................................. Map (map unit) Wetlands Conservancy Program Current Water Resource Conditions (USGS): Month Range :Above Normal []Normal XBelcw Normal ❑ Other References Reviewed: DEF APPROVED FORM 11!07195 � III FORA 11 - SOIL EVALUATOR FORM Page ? of 3 Location ,address or Lot .�o. On-site Review q�7=Z7 Deep Hole Number /f�y5 Date:. �� Time: 9074 Weather Location (identify on site plan) SCG YI Land Use , 5. Slope (°%) .5- Surface Stones 0.077- Vegetation �,� Landform Position on landscape (sketch on the back) Distances from: Open Water Body Mo feet t- Drainage way /V 'Meet Possible Wet Area fZy-'- feet 79- Property Line X49 ° feet Drinking Water Wel! feet Other DEEP OBSERVATION HOLE =.OG' Depth from Sad Horizon Soil Texture I Soil Color Sod Other Surfaca (Inches) I (USDA) ! (Munsell) ( Mottling (Structure, Stones, Boulders, Consistency, % Gr3vei) CV e _ 7 A 77-34- 95�Z �o MINIMUMH LtS REQUIRED A i tVI:HY PRUPOSED 01SPOSAL AREA Parent Material (geologic) sh- DepthtoSedrock• . Deoth to Groundwater: Standing Water in the Hole: Weeping from Pit Face:1707,ze Estimated Seasonal High Ground Water: -5?e ' 1*36ye DEP APPROVED FOR.%t-12107/95 . I 'I FOR 111 - SOIL LVALUATOR FOR.N,1 Pale 3 of 3 Location address or Lot No. Determination ,for Seasonal High Water Table Method Used: El Depth observed standing in observation hole......... . inches Depth weeping from side of observation hole ....... . inches Depth to soil mottles inches Ground water adjustment .................. feet i Index Well Number ..... . ....... Readina Date ......... ... Index well level adjustment factor rdjusted ground water level :... .. ..._..... Deoth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on 9� (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature'A-- 6A.-46—.te 1-;5b ,?4�1 DEP APPROVED FORM- 12107195 03-21-1955 ?4:35 5i7 932 7515 C'E? NCRT}?EAST PE3ICNZL P.32 FORM 12 - PERCOLATION TEST Location Address or Lot No. COMMONWEALTH OF MASSACHUSETTS Mzssachusatts Percolation Fest' Date: � �s- Time: i Observation Hole �I 4 9-S ?B Depth of Perc I f Start Pre-soak i End Pre-603k ` I I I Time at 12" Time at 9" i Time at 6" Time (9"-6") Rate Min./Inch ' Minimum of 1 percolation test must be performed in bath the primary area AND reserve area. Site Passed x Site Failed Performed By: Witnessed By:\. Comments: o�arrxovm row+c•urv�n� Town of North Andover, Massachusetts Form No.2 f MORTq BOARD OF HEALTH o g 19 o � — F "'•b°•� �- •'�" DESIGN APPROVAL FOR • *l,, ♦+no•�•�� • ssACMUSSOIL ABSORPTION SEWAGE DISPOSAL SYSTEM • Applicants Test No. Site Location Reference Plans and Specs. ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. ,t CHAIRMAN',ErOARD OF HEALTH : Fee Site System Permit No. -ro N 0 i�QFt� BO RD DF HEALTH AUG SEPTIC PLAN SUBMITTALS LOCATION: �,Q—� �� I-`Q `s��t�cry NEW PLANS: YES d $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE: DESIGN ENGINEER: When the submission is all in place, route to the Health Secretary \ AN TOW BOF 14U i I OO O OF HER HV�R/ JULY 31, 1996 SANDY STARR AUG ""S 1996 TOWN OF NORTH ANDOVER 146 MAIN STREET NORTH ANDOVER, MA. 01845 DEAR SANDY: I HAVE ENCLOSED PAYMENT FOR THE RE-DESIGNS 0 L�A�NDJERAD IV, IN ADDITION TO CAROL'S REQUEST FOR PAYMENT ON L . IN ORDER TO PRIORITIZE MATTERS, LOTS 2 AND 19 ARE MOST IMPORTANT SINCE WE WOULD LIKE TO START CONSTRUCTION OF MODEL UNITS ON THESE LOTS AS SOON AS POSSIBLE. SINCERELY, ftBERS 40 SUNSET ROCK RD. ANDOVER, MA. 01810 508 475-8715 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE:-,E/-/=/q 7 CURRENT INSTALLER'S LICENSE# LOCATION: L o LICENSED INSTALLER: 6 SIGNATURE: TELEPHONE# vro? CHECK ONE: REPAIR: NEW CONSTRUCTION: I✓ IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes ✓ No Foundation_ As-Built? Yes �- No Approval Date: Town of North Andover, Massachusetts Form No.3 e LORTM BOARD OF HEALTH —19 L f 9 � '°•,.,oDISPOSAL WORKS CONSTRUCTION PERMIT .. ,SSACHUSEt .. Applicant NAME ADDRESS TELEPHONE • Site Location Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. L4"'l�j �i CHAIRMAN,BOARD OF HEALTH CtoFee D.W.C. No. j i b�� NORTH Town of 4 4Andover - 0I' dover., Klass., �J COCHiCHEWICK BOARD OF HEALTH PER, lal TFood/Kitchen Septic System ° -2 ��14 B ILDING INSPECTOR THIS CERTIFIES THAT.......................... ....!f...../.,1 A.9 ,r./. ".O............9,_0.e5........................................... tc�T Foundation has permission to erect........................................ bi-.. ngs on ......14 ...�f. ',e 0OO.D........L.kJ v-X—...s4.Z RDu tobe occupied as............................................... . ................................................ Chimney . provided that the person accepting this per^. zhel .11 ary respe4conlorm to the terms of the application on file in Final this office, and to the provisions of the Coke. ,!id By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PERN41 i- OROUN O� PLUMpB G INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. ncGlJl_f; r D 'r' �' ;� ;7, >�� PERMIT EXPIRES IN 6 MON S iao 1/v Final a,E - ELECTRI SPECT R UNLESS CO1',?:S"rI%;T:?C11ON ......... .. ...... ..... ........................... Service BUILDING INSPECTOR DATE. dll�VI& '�aIQ:/_ ��� /` Final cttpaney Permit Require to Occu Building GAS INSPECTOR Display in a Conspicuous Place on a Premises Do Not Remove Final ough No Lathing or Wall To Be Done FIRE DEPARTMENTf Until Inspected and Approved by the Building Inspector. Burner _ Street No. wSmoke Det. TOWN OF NORTHANDOVFR ��'► SYSTEM PUMPING R..FCOR.D JUS - 3 200A 3 �l I•EM OWNER & ADDRESS w SYSTEM LOCATION (example: left front of house) U:\Tc OF PUMPINC: QUANTITY PUMPC, D LLU� � ;. 1:S.SPOOL: NO P" YES SEPTIC TANK: NO YES � ATURE OF SERVICE: ROUTINE d EMERCENCY t�Il.>FRYAT10INS: COOD CONDITION. FULL TO COYER HRAVY CREASE BAFFLES IN PLACI: ROOTS LEACHFIELD RUNBACK... EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER Al-1 R (EXPLA.)N) >1 >'I*L.m PUMPCU 3Y. � u,IkIPt.NTS: TRANSF IT, IMEDTO: , TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD ` 2 SI'STEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) tn UA'I'E OF PUMPING: o/J'-�021 QUANTITY PUMPED/r2rt GALLONS (-1'SSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY i' U13SERV:%TIONS: GOOD CONDI'T'ION /FULL TO COVER HEAVY GREASE BAFFLES IN PLACE _1_ ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) Sl SI 'M PUMPED BY: C'O'MMENTS: C ONTE'NTS TRANSFERRED TO: R�'�E��� f'OWN OF NC1K'1 tt h' UA I`k 8' �� ,�— SYs•rra�,.f PlJMP1N(.} c�c�k��EP — 7 2005 i Y 5Tv 7'�i`{ cJ�yNgR �DDitE55 _ TOWN�OF NORTH ANDOVER --- aR �1. on __ .: ... )vuuc l vit r•,: ruKb ON sbxvic tP,t�K.Ut�N urd�a MU ' 000D RQCT3 L&ACFiF'teL0 KUN(3,��:w. FLOODED YULIDCARRYCY A„AOTHfV, EXPLAIN l'VMM�NT�. uNI N tt.KK.�U ti � Commonwealth of Massachusetts a City/Town,of NORTH ANDOVER MASSACHUSETTS - System Pumping Record _ Form'4 ` RECEIVED DEP has provided this form for use by local Boards of Healt Th ster%P ,�t�Ring Record mu; be submitted to the local Board or Health or other approvingauth� UUb A. Facility Information TOWN OF NORTH ANDO Important: HEALTH DEPARTMENT When filling out 1. System Location:: - forms on the computer, use 4. _ — only the tab key . Address to move your cursor- not , Stage use the return'. City/Town key. Zip Code 2. System Owner: Name Address(if different from location) .______"._.___."_."._-•_,__.—___--__--__ City/Town _- - ------- State ------- G� _ aeph;ne pCode TNumber B. Pumping Record - / • 1. Date.of Pumping J _ �b�---- 2. Quantity Pum ed: p Ga ns 3. a of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank Other(describe): ," 4. Effluent Tee Filter present? ❑ Ye s o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of SysteM. B 6. Sy a umped By: Name - ---..5_... /� Vehicle License Number - Company 7 ' Location where contents were disposed: Si ature of Hau =—' Date-- -- �� -'A- - _------ - http://www.mass.govi/dep/water/ provals/t5forms.htm#inspect " a t5form4.doc-06/03 System Pumping Record-Page t of 1 I, `yj a jrj ri,�IM,- ,•S � 4 , thus efts + , .0. Ah��D�01��ER M�4 S—ACHUSE S .. ,. s SGy�tem p .nu,. r TT •,r \ r.J`l'' 'i/�• }S1••1ju ',•�,5•.,�' ,R@C®1.-d -..`` .. l� y • ' i{t ni.1 \r�l•+J t-,7�l�i�j J�,� 1 v J�wf.c)' :n 1 ,�t4,YY N N ® q/ 7 .. tl5 ,J 1 .11 1r ';•""Pl4 prf"�`� ' LOO/ ' provJded this form for use by Foca Boards of Health. The S stem Pumping Record must be subcnitted to the.local'Board off e�aif �o �o°t`hr�a� l ' y P 9 iMALT riU_rr.l ,,°��n 'authority. A: Facility Informtion . [ """�wtrc HEALTH DEPARTMENT Rortant; Ell �a out .1:.. System Location; /� only the tab key Address to move your n/ Onor.•do dot U34 the rotum �' Clty/Town ke !';y:X�•ci State Zlp Code . :"rrt. },, , ,Z SySta111 OWnBr; 5 r � "�� • .\_, �•yYr �:.`'v� 1�e:. 1 a•,.,r•:;r,t,+ :i. ;,n.l., ,ry ' Add.rm(if different from locatlon) t', CltylTown;..,,, c•, State ---------------------- �Zpo", Telephone Number • � ����; -`� Pu►npt�g Record: -• '�• 'i Date of Pumping `pa 2. uantlty Pumped; Ga loos ='` 3 Typ@ pf,system, ❑ Cess ool s - P � ) Septic Tank El Tight Tank Other(de scribe) cascribe) ' 4 uent Tea Fliter present? .❑ Yes. No If yes, was It cleave Z. :;�;, d? ❑ Yes ❑ No y : iJr.�-' .. _ �r:'..1 rr•(� p` Qoridition of Syst m;'' '• •••I' /.(n` ,,, ////.J - ~;�:>.• Y�� lr 1 rr_4, d1l`�'..1 r t, •�'I .�' �J'„ 3 i,c J • • ` rJ '. t,Jur i?`:';,`:; '.I- .11 y r .� • , .�i1 Y;'1Yt.l;'.n:•:I!ir:'.�(rJt , �. ::I: V e�1y>,►�'' Pumped By; �G ...�. � 1 r, �'Y '.1' ame.:\'l:ipL;I... '..•.A:: ,.'NY.�,..' �1V�IC18 UC8n*6 Urrlbef '+ ' �Y Yr. I r yr•Y" f :14r,� �$ 4%••I.fr1�' r ,�Y � �x x!14 ✓JF,i�J�l .Qjw.•.+;:::dtf' ("t•�J.F.'`J.v:�i";; r; � r,; c•X,. LbCaWn' .wher'e conte ere.di o hfiye op sed; G�✓i 3,:. IS t J •� 14 !L Y.. _1 , �/�� r V (lA 1 / I lJ// - .1, -� :.�+•v4 rr r .., /I f(J l ' t,L r•1 -4 r t 1 I +;.'0[r! � ���.1 ♦�arr fry i,,`,. Z 1 a 1 1 .....r�', :. I - :4�: .*:`r�1•,r��a, J..r `:f(.:`; Slpn. 91 Mau Mau ,�i ay:•Q.d�,:.•.4'. Date httpJ/uiww.mass.9oWdep/wafer/approvaJsltSforms,htm#Inspect t5form4.doa 0&03 r System Pumping Record Page 1 of i r �1l��ill�fii}�•. �1w 3 �RIT AJDOVER MASSACHUS Record OCT - 9 2008 ETTS 1.4•.i.. ..yl: �; TOWN OF ne,7 a,a ANDOVER DERhai provI Od thl,j loirn forJ HEF'Ll'� -_ 'A-TMFNT by e dmI,lod co chv IocaI Boarc �•eo Io'aI eo -rC_v—Q —,ITQa-!v, i,ao�.yam�a P L Od (n or cm Or ap�r0';In avinOrl(y, A, Faclllty Inforr��tion _._-_ . 'm L on, lt 1147• G:•'1e(•00 f1Qi ' Own or. •' ., :;r l• �J'./• NiJJII';,fit •.ti/ ,•..,,ry,,l g,-: ''`�''' �•r Addrei� IIdU1 r ( � �nl rcm l�uUcn) , Tolopnono H�mOer —'-- BI-Pumping Rekord 1.' Oa;e 0f Pu m In P , 3 TYPa C( bY3l9m CJ ,999p001(9) Sepc!c Tang 21 '�'�O�hor (doscribo); 4 ---------------- EMUM Tao FIIIa('Pr0sont? n a9 Y©5 No h 1:'r,SJ•� rrS„• i.,,.y�'1 i:, v II Y 99 I, Veanoo? Yes –' oridl�Jon'q . yf 'm; • �6. SY P�mped�By G ,.•a•r''`Lr' `�j}�% I I � ����:�Y` �')�.,fi'�,,; � / ^ �Vehlde U n ., - r.�';�f�S''�j) �.1� �l, I r, �' '�1 �� 'J!/�//�)/ ///y��d it N.•'^�or --- . ,, . . ' '.,�.�",�.'(,, .' !`/n l:�aA. (1,��ar�•'��r'�:d1,1�1 ��'����j,�,l;l'd�:. / /J I ,, ..J''17,`� loci 1,I•,.;.,:c,:. ;., . on.whera oorllanls',Were dl�posed: • '�. . /;,',:, ;�, ;141,';: �� it�/ .�� ^�,='''mow.mess,9ov/dei.!vreioNepprovaJaJf6lorms,r�mnl�9pecl Commonwealth of Massachusetts AgeE City/Town of NORTH ANDOVER MASSAC U.S TSystem Pumping Record Wil Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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. System Location: forms on the computer,use QU &e 17(A Xyrj df I 1W'0_ - only the tab key Address to move your mc* cursor-do not Citylrown State Zip Code use the return key. 2. System Owner: _ CII . Name Address(if different from location) Citylrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping QDate 4 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ElTight Tank ElOther(describe): T 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. tem Pum ed By: .� Name Vehicle License Number Company 7. Acation re cont nts were disposed: R" a-Z I a u of Hau r Date http://www.mass.g /dep/water/approvals/t5forms.htm#inspect t5fonn4.docc 06/03 System Pumping Record•Page 1 of 1 t Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 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. .A. Facility Information R 71ED Important: ,When filling out 1. System Location: U Hill forms on the ) e Pini N computer, use '--/ S-Anc n )n r�- d only the tab key Address TOWN r A t VAR Imo- ._.. to move your. _ _ _ .NOCth,.AnOVer _. _ m .Ma. . H�ALTHD R_ I_V�ENT�w cursor-do riot Ma- use the return City/Town State Zip Code key. 2 Sy to Owner: Name rehun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record d 1. Date of Pumping Dat 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) V/Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Name 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 ��Ili Oarn UU Signature pMauler Date Signatu ceiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1