HomeMy WebLinkAboutMiscellaneous - 490 WINTER STREET 4/30/2018 (3)41
,A 1
SEPTIC SYSTEM INSTALLATION
IS THE INSTALLER LICENSED?
TYPE OF CONSTRUCTION:
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW
CONDITIONS OF APPROVAL
(FROM FORM U)
r
YES NO
N REPAIR
YES
YES NO
ISSUANCE OF DWC PERMIT :::�L:DNO
DWC PERMIT PAID?
DWC PERMIT NO. O
BEGIN INSPECTION YE 0:
EXCAVATION INSPECTION: NEEDED:
YES NO
INSTALLER : :7--, D5W i8 50A-)
CONSTRUCTION INSPECTION: NEEDED:
AS BUILT PLAN SATISFACTORY:
APPROVAL TO BACKFILL: DATE: (p BY
FINAL GRADING APPROVAL: DATE BY
FINAL CONSTRUCTION APPROVAL: DATE:4�&BY_,LQ
Ortice Use Only
The Commonwealth of Massachusetts a4sq�
Permit No.
_ Department of Public Safcty
Occupancy b Fee Checked
' BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12-00 3/90
(leave tt,nkJ
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be pctformed In accordance with the Macsachusetu Ele�trlcal Code. 52,E CMR 12:00
(PLEASE PRINT IN INK OR TYPE .ALL INPORHATION) Date i (a - l Q
City or Town of 1" p,, 4LQ1LQQ e-_4, To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) L( 9 0 :in 4?—VL-
Owner
VL
Owner or Tenan
Owner's Addres
Is this permit in conjunction with a building permit: Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization NO.
Existing Service Amps / Volts Overhead ❑ 'Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity.
Location and Nature of Proposed Electrical Work 'T--, A'.Ak Vz, N P s v L o s oD--t—.�-��----
No. of Lighting Outlets
No. of Hot Tubs
No. of,Transformers Toovtal
No. of Lighting Fixtures
Swimming Pool Above In-
rnd. ❑ grnd. ❑
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No, of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained --
Detection/Sounding Devices
Connection ❑ Other
Local[:] MunicipalNol
No. of Ranges
No. of Air Cond. Total
tons
No. of Disposals
No. of }seat Total Total
Pumps Tons KW
No. of Dishwashers
Spnee/Area Heating KW
No. of Dryers
Heating Devices KW
No. of Water Heaters KW
Signs f Ballasts
Low V Voltage
WirinNo.
Hydro Massage Tubs
No. of Motors Total lip
UIMK:
INSURANCE COVERAGE: Pursuant to the requirements of Massachud isetts General Laws
I have a current Liabilit Insurance Policy including CompleteOperations Coverage or s substantial
equivalent. YES E? -NO L] I have submitted valid proof of same
'to this office. YES a NO ❑
If you have checked YES, please indicate the type of coverage byechecking the appropriate box.
INSURANCE Q BQND [I OTHER ❑ (Please Specify)
Estimated Value of Electrical Work $ i'2A p
o 0 xpirat i o n__I5ate
Work to Start (,. — I , dj (, Inspection Date Requested: Rough Final b — % i —9
Signed under the
FIRM NAME �ka
Licensee .14jx rl
alties of perjury:
LIC. NO.
Address 'Z.EYg, [lr>c��w_Ut✓ SLJ
BuTel. No.
Alt. Tei. No.J'd g L+ ( 7 — T 7 kzy
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-,
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)!
v"
Telephone No. T E1:IITT 1TE S/
Sirnnt.ure OF5711, ��;,;i'—_..---
COMMONWEALTH OF MASSACHUSETTS"-'
OF ELECTRICIANS
AS A REGJOURNEYMANOURLCENSET
NE ELECTRICIAN,
ISSUES
d ..
ALAN L BEAUREGARD
13 WILLIAMS DRIVE
HUDSON NH 03051-543
1289JR 07/31/98 109775
• 4
TO .. Date..T,WAJ�,A
2454
F HpRT1� , TOWN QF NORTH ANDOVER
tipk.
,eL `E�/r''1�`yy CAL
o PERMIT FOR INSTALLATION
This certifies that HALL l�!!?'.G'`��� S �? ✓ E , , , , , , . ,
has permission for tinstallation yL HI" s4�' ��`'"'� otl't�-
in the buildings,of .... � ! '' p !'� . .............. ... .
at
q. W 1't? !�.. S7i� T....... , North Andover, Mass.
Fet/� vo .. Lic. No%2@.�............................
PR i i) T N P% 96 ►P4 -1-39-
e/ 3 �9 -00 P INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
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AS BU I LT PLAN
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
Q-a-ro A � � Clove v. ,
AS PREPARED FOR
GAI, -A Y f�DyL Eqq ok l t rifiE 5-r V EF
DATE:
SCALE: ": •c}p'
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS 0 LAND SURVEYORS • PLANNERS
be PARK STREET 0 ANDOVER, MASSACHUSETTS 01110 or TEL (617) 473-3553, 373.3741
NI
�i�t ■ _.1 �l
�l� 'y JI
...
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5l�.5dqT� 5D �
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AS BU I LT PLAN
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
Q-a-ro A � � Clove v. ,
AS PREPARED FOR
GAI, -A Y f�DyL Eqq ok l t rifiE 5-r V EF
DATE:
SCALE: ": •c}p'
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS 0 LAND SURVEYORS • PLANNERS
be PARK STREET 0 ANDOVER, MASSACHUSETTS 01110 or TEL (617) 473-3553, 373.3741
NI
Town of North Andover, Massachusetts Form No. 3
e N0RTI11 BOARD OF'HEALTH t/�7
0 1 19
o
M 9
DISPOSAL WORKS CONSTRUCTION PERMIT
ACNUSEt
Applicant Uty"� S611
NAME ADDRESS TELEPHONE
Site Location_ _ 490 LJi � 1""� 1 ,t -
Permission is hereby granted to Construct ( ) or Repair (>4/an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
Fee
CHAIRMAN, BOARD OF HEALTH
D.W.C. No.
.. _ - ..b...
f JkOR71J
3?O•t„1e ,•,h0
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F
,SS�1CHU5Et�
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 2
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant3 A do_ Test No.
Site Location L kQ ()
Reference Plans and Specs. 'f Vk-U
ENGINEER
DA'
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health. _
'd/Z77"i-
--CH
AN, BOARD OF HEALTH
Fee
Site System Permit No. (?Z1.2—
PLAN REVIEW CHECKLIST
ADDRESS ENGINEER
GENERAL
3 COPIESy STAMP LOCUS NORTH ARROW SCALE v
CONTOURS �/' PROFILE i%' SECTION_L,,---� BENCHMARK SOIL &
PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS
WATERSHED?/Vo DRIVEWAY (Eley) WATER LINE FDN DRAIN
SCH40_LZ- TESTS CURRENT?_SOIL EVAL_
SEPTIC TANK
MIN 150OG 0K/ .17 INVERT DROP GARB. GRINDER -k(+200% EDF)
25' TO CELLAR MANHOLE ELEV GW # COMPS.
D -BOX /
SIZE # LINES FIRST 2' LEVEL STATEMENTy
INLET - OUTLET /C5G•3 = (2" OR .17 FT) TEE REQ'D?
LEACHING 400�
MIN 660 GPD? RESERVE AREA 4' FROM PRIMARY? 20 SLOPE
100' TO WETLANDS 100' TO WELLS ✓4' TO S.H.GW �(5'>2M/IN)
35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP
4' PERM. SOIL BELOW FACILITY C-' MIN 12" COVER C/ FILL? `7�('$5'
if above natural elev; 10'if below) T�
TRENCHES
MIN 660 gpd SLOPE (min .005 or 6"/100') SIDEWALL DIST. 3X EFF.
W OR D (MIN 6') RESERVE BETWEEN TRENCHES? IN FILL? MUST
BE 10' MIN. 4" PEA STONE? VENT? (>3' COVER; LINES >501)
BOT + SIDE_ X LDNG = TOT
(L x W x #) (DxLx2x#) (G/ft2)
Copyright 0 1995 by S.L. Starr
PITS
MIN 660 LEACHING
GW MIN 4' BELOW BOTTOM
MIN 1 (13'x16') PIT
EXC 2x EFF W OR D
MANHOLE/PIT
12"-48" STONE
BOT + SIDE x LOAD = TOTAL
(L x W x ##) (2x(L+W)xD x ##) (G/ft2)
CHAMBERS
MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT
MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005
BED/TRENCH,
BOT
(L x W x ##)
(Bed max. 60' X 60') MIN 13' X 16' PIT
+ SIDE X LOAD = TOTAL
(2 x (L+W)xD x #) (G/ft2)
FIELDS
MIN 660 GPD 900 ft2 BED �GW MIN 4' BELOW BOTTOM OF FIELD
PIPE ENDS JOINED? L/ 4" PEA STONE? ✓ DIST LINE SLOPE .005? t�
>3'COVER-VENT �� SCH 40 f MIN 12" COVER
RATE SM 1 LDG 114' X 660 X = TOTALelo
G/ft2 REQ'D (ft2) LXW
DOSING TANKS AND PUMPS
DIMENSIONS X X = PUMP CAPACITY 9Pm
L W D Vol.
DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME
9Pm
MANHOLES TO GRADE ✓ ALARM SEP. CIRC.''- GW(Min. 1' below
inlet) HWLLWL 14,5 CHECK VALVE BLEEDER HOLE c/_ MANUAL
OP. SWITCH
-IWV�6 to/
Copyright 0 1995 by S.L. Starr
FOR -S DATETIME��
f►W
11' ' Pi !QN£a '1
OF x r
PHONE I 'T I U I v I
AREA CODE NUMBER EXTENSION
MESSAGE
L4/\ WELL CALF.
9 V W 1 Y� ACAIN
CAMETO
sggybu
Q WEEP
WS TO
SEE U
l.� DiJ
SIGNED TOPS ' FORM 4003
' S, t �
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Jo
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IB
A
to IAL/17� i
William F. Weld
Governor
Trudy Coxe
Secretary, EOEA
David B. Struhs
Commissioner
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
i n
Property Address: w Address Owner: �
Date of Inspection: L/_ �- (If different) /
Name of Inspector:
Company Name, Address and Telephone Number:-qAP4-J,_
Am
CERTIFICATION STATEMENT
I certify that I have personally inspected sewage disposal system at this address and that the information reported below is true, accurate0o' n
and complete as of the time of inspe. 'The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage dispoQI syst, s. The system:
_ Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails -
Inspector's Signature: Date:
A. r
The System Inspector sall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has•a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies 'sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A) SYSTEM PASSES: L
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 115.303.
Any failure criteria not evaluated are indicated below.
BI SYSTEM CONDITIONALLY PASSES: A./
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
One Winter Street a Boston, Massachusetts 02108 a FAX (617) 556-1049 a Telephone (617) 292-5500
i4) Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: '-5 b yI-e
Date of Inspection:
,-/'jr tv
B] SYSTEM CONDITIONALLY PASSES (continued) 8 / -
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY. THE BOARD OF HEALTH: �Y
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
��,r CERTIFICATION (continued)
Property Address: !.t/ l/4!%��
Owner:
Date of Inspection: G /.
D) SYSTEM FAILS (continued):�� ! (�
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
4V'#7 -r.— 6'Ce. " 7-0 7 -OJ" '0F 04
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
i
• Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
i -j• Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: 4.
The following crit ri +apply to large systems in addition to the criteria above:
The design flov.- of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95)
l�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address.
Owner: 0
Date of Inspection:
Check ifthwing have been done:
_Pumping information was requested of the owner, occupant, and Board of Health.
V' None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
jerAs built plans have been obtained and examined. Note if they are not available with N/A.
ZThe facility or dwelling was inspected for signs of sewage back-up.
ZThe system does not receive non -sanitary or industrial waste flow
v The site was inspected for signs of breakout.
Jj All system components, excluding the Soil Absorption System, have been located on the site.
✓ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
/tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
_ The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non -intrusive methods.
—,"'The facility o.ti ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -
Surface Disposal System.
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
i0U a1/1 -1,T ele- 5-r /// 11,oG u 2.''_
Owner:
Date of Inspection: /J
FLOW CONDITIONS
RESIDENTIAL:
Design flow: Ballo s
Number of bedrooms:?
Number of current residents: a
Garbage grinder (yes or no):,
Laundry connected to system'(yes or no):Ye
Seasonal use (yes or no):-
Water meter readings, if available:
Last date of occupancy: ul l e - p
COMMERCIAUINDUSTRIAL
Type of establishment: /T•
Design flow:gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non -sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as pan of inspection: (yes or no)_
If yes, volume pumped eallons
Reason for pumping:
TYPE OF,WSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: OV
Sewage odors detected when arriving at the site: (yes or no) '40
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: a U /�
Date of Inspection: //'
4-/-
SEPTIC TANK: -,PS
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions: /49)1d le S ' �-
Sludge depth: k ''
Distance from top of sludge to bottom of outlet tee or baffle: 3 y
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: /I
Distance from bottom of scum to bottom of outlet tee or baffle:/—/
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
u
GREASE TRAP:—
%�
(locate on site platf)
Depth below grade:
Material of construction: _concrete _metal ,FRP —other(explain)
Dimensions:
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom ni spurn t, bottom of outlet tee or battle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 8/15/95) 6
rj
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: !
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _,metal _FRP —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:y'r
(locate on site plan)
Depth of liquid level above outlet invert:
A►v{ D vT�� f
Comments:
(note if level and distributicr, is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_ '
/' J / %�.
(locate on site plan) 1
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
1 7
.(revise` 8/15/95)
1
a
e
�j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
10 W
Property Address:
Owner:
Date of Inspection:
.�f
1,1
SKETCH OF SEWAGE DISPOS L SYSTEM?
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
- j r/
Lei
0
5"f� c C 7'
DEPTH TO GROUNDWATER
Depth to groundwater:_feet f�
method of determination or approximation: /pGy /a#9 -C Alyd2- %N.1
a
(revised 8/15/95) 9
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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
System Pumping Record
Form 4
RECEIVED
JUN 3 0 2009
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Ofner Forms mayt 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, left rear, left side of house. Right front, right rea Ight side of house.
Address
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
Citylrown
State Zip Code
'L5 3
Telephone Number
B. Pumping Record
1. Date of Pumping r Date 2. Quantity Pumped
_
3. Type of system: L] Cesspool(s) 91*'Septic Tank
Gallons
L] Tight Tank
Other (describe):
4. Effluent Tee Filter present? Cj Yes No If yes, was it cleaned? [ Yes [j No
5. Condition of System:
K)O(m J �Catjl
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Of
Lowell Waste Water
<t '- 0'?
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
5. Condition of System:
"I, 'j-
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
("kcz�
Signature of Hauler
http://www.mass.gov/dep/water/appi
htm#inspect
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
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City/Town of NORTH ANDOVER MASSACHUS
TTS
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System Pumping Record
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Form4
TOWN OP NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. The Syste
H
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out
1. System Location:
fforms on omputerthe
1419 V W I )y ( r-!L
only the tab key
to move your
Address
V& 4 11
cursor - do not
use the return
City/Town State
Zip Code
keysI..�
2. System Owner:
k- ALfName
Address (if different from location)
City/Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �"�_�_ t3 2. Quantity Pumped:
p g y p Date
Gallons
3. Type of system: ❑ Cesspool(s) [a-Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes D- No If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System:
"I, 'j-
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
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Signature of Hauler
http://www.mass.gov/dep/water/appi
htm#inspect
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1