HomeMy WebLinkAboutMiscellaneous - 50 WILLOW RIDGE ROAD 4/30/2018m
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System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health;..Other foams may be used, but the
information must be substantially the same as that provided here. Before lasing this form, 6heck with y�ow
local Board of Health to determine the form they use. The Sygt#t Pumping Record must t submitted to
[=Ithe Il Board of Health or other approving authority within 14 •days from the pumping date in
accordance with 310 CMR 15.351.
r.-- �Or_r_eilje�o
Cityrrown state ' Zip Code
Telephone Number
B. Pumping Record
�-�- <y-�y woo
I. Date of Pumping Date z• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) tTSeptic Yank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes a No
5. Condition of
6. System Pumped By:
If yes, wash cleaned? ❑ Yes [] No
Name Vehicle License Number
j3O f,AC Z (2k S ea �'►`C
Company
7. Location where contents were disposed:
D
Signature of Hauler Date
Signature of Receiving Facility
t5form4.doc• 03106
Date
System Pumping Record - Page t of i
A. Facility Information
Important When
IuN
filling out forms
1. System Location:
povt:R
use on 0n fioomputer,
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cursor • do notAlO
Address
r AV'
use the return
key.
m
Cny/Town state
Zip code —
2. System Owner.
�gr
d
Sa.,c�Cytt luc
Name-
rafl
.
Address (if different from location)
----
Cityrrown state ' Zip Code
Telephone Number
B. Pumping Record
�-�- <y-�y woo
I. Date of Pumping Date z• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) tTSeptic Yank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes a No
5. Condition of
6. System Pumped By:
If yes, wash cleaned? ❑ Yes [] No
Name Vehicle License Number
j3O f,AC Z (2k S ea �'►`C
Company
7. Location where contents were disposed:
D
Signature of Hauler Date
Signature of Receiving Facility
t5form4.doc• 03106
Date
System Pumping Record - Page t of i
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4;
i Commonwealth of Massachusetts
City/Town ofe �B
System Pumping Record
y p g
Form 4 JAN 2 4 2009
DEP has provided this form for use by local Boards of Health. O her arms r ay be used],b .t the
information must be substantially the same as that provided herJ. B4 -fab usi4this-farm; 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
4nportmt:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
1: System Location:
50 w/' (1gV td-ic o
Addre/s�s� d {�
/ f"/IN�Ue-ice 1414-
Cityfrown State Zip Code
2. System Owner:
A l ltd
Name
Address (if different from location)
Citylrown
State Zip Code
6n -lam` -S-OG
Telephone Number
B. Pumping Record
1. Date of Pumping W-247-0'Fj 2. Quantity Pumped: Oto
Date Gallons
3. Type of system: ❑ Cesspool(s) ,,E�Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ YeslNo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
�
6. System Pumped By:
Name
�O�Zr�1
G
Company
7. Location where contents were disposed:
1-2
S ' ature auler
2-'�b S' IM,
Vehicle License Number
Date
t5fomk.doca 06/03 System Pumping Record • Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING p_ECOIjD
lEti� OWNER & ADDRESS
All"6 a
,fz
A L G%kms O
SYSTEM
hin/�
✓ 14 JR; 'Ari,, Eft/
BC l AEALT
c OF PUMPINC: QUANTITY PUMP[[; �aa�
)TOOL NO YES SEPTICTANK �0
l'UIRE OF SERVICE: ROUTINE ENtERCE'"C'Y
NO, - 4 2002
,I,>rIZV:TIONS.
C'OOD CONDITION L'ULL TO CO`r C
HFAVY CREASE I3AFFLLS IN
ROOTS LEACHFICLD
CXCESSIVE SOLIDS FLOODED �
SOLIDS CARRYOVER Oj�HER (EXPLAIN
CVi PUMPED BY
-)'� I !.'N I'S TRANSFCIZRLD TO
4
'Ail f Sn� t%d {i{1�1 1'vi, �s t ` is s ,}
r `
TQYM0.FN0RrT
'aDOVEf�
SYSTEM PU,KP-. - CO' /, ,
4 i.
M W '.
U. NFR & ADDU, SS„ SYSTEM-L;O"CATION
��
N�:
5b-7 b
U I C UF' PUM1'INC; O QUANTITY PUmPQD �000C,,,'
c r r '1{ A4r iEi i'X' yA b jrs y r,
YES SEPTIC' TANK: NO ✓
....., YES
S
N.aTURE OFSERYIC>✓ ROUTINE EMERCEN'CY
CUUD°,CQ,NU11'LON NLL7 0 C0YCI2
FIRA,i�;Y"CREA'$ l3AFFLLS' IN i'I,ACI?
;RU:OTS LEACHFICLD RUNBACK.,.
CXCESSIYD S0)✓1DS FLOODED',�-
50Ll CAR Y,OYE<� q hER �irxr�LA.IN)
i r )
� r�� Y ft�t •�A ` v..h v, ..
't
1.
1
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M'"OF NOR•T ref 1JOVE
R..
SYSTEM P!UM'PI'.NC R COR_D
�')'1 TE UWM1ER & A0DRESI SYSTCM LOCATION
N (ez4mP 10 front of housr)
60
^►77to, -nh
y U I !r UFrPUM1'1NQi K-4 IT('UM ` I
UANTY / .
Y , •"JC!� C /l 1. 1. \ .
UI.'NO�� YES SEPTIC TANK: NO YES
• i
:NUKE OF SERVICE, ;'ROUTINE. EMER0EN'CY
11I!>rRyT1.0N �.
' UOD'CV,NU11'ION . FU, LL'T0 COYCk.
' `FI I'A`,Y•;Y CR]~'ASC ` -OAR
FLLS IN I'lrACl? -
;RUO:TS'1 LEACHFICLD RUN0AC'x.•,
cXCESSIYE 0>✓1DS FLOODED'
501y;Iu,;:CARRYOY
E V'HRR (IirXl'LA.Irr)
f �r' it � 1't11 r�p�t��',y�.reN,�A'SYv eir.a bry +�l, Ill 5 •�.1 7 f51 , 7
PUMPC f3Y,
r
r 1
i.d4il /41st
• r. � � t u yYj 5 t , .t. ...
ONT I., A. 13, 1Z RC, D TO
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
D�-
l E!y1 OWNER & ADDRESS
oviq Jn Ary
BC "OF 4EALi
r---
NU, -4W
SYSTEM LOCATION
(example: ler( fron( of hou5t)
A� C '1
L) \T[ OF PUMPING: %a (QUANTITY PUMPED 11200 C,,a
PO0L: NO ✓YES SEPTICTANK: NO YES
A-l`URE OF SERVICE: ROUTINE CZEMERGENCY
mFRV \TIONS:
C'UOD CONDITION
HFAVY CREASE
ROOTS
CXCESSIVE SOLIDS
SOLIDS CARRYOVER
,0 ) I'LM PUMPED BY
U'� I l.'N I'5 Tl ANSFEIZIZED TO:
(FULL "T'U CUvC,z
BAF'FLLS IN PLAC[�' _
LEACHFIELD RUNIUACK..
_ FLOODED �
Oj�HER (EXPLAIN)
North Andover Board of Health
120 Main St.
North Andover Ma.01845
Haul Lic. #151 -OOH
Install Llc. # 128-0
Date Address
11/1/2000 303 Chester St
11/1/2000 50 Willow Rd
11/1/2000 160 Carelton Ln
11/1/2000 165 Bridal Path
11/4/2000 174 Ingals St
11/4/2000 1062 Salem St
11/6/2000 373 Raligh Tavern Ln
11/6/2000 252 Boxford St
11/6/2000 150 Liberty St
11/6/2000 149 Osgood St
11/7/2000 255 Haymeadow
11/7/2000 850 Winter St
11/8/2000 25 Windsor Ln
11/9/2000 249 Carlton Ln
11/9/2000 767 Johnson St
11/10/2000 56 Academy Rd
11/14/2000 Sugar Cane Ln
11/14/2000 250 Abbott St
11/15/2000 195 Winter St
11/15/2000 187 Winter St
11/16/2000 85 Laconia Cir
11/16/2000 86 Willow Ridge
11/17/2000 2135 Turnpike St
11/20/2000 203 Grandville Ln
11/20/2000 391 Pleasant St
11/20/2000 124 Tucker Farm Rd
11/22/2000 394 Boston Rd
11/22/2000 728 Forest St
11/22/2000 18 Johnney Cake St
11/24/2000 106 Rockey Brook Rd
11/24/2000 258 Rea St
11/28/2000 1815 Great Pond Rd
11/28/2000 1420 Great Pond Rd
11/29/2000 266 Lacy St
11/2912000 155 Laconia Cir
Andover Septic
47 Railroad St.
Bradford Ma. 01835
Gallons Comments
1000
1000
1500
1500
1000
1250
1000
1000 Leachfield Run Back/ Ex. Solids
1500
1000
1500
1250
1500
1500
1500
1500
1500
1000 Extra Solids
1500
1500
1500
1000
1500
1000 Flooded
1500
1500
1500
1500
1500
1500
1000
1000
1500
1000
1500
FORM 4 SYSTEY1 PU�,TLNG RECORD
Commonwezrrlvlin��.Record
f Massachuset S
1� / OODOMassachusetts NOV — S 2004
I c,) QtPn7.,00vER
caner
1
�yste
1-3 �
1 I -)C) v '�! �,
yslem ocation _
C/
T\,pe. 1. Emergency ❑ Routine eY _
❑ S(-ptic Tans:: EJ Yes
Cesspc .�I: No El Yes No
--
�-- Quantin, Pumped: (��-�� _ ballon:
Date c. Pumping: ---._-_--
�BORACZF—K'S Permit—
S\.stei:: Pumped by (Company): I,_�...
Conte AS transferred to:
Cont:.tts disposed at:
c.r
D2tc l� Pumper Signarure , -
Condition of systemiother comments:
DEP APPRO` IM FORM • I:i07/9S
6-e) C51
RECEIVED
I`iRk - � '011 (
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
FORM 4. SYSTEM PUNVLNG RECORD
mmonwealth of Massachusetts
,vo A,,kv" , Massachusetts
Sy—stem Rec rd
�)yste :1 Owner
.I
Gj' ?,E — d Il — On'� S
ystem k 17 )
2f S,(d(f o' Ou4
I l' 0/f r/ .
Type: Emergency 0 Routine �
❑ No ❑ Yes
Cesspc .DI: No ❑ Yes S� ptic Tan}::
�— .G Quantity Pumped: /� JD _ gallons
Date c.: Pumpine: I a " _
I BO RACZEW$' = Permit
Svster: Pumped by (Company): -
Contc .ts transferred to:
Cont:.its disposed at: Ll
Da (e i /0 Pumper Sienature i—
Condition of systemlother comments:
k -d DEP MPROVID F0POt • I:/07/95
TO: NORTH ANDOVER, MASS -� / 19 77
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
L o 7` 9 L,&/ //&tu R/ d North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
AlkSt
-r-r,grrreerd sr g zz
vo
arlan
TO: NORTH ANDOVER, MASS NG V 2 19 7C
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
'10t `f W///OW R i d (sL t Pd. North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
192!
46-1 w
8
3
9
SOIL PROFILE & PERCOLATION TEST DATA
rown/C ty" �Uy No.&Street 1J oJ/� ✓ Lot No.�,_
Loc./Subdiv. ,�//OCJ Cl Plan Owner
Investigator.,, -_ Observer
1V 91,7 SOIL PROFILES -DATE
1. Elev. 2. Elev. 3' Elev. 4'E1ev.
n 0
0-
1
2
3
4
5
6
,o.
8
9
1
2
3
4
5
6
8
9
1
2
3
4
5
6
8
9
OBJ
� V
b
10 ��10 �� 10 j __. 1 10
Benchmark Location
Elevation Datum
Percolation 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 "Dro
Mins.2nd 3"Drop
Notes & Sketches on Back Frank C. Gelinas & Associates, North And.
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