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HomeMy WebLinkAboutMiscellaneous - 511 WINTER STREET 4/30/2018 (2)Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 4 raven Commonwealth of Massachusetts CitylTown of North Andover ,System Pumping Record Form 4 "RECEIVED �u 1014 TOW14 U!. tvule! M ANDOVER HEALTH DEPARTMENT ut the DEP has provided this form for use by samelocal asBoards that provided herreh Befo e using her forms may eb s form,check with your information must be substantially the Record must local Board of Health to determine the form th' with n 14 days from pntghe pumping date Inubmltted to the local Board of Health or other approving authority accordance with 310 CMR 15.351. A. Facility Information 1. System Location: //nn Address Ma 01886 North Andover State zip code City/Town 2. System Owner: ,-%/emn Name Address (if different from location) State Cityri-w n B. Pumping Record 1. Date of Pumping Date Telephone Number Zip Code 2. Quantity Pumped: Gallons /Septic Tank ❑ Tight Tank ❑ Grease Trap 3. Type of system: ❑ Cesspool(s) L�1 ❑ Other (describe): - . 4. Effluent Tee Filter present? ❑Yes ❑ .No If. yes, was it cleaned? E] Yes ❑ No 5. Condition of System: 6. S tem Pumped B CVehicle License Number Name Stewart's Septic Service Company 7. Location where contents were disposed: Stew�;e-pMlreatment Plant, 20 So. Mill Bradford, Ma 01835 Signatu Signature of Receiving Date Date System Pumping Record . Page 1 0 W/17 ooV(ie.rbr 44elxlil,�o- T RECEIVED. LOCT 2 2 2004 C T TOIVNVN OF Xr 0 : LT p HEALTH DEPAF 104-41V '5 /:i C--K•�4074Y VOOZ'ZIZ 1.30 u N.ha+ provided jhl+ form !or iso '1, !Deal 6oarca c hoa!;r. 7 �;T DO +'�orr,!;{ad to the local Bcarc; /„ t Oai(n pr CUrOr a��rCvinv at.lnpr ry_1 Cr Pte', , -- To'9pnpna--- f• .1 Cal>j o! Pumnq 3, Type P! bys1e`m; O ,999p001(g) SepuC TanKgrit T '� TI ani --------------- Effivan!_Too FMo(Prg3enr? Y©g nlc Pmpod .. .',a.. (;,.`.�1:; `�Y,1i, ,. )� I, }, r•i .4,ri{�ri� !'I ��'.Ifi•'J�� r .4','�. r�, � .. � In ���aA IV •(lar•:'r •� dl, I' ��Cr ��i'."'r'.� X11 SII" on. where c0r!!anls'Ware dl�poseo: I C- !/1VV/tiV. m a S3. OVId 8 B p P 9 a( r/a ov sJI6lormg,h:mulngpeC! �i/ wi,I1l It y89, n85 II C!aaneo? 7 Yes — - Vehloo A, Facility Inforr7lc!on Sys:gm lova M 74 Y,... '� V4 num''., To<rr� Sial Own or, '�',' - •', .,!, ,,�. Lam/ `A 1 ' rbulUcn) AQ4re44 Of dUifrr5fl( rc(n Cr Pte', , -- To'9pnpna--- f• .1 Cal>j o! Pumnq 3, Type P! bys1e`m; O ,999p001(g) SepuC TanKgrit T '� TI ani --------------- Effivan!_Too FMo(Prg3enr? Y©g nlc Pmpod .. .',a.. (;,.`.�1:; `�Y,1i, ,. )� I, }, r•i .4,ri{�ri� !'I ��'.Ifi•'J�� r .4','�. r�, � .. � In ���aA IV •(lar•:'r •� dl, I' ��Cr ��i'."'r'.� X11 SII" on. where c0r!!anls'Ware dl�poseo: I C- !/1VV/tiV. m a S3. OVId 8 B p P 9 a( r/a ov sJI6lormg,h:mulngpeC! �i/ wi,I1l It y89, n85 II C!aaneo? 7 Yes — - Vehloo Ang a vi I C -IR lvo 114 ptg I wo tqlm I?l I evil(: •P.^, ;�Iln Qt Facility lnf-oQn 61cl 0,,,RTH NUuvc-1 "I, ') ZXENT) .0 �rm�pplg A. ''• 1 U; ld � ;, ; '! f I i . ' • ' tom' / �"` L���Z�� to. o I, 71 I gm tow T-747 aD- ILI' .le ........................................... LA -0 11 Pvm�jnq ,' ''' l '' r r , 01;1 � n •, a r ', � �/ r � 8 � E���C"—t�- , M: sopoc Ten, . 011,111 'Y .4' T on r? 0 • Y.. PV III I V . ,r,,,: r,,;l� .,rrr :'Sr /� .,I'll Ulf XI F� yf o01Q, Yi�lul -nil �77;� Commonwealth of Massachusetts r-7RECEIVED f City/Town of North Andover a System Pumping Record 2013 Form 4 TOWN OF NORTH ANDOVER °M 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 Important: When filling out forms 1 on the computer, use only the tab key to move your cursor - do not use the return key. rad 2 A A7 reran System Location Address North Andover CityfTown System Owner Name Address (if different from location) Ma State 01845 Zip Code City/Town State Zip Code Telephone Number B. Pumping Record X) 1. Date of Pumping DADate 0 2. Quantity Pumped: LAJ Gallons 3. Type of system: ❑ Cesspool(s) [� Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes V No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: rv-s\nn q\0� . 6._ _System Pumped By Stewart's Septic Service Company 7. Location where contents were disposed: _._._..Stewa#!&­Pt-e+eat lant, 20 So. Mill Bradfot Vehicle License Number Ma 01835 Signatur f Hauler Date . Sign of Receiving Facility -Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of North andover System Pumping Record Form 4 �M 1V'y`i 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 Important: When filling out forms 1 on the computer, use only the tab key to move your cursor - do not use the return key.2 acorn System Location: 5.11 Address N. Andover City/Town System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping Date Ma State State Telephone Number 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) 0 Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Zip Code Zip Code 1060 Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No Name Vehicle License Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Signature of Receiving Facility Date Date 0400VE T NNO Gelpx9k. NT t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 `�\N Commonwealth of Massachusetts v City/Town of No.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. RECE A. Facility Information Important: NOV 10 0 2011 When filling out 1. System Location: forms on the LTOWN OF NORTH ANDOVER computer, use HEALTH P only the tab key Address to move your No.Andover Ma 01810 cursor - do not use the return City/Town State Zip Code key. 2 System Owner: Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record I �'\_� d fty)I 1. Date of Pumping Date 2. Quantity Pumped: o 3. Type of system: ❑ Cesspool(s) 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: 60 nC7� 6. Sy mPumped By: r� K � Name Stewart's Septic Service Company Vehicle License Number 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 AA Sign of Hauler D Si of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 r7 Y- 3 a � FORM U - LOT RELEASE FORM �S o INSTRUCTIONS: This form is used to verify that all necessary ne approval royals/permits from This does not relieve Boards and Departments having jurisdiction have been o the applicant and/or landowner from compliance with any applicable or requirements. �*****************APPLICANT FILLS OUT THIS SECTION'*""*** , PHONE g7_ g��`5©�% APPLICANT—/I,, y PARCEL_ LOCATION: Assessor's Map Number l LOT (S) SUBDIVISION STREET �/i � � S ST. NUMBER OFFICIAL USE ONLY e,,,A wr enMINISTRATOR DATE APPROVED -_ �� •�wTrl1 TOWN PLANNER COMMENTS COMMENTS DATE APPROVED DATE REJECTED TH DATE APPROVED DATE REJECTED TH DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT DATE___ RECEIVED BY BUILDING INSPECTOR Revised 9197 jm TOWN OF NORTH ANDOVER 4 N8R7H Office of COMMUNITY DEVELOPMENT AND SERVICES o HEALTH DEPARTMENT 27 CHARLES STREET 9 «xx.x.xx •- ��q�TlO �fr`•(h NORTH ANDOVER, MASSACHUSETTS 01845 SSA�MU`�E� 978.688.9540 — Phone Susan Sawyer, REHS/RS 978.688.9542 — FAX Public Health Director healthdept@townofnorthandover.com www.townofnorthandover.coni Ta Fax: E-� 3_ /,L (I From: Pages: Phone: Date: 10/1 q 16 4 Re: CC: ❑ Urgent ❑ For Review Please Comment ❑ Please Reply ❑ Please Recycle Please contact the Health Department at the above numbers for further assistance. d✓' a� � � l �J � l � � ��1^-�� �,,., v... a>..�.--� � �D��- t'S CS"'l ('�1.1%a /l..L rr j �/ L ✓'ts� y esu 5 I\ a Xao �0, Q" � -il, �- �� Ct�►.Z� i�� N� ►a' Stewart's Septic Service ❑ Andover Septic ❑ Stratham Hill Septic ❑ Roto -Ram 372.7471 (978)475.2593 (603)772.5548 (978)452.9022 20 South Mill Street, Bradford, MA 01835 ice 1 y PAY FROM THIS BILL tme: ❑Reg. Nature of Service j"'�jr" ❑ WC ❑ Reg. Maint. ition:❑ Emergency I t)i I K ,cf❑ Day 0 Night Phone: Contact: Billing Address: City: Special Instructions Per. AM/PM Services Rendered Zip: ❑ Completed ❑ Incompleted Reason: Vacuum Pumping ❑ Septic Tank ❑ Drywell ❑ Leech Pit / Overflow ❑ D -Box ❑ Pump Chamber ❑ Grease Trap ❑ Catch Basin ❑ Portable Toilet ❑ Other Qty: Size: O Under 1000 gallons 0 1000 gallons ❑ 1500 gallons ❑ 2000 gallons 0 3000 gallons ❑ 4000 gallons ❑ 5000 gallons ❑ Other Misc. ❑ Digging Charge ❑ Location ft./in. O Service Call ❑ Labor ❑ Waiting Time * Digging Charge is Per Driver Discretion Description of work Septic Tank Pumping and Cleaning "Done the Right Way" Observations ❑ Good Condition ❑ Leechfield Runback ❑ Riding High (liquid level) 0 Full to Cover ❑ Excessive Solids Top / Bottom ❑ Use No Powdered Soap ❑ Heavy Grease ❑ Roots O Suggest Electric Rootering ❑ Van Called ❑ Other ❑ Backhoe ❑ Consultion hrs. O Estimate ❑ Portable Toilet Rental ❑ Baffle Drain Cleaning ❑ Main Line ❑ Toilet Bowl ' ❑ Kitchen Sink ❑ Bathtub / Shower ; i t ❑ Vani y, ❑ Floor Drain ({ O Ven{ ❑ Sewer Jet ❑ Other'` -- Footage: -- ❑ Inspection ❑ Certification: PIF Reason: ❑ Pump Repair ❑ Repair ❑ Chemical Treatment O Other Terms of Payment Parts Vacuum Pumping Drain Cleaning NET 15 DAYS Yr. Month Yr. Month Tax Discount Terms & Conditions ❑ Cash 0 Check ❑ Credit Total 1. Not responsible for damage beyond curb fine. 3. 1.5% per month will be charged to accounts past due. 2. All complaints shall be reported within 48 hours. 4. The purchaser agrees to pay all cost of collection. a' 3 SYSTEM OWNER & ADDRESS SYSTEM LOCATION s Q Ism m e- rr_074�. 5'i 1 W. i` o4e- r .� N. oNoafri ma. DATE OF PUMPING L QUANTITY PUMPED CESSPOOL N0� Y£S SEPTIC TANK NO YE NATURE OF SERVICE RQUT EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN LACE r ROOTS LEACHFIELD RUNBACK/ EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN '1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: ///� V SYSTEM OWNER & ADDRESS 1�7/ �Cc SYSTEM LOCATION (example: left front of house) /v Omkkf �� " DATE OF PUMPING: �l� moo/ QUANTITY PUMPEDJ6�) _GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: nFC — 7 2001 l Commonwealth of Massachusetts ?0 City/Town of NORTH ANDOVER MASS�4S - System Pumping Record Form 4 SEP _ 6 2006 DEP has provided this form for use by local Boards of Health. �'GR �v geM f �r , .q f7ec rd mu,, be submitted to the local Board of Health or other approving a �hor'u l -TN DE 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. 1. System Location: Address City/Town Sta e 2. System Owner: Name Address (if different from location) ctty/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Zip Code State Zip Code Telephone Number Date Io -- 2. Quantity Pumped: Gallons Cesspools)eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No r 5. Condition of System: 6. SyAem Pumped By: If yes, was it cleaned? ❑ Yes ❑ No Name Vehicle License Number Company - 7. Location where contents were disposed: Si ature of Hau Date http://Www.maskgov/dep/water/ provals/t5forms.htm#inspect 0 t5form4.doc- 06/03 System Pumping Record • Page i of l i �Gp i y r i �tfy,i4\i�a!l f �� ?� V ;achusetts F0 4 DEP has provided this form for use by local Boards of Health. The be submitted to the local Board of Health or other approving autho X Facility Information Important' . System Location: ' r forms on the oornpuW, us, only the tab key Address Rn to move yosor ur cw• do not ,y� , Ste eturn use the r . key, ..•. 2, System Owner, E I Zip Code Address (K different from location) Cityffown State Zip Code Telephone Number B. PumpinS Record 2, Quantity Pumped: 1. Date of Pumping Date Gallons 3. Type of system. ❑ cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Too Filter present? ❑ Yes ❑ No 5; Condition of System: If yes, was it cleaned? ❑ Yes ❑ No 8. Sys,M.fumped By: Vehicle Uoense Number �.ec? 7. Location wh$re contents were disposed:P 1 i ofDate httpJ/www.mass.9ovldep/water/approvalsttSforms.�hnspect t5form4.d00. 08103. System Pumping Record • Page 1 of I