HomeMy WebLinkAboutMiscellaneous - 54 PENNI LANE 4/30/2018 (2) JLL: PENNI LANE
210/107.D-0061-0000.0
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Commonwealth of Massachusetts
W City/Town of Forth andover
a System Pumping Record
.�� Form 4
GSM SyO
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. System Location:
on the computer,
use only the tab 54 Penni Laner
key to move your Address
�DKf jipMDu�cursor-do not North Andover _use the return _- MaH 0EPARTMF-11..—
key. City/Town _ States"'-` _ Zip Code
t�
2. System Owner:
Name
� � I
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping RecordQ,
at
1. Date of Pumping2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) Septic Tank [ITight Tank ElGrease Trap
ElOther(describe): — \ - -
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yeo
5. Condition of System:
G-
6.
Sy umpe/dd Dy:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewa s -treatment Plant, 20 So. Mill Bradford, Ma 01835
SignaturlRe
Date
Signaturng Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Town of North Andover, Massachusetts Form No.3
BOARD OF HEALTH
F A
DISPOSAL WORKS CONSTRUCTION PERMIT
�S$ACMUSEt
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Applicant
NAME ADDRESS( TELEPHONE
Site Location /V� �h/yL JL
: Permission is hereby granted to Construct ( ) or Repair (Xan Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
e CHAIRMAN BOARD OF HEALTH
G 0C No. �''o
Fee D•W.
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TO: NORTH ANDOVER, MASS NOV �` 19 7,5—
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
�a 7— / bk - North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plan l bdtjif cal-rons dated
f Reg. roe. °fi��r��i€NLS, unitarian
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PARCEL # _ STREET...._�...._/._.._��/1/�I/L....Gi����.....
CONSTRUCTION APPROVAL
HAS PLAN REVIEW FEE BEEN PAID? YES NO
PLAN APPROVAL: DATE APP. BY
I
DESIGNER: PLAN DATE.
CONDITIONS
I
WATER SUPPLY: TOWN WELL
WELL PERMIT — � DRI LLE R.._.........._.......__..._.._
WELL TESTS: ',.,,CHEMICAL DA l E APPROVED __.............__...._.__.
BACTERIA I DAIS OPPRUVED
,r
BACTERIA II DATE APPROVED._....,......................_._...__
COMMENTS:
I �
FORM U APPROVAL: APPROVAL TO ISSUE YES NO
DATE ISSUED BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES No
OTHER YES NO
ANY VARIANCE NEEDED YES t NO
FINAL BOARD OF HEALTH APPROVAL: DATE:- .-BY: -
... .._.....__...
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SEWER
119 West Street
Methuen, MA 01844 SERVICE
(508)683-5709 n,
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43
w L. GILES, R.P.L.S.
50 Deer Meadow Road
North Andover, MA 01845
® 683-2645
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SCOTT L. GILES, R.P.L.S.
50 Deer Meadow Road
North Andover, MA 01845
® 683-2645
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