HomeMy WebLinkAboutMiscellaneous - 549 WINTER STREET 4/30/2018 (3)1
4\ Commonwealth of Massachusetts
City/Town ofo
b �A Y
System Pumping Record
Form 4
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.
City/Town State Zip Code
Telephone Number
B. Pumping Record
11. Date of Pumpingl-�-- 2. Quantity?umped:
Date Gallons
3. Type of system: El Cesspool(s) Septic Tank D Tight Tank El Grease Trap
El Other (describe):
4, Effluent Tee Filtei present? Ej Ye 0 if yes, was it cleaned? (I Yes No
5. Condition of System:
X/�C 4
6. System Pumped By:
7n'n
Name
Stewart's Septic ervice
S
Company
7. Location where contents were disposed,:
t5form4.doc- 03/06
A. Facility Information
Impgrtant: When
filling out forms
1. System Location:
on the computer,
s5 q Q \,kj li
use only the tab
rwCflVCR
key to move your
cursor - do not
Address
use the return
key,
Clty[Town
State Zip Code
2. System Owl ler:
Bilrn
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
11. Date of Pumpingl-�-- 2. Quantity?umped:
Date Gallons
3. Type of system: El Cesspool(s) Septic Tank D Tight Tank El Grease Trap
El Other (describe):
4, Effluent Tee Filtei present? Ej Ye 0 if yes, was it cleaned? (I Yes No
5. Condition of System:
X/�C 4
6. System Pumped By:
7n'n
Name
Stewart's Septic ervice
S
Company
7. Location where contents were disposed,:
t5form4.doc- 03/06
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Date
Date
System Pumping Record - Page 1 of 1
Vehicle Lice'nse Number
rwCflVCR
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Date
Date
System Pumping Record - Page 1 of 1
FORM U - LOT RELEASE 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 or requirements.
►*************"*'***APPLICANT FILLS OUT THIS SECTION*
APPLICANT cti �?/10 A� PHONE
LOCATION: Assessor ap Number ---ZD PARCEL
SUBDIVISION
LOT (S)
STREET ✓ c/ Gr/l/l/T��Z ,o ST. NUMBER
-,--•--�....,***.*****""*'**'OFFICIAL USE
RECO IYIENDATIONS',OF TOWN AGENTS:
X /oll I �;
CONS RVATION ADMINIVT TOR
COMMENTS_a (A of
TOWN PLANNER `
r�
COMMENTS
FOOD INS, .ECTOR-HEALTH
DATE APPROVED /b• �`� �1
DATE REJECTED
DATE APPROVED
DATE REJECTED_
DATE APPROVED
DATE REJECTED_
I ECTOR-HEALTH DATE APPROVED
DATE REJECTED_
COMMENTS
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRJVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTO
DATE
s
N
U.
0
JvvGC.�3s �10�
%AI�u 10
Q
0
m 3 ce
P .37yt.'
P-uRD OP HEq-;j-j
kol�TTH Atipovei,�, MA,
�1.�P�� Citi I 171 D�
aW TER 5�t'I'Ly T e)W C7 WEt.c
-
Q ._
SS StP-fic SYS TE-
( aOMPITIO"5 =
DI SAPPPU v5D 1A Te
Re,45oms
. PLOL —1 (
FINAL (ti5p6-- i lonj
5' PP -'
Wer
4PPRovED
�4D1�ITjDIJAC� INSt�Z' .j lONS ��� A►�-'y)
D�S�' PPRov�.D D,a i C
RUAL APPFZVAL DAi�
.RD OF HEALTH µ
No.Andover, Mass.
APPROVED
Provided:
Title V
Reg 2.5
Reg 6
Reg 10.2
Reg 10.4
DATE/ -
SUBSURFACE DISPOSAL DESIGN CHECK LIST
DISAPEROPED DATE
Reasons:
ANS Slc
LCT #
FAIL OK
The submitted plan must show as a mindm m:
a) the lot to be served -area dimensions lot #,abutters
b location and log deep observa.tior hoes -distance to ties
c location and results percolation test.z-distance to ties
d design calculations & calculations shm� mg required leaching area
(e) location and dimensions of system-inc'.uding reserve area
f) existing and proposed contours
(g) location any vet areas Athin 100' of sewage disposal system or
disclaimer -check wetlands mapping
(h) surface and subsurface drains within 100' of sewage disposal
system or disclaimer
(i) location any drainage easements vithin 100' of sevage disposal
system or disclaimer -Planning Board files
(j) known sources of vater supply within 2001 of sewage disposal b
system or disclaimer
(k) location of any. proposed well to serve lot -1001 from leaching facilit
(1) location of water lines on property -101 from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used In construction
(q) profile of system -elevations of base rent, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Otter elevations
(r) maxEmam ground water elevation in arra sewage disposal system
(s) plan must be prepared by a Professiotal Engineer or other
professional authorized by lax V pr pare such plans
Septic Tanks
(a) capacities -150% of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 10+ from cellar wall or inground swimming pool
(d) 25+ from subsurface drains
Distribution Boxers
a) slope greater thwc 0.08
b) sump '
SOIL PROFILE & PERCOLATION TEST DATA
North Andover, Mass. Street No I twT2 Lot No
Ice/Subdiv. Pland Owner
Investigator Observer
SOIL PROFILE DATES
l.Elev 2.Elev 3.Elev 4.Elev
0
1
n
Benchmark
Elevation
2
3
4
5
6
7
s
9
10
-L
DATES
0
1
2
3
4
5
6
7
8
9
LO
3
Location
Datum
PERCO ATION TESTS
w 6 q),*' 1A � %s
0
1
2
3
4
5
6
7
s
9
10
Ties Pits est
Pit Number
l 2
3
�}
Start Saturation
Soak -Minutes
Start e
Drop of 3" -Time
Drop of 6" -Time
M6ms-lst 3" dropInv
Mins . 2nd " Drop
Percolation
� K J5,0 t7.5► .._
Tom C Fi.S'b IEU (Uy.
Cc. ,I.
EI.�V 11.a 5thY, 6.. <
141V, CXSC' � L i1a�11C. �Q`K�L=1b1.32
\uv, cam- CT\-��) t'-= \01,1 o
��1V. t"NcJ 7REV-�L\-\. T'*) = ioo,g5
Zit ( EL = k00 . iNe
7ZEM a\' 1 1k—=1 vG , g 2
TtZr=�u iFL = � oc-> .q 4
QR �WVIICZ
0rr iuE �\SPceitx, TtOLATY &T
UL >7 Es'� �Akk17E.. sm
1 AOVT\ , 4-\=� o .1 cis,
aRya (�4 cmm>u alcE I A\Tu4 tea$ l
0
I
SLAB E
1 1
OF BIT Gout1
Jx�v�wr;y �
► �.0` •�3'- 47`x`
s 1 --lig ' EI-
A (oo'
AS BUILT PLAN
OF
SUBSURFACE DISPOSAL SYSTEM
LACATEDIN l,
AS PREPARES FOR
To1.1�,' �s1t�10
LATE . -1 Y
SCALE.: III A
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 -CARx. STREET 0 ANWVEk MASSACMUSETTS 01810 • TELL (617) 475.3955, 373-5721
m
Oro cutvr�� S
z -a7
1
IX
a4 ga
��-•.11�. tit ��'L—�Clt... T�r..�',,,�. �= ��7#a to.��
OUT
D4 04. kl�ik
k7, O -o 'ZbF
.' : `fir � ' + •�#
a _
$'f `3TC,
C04
vI� �
47
i
/4,
AS B I PLAN
OF
suouc-3URFACE DISPOSAL SYSTEM
LOCATED W _
+ �s
AS PREPARED FOR
DAT£
SCALE:
~` MERRIN1ACK ENGINEERING SERVICES, INC.
PROff SSKQNtAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 PARX $TREET s ANDOVER. MASSAC"UWTS 018)0 • 7Et (617) 475.3355. 373-5ni
"`Com'monwealth of Massachusetts
�Y :City/Town�of NORTH ANDOVER,
System' Pumping Record
-..Form 4
I up
Important:
When filling out
forms on the .
computer, use
only the tab key
to move your
cursor - do not
use the return
key,
DEP has provided this form for use by local Boards of Health. T e System Puumping® ecor mu;
be submitted to the local Board of Health or other approving aut ority,
----
A. Facility Information
1. System Location:
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Address - _...__--~•._—•-.•__ _—._.._.__.._ q
City/Town ,
Zip Code
2. System Owner:
Name
Address (if different from location)
City own
B. Pumping Record
�J, Date. of Pumping
hype of system: ❑
❑ Other (describe):
ate
Tip Code
Telephone Number
! 1tY.o
Date __2. Quantity Pumped
Cesspool(s)Septic Tank
4. Effluent Tee Filter present? ❑ Yes ❑
5. Condition of System:
m Pumped By: �--`�
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
r Vehicle License Number -
Company
7. Location where contents were disposed:
010 \L�
Aw
Si ature ofHeu �- Date
http://www.massbgov/dep/water/ provals/t5forms.htm#inspect
t5form4.doc• 06/03
System Pumping Record - Page 1 of i
0
OVER MASSACHUSETTS
OEP-hsi PjQyj(jQ0 f h I
(Q 00 local
A. Facility —1n—f
Ion
$0',9M L QrA V Q nTOWN OFNORTHANDOVER
: - HEALTH DEPARTMENT
HEA
1,4.: L4,
vq r1t.,vi":
Pr
I. N) * V, "J Of QV(I I M (I= low vQfI) ONE-
— — — — — — — — —
�0933
P Umpino
Rekord
fj
oa,o Q! Pvm In,
CX00 9 Z'3 0 P 0 C T'a n 7
— '.19ni Ter,
E*on( Too F11(0( p Y05
r
q'Ov, I . 11 C -Q anej?
Y�5
1. .6
..................
1ju
I Y
, &.ovo
z
Board of Health. -
North And_over2Mass.
-APPROVED DATE
OK
SEPTIC SISTEM
INSTAMATICK CHECK LIST
MUPPROVED DATE
easons .
A6�
LOVJ'
[MCAVATTIOMN Og ML
1.
Distance To:
a. Wetlands
b. Drains
c.. Well
/2.
Water Line Location
3.
No PM Pipe
4.
Septic Tank
P/pG
a. -Tees -r-Length & To Clean Out Covers..
Both Sides Tank
b.- Cement Pipe to Tank.- Oa of
pG
5.
Distribution Box
a. Covers & Box No Cracks
b. All Lines Flowing Equal Amounts
c. - No Back Flow
6.
Leach Field or Trench
a. Dimensions
b. Stone --Depth
a' Capped Ends
do Clean Double -Washed Stone
7.
-Leach -Pits
a. Dimensions
b. Stone Depth
a. Splash P
do Tees
6:0 C t Pipe to Pit Both Sides
f --Clean Double Washed Stone
No Garbage Disposal
9.
Final Grading Inspection
10.
Barricading Covered System
11.
/-._
As Built Submitted
a. Lot Location
b... Dimensions of Sy -stem
c. with Regard -to Perc -T est
-Location
do 'Elevations
ao' Water Table
B���,d of Health' Nc'P.. ,ndover,K.aBs
SUBSURFACE DISPOSAL DFSIGq CHECK LIST
i
APPROVED DATEu-
Provided• , ,� ;•
`#,. fig
Title V FAIL I CII
Reg 2.5
Reg 6
Reg 10.2
Reg 10.4
LOT
,;aWPRCiM DATE
Re"on s s
Me submitted plan xTast show as a mini UM"
a) the lot to be served -area., dimensions lot #, abutters
location and log deep observation hofes-distance to ties
c location and results percolation tests -distance to ties
d , design calculations & calculations shouting requirc4 leaching area
ocation and dimensions of system -including reserve area
existing and proposed contours
g) location any vat areas Athin 1001 of se -,age disposal system or
• disclaimer -check 7,--tlands mapping
k)"..gurface and subsurface drains -within 1001 of se -w -age disposal
stem or digclainer
ation any drainage ease
J)
100' of aege disposal
Wetem or disclairtir-Pla_*zning Loa -rd files
j) sources of .ate r sLTply within 2001 of s e-�age di apo sal a
V
or disclainer
on of my proposed :-ell to serve lot -1001 from leaching facili
on of meter Lines on property -101 from I caching facility
4,+location of benchmark
n): "drivek-ays
.garbage disposals
p),_ no PVC to be used in construction
Pro e of system -elevations of basement, plumb, pipe, septic tank,
tribution box inlets and outlets, distribution field piping and
oee Other elevations
r ground meter elevation in area sewaP;e disposal system
s) plan rest be prepared by a Professional rinser or other
professional authorized by lax to pmpar'e such. plans
Septic_ Tanks
capacities -150 of flow, -sten table, tees, depth of tees,
access, punping
cleanout
101 from cellar ,-all or inground si4�9 pool
251 from subsurface drains
�--Dis ,- i bution ryes
ope greater tI= 0.08
SOIL PROFILE & PERCOLATION TEST DATA
North Andover, Mass. Street No x,.11 So- -I S'[' Lot No C.
Loc/Subdiv. Pland Owner 1 0 1 o
Investigator MGleAa k M A.<< � Observer
SOIL PROFILE DATES
1.kev 2.Elev 3.Elev 4.Elev
n
2
3
5
6
7
8
�' 83
� 0 7
1
Benchmark
Elevation
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
n
Location
Datum
PERCOjATION TESTS
DATES `5/$ 3
0
1
2
3
4
5
6
7
8
9
10
Ties to Test
Pits
Pit Number
1 2
3
4
Start Saturation
Soak -Minutes
ar e
Drop -of 311 -Time
Drop of 6" -Time
M ns-lst 3" drop
Mins.2nd 311 Drop
Percolation
TOWN OF NORTH ANDO,VCR,`,' ,� i
SYSTEM PUMPING RZECOR-D
i
1 EN1 OWNER & ADDRESS
I
iv,-) 14" al vel'.
SYSTEM LOCATION
(example: lCf( iron( of housr)
+iA �L i n �-dh-f-0"� 4)j-`<-
1,
CF PUMPING' �� �?� �1L1.4(�T!� �: �I1 ter _
..:: SSPOOL: N0 X/— YES SEPTIC TANK: NO YL:S -/
",ATURC OF' SERVICE: ROUTINE EMERCENCY
;.) i 1>FRV:\T10NS:
COOD CONDiTiON T FULL TO COVEII
HFAVY CREASE BAFFLES IN PLAC1.'
ROOTS LEACHFIELD IZI,NUACK...
CX,CESSIVE SOLIDS FLOODED �
SOLIDS CARRYOVER O. HER (EXPLAIN)
>> >
11'M PUMPED BY:
U�)"di:NTS:
U^\ PI,"NTT; TIZANSFEIZIZED TO:
b
t
-3 �s-
7 ��`• �''��... % _'� ft ��
ry1 \.t � F-.3 ` ; o, �`"',; �„j' � = t -•J f '. T�.t i.-��i }�r4� � f F� � f",3,
A- �'T'^ �, •q J. i �j i•+. �j � ice,:-.� ��-i �.r� `• �� �.S yp- � � i�^:3 J� � f'.ny. ;
�•+f'.nF �•� ;�4•`�s-+-E..J z't{$; !• `�,,��`_.:�: t
uf
i � `�s• - .,/ w..,. :` I � b... i..er� {�i�/�� �b � �j fix, +
t
L
— j
Y
3
a
♦ t
i IL P L`
,...
r .'.. .sm i
, U-
SPOS
x.:. �. • R �j�,:�•' ., a .'-. 4- .-.�j - _ �
jj
IV
�5,
EPA
77 V
4
FA
—q"%WN, I
Y
SEPTIC- Tl#�jK
DOT
! N V �..1 .F :,1 ! �•�`..iE..�� 4.�`fr s
1 S„�l`.,,%. � i
i
t
-3 �s-
7 ��`• �''��... % _'� ft ��
ry1 \.t � F-.3 ` ; o, �`"',; �„j' � = t -•J f '. T�.t i.-��i }�r4� � f F� � f",3,
A- �'T'^ �, •q J. i �j i•+. �j � ice,:-.� ��-i �.r� `• �� �.S yp- � � i�^:3 J� � f'.ny. ;
�•+f'.nF �•� ;�4•`�s-+-E..J z't{$; !• `�,,��`_.:�: t
uf
i � `�s• - .,/ w..,. :` I � b... i..er� {�i�/�� �b � �j fix, +
t
L
— j
Y
3
a
♦ t
i IL P L`
,...
r .'.. .sm i
, U-
SPOS
x.:. �. • R �j�,:�•' ., a .'-. 4- .-.�j - _ �
jj
IV
�5,
EPA
77 V
4
FA
—q"%WN, I