HomeMy WebLinkAboutMiscellaneous - 59 PENNI LANE 4/30/2018 59 PENNI LANE
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210/107.D-0072-0000.0 _
RECEIVED
Commonwealth of Massachusetts S ' '1
22 2013
City/-Town of No Andover TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4 7
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
fining out forms 1. System Locati n:
on the computer, ��/'1
use only the tab /1 1
key to move your Address
cursor-do not No andover
use the return Ma .
key, Citylrowh— State
Zip Code
2. System Owner.
Name
n�
Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �--�--— 2.
Date Quantity Pumped: c Ila– n
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
9 C3 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 91 No if yes, was it cleaned? ❑ Yes ❑ No
5. Conditi of System:
' 6. S
yste u y:
Nam vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
SteWhrrs Pre-treatment Plant 20 So. Mill Bradford Ma 01835
Signature g of Hauler Date
Signature of Receiving Facility Date
t5fomn4.doc•03106
System Pumping Record Page 1 of 1
FORM - U - LOT RELEASE FORM .
INSTRUCTIONS: This form is used to verify that all necessary approval/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
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APPLICANTPHONE
ASSESSORS MAP NUMBER �U 7 LOT NUMBER G�
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RECOMAdENDATIONS OF TOWN AGENTS
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DATE APPROVED
TOWN PLANNER
DATE REJECTED
COMME'N'TS
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DATE APPROVED
F90D INSPE TOR-HE DATE REJECTED
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DATE REJECTED
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CONQvfENTS /dam / �[�a r Cl"�� Sty//I�� !' 5 y .,
PUBLIC WORKS-SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
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TO: NORTH ANDOVER, MASS '3 19
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
r pe-OVN/ Zof*4r North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19 ��P��N 0 F MASsgci
o� JOSEPH yGr
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FORM - U - LOT RELEASE FORINT
INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT 5 PHONE q�`Jr
ASSESSORS MAP NUMBER LOT NUMBER
SUBDIVISION LOT NUMBER
STREET �N N / � STREET NUMBER /
�.......................... OFFICIAL USE ONLY `: l goods.hof M;o?��oo p� D F_c K_
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NDATIONS OF TOWN AGENTS w L {—�
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DATE APPROVED
,J CON RVATION ADMINISTRATOR
JDATE REJECTED
COMDENTS t/ ' `.{: UIO � ! C h�� l I�/) 10'1 o\tom
DATE APPROVED
TOWN PLANNER
DATE REJECTED
COMMENTS
DATE APPROVED
FOOD INSPE TOR-HEALTH DATE REJECTED
DATE APPROVED
SEPTIC SP CTOR-HEALTH
DATE REJECTED
CONflyfENTS L l $ z,
PUBLIC WORKS-SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
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Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
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TO: Building Commissioner or Board of Health or t
Inspector of Buildings Board of Selectmen j
Town of N. Andover ) ( Town of N. Andover
(
addresses
N. Andover, MA 01845 ) ( N. Andover, MA 01845
)
RE: Insured: Gerald & Elizabeth Cheevers
Property address: 75__9Penni Lane
North Andover, MA 01845
Policy No. HP 1275240
Loss of December 10, 1992
File or Claim No. WAP 15247(water)
Claim has been made involving loss, damage or destruction of the above-captioned
property, which may either exceed $1,000.00 or cause MASS. GEN. LAWS, CHAPTER 143,
SECTION G, to be applicable. If any notice under MASS. GEN. LAWS, CH. 139, SEC. 3B
Is appropriate please direct it to the attention of the writer and include a reference to the
captioned insured, location, policy number, date of loss and claim or file number.
Adjuster
Title:
On this date, I caused copies of this notice to be sent to the persons named above
at the addresses indicated above by first class snail.
PATRICK J. DONOVAN ASSOCIATES, INC.
P. 0. BOX 110
21
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WAKEFIELD, MA 01880 /93
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Signature and date
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TOWN OF NORTH ANDOVEP,
UA rk
SYSTEM PUMPINU RECOKL'
SYSTEM OWNER do ADDFt�SS SYSTEM LOGATiQN
r1vi ` �i
f U . Qlvaleq ✓ems ri1 q.
DATE OF PUMPINQ; �..—............,.. _QUA NTITYPUMPED; ff
VtSSPOOL; NO__......,..YBS . Snptic 1'ink: NU
Y E S�
NA PURE OF SBRVICE; KOU'PINk tMERUENC'Y
RECEIVED
DbStRVA'I'IUNS;
OOOD CONDITION FULL 'rU c.`ovER MAY 0 6 2005 �►
ISAVY ORWB _w BAFFLES IN 1`4AU
ROOTS .. LEAC P1ELD RUNBACK TOWN OF NORTH HEALLTH DEPARTMENT
OER
BXCRSSYVE SOL1pS „__, FLOODED
10LI0 CAkRYOYER, OTHER EXPLAIN
Sy.t.m Pumpcd by __ Tom...... T/.G..
VVMMENTS. ^
�-'uN mm's PKANSJ:'tRKBD I'U
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: /°�� -- G/
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
o it D 6,1� ,
DATE OF PUMPING: - ! QUANTITY PUMPED //Q00 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO K 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: , aw en .Q
COMMENTS:
CONTENTS TRANSFERRED TO:
DEC 12 2001
Commonwealth of Massachusetts RECEIVED
City/Town of No.Andover
W
System Pumping
y Record
TOWN OP NORTH ANDOVIR
Form 4 HEALTH DEPARTMENT
�M
SVO
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 1. System Location: p
forms on the � `e`^� f Lane,,computer, use J /
only the tab key Address
to move your No.Andover Ma 01845
cursor-do not City/Town State Zip Code
use the return
key. 2 System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingDated 2. Quantity Pumped: Galls
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes IJCJ No. If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name r Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signatur f a ler Date
Signature tleceiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1