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HomeMy WebLinkAboutMiscellaneous - 62 GRANVILLE LANE 4/30/2018 �62 GRANVILLE LANE 210/106.C-0069-0000.0 2 �' I Commonwealth of Massachusetts W City/Town of No.Andover - a ° System Pumping Record Form 4 , DEP has provided this form for use by local Boards of Healthomw but the information must be substantially the same as that provided , 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: forms on the �n computer,use /"1 l� I / / e— only the tab key Address to move your No.Andover Ma 01845 cursor-do not use the return GiiyiTown - — State Zip Code key. 2. System Owner: tab ' Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 11-7 -11 2. Quantity Pumped: �da© Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? E] Yes qfNo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name 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 Signature aul Date 1 Signature Iq eceiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED w _ City/Town of North Andover System Pumping Record AUG 0 4 2014 f Form 4 TOWN OF NORTH ANUOVI R °w 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. System Location: on the computer, G— ran, a ❑ use only the tab Q key to move your Address T "` cursor-do not North Andover Ma _ 01886 use the return key. City/Town State Zip Code 2. System Owner: Name rerun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 73111 1. Date of Pumping Date 2• Quantity Pumped: Gallons 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: 6. System Pumped By: Name 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 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 at � •�� � ;'�j ,,�„� � , ' i f F..., . 00T d� OWN ur NUxIl1 ;� ' 0 7 2005 9/ �.� ki un ie JY9'T`>aN" PUMPINQ RP_C� T&h- lir SM`}'?TH ANDOVER y� ? i ARTMENT T DATI OF pVkpqNQ: �7-e '-'lllKl0L: Np fVK� Oe 3eRYi .. _ . �nif✓Kl.lt.tv� Ub�liJiY i�J. ► 0000 00tN0I,rIUN ruts tt, �'ii� rY, RP05!3 B�YYI 83 IN PL��.� 1"3 PLOOD80 $OL CDCAKAYQ.ny,—_ ONE ONER EXPLAIN �'UMM!~NTJ. v!r I !rN I'J t'1l.�Nyl��It�hU .'i TOWN OF NORTH ANDOVER s� YSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) IVO 5 DATE OF PUMPING: QUANTITY PUMPED ,5 c� GALLONS CESSPOOL: NO y , ES SEPTIC TANK: NO YES '�ATURE OF SERVICE: ROUTINE " EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE FULL TO COVER ROOTS ------ BAFFLES IN PLACE EXCESSIVE SOLIDS LEACHFIELD RUNBACK SOLIDS CARRYOVER FLOODED OTHER (EXPLAIN) ----- -SYSTEM PUMPED BY: i 4�vVN OFOFNO-` ANDO'u 804RD OF HEALTH .O-MMENTS: CD 7 2002 ONTENTS TRANSFERRED TO: Address I CAAN V t, -05 4A(., Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planning Board — Conservation Commission-:- ommission — Building Departrmen4 Watershed Septic System TOWN n incITH.INDOWER/ ` qS,e_P'C .Rec-ort Date: t IIAY 6 Alz— Pumne Street .� _Co , Address: Phone : s -- - =�— Phone ( I Nature of Service: Routine � Emergency Observations: Good Condition Full to Cover � Baffles in Place46 LeE.chfield Runback Excessive Solids NO i Heavy Grease Roots Other (Explain) Description of Work: Comments: 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*********************** vAPPLICANT -y-P+��r, J'''`am.�'y PHONE v LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET °' '`, '` a wr ST. NUMBER e.••a s ******* *************OFFICIAL USE ONLY ********************* RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPEG,TOR-HEALTH DATE APPROVED DATE REJECTED T I PECTOR-HEALTH DATE APPROVED -S-7-7 DATE REJECTED COMMENTS �•'� �;u C.� '� PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE flE`n/EIJC�I.dtJD�T E2 �' ' ►y� I LOT . Z U) w Q.T. d d A,4 LOT 24 ,7 LOT ZC� r m .f/t1 ISOO GAL. CO = ft a00 N � SEPTiG TcuK N � r 4'± Q 3 i DOTE A-PP20XIMCTE.LOGGTIOAI OF -^ l UNEVC2.Geoo"D El-E.CTGIG �T fi.LEPNONE. i j So't w I � I I EI. VAT1 r -elf D�Stc.N AS 29-IVT IPE OUT OF HSE.' 121.53 tZ) 1 1 f L I INTO V_ 12►. 33 V E TOP-7 121.Og PeECUT HOLE IW a SUES SUtz. �' + j.�1V: PIPE INTO o. o IZO.92 P�`XT Zoa E. INV VICE OUT P, E50x . 120.'75 120.35 SY5T E-f-71i I I Z O.S I 1 Z0-04 - 1 A.1 V. Ef-1 f7 OF p I P E. 42- 12 O.J I 180.04 I Nv.E r.I D OF MPC-_ 2D.51 1FJ"/. C t1D OF pIPE # 4 120.51 12 Ikiu. E►.ID Or- hl Pt= 5 120.51 I ZC) 17 NdK•T I-1• l_ , TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE SYSTEM OWNER&.ADDRESS SYSTEM LOCATION r r ! a � t DATE OF PUMPING: S. Rh O Y QUANTITY PUMPED: CESSPOOL: NO_tz�S Septic Tank: NO YES (/ NATURE OF SERVICE: ROUTINE (/ EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS EACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN System.Pumped by � COMMENTS: CONTENTS TRANSFERRED TO /-->)/) �j� rSij-�'• �•���I�•.4Trtt^'�I���t1111:i � t - r husetts + 1 ; t. � '♦ ANDOVER MASSVRA rytnl3k `. �'Q j �y , + t+ r n. r ir:t, x �..ti "�,�rrs} Y\sr + OCT_ e7 ��U� . tri r, +,t,J �. >J'. ,.. + ,•:;B•i>�;t.r.;:;,•. �, `°. 'DEP..has provided this form for use by local Boards of Health. hely etrfpumpfng Record must be submitted to the.local'Board of Health or other approving a ShA LTHr ,.,:., . A ..Facility lnform�tion ��-lmgortant.. jJ,.yVhen filum out 1 System Location only the tab key Address U to move your:; />�� �� �/• cursor.•do not L, use the return Clty/Town State Zip Code �y:,t �,•,,t. ., , P t• Nams + r : ""' : Address If different r f om location) Ctt)rlTown a State Telephone Number 1 W.Rum.ping:.Recprd ���� •, t✓. CY1-rtf.+�'r t- �j lsc..ay ��{,Y�;LJ°�r� ✓/ ..•' ��. r� r Date of Pumping 2. Quantity Pumped: Date ry p Gallons TYp9 4f.systemr ❑ Cess ool s Erb P ( ) L'7 5eptic Tank ❑ Tight Tank "Other'(describe); "- -. 77 4, Effluent Tea Filter present? ❑ 'Yes. to If yes, was It cleaned? ❑ Yes ❑ No 4+ ;Coiidiu of:Syst m .,- ' +J. +•Fr JJ ��ii' r r t J %+r Sy. Pumped7. • ;�i.� I?iii :'a''y�ii5'• :+'.' l� I /� Vehicle Ucen*e Number u. +V�s'r+ jw4K�y��,"��'�FC �yJ .>7✓'rzl�J�t fvI t t t �,�! t %'r - {'�f r,�rf '. �j�'•�14r�. e:JC i<!C c: d/f//�/�}/y/y/./ ✓.•.s t- �?-;.^r.Y �"` r��,q•'K::•'•J, t• 'v�tr'y '•r14•JI j•�r ,4/ ,1r1, .. . + .. i r Y �° !i�A li;tjri•.;a:r.:� } f r�i'.!. tW�; .,; ` - s; Location where Contents Were dlposed: tit Ri, `_ , {, .-•T•..,�'.4•.<,. ,�, .,;:; ►..,>.. �. , r., Sa of Hau (• .,,.�.,,.,,r'. . Date .;. :�fittp://www;mass.gov/deptwafer/approvals/t5forms,htm#inspect . t5fomti4.doa•t�Q103 ��.,. • - S stem Pumping : Y p 9 Record•Page 1 of i �`/'moi t• �' .1�1 1,)',',,.,, �,'�;, , , . ' °,r. lye .� : ;��,8�sr`i�:• , USE1� '��:, ,,,,,,1,�1�;,� .+a,,�ilyji,l�;,��I+;J•'.'1 ,,; ;, r;• ell.:, N 0 V 1 a-2003 vcrnlhif Dod jlo�0 ON lolrn 19, r o c l , „ 00 1 phi Iocrl 8oe/ o I„ 8 c r l cr �', n o o n �'OVslhil w��• F��NDO� A F a C I I I I n I MEf\LTM�ARTI`ZI@f�}Qn o ry . , ty orM�Uon Sys em I. /'1,•��. 'I�,! 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