HomeMy WebLinkAboutMiscellaneous - 695 MASSACHUSETTS AVENUE 4/30/2018 (2) Health Department
695 Mass Ave
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TOTAL NUMBER OF-T'KOCKS: --
LICENSE NUMBERS:
Signature of Applicant Add
These applications are subject to review by th(
check in advance. You will be notified directly
submitted to the BOH at time of pickup.
WHEELABRATOR(North Andover)and/or COVAN
EXEMPT PLACARDS- $100—Fee for each exemp�
Checks Payable to: Town of North Andover
120 Main Street North An
Phone 978.688.9540 Fax 978.688.95}
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BOARD OF HEALTH
1600 Osgood Street, Suite 2035
North Andover, MA 01845
978-688-9540
APPLICATIONFOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
Pursuant to Section 310 CMR 15.354
Of the State Environmental Code, Title V
Name c� �'2 lid Phone
Address
Contractor hired for work:
Name Phone 2)
Address (�, p�.�C-�'�
Date for scheduled abandonment
The s tic system at the above address has been abandoned according to Title V specifications.
n, on
Signature ofnt actor
Method of septic tank abandonment (check one). O removal O sandfill crush O other
Name of Offal Hauler961 1'1 d
This form must be returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH REPRESENTATIVES ONLY
Inspecting Agent Date
r
RECEIVED
�L\ Commonwealth of Massachusetts ,� �1i
City/Town of APR
System Pumping Record NORTH ANDOVER T WNOFNORDEPARTMENT
ER
Form 4
h
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:
forms on the s
�s5 Ems`
computer,use _ ------ _--- -----------_____.._. .--
�—._——reg-_-----only the tab key Address
to move your ! /► ��! ®/� .--
cursor-do not -r`s— '---l-a4f�d�-.-- ----------- State.�---- ---..--- Zip Code
use the return CitylTown
key. 2. System Owner:
Name
Address(if different from location)
- - ---------
---- .__..--------
City/Town State Zip Code
_ � ----
Telephone Number
B. Pumping Record
Quantity 2.
— tity um Ped: / C>—
1. Date of Pumping safe / p �
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
Company
7. Location where contents were disposed:'
Signature of Hauler — Date f
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
�l STE?y1 OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
U.\"I E OF PUMPING: 9 //tJO74-- QUANTITY PUMPED 0 LLU'v-�
u. .SI'OOL: NO YES SEPTIC TANK: NO YES
Al E OF SERVICE: ROUTINE 1/ EMERGENCY
(m.. 'RV;\TIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O�jHER (EXPLAIN)
c U m M ENTS:
U^ TENTS 1'S TIZANSFE1ZIED TO: