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HomeMy WebLinkAboutMiscellaneous - 71 CANDLESTICK ROAD 4/30/2018W R+ Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 M 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. on the computer, System Location: I C use only the tab key to move your Address cursor - do not North Andover use the return City/Town key. 2. System Owner: CCG Name rzMn Address (if different from location) State RECEIVE® JUN 15 2015 TOWN OF NORTH ANDOVER o �+€W ip o e City/Town State Zip Code Telephone Number B. Pumping Record A_tel W 1. Date of Pumpingpate - 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) VSeptic 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 mp By: ame Vehicle License Number 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 I Commonwealth of Massachusetts W City/Town of NO ANDOVER System Pumping Record iG^M Form 4 1 JUN 1 U 2013 DEP has provided this form for use by local Boards of Health. Other formjiln „ , IiVER information must be substantially the same as that provided here. BeforeFNA ', rMpaheIB1l *jth our local Board of Health to determine the form they use. The System Pumping Record must esu mi ed to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. B. Pumping Record 1. Date of Pumping Date I f 2. Quantity Pumped: Gallons 0 3. Type of system: ❑ Cesspool(s) R1eptic 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: ,1, C2 (3 6 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where ntents were disposed: Stewart's Pre -t atment Plant, 20 So. Mill Bradford, Ma 01835 Sign Date t5form4.doc• 03/06 t -I System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms 1. System Location: on the computer, use only the tab 71 CANDLE STICK key to move your Address cursor - do not NO ANDOVER Ma use the return . key. . City/Town State Zip Code - 2. System Owner: MCCARTHY IL ierton Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date I f 2. Quantity Pumped: Gallons 0 3. Type of system: ❑ Cesspool(s) R1eptic 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: ,1, C2 (3 6 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where ntents were disposed: Stewart's Pre -t atment Plant, 20 So. Mill Bradford, Ma 01835 Sign Date t5form4.doc• 03/06 t -I System Pumping Record • Page 1 of 1 f ( 1Y��i. 'Id4•t r. It A' a r ORT OVa �l ��/ 1 H. AND MASSAC TTS ;, H S ,.. Vie. Rico �r1K0Jrt't�': : r `+ ;��; y�';?'•Mr.)�� ��ti'r+.r:( "r,::' NOV © 5 200 '(.. ,;{� ,, �•r; ,'r' .r.)�'°{i'1;�;.>��li;.;'�);;: �� c +, : � inn 14 'r'•'r %' DEP,,has provided this form for use by local Boards:of Health, The $ys,tem Pump►ng Record mus; be :ubmltted to the local'Soard of Health or oth_e.r-IiWrd�il_iig authority A:..Faclll Inforrm�tlon �;��Itri:, >''f:: ,`j�TitW119-out' .1:. System LocatJon'' - Y ,'COrrIpUtBr USO / only the tab key Address to move your .; cursor • �� (het `US$ the'retum':;�:. CItY/Town Stat V•1:! '�;,;�,':':, `. .,.•,�;,,,•:,; ;'.. .. a FP Coda- - Y. ';r. <•• . ';2 !' •System Owner,*:,'. ' �',4i:; .L,\Ti ii' Ilv�.fi1144..r , t•.��.4. 1'i. i / 1''Y' � • •:r".,,,:��. :Ji'.• :',•;)r~.:.Name' ',;;�, �•.,,;.;, ,< .. ,�. .:fir ;',:l•,.;�; .: f.'.:.•�;,;�,1,'...�r 1,. ; ., (..:'�:i� �, '.; :,''.:::, �, ""', rt : Addrass (If different from location)-------------- , State Telephone Number Pumplg:Record , P�92 trl44, fq fi +(i. ;i.`7� J {i1 ,,1.,.•r'�•!t, .' • 'r ) 1, Dai of Pumping ' Dat 2, Quantity Pumped: d� Gallons :TYP`e Pf.system;', ❑ Cesspool(s) ept)c Tank ❑Tight Tank !.Other (descrlbej 4,v Effluent Tae Flite(present? Ye leaned? o If leaned? ❑ Yes ❑ No , ',:=,;�i; ..R�'b•(�''Co�dltlori'ofg �f,;i.:'`,.... •'.4• ( �; -Y r'f it ) ,t,l:t,. }':. /,li•I •I.,',1�•f.,i��e��/r 1 S r' P. timped�By,' Vehlcle U ;��' •�' ��. �;,,,./ �n�e Numbor S +r ¢ ••yt;n• k,i , � ::/.: .y;i e•' V � .• >�•:!i,.• ,•}I��1,6J/i• .. „1Jy,uy� 71', l� , �•.. I/�+ hi 17e .�.'..:: / .. . • ••: .),. `X�,�%:'!F"': •:.r{.,'v J✓f'�A�l �`�� v•� F/ � f�{ 41"...},, .Ir�li',.,..., ::Y>�•,': % r•,:r L.,t i r'' •�j"!;•,r,.;•iS;,t�G't'1.4'`.1",.oil'" .;.f�'•,Ff, 7;";, l.ocatloh where contents Wert:dlpposed: .:5�.. :Ir.. ',Y 7: i�{r.,'r�; ai���• J.:+rte '•�:. .ffl.;,;} .:1i 1S`' + ` _ , J. ,. !t)r. �';J ,, ,N ., i� i � lr1 •4. .. ',1 ct ,'.�::'ltir' .; L. , Date http: www;mass.gov%dep! ater/approva)s/t5forms,htm#Inspect ' System Pumping Record Page 1 or f ••lr.'.'..i �}(r ice!. 1" r .1 (.rlt Y ,,.1 }. ull � r\i. . L - r 7i 111r-i\ir c c iCfr 1 1 j .. ti•, i .. I 1 Commonwealth of Massachusetts t City/Town'of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 RECEIVED DEP has provided this form for use by local Boards of HeaFhTh !Syste-/n roping ecord must be submitted to the local Board of Health or other approvlhor)ty. A. Facility Information TOWN Or. NORTH ANDOVE HEALTH DEPARTMENT Important: When filling out 1, System Location: forms the } j (c computeto r, use '—j" 1. c only the tab key to move your, Address. cursor -.do not use the return City/Tow Stat Zip Code key.. 2. System Owner. Name Address (If different from location) Cityfrown State Zip Code Telephone Number B. Pumping Record 1. • Date of Pumping Date 2. Quantity Pumped: cellons 3.: Type of system:.. ❑ Cesspool(s) U' Septic Tank ❑ Tight Tank Other (describe): 4 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Company a `i r+s 7.. Location where contents were disposed- Vehicle License Number Y-12 SI ngure of Hauler Date • , http:/twww. mass-gov/deptwater/approvalslt5form s. htm#inspect t5form4.doa 06/03 System Pumping Record - Page 1 of 1 \ iPr TOWN OF NORTH ANDovER SYSTEM PLWING RECORD DATE_YZ2_,I-v' 14_� Jr Ziyzi-IEM OWNER& ADDRESS -4Wa V -e,( A137- am DATE OF PUMPING ,qlb q SYSTEM LOCATION QUANTITY PUMPED /5a 6 CESSPOOL NO YES I SEPTIC TANK NO YES k1 NATURE OF SERVICE: RdUTINE� EMERGENCY- I OBSERVATIONS: GOOD CONDITIONw -VI/ FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVEROTHER EXPLAIN SYSTEM PUMPED BY COMMENTS: CONTENTS 'T'RANSFERRED TO 1 R ` DATE: t , y 91s •t $ ill c r 5 !t .. - '�,tlrt?'' SYSTEM OWNER'& ADDRESS SYSTEM LOCATION (example: left front of house) id?� Ca A-10 L 1—vll i[a. c r..,.,P ',p. i_. •-y l± a_ ...-... .. - -_.. -..... DATE OF PUMPING: QUANTITY PUMPED --2 +—=— GALLONS n CESSPOOL: NO _ YES SEPTIC TANK: NO YES I NATURE OF SERVICE: ROUTINE. "ERGENCY k rla �r O$SERVATIONS:. 01 -�' GOOD CONDITION` FULL TO COVER ' HEAVY GREASE BAFFLES IN PLACE f ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED _ SOLIDS CARRYOVER _ OTHER (EXPLAIN) F '-NTS :TRANSFERRED TO: �0v A r� 7ZO) '-ca J Y TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD 1 R ` DATE: t , y 91s •t $ ill c r 5 !t .. - '�,tlrt?'' SYSTEM OWNER'& ADDRESS SYSTEM LOCATION (example: left front of house) id?� Ca A-10 L 1—vll i[a. c r..,.,P ',p. i_. •-y l± a_ ...-... .. - -_.. -..... DATE OF PUMPING: QUANTITY PUMPED --2 +—=— GALLONS n CESSPOOL: NO _ YES SEPTIC TANK: NO YES I NATURE OF SERVICE: ROUTINE. "ERGENCY k rla �r O$SERVATIONS:. 01 -�' GOOD CONDITION` FULL TO COVER ' HEAVY GREASE BAFFLES IN PLACE f ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED _ SOLIDS CARRYOVER _ OTHER (EXPLAIN) F '-NTS :TRANSFERRED TO: �0v A r� 7ZO) '-ca r _ TpP AWO �� C1iYGl� N IN 21 V 2D _---ZDT 1 Shy •� � �� i i i I Gt�G'. tt reO 4V Board of Health 8EP'iIC SISTEK North And-ova-KIY1ass. CJ INSTALLATICK CHWK LIST LOT ' Z �'.A Pl•� S'nL� c0L- ea`snnst /. I Are-, of 1. Distance Tot a. Wetlands b. Drains c.- Well 2. Water Line Location 3• No PPC Pipe pyc7 %. Septic Tank 7; a. _Tess -_Length & To Clean -Oat Covers - b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers k Box - No Cracks b. All Lines Flowing Equal. Amounts c. No Back Flow 6.- Leach Field or Trench a. -Dimensions b. Stone _Depth c. Capped Ends d. Clean Double Washed Stone' 7. Leach Pits a. Dinansio b. Stone epth c. SO sh Pads d. ees e Cment Pipe to Pit - Both Sides Clean Double Washed Stone 8. No Garbage Disposal 9. -Final Grading Inspection 10. Barricading Covered System As Built Snbimi.tted a. Lot Location b. Dimensions of System �,/ c. Location mith Regard -to Pere Test d. Elevations e: Water Table Board of Health North ,,,ndover,?Sass APPROVED DATE Provided: SUBSBR- CE DISPOSAL DESIGN CHECK LIST DISAPPROVED Reasons: DATE LOT ZD e'OVIOZ rle-'e- Title V FAIL OK _. Reg 2:5 r/�'r $,�3$dj &P y� The submitted plan must show as a mini elm: the lot to be served-area,dimensions lot #abutters location and log deep observation holes -distance to ties location and results percolation tests -distance to ties design calculations & calculations shozring required leaching areaevroy , location and dimensions of system -including reserve area existing and proposed contours location any vat areas -ithin 100' of se -wage disposal system or disclaimer -check wetlands crapping h) surface and subsurface drains Nithin 100' of sewage disposal system or di sc1 ai agr i (i) location any drainage easements within 100' of swage disposal system or disclairer-Planning Board files kno= sources of water supply within 2001 of se�_ge disposal e _ - --- system or discla ner ) 3ocati-on-ef imy- proposed vel to serve loi-100' from leaching facili - _ tY _� , )'location of meter lines on property -10' from leaching facili --- location of benchmark n) arivekays garbage disposalsno PVC to be used in construction Profile of system -elutions of basement, plumb, pipe, septic tank,distribution box inlets and outlets, distributionfield piping and CtLer elevations mayJ-mam ground water elevation in area se -,,age disposal system plan roust be prepared by a Professional Engineer or other professional authorized by law to prepare such plans jfq) P.eg 6 Septic Tanks (a) capacities -150 ' of flog, meter table, tees, depth of tees, access, pining (b) cleanout 10' from cellar imll or in.groundsem';-ng pool Elc) id) 25+ from subsurface drains Reg 10.2 Reg 10.4 Distribution Boxes a) slope greater than 0.08 b) scamp , [-_ ( ,.--} --- ibsurface Desi ` . I FA31 -g 15.1 15.4 15.8 3.7 g 14.1 14.3 14.4 14.6 14.7 1!, .10 g 9.1 -� 9.6 Check List I CK Leaching Pits Leaching pits are preferred where the installation is possible _ a) calculations of 1 g area-nd nimum 500 sq ft _ b) spacing c) surface a 2% d) cover tial e) kIx2I n splash pad r f) to at elbow _ g) bends in pipe from d -box to pipe Leaching Fields _ fno greater than 20 minutes/inch area-mininram 900 sq ft c construction of field d) surface drainage 2 % e) 202 from cellar tall or ingrotmd swdmning goal Leachin Trmcheo. _ a)—c-0 c ons eaching area -tin 500 sq ft b) spacing -4 min 6 ft with reserve between _- c) dimensi s d) cans •ctian e) s e f surface drainage 2% Do ill s pSlope e y/x = '(to be s`wwn) b) y/x X 150 = (to be shown) _ Purfls a)app -7 b) s -id-by power SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No C',�l.c/O �E C -f 7-/C Ae Lot No Loc/Subdiv. Pland Owner Investigator -4. Observer SOIL PROFILE DATES 1_tlev 2.Elev 3.Elev 4.Elev ��-� �'`'� toss 'ria.►-, � cx�' . 0 1�� o -r, � Z 0 .r.P 3 �� � �� s o 10� 9 1 Benchmark Elevation 2 3 4 5 3 Q �I 6 Start Saturation cj , Zig tc •. 1; 7 6 8 Soak -Minutes 9 10 DATES T -,q 5 2 Pi F7 , 4 3 Q �I Start Saturation cj , Zig tc •. 1; S(o 6 Soak -Minutes 7 Start Te -C-11 ieV 38 ' Drop of 3" -Time 9 10 Location Datum PERCO;,ATION TESTS s /,- /e 1. 2 3 4 5 6 7 8 9 10 , 5 -Ale, -? Ti,esA Test hs Dem E ►v MaYd,vau et-s�o� X04 6 I N C;L"* T of (. er 4 - -r•p 1 No -r To "F�5E Qsoo Pit Number 1 2 3 4 Start Saturation cj , Zig tc •. 1; S(o Soak -Minutes Start Te -C-11 ieV Drop of 3" -Time Drop of 6" -Time ! •. 01) ; y M6-s.lst 3" drop 11 Mins.2nd " Drop Percolation LZ S '�6� le s -n c, tL mo -re -Bc-rp --,NMLD LD MCYT C0K E C(056e- TW C F o :r- C.c t— Pcr � C> i w SOIL PROFILE & PERCOLATION TEST DATA G� 2 U Town/City No.&Street Lot No. ��,-,�✓'� Loc. /Subdiv. Owner -/- h Investigator ��0,/, Observer SOIL PROFILES -DATE 1' E ev. 2' Elev. 3' Elev. 4. Elev. � 0 6 77 0 0 0 \ 1 1 1 2 K 4 5 6 7. 9 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 lI 10 10 I 10 Benchmark Location Elevation Datum Percolation Tests -Date Pit Number 1 2 3 4 S Start Saturation Soak -Mins. Start Test -Time Drop of 3" -Time Drop of 6" -Time Mins.lst 3"Dro Mins.2nd 3"Dro Notes & Sketches on Back Frank C. Gelinas & Associates,'North And. V 9 /C?CGc 461� Lot # 2� STREET BOARD OF HEALTH DESIGN APPROVAL Proposed Construction Septic Tank Permit # Approx Building Size 3yx $v Garage Under /Attached None Min elevation of top of slab /oma%• %4E� Min elevation of top of foundation Height of foundation wall 7�%Z Footing in fill yes V/" no Further Comments Commonwealth of Massachusetts = �I`�a,j =�- W City/Town of North Andover System Pumping Record P`u'tU12 Form 4 Tt�\ � 0 . t.iNDOVER Ir Yk:1V 1 'i 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 on the computer, use only the tab key to move your cursor - do not use the return System Location: Address North Andover key. City/Town 2. System Owner: E Name C Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) Ma State State Telephone Number X0131 / 2 Quantity Pumped: Date y p ❑ Cesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 01845 Zip Code Zip Code /6-0G Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No 6. System Pumped By: n it, 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 4f Hauler^ Sign re of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 C'C)ur'N UA i`a,., PUMPINU R�C�l7k1.. SEP - 7 2005 5M O�NEiR n a Res s 7---.-._..,._..____..._ . , � ,., .�f*tiiv"a`�� r�F_n1nt?TH.An:`:'J c HEALTH DEPAR- io'.`_N f Ifo, ons o� �No; 13y -.. . _._ QOJANTITY PUMPEC, >5 NA ruKFs CJN ssaRvrvt;: Mvurirr�� OOOD CUNO►TrUN NVi: (�� fMAYY OUgg V Br�YF�BB !N Nl.nk-:L \J�� "C"8IY6 SOl,1pS - WD�D $OLCDCARRYQ` +R„� OrKER EXPLAIN l'VMMIHNT'�. Vlr I �N r J !'1lrllv,�th.K1Z.:aU i C G u R c 0 Z) 0 3 t o' I 1 a C a Ln r� LO Q _I r+ m 0 h rD Z v C O v 0 n cu Q -h D 4 D p' �I Lo I 07 . O v IZ O CD C rr ID ' 3 0 i m m 3 3 X 5 n m ij m o � O i m r e rr t ' 'fl 0 m � o -n C3 0 c 3 a C a Ln r� LO Q _I r+ m 0 h rD gc,o a CV t c�� '� sc�u-est° �i.e �� •. h �!/ a � • n �IJ a — 4,