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Home My WebLink AboutMiscellaneous - 71 PADDOCK LANE 4/30/2018 (2)i Commonwealth of Massachusetts ? u 04/Townof NORTH ANDOVER MASSACHUSETTS System Pumping Redord M. Form 4 DEP has provided this form for use by local Boards. of Health. em -Ru be submitted to the local Board of Health or other approving a thority;;,_ ord mu; "" �C�I0- Important: When filling out forms on the . computer, use only the tab key to move your cursor - do not use the return key. A. Facility Information 2. System Location: ` Address Cityrrown DEC 6 2006 OF NORTH ANDOVER LTkI DEPARTMENT State Zip Code -- System Owner, Nams Address (if different from location) Cityrrown --- — - _ —_---- State ----- -- -- -. -. d Telephone Number B. Pumping Record 1. Date. of Pumping Date-' 2. Quantity Pumped: Gallons Type of system: ❑ Cesspool(s) zArSeptic Tank ❑Tight Tank ❑ Other (describe): ---- ------.—__ 4. Effluent Tee Filter present? ❑ Yes o r 5. Condition of System: If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number r. .. Location where contents were disposed: Si ature of Hau_-- Date http://www.mass.gov//dep/water/ provals/t5forms.htm#inspect t5form4.doc- 06/03 System Pumping Record • Page t of t 05/11/2000 15:57 5083736611 STE•IART/ANDOVER PAGE 02 A1,6r 17 ANL16ver Q -o. µ, Ian McaIn St. Na /I ti A r m ov,*,e- W-cau1 Liz- r5l -pp 4 STE WART I S SEPTIC TANK SE VICE 47 RAIIROAD STREEr BRADFORD, MA 01835 978-372-7471 MMM OF M MILY REPORT MR T IWN OF DATE _ ------_.__-- ADDRESS ------ GAIlow w yi7 �:Sk 'x"3 e I v �L) l --- Jc.- m /)i 1. ►.x-r� 1 Ll "y S'T"e Lj A -P' 1 P i i P I N iySTEM OWNER & knDp Y- DATI0FPWjq)qQ. �7 UAN7 i TY P, yV N -A rU1t6 oe CD "A t K � oj e R RECEIVED '0 U, fu OXCUSIVE SOLK)S AUG U UG 12 2005 0 5 2: [HEALTH $0LrDCAUYoyBX FLOODED IfE R EXF L A TOWN OF NORTH ANDOVER Z DEPARTMENT "-),o 17" W, rw_ rw�cv e�eeaCi` 4 F.I..EVAT 1 O N's. ► .� 10 M. - i./ Aw ► • =� i► 0 of M�ssq �o FRANK c�N og C. a GELINAS cn -o A No. 22738 90� FGIST��` `cs�lONAL t4� I � ij E �-�►5 �UII...'T SY'JT EM AA II (N Q S.L5.HoM�S 5G4LL I- - in FacaNK GeE.uINA.S } AbsoGIti,- e"S E N Cwt tN"-e 23 + (Time --rib ..� t �_. /� � � � µ � � I\ �� ,y � // +/4oV- 44 r -'L �s� � �-�` � ' ,+�i� _ � �� / _j � /,��," � � } �,� e �., `+ r � � O� o-- 9 fes,_ � �� ._ c, av«r., , �� y �/ i�v�.v.,.- Board of Health North An(joverjMan5* srXMUV TW Diu 15 + i W E� a SEPTIC SISTER INSTALLATICK CHECK LIST 3a,S�pZ�1 j `• ITS<'�c'C/ LOT AVATI Oat OS FAI L 1. Distance Tos, a. Wetlands b. Drains c. Well 2. Water Line Location 3 No 1VG=Pipe ic. Septic Tank - - I a. _Tees _Length do To Clean Out Covers. b. Cement Pipe to Tank -- On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks i b. All Lines Flowing Equal Amounts �,,�C. No Back Flow 6e. Leach Field or Trench a. Dimensions b. Stone Depth c: Capped Ends d. Clean Double Washed Stone' 7. Leach Pits ^" a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cement Pipe to Pit - Both Sides. f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System M. As Built Submitted = -- a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e: Water Table e I Health" ,ndover,Mass SUBSURFACE DISPOSAL DFMGN CHECK LIST PPRUM DAT$-____. rovidedt M121 DISAPPROVED DATE______ Reasons: LOT # , I I � M__ " teg 2.5 ie submitted plan must show as a d ni numt the lot to be served-area.dimensionslot Cabutters location and log deep observation hoes -distance to ties ties location and results percolation tests -distance dsign calculations do calculations showing required ec g area location and dimensions of system -including reserve area existing and proposed contours (g) location any wat areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within lAOt of sewage disposal / system or disclaimer (i) location any drainage easements within 100' of sewage disposal system or disclaimer -Planning Board files disposal knom sources of water supply vitbin 2001 of sewage system or disclaimer location of any proposed well to serve lot -100' Brom leaching facility ,/ 1�' location of water lines on property -101 from leaching facility . I'll)location of benchmark t/ (n) driveways o garbage disposals (p no PVC to be used in construction s tic tank q profile of system -elevations of basement, plumbs p p , eP distribution box inlets and outleta, distribution field piping and Other elevations ''maximum ground water elevation in area sewage disposal system (s) plan mast be prepared by a Professional Engineer or other professional authorized by lax to prepare such plans Reg 6 septic Tanks (a) capac t es -1 % of flow, water table, tees, depth of tees, access, pumping (b)� cleanout lot Brom cellar wall or ingro and swimming pool AoV W (d) 251 from subsurface drains Reg 10.2 /Distribution Boxes a) ope greater 0.08 Reg 10.4 b) sump Board of Health North ^AnOoverxMasa.` U SEPTIC SISTEK INSTALLATIC K CHECK LIST DI SUPRO ED DATE easunsi LOT AVATICM Ob ML IT 1. Distance To a. Wetlands b. Drains c. Well 2. Water Line Location 3• No PVC Pipe $. Septic Tank = --- - a. _Tees -_Length & To Clean Ont Covers. b. Cement Pipe to Tank- Oa Both Sides of Tank 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 c: Capped Ends - d. Clean Double Washed Stone' •7 Leach Pits • a. Dimensions b. Stone Depth c. Splash Pads . d. Tees e. Cement Pipe . to Pit - Both es. f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Subnitted a. Lot Location b. Dimensions of System c. Location with Begard_to Pere Test d. 'Elevations e: Water Table a -- NORTH AND -AVER, MASS. , L ' ' 19 z BOARD OF HEALTH FROM: �� /; � _; L ( � ,`r ; /� � 3 DESIGN ENGINEER Re : Soil Absorption _ Sewage Disposal System This is to certify that I have inspected the construction materials of said disposal system at LC, T'>/� Site Location North Andover, MA. The grades and construction materials are as -specified in my plans and specifications dated _ 19 �/ ``I and !--756=/-- - 4 19 � I . f � n L Reg. Prof. Engineer/Reg. Sanitarian 1 om ttnr Y D LoT q m I`EN/AT 1 ON'S. J- . • - - vvm s 1 ON - r ar r 9 N C i A 5 ewlu 5Y5T �M �N N OFM�ss 1`I O 4 hj7->o,jez , FRANK 9cyN C. C3 GELINAS S. 13 a tai �'S 09 pyo. 22TpSCA L..W- i " -40/ PA rMLj o G/57.� ONAL �4 at .n►rf.� tx� t.c2 `3T t� c.�. ANY C�I'�=1"�, , a TOW-,\,, OF,'NORTH ANQC)\k- p V1 p I CIL r. SYSTENI NEC - Out &C A I �, Q�1-7e K - v 1 C E ROUTINE 'RC, E A S C RUCTS EXCESSIVE SOLIDS SOLIDS CARRYOVER I , . Lv I P, -) , ,,1 1) f, 1" 3Y FI -00 D ED 04HFR %(EX.",:--� - 1\1 T!ZANSFCIMLDTU TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: r b ( 1(0101 SYSTEM OWNER & ADDRESS rl l Pc,Jdo k LamQ,, M, kndovex- SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: ly 161 QUANTITY PUMPED lSvo GALLONS CESSPOOL: NO YES SEPTIC TANK: NO 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: A hoover 2g p4 c, COMMENTS: CONTENTS TRANSFERRED TO:o TOWN OF NOR.TPAANDOVER SYSTEM PUMPII,G RECORD _ DATE SYSTEM OWNER & ADDRESS �j �GG/�a cc `—/�• x'S TEM LOCATION 9e. -C uL CESSPOOL: NO___ZES_—� Septic `Fank: NO YES r/ NATURE OF SERVICE: ROUTINE_ 4,- EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLID CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER EXPLAIN System Pumped by COMMENTS: CONTENTS TRANSFERRED TOU s ��••' :L��•�!.:- �--.• �• ••_...-�a1;I Ila � /I:T 1.11'I^r i•'�il/ . % -• 1�i) : •�:i•• ' ..�.':• � : htw '�. (.��••..I:Ii /•:Y�ii:�li':�I:Y•. S�.I',{i�. I t� '`. frv.lull i A. Facility Infortal lon location: lt: L4, �� n gym'.,; : • Clr�/Torm , 1: u!';:.';'v;t.;�:';,,,: :.'J•.i;r;,.,;,,'!•';•%,,�i., , Skil! j Sii Sya---- lem e r • UI 4VfCInl It= buUcn)---------------- Cq^o..n B,:Pumping RQ'Cord 1 Oal� o! Pumpinp , . a� Vitt Tf e�nonr n.mOr� ' 3. ,Type pl ayslom; Ce99�001(9) SOPOC Tangy Emuen! Tee F1 )(o( 7 Yo9 n'o , e,� sy �• ym ed e •. . P' D 4G '., , ,.;(1;�'•;��iS�\'I(j; ung .��)�}';?;i ' ' •' ;•,y� r (i1(�r.'I.'•��i,�' on.wheie cofrlanra{ . r. � ,We e dlyposao: %•,� r.., Sl�nilwi o/ h'iV+(: ��,:.''�w.mas.9.pov/ds�Jvralei/epprOvaJa/Iblorm�.r,:rnph9�eCl yes a� 1; c eanao? �? Yes _ VeNcif 'Jun, Mffll�-� Q Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. . �J Commonwealth of Massachusetts City/Town of NORTH ANDOVER. MASSACHUSETTS System Pumping Record Form 4 r KCUCIVC DEP has provided this form for use by local Boards of Health.he Sin4bA' 0i� be submitted to the local Board of Health or other approving a thority. Team e e MMOVU Alarm A. Facility Information 1. System Location: JAO State 2. System Owner. _ Name Zip Code Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumpingpa 2. Quantity Pumped: Gallons 3.. Type of system: ❑ Cesspool(s) M/4ptic Tank ❑ Tight Tank y� Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If ye§'was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Systtem Pumped By: .'io�arperVehiGe license Number Company �1 /r 60 JACP' 7. Locationhere contents were disposed: ac��)` n rn -I I I (,ire -i- J;� (r'i' g tura of Ha http:/Avww.mass.gov/dep/water/approvalstt5forrns.htm#inspect t5form4.docc 06/03 rd must '?. System Pumping Record , Page 1 of 1 Commonwealth of Massachusetts W City/Town of No.Andover W° System Pumping Record Form 4 M Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key v l� l 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 1. System Location: Address No Andover City/Town 2. System Owner: rah Name Address (if different from location) JI/oK*) An City/Town Ma State State Telephone Number rl'Ec - 9 ZU11 TOWN OF B. Pumping Record 4 I I 1. Date of Pumping 1 0� - Dat 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: T D od 6. System Pumped By: Name Stewart's Septic Service Company 7.ocation w4re content ere disposed: SPr -tr ent Plant, 20 So. Mill Bradfor Signature of Receiving Zip Code Zip Code f U Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Ma 01835 Date i I OU Date J t5form4.doc• 03/06 System Pumping Record • Page 1 of 1