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HomeMy WebLinkAboutMiscellaneous - 740 FOREST STREET 4/30/2018Commonwealth of Massachusetts RECEIVED CitylTown of AUG 0 12015 System Pumping Record NORTH ANDOVER OF NORTH ANDOVER Form 4 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. B. Pumping Record 1. Date of Pumping ate 2• Quantity Pumped: Galion D 3. Type of system: ❑RV6jffM is Tank ❑ Tight Tank ❑ Grease Trap 40 S -p - �+ ❑ Other (describe): Bra el- St _ rdV382' 835( es, was it cleaned? Yes o4. Effluent Tee Filter pret.� ,�4y❑66 e 5. Condition of System: 6. System Pumped By: Wind River Environmental - - - - ------ --- Name T631Nesicrn Ave. Vehicle!License Number - Company 7. Location where contents were disposed: Signature of Hauler Date Signalure of Receiving Facility' Date 15fo(m4.doc• 03106 System Pumping Record • Page I of I A. Facility information Important: When filling oul forms on the 1. System Location: O �-- computer. use only the tab key to move your Add re /�_- -ij � ����— cursor - not �.Ard.p _ _ Cityrrown State Z p Code et use the return key. 2 System Owner: - — y^ Name different from location) " Address (if City/Town — State Zip Code Telephone Number — B. Pumping Record 1. Date of Pumping ate 2• Quantity Pumped: Galion D 3. Type of system: ❑RV6jffM is Tank ❑ Tight Tank ❑ Grease Trap 40 S -p - �+ ❑ Other (describe): Bra el- St _ rdV382' 835( es, was it cleaned? Yes o4. Effluent Tee Filter pret.� ,�4y❑66 e 5. Condition of System: 6. System Pumped By: Wind River Environmental - - - - ------ --- Name T631Nesicrn Ave. Vehicle!License Number - Company 7. Location where contents were disposed: Signature of Hauler Date Signalure of Receiving Facility' Date 15fo(m4.doc• 03106 System Pumping Record • Page I of I n�n^rn��r�o System Owner Thompson Jane & Stuart 740 Forest Street North Andover, MA, 01845 (978)-682-7544 x Type: Em Cesspool: No Date of Pumping: System Pumped By: Contents Transferred to: Commonwealth of Massachusetts Massachusetts System Pumping Record Routine Yes Wind River Environmental, LLC System Location Primary Home 740 Forest Street nF.m 1 rannn Form 4 -- System Pumping Record t RECEIVED AUG C 'l 2015 TOWN OF N(„ -'T'. North Andover, MA, 01845 (978)-682--,544 x Thompson June & Stuart Septic Tank: No Yes Quantity Pumped: Gallons Permit #: Hawohill WW e P Contents Disposed at: 40 S Porter St Bradford, Ma 01835 kz7fo) 6141-2382 Date: "1� t Pumper Signature: Condition of System/Other Comments ® Printed on recycled paper Dep Approved Form - 12/07/95 RECEIVED 1�- Commonwealth of Massachusetts City/Town of ��*L 2014 System Pumping Record NORTH ANDOVEF W, o, NORTH ANDOVER Form 4 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 on the computer, use only the tab key to move your cursor - do not use the return key. 1. System Location: Address Cityrrown 2. System Owner.- Name wner:Name — — State Zip Code Address (if different from location) _- -- -- CityfTown State Zip Code Telephone Number B. Pumping Record 1Z�/- �— 2. Quantity Pumped: 1. Date of Pumping -6-3-ie -.__- --- - YGall n�� 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 2"'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Sysstt m: 6. System Puma%ed By: / f Vehicle License Number Name �( Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility G•L S D k . oah dove~ Date Date i5form4.doc• 03/06 System Pumping Record - Page 1 of t Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record NORTH ANDOVER JUL9 2013 Form 4 TOWN OF NORTH ANDOVER ti HEALTH FARTMENT DEP has provided this form for use by local Boards of Health. Other forms ma 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 computer, use C only the tab key Address J 's to move your cursor - do not ----� — - �® Slate / Zip p Code use the return City/Town key. 2 System Owner: Name �+^ Address (if different from location) City/Town - — State Zip Code -- Telephone Number B. Pumping Record 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 Qt*to If yes, was it cleaned? ❑ Yes No 5. Condition of System: 6. System Pumped By: - - -- - - - --- Name Vehicle License Number � ` � Company j� 7. Location where contents were disposed: J Si at Hauler Date Signature of Receiving Facility Date 15form4.doc• 03106 System Pumping Record • Page 1 of 1 17 3 Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER 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. RCmm - - State Zip Code City/Town Telephone Number B. Pumping Record L +-- 2. Quantity Pumped: - -- --"- 1. Date of Pumping nate Gallons 3. Type of system: ❑ Cesspool(s)' eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): - 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of S tem: If yes, was it cleaned? ❑ Yes ❑ No 6, System Pumped By: i ---- ce. Ve. _ - ---------- --hiclLicense Number ----- — — - Name Company 7. Location where contents were disposed: Signature of Hauler �— u Date Signature of Receiving Facility Date t5form4.doc• 03/06 L _ v MA: System Pumping Record • Page 1 of 1 A. Facility Information JUN -4 N j j Important: When filling out 1. System Location: TOWN OF NORTH I ANDOVERforms HEALTI-I DEPARTMENT on the __-- -- computer, useonly the tab key Address C� to move your cursor - do not (y�rown -- - _- State Zip Cade use the return key. 2. System Owner: Name from location) — Address (if different - - State Zip Code City/Town Telephone Number B. Pumping Record L +-- 2. Quantity Pumped: - -- --"- 1. Date of Pumping nate Gallons 3. Type of system: ❑ Cesspool(s)' eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): - 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of S tem: If yes, was it cleaned? ❑ Yes ❑ No 6, System Pumped By: i ---- ce. Ve. _ - ---------- --hiclLicense Number ----- — — - Name Company 7. Location where contents were disposed: Signature of Hauler �— u Date Signature of Receiving Facility Date t5form4.doc• 03/06 L _ v MA: System Pumping Record • Page 1 of 1 iY Bch'. of Health North AndovPa. Rea F-Pnst SEPTIC SYSTEM INSTALLATIOK CCK LIST 7� LOT kVATiag OK FAIL' OK 1. Distance Tot a. Wetlands b. Drains ° c. Well 2. Water Line Location 3: No PPC Pipe - ,� �. Septic Tank - a. _Tees -_Length & To Clean -Oat Covers-�=— b. Cement Pipe to Tank - On 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 1 b.. Stone Doth _ c. CappedEnds' d. Clean Double Washed Stone';- tone''-7. 7. r rc. Leach Pi�epth­ a. Dimen!' b. Sto C., ash Pads ' Tees e. Cement Pipe to Pit - Both Sides. f. Clean Double Washed Stone `8. No Garbage Disposal 9.Final Grading Inspection l0. Barricading Covered System 11. As Built Submitted_,._-----___.___ - - a. Lot Location b. Dimensions of System - --- c. Location -Ath Regard -to Pere Test d. Elevations e: Water Table Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 qjb6JE- DEP has pro ided 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. RECEIVED A. Facility Information JUN 4 2009 Important: When filling out 1. System Location: TOWN OF NORTH ANDOVER forms on the S"� HEALTH DEPARTMENT 7U computer, use only the tab key to move your Address cursor - do not use the return City/Town State Zip Code key. 2. System Owner-: � IriDw•�So� 1� ��C Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 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 s' No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: U��ey /168 CA Name f Vehicle License Number L-J;V,s Company 7. Location where contents were disposed: G.L.S.D. Signature of Hauler r Signature of Receiving Facility Date Date t5form4.doc• 03/06' System Pumping Record • Page 1 of 1 11 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. r' tab retrmn Commonwealth of Massachusetts City/Town of NORTH ANDOVtR­, System Pumping Record Form 4 SSACHUFS—gff-IVED 0 4 2008 OWN NORTH ANDOVER TMENT DEP has provided this form for use by local Boards of Health. The Sy H uEP be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: -?'(a loo��� �t Address W oyt tf �— City/Town State Zip Code 2. System Owner: `Tho�so Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ 4 Stated 7 C/ / Zip Code S� 7 5 '4 Gr Telephone Number Datel O 2. Quantity Pumped Cesspool(s) Septic Tank ❑ Other (describe).- Effluent describe):Effluent Tee Filter present? Yes ❑ No 5. Condition of System: (Soo Gallons ❑ Tight Tank If yes, was it cleaned? _4Yes ❑ No 6. System Pumped By: Name Vehicle License Number Company ---"- 7. Location where contents were disposed: S'CfJ�h Signature of http://www.mass.gov/dep/wate provals/t5forms.htm#inspect Date 03 t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Mass usetts City/Town of NORTH ANDO System- Pumping Record Form 4 MASSACHUSETTS DEP has provided this form for use by local Boards of Health. The System P ing Record must be submitted to the local Board of Health or other appr ving�ata�ho0; A. Facility Information MAY 17 2006 Important: When filling out 1. System Location: TO'tA:N OF NORTH ANDOVER forms the --74/oU computer, use LG� S HEALTH CEPARTMENT 6 only the tab key Address to move your cursor - do not use the return Citylrown State Zip Code key. 2. System Owner: Name 5:-:7A Address (if different from location) City/Town State \ p Zi–p7Coode Telephone Number B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [�eptic Tank ❑ Tight Tank ❑ Other (describe): — 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: '1 Name ° Vehicle License Number Company 7. Location where contents were disposed: 09 _ Signature of Haul r %- http://www.mass.gov/dep/water/app.rovals/t5forms.htm#inspect Date - RR.06 t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 System Owner `.. E : Ian t. 'z Type: Emergency Cesspool: w t/ Date of Pumping: d /Form 4 -- Commonwealth of Massachusetss Massadwsetts System Pumoine Record Routine Yes System Pumped By: Wind River Environmental, LLC Contents transferred to: System Location t Septic tank: w =Yes �✓ Quantity Pumped: Gallons Permit #: Contents Disposed at: AUG 0 2 2005 ANDOER East Fitch (jr TOWN OF NORTH EPARTM NT Waste Water Plant, Naze: runwor 0"EI -Fum; Condition of System/Other Comments Dep Approved Form - 12/07/95 4 :.� F [I' H O a € I I I p 3 o � tD H s E O a L � a c � L y O � n r tV s= a = m o E c t GCQ _ 0 a 0 m t c o a Q Q o CD o E m U O C zj CURRIER SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON, MA 01949 (978) 774-2772 SYSTEM OWNER: FORM 4 - SYSTEM PUMPING ORD COMMONWEALTH OF MASSACHUSETTS ��. al?-� , MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM LOCATION: Com, awl DATE OF PUMPING: 4 -.Z • / QUANTITY PUMPED: .g�- GALLONS CESSPOOL: NO YES a SEPTIC TANK: NO YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: • 'Z • 9 ( INSPECTOR: ` r- Fc . iC yvN OF 1�ORTH JD(0VE€i/ BOARD OF 0e HEALT H JUL - 81999 CURRIER SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON, MA 01949 (978) 774-2772 SYSTEM OWNER: FORM 4 - SYSTEM ING RECORD COMMONWEALTH OF MASSACHUSETTS. - �a '_'�7 , MASSACHUSETTS SYSTEM PUMPING RECORD DATE OF PUMPING: CESSPOOL: NO YES SYSTEM LOCATION: qi A6q_AvTz,,diNy QUANTITY PUMPED: ��" GALLONS SEPTIC TANK: NO a YES SYSTEM PUMPED BY: CURRIER SEPTIC &DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: } INSPECTOR: TC PVN OF NORTH ANDOVER/ Ft^LARE3 OF HEALTH r ._ a J�';'. 10 1999 PRR U -n. R SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON, MA 01949 .(978)774,2772. FORM 4 - SYSTEM PUMPING RECORD r_ A, COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER:—r O n pS' y, SYSTEM LOCATION:t �r�c� 0 c) e r s 1,6J e c) b �,s �u po.S4- sri,gli Cover- ,- L.krl e -1 - DATE OF PUMPING: QUANTITY PUMPED: GALLONS CESSPOOL: NO YES SEPTIC TANK:NO YES �--- l.eAE — & JANE THOMPSON 740 FOREST ST NORTH ANDOVER, MA 01845-3321 978-682-7544 Type: Emergency Cesspool: No Date of Pumping: 'd; System Pumped By: Contents transferred to: Contents Disposed at: Date: Form 4 -- System Pumping Record Commonwealth of Mossachusetss Routine Yes Wind River Environmental, LLC of Systen✓Other Comments : Massachusetts System Pumping Record Location .June 740 FOREST STREET NORM -I ANDOVER, MA 01845 Dep Approved From - 12/07/95 Septic tank: NoYes ©--� Quantity Pumped: /5 b Gallons Permit #: SOPAD OF JU►►o1 co'l 2001 {� ._�... ._ ...t� .. '� .. f 1 !: 111/ —L- � n a-, v A-^1 1 V dr 1 I J 3 UH'l l`4 N -th An d D v er, P �� s s . ?J o , � S t: r ox e.e t r%y� ,��'v �% bo t No. _ _ __- -_ Loc.,/Subdiv. P1 an OvJner,t/ _ Investigator _ Observer SOIL PROFILES -DATA jj i Elev._Flev®— ---- Elevm _ 4.-EIev. 0 _- 0 _- -- _ 0 0 7-f f i Ties to Test P-.tz 2 -- 2 2 _ i 3 3 3 3 4 4 - - .4 4 6 /Tv 6 6 G . 7 7 -----_ 7 _._ 7 _ g - -- 8 -- 8 - - - 9 9 9 10 ----- 10 -------- 10 — - 10 — _ Benchmark Location - Elevation Datum 1 Percolation Tess -Date bate---;- ^. Pit Number 3 r 4 5 Si_a>_-t Saturation St - art Test -Ti me Oroj� of I�1"o U 6,1 -iLine o Pw,,,n 0.t0�d, TIntoi f Foard of Health North Andover,p� �s APPROVED DATE Provided: 3/a SUBSURFACE DISPOSAL DESIGN CHWK LIST DISAPPROVED DATE Reasons: i V LOT � SS Title V vmuljV('ee'_), Reg 2.5 he submitted plan mast show as a : ) the lot to be sued-area,disensians lot i,abuttrs location anal log deep observation hoes -distance to ties location and results percolation tests -distance to ties design calculations & calculations showing required. leaching area location and dimensions of item -including reserve area } existing and proposed contours (g).,location any wet areas within loot of sewage disposal system or disclaimer -check wetlands napping �)�surface and subsurface drains within IMI of sewage disposal system or disclaimer (i)�location any drainage easements within 1001 of sevvge disposal system or disclaiwar- 3 ~ ig Board files ( known sources of water pl.y within 2001 of sewage disposal system or disclaimer ( location of my. proposed. well to serve lot -1001 from leaching facilit) 71(11 -location of water linea on property -10I from Leaching facility v"W'.-loeation of benchmark t�)�cn=��ways o) garbage disposals p) no PVC to be used in construction q) profile of system -elevations of basement, plumb, pipe, septic tank, e-*, distribution box inlets and outlets, 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 law to prepare such plans Reg 6 / Septic Tanks (a) capac t es- 50% / access, pining ( _�Icleanout of flow, water table, tees,, depth of tees, 101 from cellar vall or ingmund stiring pool 251 from subsurface drains Reg 10.2 Distribution Boxes �(a) slope greater than 0.08 Reg 10.4 ,,.,K' b}mmp e Dossign Check Li FAIL I OK 2 Leaching Fits Leaching pits are p ed where the installation is poskble calculations f leaching area -minimum 500 sq ft spacing c) surface a 2% d) cover,material e) 11, tx4" dash pad f)1ee at elbow no bends in pipe from d -box to pipe / Leaching� Fields ,a)* no greatterT 20 minutes/inch ,b) area-minimm 900 aq ft _w),constrcction of field .d`) surface drainage 2 % e) 201 ism cellar va.11 or inground sdmmfng pool Leachin TraEKLn6 a)�c onsaching area -min 500 aq ft b) spacing -4 t ft with reserve betuv®n 0 dime s f) s iface drainage 2% Do Slo e a) s op y x = to be shown) b) y/ x 154 = (to be shown) EUMS a) app b) s d -by power Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of" System Pumping Record NORTH ANDOVE AN -9 ?�Qjo Form 4 TOWNI$ ANDOVER DEP has provided this form for use by local Boards of Health. Other forms ma be�, information must be substantially the same as that provided here. Before using 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: q0 --c'ms-�,vt Address City/Town 2. System Owner: Name Address (if different from location) City/Town State Zip Code ---- -------- State Zip Code Telephone Number B. Pumping Record `� /l� - 2. Quantity Pumped: Z -00 1. Date of Pumping Date � y 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: A�1- 6. System Pumped By Name Vehicle Vehicle License Number Comp ny ---- 7. Location where contents were disposed: -�-�---- ---- ig ature of Hauler Date Signature of Receiving Facilbawiencer MA. Date f© t5form4.doc• 03/06 System Pumping Record • Page 1 of 1