Loading...
HomeMy WebLinkAboutMiscellaneous - 790 FOREST STREET 4/30/20187 Q Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record NORTH ANDOVER SUN Form 4 2015 t DEP has provided this form for use by local Boards of Health. Other forms may(b%NEeM`ttM00VER information must be substantially the same as that provided here. Before using tNW4W&W[q 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. Important: when filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 15form4.doc• 03106 A. Facility Information 1. System Locat 0 Addre City/Town 2. System Owrter: t Name — Address (if different from location) State Zip Code Telephone Number - City/Town - —.. -- B. Pumping Record 1. Date of Pumping -23 ( 2. Quantity Pumped: ---- \ Date Gallons 3. Type of system: b�Q Rgiol v tic Tank ❑ Tight k ❑ Grease ❑ Other (describ4 -O S Porter St 4. Effluent Tee Filter PREW5 If yes, was it cleaned? es ❑ No (9,78) 7423 5. Condition of System: 6, System Pumped By: 0 Wind River Environmental ------ � _er Name 1� 11VesterD� AVe. Vehicle License Number - -._.. _.!Gloucester,_MA►0193�____ _ Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility Date — -... ..._.__........... Date System Pumping Record • Page 1 of 1 <C'\ Commonwealth of Massachusetts RE-CEIVED City/Town of System Pumping Record NORTH ANDOVER jug, Q 3 2014 Form 4 TOWN OF NORTH ANDOVER HEP.LTI� F RRTMENT DEP has provided this form for use by local Boards of Health. Other forms ma�^°beseut�tfi�e 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. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. I&A� A. Facility Information 1. System Location: Address Ja 0011 City(ro�7n State - Zip Code 2. System Owner: • ern-. i - --- . -- - Name Address (if different from location) CitylTown State Zip Code Teleph ne umber B. Pumping Record 1. Date of Pumping — 2. Quantity Pumped: Gallons - Date 3. Type of system: ❑ Cesspool(s) "4" Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): - _....._. _ _ ... ___ _.... _. _..__....._ .._..._ _...___... _._.......... _ . _. 4. Effluent Tee Filter present?(XYes ❑ No If yes, was it cleaned? &,Yes ❑ No 5. Condition of System: o 6. System Pumped By: Name --._..._.__.... — - ..._.. Company 7. Location where contents were disposed: Signature of Receiving Facility Vehicle Licensqe16 el G.L.S.D• ,Andover. MAS Date Date 15form4.doc• 03106 System Pumping Record • Page t of t 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 ANDD Form 4 RECEIVED =RjU-1 "t 9 2013 TOWN OF NORTH QNdOAR 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 1. System Locatio Address City/Town State Zip Code 2. Syste Owner: ko Name Address (if different fro to City/Town — -- StateZip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallns 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): l/� --- - --- -- -- -- 4. Effluent Tee Filter present? )(yes ❑ No If yes, was it cleaned? Yes ❑ No 5. Condition of System: ,rad (� 6. Systegi Pumped By: G Name Vehi le License Number 14 1,111d m ny 7. Location where contents were disposed: Sigtrmau er Sig ature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 ecor ' :'p;ry,;;,'.,,, • �j�.',7�,•. ply,' � y.O,�"s;+•���� r�!•yJayi ��,1N�vii��a�Lt!i:7:J7.!'"• 't • • 1. l .. Kd %v 1 i4ul' , +t"v', ;1'!' .Y;, r/ t: . :i•. Lir{S;,Iv,vt vyit;���r::r1,�,rV,�j,���li�ifvSy�:el �,�ti'i., ly,�7r��, n.iri%}.jtti�'' .r • l�jt'7 7. tt•,t.w. r,.<, 1" r''i•!' :h S':'Uun�Ji,1.,..('„"j ;ii DEPThas provided 014 form for use by local Boards of Hea I lth. be subinl ed``to the.loICal'Board of Health or other approving a • _ r _ )).� •1::i i!•„•:ii:,tY::t:I''.r.:'i,.(::.Y!.b`',. :. 1,:•J..,.,, , ;,A1 Facility ,information Lin :x�T•WhentI out 1• System t.ocal on:* :;;,t,;;.":\•.;•Ort?.^..`:t '•'�' , ' .;Y, �corrtputerl use,i!' . • ony the tab ke .� ,� Add • y ress ' to move your':;' arson do not ' :'r' use•the rotum �:�;,'� � ' .CItY/1'ON!(1 ; ... ; ; • .;.,. ' r . , ' •,, r /� iI�IV �,,+1'.l 1'I�Y7',w �,J''! .ti. .,�1jA,1' �4'III,� `•''. �.f:.,. .• 1 .1,1'.J _ .Y �'.:'.a- �'�, :tr: r'I,,i.•:?{.? ''2.•'`".,SVQtRr11 [�uinor''t' r�': .... , ;1,' •.r'..rj 'r;Ja . Hamer' ,),'i'wr i'•ileiSii r`..r,;:',::v..: _ — —. ;.l: ': �' , ra41:' Iti F;,,h•rKl.',','�:y �y i;Qtir' '�`: "" Address (If different from bcatlon) Zip Code y ... / Telephone Number .. .'1 •., i7;•��'.4.Iri.'l, rl'.•'`,i 1'. •',CA�',�� ,'I IJ,�.,:.�. 1.. .'.1.1�... .: • 4! Record; ' :�' ''yy•ti'.i;i+''15.1:''•.. i';:,..'4:I,1..�.,4;Ii'.';'r,,5;'.+'•�'•' (`/� r•� °r . 1 • ..Ott W. of Pum in `.:;: p g' Dat 2. Quantity Pumped: 'i• .': pi •;'�• ;:'` lions ypo of. ayatem ; ,[] Cesspooi(s) eptic Tank ❑ Tight Tank I' -Other (descrlba);:` .'r• !• .•j.: t!..,:i�i'i 1✓'1./ v:';+5'nx!�i�:;yti'+"'!iM ���" '�9:. •v'• ":; :''' • l' ""Effluent Ter;< Filter resent? : C� Yss If yes Wasaped? ❑ Ye ❑ .y:'• 7 �,i;, y,• ;t:. {.p... C 1 IfCle s No '''' ;y'`•'d:,+;•`' `;,6,r' 0►1 itlon of;8y>ff M0, .yt.. !A'^,'�•I•.!,".i,'w t%fr �i:'i+��/'�1�•li�l%(it ' i.•a,. �::,rl N tr,,yt.�.."�o,,: ' .. . • ter: ,:6�!i; .i!(. i r�• jr,7!(.1•y'jhC'�•,(11`,V:,•`If41.a,•'/I/��:i ���!(�: i'!:«, pi'ris l,,1• ., .. '•! • .l •fir .i,J fl L•, (7t '{Y y'.+?•'t { v+l ,' i��l!!y aryl ;� :a• Si'r!.','ISI'e;,Y.,i�v4:•b;i'U••r71d5>� •���'C'(�'lyr'V•;',•. �•i.� �j:•ii IL , 'i�l'i•.. ;; ,; Vehicle U "Number u:X t ;cl '�-' •.�; •rr`�.:J,•��,i„ l;•l�y.yt?I, J:'d�>,h' �.,1'�. .,1.15',4( ., t .1' ii {v� vl :y+ ili;lti ' , +•'li' yl;nvJyi ji g` W y ii+�•IfitJ;''' -r.'. ."v'! v1.J'i'!!,b s v+('S'S�•HY,�JtU. �Yj ,,•I,j., :flJ, Gr•)IE, •.9:�j',.r , t t.oca oh -Whore contents Were.dl;3posed: _tv..�. r; .., ., ..• ,,tilt, �;:.,: +�:';',: �?,!y.'•I' ;li Yjl'(t � ,' ,� !• •i •.j.. ./,,} ::h r;}:•'�+%iv7t,�• l;�v�r•>(:''t ;+..ey; •.. '!.' 7.1: .yl.. � �.� .�Vanj '•yi'•,.S VJi;•h,r'!;rlv�'iJI'S'''i'!t '•'(7:,1: i'1r C'1,•r J'l•1{: �";., ,. •; t.,•r• ' .t; `•'S.ayrt• .) .^71..•'�r,,yi�l.'.:�,�,V. ,jt(H.,�..I'fAn.�t..pr. rl.a' , ;•r•" :', �r:.�.iii;?�yfii�.tll:'�.�e!'iia/:itii%''li'4V,1}itif 1!'ly' v �;.t'i�.,t�G17.1;1).i''a�;if _� i.,':+. `:<+.• L% •: •., ,.v,�4.?,Y' i:.:^• i'.J {'k:i,•.... ': 7'W'Y. ..�.1•V'.r ! n Date http://wwyv.masts.gov/depJrvate�/pprova)s/tbfonnslhtm#Inspect System Pumping Record Page 1 or t Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. �I Commonwealth of Massachusetts '.City/Town of. NORTH ANDOVER, System Pumping Record Form 4 MASSAC JUL 19 2006 DEP has provided this form for use by local Boards of Health. Th OrM&A be submitted to the local Board of Health or other approving auth ritpEALTH DEPARTMENT A. Facility Information 1. System Location: Address /tID. City/rown 2. System Owner: Address (if different from location) City/Town B. pumping Record 1. Date of Pumping 3. N'ype of system: ❑ ❑ Other (describe): 9qD Sta e State Telephone Number � w Date Z2.uantity Pumped Cesspool(s)ic Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No Condition of System: Zip Code Zip Code 1006 Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No 6. Sys Pumped By: Nara Vehicle License Number N3)L Company 7. Location where contents were disposed: 2%a Signature of H r eDate http://www.mass.gov/dep/water approvals/t5forms.htm#irspect must t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 UA I'tvc- � /4� j` RECEIVED -- 'FOWN OF NORTH ANf>0VL,, JUL UL - 6 2005SYS7F..Nl PUMPING} "COKL,TOWN OF NORTH ANDOVERHEALTH DEPART MENT IN T m -M Vl vv 1-1 WN M AE3C7it 55 1 7 &,eq, DATE OF SYST M LOCA70N AIA� _..-QUANTITY PUkfpED. ,-'tz'SK*L; ?qo_YE3 7)'o I'Xnk, Nu NA ruKb ON SeRylce: K(>u . riNc Otl3hAVA'num , C00D Cot4ol-rioN �u Love E)'kMBS IN PLA(�L ROM LILACP_LD RUNBACK OXCUSIVE SOLIDS $?Lt DCAUYoYF,f,'—" 01"HER EXPLAIN okom P%mnp4J by 7�, C57L,.. �-'UMMhNT�, "-VN rN-ANdkbKRbL) I u ' x 7 �-',5{� Sr�r ♦"1� YSnr I��J�I�1 i� 1'71x11 11 /� � �. 4"'... '., 7'bWN OF NORTH'At�DOV� SYSTEM PUMPINGr`kY '1C0 RD°- L 1 � •�, 2003 i �1 D'I'EM UWNER & ADDRESS„ SYSTEM LOAT10.��.--- -- (ez�m�le� Icf� from of n��>: U I'C OF PUMJ'INC; (QUANTITY PUMPC- D/ »I'UUL,•NO YES SEPTIC TANK; N0 -NUKE OFSERYIC ROUTINE �EMERCENCY II,>PRYAT10NS; C,UV;D`'C.V.NU.l1'ION, FULL TO COYCk : fIEA'•Y,Y:O:fZ ;r�SC''f,.. 13AFFLLSI IN PLAC!' --- RUOTS LEacNFICLo IZUNuAc`K. ------ CXCESSWE SOLIDS FLOODED` __---- SOLIDIj' CARRYOYER IJMFR (irXf! rNTS, , .Jr : .: .'., Al ;1. :v.�„�'• �1 x17. � ------ TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD 1). ATE: � Z rl,,� —t)— SYSTEM OWNER & ADDRESS -7'9W FO 1� &.57—P�'C SYSTEM LOCATION (example: left front of Ihouse) {Cpl c� is ►�c (� rl-`6 op-cn DATE OF PUMPING: dff QUANTITY PUMPED GALLONS CLSSPOOL: NO YES SEPTIC TANK: NO YES (� NATURE OF SERVICE: ROUTINE L' EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: CONI MENTS: CONTENTS TRANSFERRED TO: FULL TO COVER BAFFLES 1N PLACE �— LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr. Health Director January 3, 2002 Paul Guerrieo 790 Forest Street North Andover, MA 01845 Re: Application for a 3 -Season Room Dear Mr. Guerrieo: Telephone (978) 688-9540 Fax (978) 688-9542 Your application for a 3 -season room at 790 Forest Street has been reviewed by the Health Department. The application was denied on December 21, 2001 for the following reason: The submittal did not have adequate information for the Health Department to render a decision based on current Title V Regulations and The North Andover Minimum Requirements for The Subsurface Disposal of Sanitary Sewage Revised June 1997. The Health Department requested a certified scaled plot plan depicting the location of the septic system, dwelling and the proposed construction. The plan was to include scaled distances from any component of the system to any proposed work. The Health Department met with your contractor, Michael Windsor, and explained the required information necessary to complete the submittal and the required setbacks needed to obtain approval. A certified plot plan dated 12/23/01 REV 12/27/01 was submitted by the homeowner to the Health Department and reviewed for compliance with Title V Regulations and The North Andover Minimum Requirements for The Subsurface Disposal of Sanitary Sewage Revised June 1997. At the time of submittal, it was determined that the proposed construction did not meet the setbacks from the septic system as mandated by the Title V Regulations and The North Andover Minimum Requirements for The Subsurface Disposal of Sanitary Sewage Revised June 1997. Pleas re -submit a revised plan relocating any proposed construction within 10' from the subsurface disposal system. Upon submittal of a certified plot plan meeting the required setbacks, the Health Department will issue necessary approval for a building permit. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, Brian J. LaGrasse, Health Inspector Cc: Sandra Starr, Health Director Building Department File BOARD OF APPEALS 688-9541 BI TILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Health Director January 3, 2002 Paul Guerrieo 790 Forest Street North Andover, MA 01845 Re: Application for a 3 -Season Room Dear Mr. Guerrieo: Telephone (978) 688-9540 Fax (978) 688-9542 Your application for a 3 -season room at 790 Forest Street has been reviewed by the Health Department. The application was denied on December 21, 2001 for the following reason: The submittal did not have adequate information for the Health Department to render a decision based on current Title V Regulations and The North Andover Minimum Requirements for The Subsurface Disposal of Sanitary Sewage Revised June 1997. The Health Department requested a certified scaled plot plan depicting the location of the septic system, dwelling and the proposed construction. The plan was to include scaled distances from any component of the system to any proposed work. The Health Department met with your contractor, Michael Windsor, and explained the required information necessary to complete the submittal and the required setbacks needed to obtain approval. A certified plot plan dated 12/23/01 REV 12/27/01 was submitted by the homeowner to the Health Department and reviewed for compliance with Title V Regulations and The North Andover Minimum Requirements for The Subsurface Disposal of Sanitary Sewage Revised June 1997. At the time of submittal, it was determined that the proposed construction did not meet the setbacks from the septic system as mandated by the Title V Regulations and The North Andover Minimum Requirements for The Subsurface Disposal of Sanitary Sewage Revised June 1997. Pleas re -submit a revised plan relocating any proposed construction within 10' from the subsurface disposal system. Upon submittal of a certified plot plan meeting the required setbacks, the Health Department will issue necessary approval for a building permit. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sine , c BriayrfLZrasse, Health Inspector Cc: Sandra Starr, Health Director Building Department File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 O 1= a) E L- L- Q) Q) 0 Cn C �Q in I C 0 V) rE CCCCC 0 O 0 5 L Q) V) C: O U I O m On C C d t t a� 0 L co 0 m _V) Q) Q Q O L ra 0 m 1 C }O V Q t� V Q 0 0 Q) y O c. L a L 42 W E1G 'C N o E C v = 0 R C , t D O Q V � Q 41 v E U O D C 0 to Z 1= a) E L- L- Q) Q) 0 Cn C �Q in I C 0 V) rE CCCCC 0 O 0 5 L Q) V) C: O U I O m On C C d t t a� 0 L co 0 m _V) Q) Q Q O L ra 0 m `MORTIr :O`e e,ti00 VIA ♦ s .Too -_ ♦ BOARD OF HEALTH ,SSACMUNORTH ANDOVER, MASS. APPLICATION FOR WELL AND PUMP PERMIT n (��1 Permit # 8l Date RUQ i [ . ) 7 14ee- e� A permit isted-t-e* a well �' install a pump LOCATION • .� J� Lot —# Owner $ V-- Address'�%Qa Well Contrctr dP1, Wf Add . 14 L4 TelLd3- 9 L - g%3 g�_ Pump Contrctr Add. �Tei c3 = WELLS (To be completed at time of pump test.) i Type of well DrIcUeX Deems Use po'f L l -L �/� 6a 61,Diameter of well to Size of casing Depth of bed rock Depth casing into bedrock N/✓A Seal been tested? Yes (%�) No (_) Date of test - ' Depth of well Water -bearing rock Depth to water p� Delivers GPM for (how long?) Drawdown feet after pumping ( hou at S G Date of completion 21/x/ S nature of well contractor PUMPS (To be filled in before /installation.) �J,O Name & size of pump �Bul�,�� Sf®��llesr��GI'•r /�// Type �c/ Size of tank 7 7 �1�,� Pump delivers �_ GPM Pipe used in well: Cast iron (�) Galvanized(_) Plastic (5 Sleeve used to protect pipe? Yes ) No ( Type well seal Date Signatur o ump installer Date water analysis report submitted to Board of Health Plumbing inspector Wiring inspector Board of Health Ta THE COMMONWEALTH OF MASSA (Ht)SETT , .l TO WN OF NOR THAND 0PER BOARD OF HEALTH Perinit This is to certify that Policy Well And Puinp ' IS IIERkB Y GRANTED A LICENSE For well consttuction/renovation at 790 Forest Street a ` This license is granted in conformity with the statues and ordinances relating,thereto, and expire§ DECEMBER 31; 1997 unless sooner suspended or revoked. Gayton good, Chaiimdn P Fr t i � Jo zza; D.M.D.; Mem er '' L Z# 4*ago �J m 3.t t4 VMM* V••* oo* 304 Hz 4 �A oz a3 OD m Q1 O m W to N O zz r z � O rn P z w uw wU UQ � Z Z) Q O� N J • w Q z Cc W w Q Z •�Q U. j 0 W U LL �o o~ Z ifw • °cc U Q wa Q 00 v CD OT V ) 0 O G I t Ir i SA'7 T, �� ,. il�}�p,T Jy !}l, r j ,,� ! f d ��, P , �'•.A '' �'. i.�r � I • 4 � F'�""O�T.T!'��, 14 �'y' ypi� L�d • t , {� _ SI i - 1 � 1 .. t t ' ,, � _ i I f , f iit TOWN OF NORTH ANDOVE R SYSTEM PUMPING RECORD i;#�411'�'�'S�� r �;ahl � , ,,; c, ,�,_ � s�rbr , :� � ,. •.. • 4 - # L i:r re � r {I � j '{ { r. sr 1•r .r..•�'14� t� fila �� { '. ., '9 ` I . , Tti!..1.• . r d� ��t!' n 1• q u ,, i 1� y S h s k4,(��� ,If f 1Nb .� �a'r �•I,� 'i � h •� Titnfr.�btrV s8 t, � I ] �' 7t S ,, > SYSTEM OWNER & ADDRESS SYSTEM LOCATION 1. t 4 i CG�/ e /� C) (examples of of house) ,i �ai51 iY0.•Ps �"• toll- / K 7 ff4 ,yt.� r 4� X jG6 .�r.u� J..Id. ..,.L:.- �i�,}•. I.. ,ice 1 } a+• ri s ��: �/ l ���/ �t rr + `tsYfi' '+1 ^ AjFh'��/u,�'4i}�NA�°PFk��-�};'T[.,;7 ,` a ✓r ti R .4r.r ,,, t, �.:. At. OF Pl QUANTITY PUMPED U GALLONS ;SSPOOL: NO' YES .. SEPTIC TANK: NO YES y h t� , w �} to J . : ,.: , ✓ T[T,E ROUTINE" NAOF .SERVICE: t EMERGENCY TTT . GOOD GOND ITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACKEXCESSIVE SOLIDS FLOODED CARRYOVER �+ OTHER (EXPLAIN) . 1 t��Rt dNe� �11"':i� 'a� i�� �1 �t Fja:!• �'iy,51 ri; �^i �. t,mix,r �• , , s t t Y .�� t �.x��r,+Yj+�:j��Y`,:!'nT•N4+ ,t„�4y� , , :. i �. � t .. e . TC�t/ ' _ i / t %a f �yw �0'y��"'�'7y1�1� �� � '' � 2 ',. � � ' � n' �' r' .. .. e.•r �C /I Y �,t"ff y b I� Qr..•! It - K I - Cy� r p G 7� � dAY k1 S t ��}�� 1 M 1.� i r¢ i..'' j � - . 1. •t _ V L . ` I , W."N Vwal � S RA O cj y�'"L4;•'���i.��l'��9h � rt1 F{ + t � +r ' I•,y ` A -r Il�.. i ,• r.:. TOWN OF SYSTEM PYJ DA ll ILIN M t 75/6 To-resT sT No, Olv66ve-le-, 1%a. -'RECEIVE-D (RTH ANDOVER MPING RECORD AUG 0 9 2004 TOWN OF NORTH ANDOVER `i y S FEN 4 LOCATION Alk\ DATE OF PUMPING-., 7—lj6 - AWITY PUMPED: -To-o 0 CESSPOOL: NO-....-- YES Septic"I'ank: NO y Ls V'� NIA FURL OP SER ROU -1 -INE VICL 4'MERGENCY 0BShRVA VIONS GOOD CONDI'1'1(,)N /FULL TO COVER HEAVY GREASE BAFFLES IN PLACi- RO(-.)I'S '---LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN System Pumped by COMME.N-I'S CON I*bNI'S I'RANSFERRED'l() Commonwealth of Massachusetts W City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record •4'tH Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving auth A. Facility Information Important: JAN 1 0 2008 When filling out 1. System Location: forms on the TUVA'w cjr 1-)R i �d -ANDOVER computer, use 'UYl-Lfi _ �E_�L 1; i v P yRTMENT only the tab key Address to move your cursor - do not kjdaA A NI���C M use the return � City/Town State Zip Code key. 2. Sys m Owner: �& L Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 91"). 1. Date of Pumping 2Quantity Pumped: Date . ay umpe: canons 3. Type of system: ❑ Cesspool(s) [peptic 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 J Na ePumped.B/y: �-�M- Company Vehicle License Number 7. Location where contents were disposed: Signature of auler Date http://www. mass.gov/dep/water/approvals/t5forms. htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q Commonwealthof assac usetts City/Town of Pumping Recor Form 4 DEP has provided this form for use by local Boards of Health. Other formE mayREGMfig information must be substantially the same as that provided here. Before i ising this form, check with ur local Board of Health to determine the form they use. The System Pumpin Recr u_sWeVp Itte to the local Board of Health or other approving authority within 14 days from he pu?o d accordance with 310 CMR 15.351. TOWN OF NORTH ANDOVER A. Facility Information 1. System Location: - ) '7 U CoccSS -'t. Address /Udc-�. i1w�o�cr J`1�- 018 S� City/Town State Zip Code 2. SystemOwner: // �-4e ('<<c Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping Date State Zip Code _ s?v-683-�Lf Oq Telephone Number 2. Quantity Pumped: /600 Gallons 3. Type of system: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 2 No rli���e� �fIN"Ads��crtI�5. Condltlon of System: ,�e , 0 6. System Pumped By: P p4 V• Name Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility Date Date NX W nci *Licumber t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealthof assacusetts RECEI�l City/Town of 2008 10 a System Pumping Recor / JC1L 3 1 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Important:, When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. t[� 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: 790 Forest Address 1o©Oh Andover MQ D19 City/Town State Zip Code 2. System Owner: ?(am 4 '�,>Qu I Name Address (if different from location) City/Town B. Pumping Record State Zip Code _q_7'3 - LfoLf Telephone Number 1. Date of Pumping 6-7-03 2. Quantity Pumped: 1000 Date 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 [s"No 5. ConditionSystem: i-9C)o o 6. System Pumped By: Ga ay -4 6-7 C 3 Name _ Vehicle License Number W,fld>>v�r Eny��an�men�c� i Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility _?_o R Date Date t5form4.doc• 03/06' System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of a System Pumping Record NORTH ANDOVER Form 4 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 withirL ,- date in accordance with 310 CMR 15.351, A. Facility information JUL _ 701 Important: TOWN OF NORTH ANDOVER When filling out 1. System Location: HEALTH DEPARTMENT forms on the computer. use _-! D_ +—�--- --- — --- -- — — ...-- - --- -- .. only the tab key Address move ,�— ove your to mor do not _LZ -- -- --- - --- - — cursor State Zip Code use the return key. 2. System Owner: Name Address (if different from location) City/Town ----- — — State ©Ziiip Code - --" Telephone Number B. Pumping Record 1. Date of Pumping -�=--I�� 2. Quantity Pumped: Gallons Date 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): --------- - -- - - -- — - -- - -- -- 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condigtionof S#Vem: 6. System Pumped By: Name Company Vehicle License Number 7. Location where contents were disposed: G.L.S.D_. _ Lawrence, MA. Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Important: when filuAg out font's on the computer, use only the tab Key to prove your cursor - do not use the relum key Commonwealth of Massachusetts Cityfrown of System Pumping Record NORTH ANDOVER Form 4 DEQ' 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 usi_29 this form, check with your local Board of Health to determine the form they use. The System bumping Rew9ro mbu,44P--� the locale Board of Health or other approving authority within 14 days Pram t e p� accordance with 310 CARR 15.351. A. Facility Information TOWN OF NORTH ANDOVER HEALTH DEPARTMENT i. System Location: —" C Address � 1 � � CJI State Zip coot 4y/Fown _ 2. System Owner: -Phul..._G.ur�.rrti.eO _�..... ..._ Nan* .._.� Address (ff dif[erent from - .—.-.�_ ate Zip Code CitylTown gid' bsa--- .' ...,,,,_..... ..._ phone Number B. Pumping Record - 2. Quantity Pumped: i. Date of Pumping Date �— Gallon$ 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank [] Grease Trap other (describe): 4, Effluent Tee Filter present? 2Yes E) No if yes, was it cleaned? YYes ❑ No 5. Condition of System'. 6• System Pumped By: Name — Vehide License Number i VCS>_C(Y�Q _4�.',►,..-.Y1V 0rl company 7. Location where contents were disposed: North Andover, MA . Sigrralwe of Hawer Date 15faerM.doc, 03M 5lgrtaiure of ReG h ng Faculty Date System Pumping Record - gage t of 1