HomeMy WebLinkAboutMiscellaneous - 834 CHESTNUT STREET 4/30/2018BA C
RoaERry OF
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FORM U - LOT RELEASE FORM
ii"�ISTnUCT10NS: This form is used to verify that all necessary approvals/permits from -
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
FILLS OUT THIS
�\ APPLICANT Pt j C? �'' 4 PHONE �,? )40F
LOCATION: Assessors Ma Number c
SUBDIVISION &ZA
STREET C h e y.A'U 5 /
�. PARCEL Dog
LOT (S)
USE ONLY
ST. NUMBER a 3 %
RECOMMENDATIONS OF TOWN AGENTS: 54e lqclWtlolt.) D G X -
CON ERVATION ADMINISTRATOR DATE APPROVED 101 (Z< I q`1
DATE REJECTED
COMMENTS
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
COMMENTS
OR -HEALTH
DATE APPROVED
DATE REJECTED_
DATE APPROVE
DATE REJECTED
DATE APPROVED
DATE REJECTED
PUELIC WORKS - SEYVER/WA T ER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT r l ✓ G% / 7�
RECEIVED EY E -1 -111 -DING iNSPEC CR DA r
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D WITH THIS FORM:
eed, or letter from owner permifting
iction. This covers the minimum two deep holes
each disposal area. Fee of $75.00 per lot for
,rform deep hole inspections.
,id Professional Engineers can design septic
,blation tests are required for each septic system
as and at least one percolation test, at the
dditional tests within two weeks of testing.
an (no smaller than 1 "- 100) shall be submitted to
I
'Jon of all tests (including aborted tests).
on forms shall be submitted.
Commonwealth of Massachusett!g�"
_ City/ -i -own of North Andover 1 IVEW
yStem Pumping Record
Form`4�1014
,but the
DEP has provided this form for use by local Boards of'Healt *WWW ' check with your
information must be substantially the same as that provided
Au 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.
a
raum
System Location:
(-,- z u04-\ , ��
Address 01886
North Andover Ma
State Zip Code
City/Town
2. System Owner:
Name
Address (if different from location)
State Zip Code
City/Towh
Telephone Number
B. Pumping Record
6 -1 2. Quantity Pumped: Gallons
1. Date of Pumping Date
3. Type of system: ❑ Cesspool(s)
Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
If yes, was it cleaned? ❑ Yes ❑ No
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. 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 c
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