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WATER SUPPLY:' KTOWV WELL
{ WELL PERMIT DRILLER.__..____...__-.-._...__._.._._._.__..___...._.___..W._..______.._
WELL TESTS: CHEMICAL D APPROVED._.___________
BACTERIA .I DATE APPROVED
B DATE APPROVED,_____���__
COMMENTS:
:
FORM U APPROVAL: APPROVAL TO ISSUE YESj NO
DATE ISSUED
CONDITIONS:
'-
FINAL APPROVAL:
ALL PERMITS PAID
YES
NO
-
WELL CONSTRUCTION APPROVAL
YES
NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL
YES
NO
OTHER
YES
NO
ANY VARIANCE NEEDED
YES
NO
",'''
FINAL BOARD OF HEALTH APPROVAL:
DATE:
BY:
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:.,
9EFTXG.__Q.YS.IE.M__N.a.TA4.L,.R...QN.
t,
IS ,THE INSTALLER LICENSED?
NO
TYPE OF CONSTRUCTION:
NEW
[REPAIR
NEW CONSTRUCTION:' CERTIFIED PLOT PLAN REVIEW
YI=S
IVO
CONDITIONS OF APPROVAL
YES
NO
APPROVAL TO BACKFILL:
DATE:-- -- -
FINAL -GRADING APPROVAL: DATE /g--BY------------------------
Y
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
�w 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.
JJL 07 2014
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENiT
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
Ma
01886
key. City/Town State Zip Code
r�
2. System Owner:
Name
ietran
Address (if different from location)
City/Town State Zip Code
`7&" 1 r
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
llb�septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ YeNo
5. Condition of System:
6. System Pumped By
nl.�
r jMr,,c#0,be�so!1
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewarfs Pre-treatment Plant. 20 So. Mill Bradfoi
of Receiving Facility
`,4.doc• 03/06
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
Ma 01835
Date
Date
System P g Record •Page 1 of 1
1
�I.assac�usetts
V'VW'4,V . `....... =E1 6 2010
Syst�ln Pupitlg Record;.
Font 4 . e TOWN OF NORTH ANDOVER
HEALTH EP TME T
DEP has provided this form for use by local Boards of Health. The S t
be submitted to the local Board of Health or other approving authority.
A -Facility Information
1. System Location, n 1
forms on the I �
�l ► � 1
comp", use
only the tab key
Addr»s
to mow your
,
cusor - do not •
OyWown
use the return .
keys'...
2. System Owner
�C� 1C�11r1
r}�'J`
State
Zip Code
Name,
AW I. Address (if different from iocation)
C4ty/Town State Zip Code
Telephone Number
B. Pumping Record
2. Quantity Pumped: Gallons
1. Date of Pumping Date
3. Type of system: ❑ . Cesspools) [Septic Tank ❑Tight Tank
❑ Other (describe);
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was It cleaned? ❑ Yes ❑ No
5: ; dondition of System:
8. Sy m.Pumped By;
fin A
Vehicle Ucenae Number
max(?.
Y
7. tion re tents were disposed;
rnM
p Date
http:/iwww.mass.gov/ 0fer/ap ro4alslt5forms.htm#inspect
t6fonn4.do0, 08103 System Pumping Record - Page 1 of 1
rl S Pi "�7 1 ,� ,'t, � •,
VER••j' MASS AHQ
'a SySem PumipjnqRecord
_
Ill).�I P 4t1• 117+ 1 ' •.• JUN 4 2007.. .
TC << :•tc,PTH ANDOVER
DEP.has 'provtded this form for use by local Boards of Health. rd must
be submitted to the local'Board of Health or other approving authority.
A: Facility lnfornation
-Important:
,7
'filling,o 1 System Location
forms on the = `.
'computer, use
only the tab:key Address
to move your ♦
use the rdetumt City/Town Stat
Zip Code
{ y,
1. keySystem Owner, - r
.J +
r Name':
Address (it different from location)
' CltylTown tat
//may Zip Code
Telephone Number
;� B.J Pu in
' mp g Record
,a 1 Date of Pumping Data 2. Quantity Pumped:
Gallons
Typo of system ❑ Cesspooi(s) eptic Tank
❑ Tight Tank -
r EYOther (describe);
4 Effluent Tee Fllter present? . ❑ Yesj�No If yes, was if cleaned? ❑Yes ❑ No
S Condition of:Syst¢m.'`
1A
1
6 Sy e1n P
�
umped By
, � Name ; > •. Y
�1
{ a 4 } r L , b1� #.:. � 4 �,VehicleUcen
e Number
ti K.4Ci t.J� . J
company;' .
55.
tJrWa.•i}1
7 Location where contents wpre.disposed:
r
4
a , , Signature of Hauler;„ L.
Date
httpJ/www mass gov/depJwater/approvals/t5forms,htm#Inspect
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System Pumping Record • Page 1 of t
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47 RAILRoAD STREET
BRWFORD, MA 01835
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978-372-7471
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7/9
AS -BUILT CHECK LIST
and
.FINAL INSPECTION
Proposed Elevations
House /tea "fid
Tank IN A17.99
Tank OUT
D -box IN
D -box OUT
Trench Inverts
Line 1
Line 2
Line 3
Line 4.
U
As -Built Elevation
ISA G 7
/,f/" S¢
Bottom
of
Exc.
Stone
OK?
D -box checked? Pipes cemented? "�
V
V/.
s�oP� 2�avi���Enrr
DE5/6N 6'C E/.4T/ON ,4T.........(TOP OF STONE) _
EX/57/NG ELE&TION ,47 ......... 2EQU/2Lr'D /C/LL =
zFZ 4Ek QT/O1V 5
DES/(�N 4.5 30/LT
/NV P/PE OUT 011110U5E
S2 50
X52,11 ,
/NV /O/AE /NTO T4NI,�
Szo
INV P/PE OUT OF TANK
INV PIPE INTO D. BOX
s I C2
INV P/PE OUT OF D. BOX
i ,
, S4.
INV END OF PIPE
91-d TE2 EL EV.4 T/ON
.4VE240E STONE
DEPT/ ,47 P,eOBE
NOTE: 7-11/5 10L.4N /5 NOT ,4 &,,41eiP,4NTY
OF T//E SYSTEM BUT 4 VE�2/F/C,4T/ON
OF T11E LOCATION OF TWE E1/5TIMG
ST�eUCTU2ES .
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s UB-SU•PF.4CE D/.
SYSTEM
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ri
CAIRI5T/Q NSEN SER GI , INC.
I&D SUMMER 57MEET — HAVE1?1I/LL , MASS.
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\mac. b0, \ \
63'
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6�
sGo110-E 2EQVIEMENT
(/50) X /50 - _ .........' ................ .
DE5/6N EZ EV4TION 47 , ..... , , ,(TOP OF 570/VE) ...............—
EXI5TIiV(:� ELEV47-10i1/ 4T ......... 2EQU/ieEO FILL
EZEV.4TioN,s
oE51(�N 45 3OV'
INV PIPE OUT 0F1-1OU,5E
5d
162,'1"1
INV P/PE INTO T4NK
/NV PIPE OUT OF T4NK
1 1 Z2„
IS1,11
INV PIPE INTO D. BOX
INV PIPE OUT OF D. 3 a
INV. E'NO OF PIPE
Gt/,4TE2 EL EV4 TION
,4 VE2,44 E 5 TONE
DEPTH ,47 f',eOBE
MOTE.- T'1II5 10L,4N /5 NOT.4 GV,4,6ie4NTY
OF T1IE 5r57 -EM BUT ,4 lIE�2IF/C.4T/ON
OF THE LOC•4T/ON OF TWE EX/5T/NCS
5T�eUCTU2ES.
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SUB-5ZWF.4CE D/.
SYSTEM
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FOR
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1SSACNUSEt
Applicant
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 3
DISPOSAL WORKS CONSTRUCTION PERMIT
NAME ADDRESS TELEPHONE
Site Location__
Permission is hereby granted to Construct )() or Repair.( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
CHAIRMAN, BOARD OF HEALTH
Fee 6 D.W.C. No. L13 �0
FORM U - LOT RELEASE FORM
INSTRUCTIONS: 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 local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: W� )J ��/k- _dkT� Phone _6 6-7- r 3 t
LOCATION: Assessor's Map Number
Subdivision
urh %471 �
Street _zxl✓L h
/'i' ) I
Parcel
Lots) S—
St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Date Approved
Date Rejected
...-►Adwn �DY1
Comments
Health Agent
Comments
Date Approved yo - d? 2
Date Rejected _
Date Approved1L�Z�
Date Rejected
U
Public Works - sewe-r/water connectionk VQ2r1k,
driveway permit 1A
I r A tI J-
Fire De
art�ment
Received by Building Inspector
Date
I
DATE 4 leco.tw
Sheet of Z
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DEESIGN REVIEW
FEE PERMIT #S DATE RECEIVED g�
APPLICANT �D1IN �/��. ASSESSOR'S MAP
ADDRESS PARCEL #
LOT #
• , STREET c.v
ENGINEER AlatSE
ADDRESS 3 &D daJ e, TAO&O A44 cye7tP
PLAN DATE 12zab0 REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED k
e6440 bn o 4 5 664CAMEo�
Z -P pa�1S� ���►ov�� I�c.�uc�� t�.11 �lc� ��v ��eHc�Ts 4s
o�T Lim to '�EcTtoti4 �•-p
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y
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Fac G�
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Ls V,eevev Tlmwv?. -m -a rm of tA.CAL lA •
sl u. -13E Wo.4A co pWQs
wall 1�6 Goy A4100
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fid• �to2 S �'�
iV6COOCt O LA 4=o� j t I s 5 tjo �A
0
REVIEW CONTINUED
SHEET Z- OF Z
(p) �P�C-�sG S�,j %,tau-ti1�►a, (,ot �$ ou
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Co Fr pp �W vsyS S k y
s h&� �
Stan tea' tk OQTr l(
Common -wealth of Massachusetts
City/Town of No Andover
System Pumping Record
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility; Information
Important: When
filling out forms 1. System Location:
on the computer,
use only the tab 2j t '\
key to move your Address
cursor - do not
use the return ---_
key. City[Town State Zip Code
2. System Owner:
mb
Name
Address (if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da�2. Quantity Pumped: Gall s
3. Component: ❑ Cesspool(s)5 ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes E'No
5. Observed condition of component pumped:
6. System Pumped By:
Name
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mi .1-.s0radford ma
Signature
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
Date
Signature of Receiving Facility (or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1