HomeMy WebLinkAboutMiscellaneous - 89 DUNCAN DRIVE 4/30/2018 (2)b
m
CONDITIONS:
Is the installer licensed?
Type of Construction:
New Construction:
Issuance of DWC permit:
DWC Permit Paid?
DWC Permit #
Begin Inspection:
Excavation Inspection:
Needed:
Passed:
Construction Inspection:
Needed:
As Built Plan Satisfactory:
YES:
SEPTIC SYSTEM INSTALLATION
YES
N$-- ,
NEW
REPAIR
Certified Plot Plan Review YES
NO
Floor Plan Review YES
NO
Conditions of Approval from Form U YES
NO
YES
NO
YES
NO
Installer:
Approval of Backfill: Date:
Final Grading Approval: Date:
0
M
M
Final Construction Approval: Date: By:
Certificate of Compliance: Approval: Date:
YES NO
Commonwealth of Massachusetts M.AY '14 2013
City/.Town of No Andover TC' C _ ,C.
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
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
-�
1. System Location:
Address
No andover
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
Ma
State Zip Code
State
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping D to 2. Quantity Pumped: —dll6ns� v
3. Type of system: ❑ Cesspool(s) 17rSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ( No
5. Conditi n of System:
c�
If yes, was it cleaned? ❑ Yes ❑ No
6. Syste By: �- r
S X35
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Hauler
Signature of Receiving Facility
Date
t5form4.doc- 03/06 System Pumping Record • Page 1 of 1
yf
36
I/
•y
Y\A
a
r.
WELL DATABASE
ADDRESS:
AGE OF WELL: WELL DRILLER: M
WELL PERMIT: WE L LOCATION:' I �,
WELL PERMIT DATE: EPTH OF WELL:
TYPE OF WELL: a.. DRILLED ? b. DU c. UNKNOWN
TYPE OF WATER BEARING ROCK:
WATER ANALYSIS DATE: ? HIGH MANGANESE: Y N
HIGH IRON: Y N OTHER CONTAMINANTS: Y N
WELL DATABASE
Q i1
An !/ (�-✓
AGE OF WELL: I J�/`j/� ' WELL DRILLER:
WELL PERMIT 4- WELL LOC TION: u�
WELL PERMIT DATE: DEP OF WELL:
TYPE OF WELL: a.. DRILLED � . b. DUG C.
UNKNOWN
TYPE OF WATER BEARING ROCK:
WATER ANALYSIS DATE: 11 HIGH MANGANESE: Y N
HIGH IRON: Y /,N OTHER CONTAMINANTS: Y N
<L\ Commonwealth of Massachusetts
x W City/Town of No.Andover
m System Pumping Record RECEIVED
Form 4
M
FOR 3 2012
DEP has provided this form for use by local Boards of Health. Other f ms may be used, but the
information must be substantially the same as that provided here. Bef rNFtNi rANDbr5ti31e f ith your
local Board of Health to determine the form they use. The System Pu b itted 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.
Q
,ewn
A. Facility Information
1. System Locati
Address
No.Andover Ma 01886
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
State
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping ate 2. Quantity Pumped: Mons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ YesNo If yes, was it cleaned? F1Yes E]No
,x
5. Condition of System: /
Lf
6. Syste Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
t5form4.doc• 03/06
Date
Date
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSAVHUSiTTS
System Pumping Record s�F'R -� g 2Q10
Form 4
L
WN OF NORTH APfDJR
DEP has provided this form for use by local Boards of Health. d must
be submitted to the local Board of Health or other approving auty.
A. Facility Information
Important:
When filling of 1. Sy§tem Location::forms on the
��
computer, use DV l j''� l
only the tab key A es d-o�
to move your
cursor - do not l,.—r ma w(a
Ci !Town
use the return t' State Zip Code
key. . 2. Syste wner
e n C.�=
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3.: Type of system: ❑
-j Other (describe):
Date, aG 2. Quantity Pumped: 5(y
Gallons
Cesspool(s) @/Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
WC
If yest;'ovas it cleaned? ❑ Yes ❑ No
u
6. S stem Pumped By:
LQ (2.
erne ,1 Vehicle License Number
a,�t� CeeEUme .
Company
7. Scation where contents were disposed:
gnature o Hauler Date
http://www.mass.gov/dep/water/approvalstt orms.htm#inspect
t5form4.dooa 06/03 System Pumping Record • Page 1 of 1
FORti14 - SYSTEM Pt11PV\G RECORD
Commonwealth of Massachusetts
, Massachuse s
System Pumping Record
ystem Owner System Location
Date of Pumping: v c Quantity Pumped: P�> ogallons
Cesspool: No Yes ❑ Septic Tank: No ❑ Yes
1P� #:
System Pumped by: License.
Contents transferred to: - ` �-
Date Inspector
TOWN.OF`NOZTH ANDOVER
SYSTEM PUMPING RECORD
DATE p +
SYSTEM OWNER & ADDRESS
11Y L
$9 �*iuNcati
SYSTEM LOCATION
�G c
DATE OF PUMPIN9_ 4�r�W1 OUANTITYPUMPED
CESSPOOL N0 -)L YDS SEPTIC TANK NO yE
NATURE OF SERVICE;;,RQUTINE EMERGENCY
OBSERVATIONS:,
GOOD CONDITION FULL TO COVER
4AVY GREASE BAFFLES IN LACE
ROOTS LEACBFIELD RUNBACK
EXCESSIVE SOLIDS -FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM P, BIPED BY y, 7L
0
CHUSE17S
--"'" w vi nnalm, the System Pumping Recc'c
Qe subml ad to the.local'Board of Health or other .>,.... .:r:r• e PProving authority, `
A; Facllf ty .lnforr' -a lon
'�r.TY� r�na out' ..1; .' System l.ocatlon;
only 0 lab key Address14 /
movo yow--
wruv r do pQty ; ` CI R
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44 ��m. �; •��'} ^li '+,'• 'rye
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�� '' ,1 ',�"'�,T''•�1�Yt1c '�)`y�,t Nilill yet;, 4 I „'r"11 l ;r r, :�.•.•� ,
r'Add[w (It vuferent from 10Cauon)
.,. `• , �•' " Stat
Tolephone Number
f'
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Y:1 ,• ,,
6R;Pum.plhg'R.egord
. � .�'-%!nf(vlFl:,•t'firl„f(,!(I�gr(f�/��f14i�L�'"gf / ,A'�”'
,.� Date of Pumping`+'' 2
Dole VN 2 *uanU umped
"/ 3 : TYP,a Pj.aystam; . ❑ CO3 pool() oovE
" /I•:•.. l 1!v S tip
0ther(desorlba
❑ Tight Tank
!�f `,I`.l il!1'�i �y1r.ly���l ,I'i, �i N'�'�'`' '�•.�I "
MOM Tee Flits
" ('pry ent? iyes, was It cleaned? S Nc
S
ndl�Jo,n,Q.(. y, m.;':-
l:�,,''�'.r:
. .1 �.(1':�%%.�I,:Ir.r�.,l`j,'`'1�.r:,�i1`.',.'I�ii ��'1�(��%11'llf �.'���•
�'�'r�>;t•j?';-"'jr``` r,�ivF�l;f��•'l• ,Y��• .�7;1'-' 'iCc •%�' }' I�'� �'.
.':r':.,r i•,:,. ''SI�.I;•.�,�ti i+ .Gu �; I v 1jf0 7t'tcY•y�'.)'•:;
`ri. /'�'i�rG„af'\��fHl;la�( '6/d�',i'�;d i •
�: •r:�,� .fr•�„ ..,:7;:�', L'oca oh,whare Co�l�nts,Were.dl�posed;
!•Ci'};I % ��' ,!il �''�, �. '`�'•I''.i'l�ii�f� `'lr ••H ijd l' ,,I �,�• •;' c
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/� :ra!':IJ"•� SS r,1S'•{i. illi �� `rl� ��"''�}f'i'�lii.. r'I'.
' ��• ':, •ir:'�!, 1fY';.i n,'q!'J1pdi 'rr r,�• 1 tlfy�'il}' ,
h'1•,':?l;c'�.•, !;,SIQMIWI OlHiule(;}
��.r,.',..:...r..
hUpJlw vw,`mass
'9 F�walar/apprCvaJ$%tb(orms,hfm#Inspect
lricrrM,doa 0.NQ3 '. . ' '
IVehlcJe Ucen�e Number ,
rd J `ins ,
Dote
Syclem Pumping Recom ' pl-e ' -
SEPTIC PLAN SUBMITTAL FORM
LOCATION: 81 DUU' AO Cm UE
NEW PLANS:(APES/ 60.0 Ian ek w 1001
REVISED PLANS: YES $ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: C7/1_� NO
DATE:2-
DESIGN ENGINEER: 1J-''jIG�G,
DATE TO CONSULTANT: ;P-/
When the submission is all in place, route to the Health Secretary.
Off'
180 0 ANO.(►{
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