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HomeMy WebLinkAboutMiscellaneous - 90 LACY STREET 4/30/2018 (2)0 •�� 3.tr"aflti x ' It/�r{+Yt r e fiWcN,I 11� tr t1 XlopA•�l l .! t�9't+);.yy N �„ ,,K,�,}!xA �Vrrl �• � r t4 �i .p � „4', 4 , , � ,. „) a . y,'ftjtr jQil I y s 1+ f(• +4 ' CIA •, r �' i vj�•�ytt �i i'� 1;4r n ,} y k 1 4 �f � "� 71i, �� A+d�hM.f 4 j � Id! t +"•y+ frill •t aJ:, �;r 4 i��irr , 'S �'•{. t« FYh 'L'll; 4t".{ 3.t t�'t t1. �J.. /L!11Irl:AY 1 h s R , r r ,Yi ar,��!...... rt r ?,. 1. "' f F x � ,n �,a n n..4, a ,,• r f 1 •n'... ilii•••"``" ., �M O. 11 , V . WN'UF' NORTH AND SYS 'vER L%rljZ'EM PUIylgIN . • ' �1• �f 'Y• a' J„ a}r "rt K.,Z. A T'11;} ,,.! a...ucb /.,.:,Sy��.. fi t«L Mit� •iv� i , „r f' 9�. �; ( V: ••, t v t kA�7f•s✓'�Q.aJQ���}1,f<r i 9r.+ ,.t n {�N` i � r y>:•„Y!, . 1�, .•AI's O WCATION I f r. ! i ' �„5 `' k i •hit++ 1 ` ; ft hoot of h0u”) >f• r 4 tr� i Al 4•t+w}. I'y',►,p}y'h7 •f ,....V4 '}��il: �i r' ' �i%'Y�i A. b ±,. r ,� 7 � ,iA [I }. l• fLy`y [ 5, �.!�.�'rLY1�w �.' :: i,pq, ' y •�.1 � j� i j `..�, Y �•�4 "i' . ri i n .t..fi 1 r.f. ',,jl Vl'�Ay} f. 1'S,R �',„r! i• 4r,'t,a'ft A'd T.. Y •`^ f QvA►N'1'Y MWED GALLONS 4 „ + SEPTIC TAMC; NO YES v, r�s3���r!f:,l'ra 1 I�r1,.A J " 4 '•i,h 4r ,4, !' V {.Mti.t(�tr a";:S"'' .. OUTpvE �jXMERGEN CY VAN- �MUNS �• t Tx$ v, 1 � 11 . '•a ��11.yPA S� �, t Co. 117■� 1 iq !' .N '' ^ r!' .fe "t� Aa i``wr/1 i 3lj.r � • `�•�"ON • �'�.I, �i'1�w _. °.RO GRASE ' '"'"'"...,, .. T COVER � .�t4 �l•y• J� j �121.�.� .. ... TS S IN PLACE M t ;;EXLEgCgrzL SO CESS SOLIDS _ RUNBACK S CARRYOVER ----•w . OOI%ED 4 _ t d s pip ®� XXPLAIN) f r �rRl�t�.�t���a"f�['9� �'�! �.�• r f 7t>R,' M��,rj • ' r • +. � i'AJ '�3L"rf.R A T f' •`I $. :s {fr!'71' f , ' �,y., { ty i s Ar7r t' A tt�[�'i I_} qt r Ail ��" i ]I�{•• C .. .. , • 'i f rd V. t r T. •. a t.}wl. 1� k - 1 � .. i • 1� � v ?p„f F7 i fA .�IU er.11 1111111111 1 11111 WIN III, X ply h t t, PUMP 1... .T .1. • r et �• ,.t,.A ., � j..l... �,•'r1J ym4 ! ,Ja'I T i •' x 4�,.t'f1 si, .�. f*:!•NrEyAj�51, L q� ^•t�^' t {.'' !+ � Sr } .,t y t r , •%i. f f.•.4�� 1 .J U „114111 't - F' STtiad tf 3; lr CSS Ejr..x .1.MINIMUM III, 1 1yl1� L. '!'.t C -: 4 �ryf ..6 ri•!;!1 q'Sd ,t; ;1 rw' �} i �}•�,y� �•_� � � 7' :S• f _ ,�Y }l^1�}th�j�T}fp,l'►Nj.S �l�d fP, �4}i f�s j�}.�y�S�'.�1 lyr�.Jy N�41 •�, ':T.•' O A- : 4-J Ott.ao ,• �b0 Y I V` ���4 j Y I rl�lb� Y 9 ►�' °•'t� BOARD OF HEALTH ^, sS�CW NORTH ANDOVER, MASS. APPLICATION FOR WELL AND PUMP PERMIT '�J d,� Permit # d Z Date`� Q d, 7//'L A permit is requested to: drill a well install a pump rr J* No AA-Teyz _ ex 19i1 �J(, LOCATION:—el- b 1 } G, S`j Sd' t4,r, ,J Wt—'LL— - AIt,?;)Lot #r /_W 1 oDD 1Jf c-&-7 4 Owner DoiyN f"IC (; F1��Cy Address qO M 6 S I- Tel `��� 6�S c� ESL' ed Y p Well Contrctr 451e);wa�(00!, Add. ?kYe"/---ie S> Tel Pump Contrctr POb N OJ'eII _ IVa( Add. CJ/Tel 2p0-99c�->P'6J �rictkk�r�e�eY9rk*�rk�e*�c4eFrk�r9eFkIc9cle�eIc4e�eIekicir�eick*9clr9eickk�r4eilc*�ek�e�c9c�e�ek�e�lrir�e�rk�e�cic*fir** WELLS (To be completed at time of pump test.) Type of well bQ/CCEd Use ►\d`t1 �t� Diameter of well //i Size of casing a Depth of bed rock 30 / Depth casing into bedrock /O Seal been tested? Yes No (_) Date of test %� / •-� Depth of well 5�05', Water -bearing rock AAkV Depth to water Delivers ZI GPM for / Q (how long?) Drawdown _,74:5' feet after pumping / ours at PM Date of completion *7-13-01 ignature of well contractor PUMPS (To be filled in before installation.) Name & size of pump 6W(IS S�(lir, s���l 76 SO %Ya?vZ Type � ��6�loa✓ b !`� w po �% _ Size of tank AQ./ �d-{a((/��Pump delivers -/d GPM Pipe used in well: Cast iron (_) Galvanized/(_) V Plastic ( V) Sleeve used to protect pipe? Yes ( ) No (_). y well seal -Or,,,,�� Date 3 G ignature o ump installer Date water analysis report submitted to Board of Health. TOWN OF NORTH AD'DOV4:_R/ rt fl A r" CLr F.1 C n� I T1 -I Plumbirig-inspector Wiring inspector JUL 11 2001 Board of Health Massachusetts Department of Environmental Management 100876 Office of Water Resources 10 0 8 f'7 6 TYPE OR PRINT ONLY Well Completion Report 1. WELL LOCATION GPS (OPTIONAL) LATITUDE LONGITUDE Address at Well Location. �� � �� Property Owner: f 1/C Subdivision Name: Mailing Address:: 90 GAC S T` City/Town:/af_%`cAAA c&Ile-,1? City/Town: Ike 7 i - Assessors Map /0 Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available Board of Health permit obtained: Yes [Z Not Required ❑ Permit Number 024P. Date Issued >-/%?-O/ 2. WORK PERFORMED 3. PROPOSEDUSE 4. DRILLING METHOD ❑ New Well ❑ Abandon ❑ Deepen ❑ Recondition UeRe lace ❑ Other YT Domestic ❑ Irrigation ❑ Monitoring ❑ Municipal ❑ Industrial ❑ Other EJ Cable ❑ Auger Air Hammer ❑ Direct Push ❑ Mud Rota ❑ Other S. WELL LOG lY W Q Unconsolidated Consolidated 6. SITE SKETCH (use permanent landmarks with distances) From (ft) To (ft) Permeabil'dy High Low U = `o : � W > a P o 0 Other Rock Type _ f 5 1. gou5 t= 192 1 bG 1 0 30 ll v 0 /!ao .. MEQ Qt 2�/4 7. WELL CONSTRUCTION' 8. CASING Total Depth Drilled C75. Date Drilling Complete 2 -/.?-05/ From (ft) To (ft) Casing- Type and Material Size O.D. (in) Well Seal Type Q 5 r L / '7.�� 4�_ 9. SCREEN From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter 10. FILTER PACK / GROUT / ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION From (ft) To (ft) Material Description Purpose Developed? ❑ Yes ® No Fracture Enhancement? ❑ Yes E9 No Method Disinfected? 2KYes ❑ No 12. WELL TEST DATA (PRODUCTION WELLS) 13. STATIC WATER LEVEL (ALL WELLS) Yield Time Pumped Drawdown to Time Recovery to Date Method (GPM) (hrs & min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Depth Below Ground Surface (FT) 14 50 5 JA a fl"' "2-/. --o / GQO 14. PERMANENT PUMP (IF AVAILABLE) 15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY Pump Description Horsepower Pump Intake Depth (ft) Nominal Pump Capacity (gpm) 16. COMMENTS 17. WELL DRILLER'S STATEMENT This well was drilled and/or abandoned under my supervision, according to applicable rules and regulations, and this re ort is complete co ect to the be _my knowledge. Driller: /��1 I tq� Supervising Driller Signature: Registration #:I i" Firm: �, Date: �K "0—Rig Permit #: Z NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH COPY Massachusetts Department of Environmental Management Office of Water Resources PF.OR PRINT ONLY Well Completion Report 100877 1. WELL LOCATION GPS (OPTIONAL) LATITUDE LONGITUDE Address at Well Location: 90 4AC)Z 5 7- Property Owner: 1J4 6/4 R t Subdivision Nam/e: Mailing Address: elC 5 r City/Town: AL A2 ZX&yr(o l--- City/Town: "X� T% /4i clo vt Assessors Map . 16 Assessors Lot #: NOTE: Assessors Map and Lot # mandatory if no street address available Board of Health permit obtained: Yes L Not Required ❑ Permit Number O 2 Z Date Issued 2. WORK PERFORMED 3. PROPOSED USE 4. DRILLING METHOD ❑ New Well ZAbandon ❑ Deepen ❑ Recondition ❑ Replace ❑ Other ❑ Domestic irrigation ❑ ring ❑ Municipal ❑ Industrial ❑ Other ❑ Cable ❑l_&uger— ❑ Air Har tle - —M Direct Push ❑ N1ud Rota ❑ Other 5. WELL LOG T ll-- -9 Permeability High Low T U `a Unconsolidated v C 0 a o a m Other Consolidated Rock Type 6. SITE SKETCH (use permanent landmarks with distances) !! !! � r 166 �QO BA g8I6N;� CUjLC. From (ft) To (ft) 7. WELL CONSTRUCTION 8. CASING Total Depth Drilled Date Drilling C plete From (ft) To (ft) Casing Type and -Material Size O.D. (in) Well Seal Type 9. SCREEN From (ft) To (ft) Slot Size Screen Type and Material Screen Diameter 10. FILTER PACK / GROUT / ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION From (ft) To (ft) Material Description Purpose Developed? ❑ Yes ❑ No Fracture ./� Enhancement? ❑Wes ❑ No Method ! Disin ectY ed? ❑ Yes ❑ No G f'�iv _W % vT MAIV ,J -- 12. WELL TEST DATA (PRODUCTION WELLS) 13. STATIC WATER LEVEL (ALL WELLS) Yield Time Pumped Drawdown to Time Recovery to Date Method (GPM) s'& min) (Ft. BGS) (hrs & min) (Ft. BGS) Depth Below Date Measured Ground Surface (FT) 14. PERMANENT PUMP (IF AVAILABLE) 15. NAMEIADDRESS OF PUMP INSTALLATION COMPANY Pump Description r Horsepower Pump Intake Depth (ft) Nominal Pump Capacity (gpm) 16. COMMENTS 61N7 &j G..t~C 17. WELL DRILLER'S STATEMENT This well was drilled and/or abandoned under y supervision, according to applicable rules r / and regulations, and this tepnrts complete c rect to the best of my knowledge. Driller: LST V iEiPA Supervising Driller Signature: ' R gistration #:1 1 1 1'6� Firm: r Date: — O Rig Permit #: 1 I? l y l 31 NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion. BOARD OF HEALTH COPY �� �,;� �°x' �� . 4, z of 1tuu3d v joj apuui fq;)jou st uoilmiiddV alvG UaAOQNd H.L'HON Ild CINd `smV7 'IVIdgN3J alll 30 I £ NO.LD3s OZ ,LNv ls,,and 2103 NOIIV31 Iddv HNOHJHla L 3rMVH3 LZ 10 crdvou HON JOKMOI 0 4%tlt F C� � Y $ACNUSE BOARD OF HEALTH =a ' r t i f• s NORTH ANDOVER, MASS. .r CM APPLICATION FOR WELL AND PUMP PERMIT ,� d C COO � Permit # Date -7/11/'D, d �" A permit is requested to: dr,.ill a well Lf install a pump LOCATION:—577- `f� J,� S`% - 0M-Luij W to � 4'A�;)Lot #? /3'7V, I UJi� 7 Owner �IJANE I"1� (� Fl �C Address_ C(O —Tel- Well elWell Contrctr 0 #�AA Add. Tel Add. Tel Pump Contrctr WELLS (To be completed at time of pump test.) , Type of well Use d"Cts-��eItL-Ik;� Diameter of well Depth of bed rock Seal been tested? Depth of well Depth to water Size of casing Depth casing into bedrock Yes (_) No (_) Date of test Water -bearing rock Delivers GPM for (how long?) Drawdown feet after pumping hours at GPM Date of completion Signature of well contractor PUMPS (To be filled in before installation.) Name & size of pump Size of tank Pump delivers Pipe used in well: Cast iron Sleeve used to protect pipe? Type GPM (_) Galvanized (_) Plastic (_) Yes (_) No (_). Type well seal Date Signature of pump installer Date water analysis report submitted to Board of Health 3j j�,�j OF 6ta S€R'H f?NQ0'V =-Rj~� um fg =zn�pector Wiring inspector a `U � � � � $ Board of Health a 4 . ,•_.. ...-..-ray+.-s..aa..-a-parr.-a-n..a.na.v:e�cF-.r : -..>R THE COMMONWEALTH OF MASSACHUSETTS TOWN OF NORTH ANDOVER BOARD OF HEALTH Permit # 022 Fee: $50.00 Date: 7/12/01 This is to certify that: Policy Well & Pump IS HEREBY GRANTED A LICENSE FOR THE PURPOSE OF DRILLING A WELL AT: 90 Lacy Street This license is granted in conformity with the statutes and ordinances relating thereto, and expires DECEMBER 31, 2001 unless sooner suspended or revoked. Gayton Osgood, Chairman Francis P. MacMillan, M.D., Member John S. Rizza, D.M.D., Member Qau 2 EASEMENT roR SAD /y/Q6/V/N6 AS .5NOWN 0/4 OtAN 0753S N E. R. a 7 _ , /9.39 1 1 5!)U SS'2� -r)? p,Cy WAY) ( IALIC n hereby certify that this survey snows .ocatjon.of the property boundaries and the M:iId.jm8s. on the premises; that there are no a e ►eats . o� ,encroach Bata other than Chose iho and there are Sao violations of zoning���doe ordinances . yam, 3ased ou: the Flood, Insurance Rate Map for'2azRs o G th :Tovn of .Forth Andover, Massachusetts, Essex; County,.: dated. 15 June 1983, the r erty does no surveyed .p op t lie within a federal flood hazard area. LAND PLAN OF ,90 Z A C Y 6TRoE2 r 1vvRrH AAID4VE'R, MASS. (�dM l,oS� � 2�'Lvp NMdOH3S' V SrS9NLl"/""of M.9; lsb '��311�s; M � pycp' ifcv 1N3W3Sd.F 1 b � 4 J9 ,Cyo1s-z � r 6•p9 i 0,71 107 ti 7,71`17r1 -7 �,� _ �- N' m I 0 � _ m lio z C ci m D a 11 'A > FR ii � ©1�{1 M 0 (1) mZ -< -4 fmttK -< m 2r~- D' 0 ,� m AC t7 Q to 8 -4 A C1 A 2 m �Q CC' D r �m0 �< i ° II� ''o z m [n 3 p 0 0 m I 0 Z (n 0 Il m to Z 0 m `m D D D O O J � 1 m m D 0 D m mm m Z N O Z l y � m Q NC7 mD D� Om m cn MD o o mZ m m� <m L7r Dn D m m y �C = O 0 o� c°�' zD r� Dm m �D 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 or requirements. ****t**********************(�**APPLICANT FILLS OUT THIS SECTION*********************** Ll-'APPLICANTt� fgob .tCVf. / c^ PHONE ,//LOCA -TION: .:: �9 -�o�, -��w; to s � ✓ � 7 r TION: Assessors Map Number PARCEL SUBDIVISION LOT (S) -, STREET JUN J^ �T .NUMBER (�; ` *************************************** OFFICIAL USE ONLY' RECOMMENDATIONS OF TOWN AGENTS: -71 CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS FOOD INSP ✓— Sf 5.0 INSPECTOR -HEALTH DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED —� COMMENTS E PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9\97jm ATE Jun 22 99 10:47a Diane R. McGarvey, Esq. (978) 682-8108 tyW ""' ; 6,aaf- p S, L r mow -S&fiC q,-j- tyW ""' ; iUc�2 66 OY� 1 Y 13 �Lo� �2 PLtI�J 5'tfz&-- QD� t 2Z p.2 i so, ly. eb O 1( So/�w L ,n, C_ �,-r L.E. \/A-T- T /ATT 4r,-F1C INV nOT D E� s I - - GE ATTiME ©p IN0t,4 SYST Eta I N F -o � Gc-r- �4�19�g F RAN 1� C C7 E c .NAS ASS 6X-_ 1 "%—r- E S �NGINEE�S E-AITE-GT S L- -, Vk �� - -• i i t ,\ _`; � � 4' '� �� �y �� �� 1 r -' _s V -, Vk �� - -• i i t ,\ _`; � � 4' '� �� �y �� �� 1 r -' _s AIL I OK I TdORTH ANDOVER BOARD OF HEALTH r R. INSTALLATION CHECK LIST DATE DISAPPROVED DATE R.EASQjdS: 1. Distance To: Wetlands Drains Well 2. Water Line Location � VC Pipe 4. Septic k ees - Length & To Clean Out Covers Cement Pipe to Tank - On Both Sides of Tank 5. Dist 'bution Box Wineslowing oua moun J M 6. Leach Field or Trench sion I' ed Ends ) � Clean Dou e Washed Stone 7. Leach Pits Dimensions Stone Depth Splash Pads Tees Cement Pipe to Pit - Both Sides Clean Double Washed Stone 8. NoL--G�aT',age Disposal 9.isa1 Grading Inspection Barracading Covered System i'i'i . As - Built SubmJ:TTed--) o Location Dimensions of System Location with Regard to Pere Test Elevations Water Table tXCAVATION OK C-oTy to Public Works SUBSURFACE DISPOSAL SYSTEM CHECK LIST G � L a NORTH ANDOVER BOARD OF HEALTH U APPROVED DATE PROVIDED DIS ROVED DATE TIME REASON. Title 5 Reg. 2.5 Fail OK The submitted plan must show as a minumum: i Z � Reg. 6 Eek—t`fie lot to be served (area,dimensions,l,ot //,abutters) (Planning Board files) (b)'location and log of deep observation holes -distance to ties (_,P�location and results of percolation tests -distance to ties (tTy- design calculations & calculations showing required leaching area location and dimensions of system (including reserve area) existing and proposed contours location of any wet areas within 100' of the sewage disposal system or -disclaimer (check wetlands mapping) {) surface and subsurface drains within 100' of sewage disposal system or disclaimer f7S) location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) {-- known sources of water supply within 200' of sewage disposal system or disclaimer location of any proposed well to serve the lot (100' from leaching facility) (Tj— location of water lines on property (10' from leaching facilities) Mt_m location of benchmark driveways garbage disposers p no PVC is to be used in construction a profile of the system (elevations of basement, plumbers- pipe lumberspipe septic tank, distribution box inlets and outlets, distribution field piping and any other elevations) (r) maximum ground water elevation in area of sewage disposal system (-�fj plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks (a)pacities - 150% of flow, water table, tees, depth of tees, access, pumping, ( Cleanout c 10' from cellar wall or inground swimming pool d 25' from subsurface drains SOIL PROFILE & PERCOLATION TEST DATA " Board of Health -North Andover, Mass. .Street Lot No-, C Subdivision Owner_ Scr� Investigator --,L, j,4, 6A4,lftze Observer P{.yC'C( ps ` 1. Date 57-2-4-7$ Elev. Feet Inches I n SOIL PROFILES 2. Date 3. Date Elev. Elev. 'ote: Top & subsoil depth; depths of other soil depth of refusal.__ _ PERCOLATION TESTS Date R Date Date types; Date 4. Date Elev. Ties to Test Pits 2. 4. depth of water table; natP Pit Number 2 3 4 5 Start Saturation Z: SoakMins. Start Test -Time Drop of 3" -Time Drop of 6" -Time CAA 'T Mins. 'Ist 3" Drop Mins. 2nd 3" Drop Rate Min. In. TOWN OF NOR 'H ANDOVF,f, SYSTEM uM INQ RECORI) -SYSTEM OWNER &ADDRESS I // c7i • SYSTEM LX�-ATI()N RECEIVED OCT 0 5 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT m DATE OF PUMPING PUMPED: C0 S POQ L: NO_ rs SOPtic Tank: NO_ YES NA rUKE OF SERVICE: ROUTINE 013SERVA riuNs: GOOD CONDI'rl()N- V.ULI.''W COVER HEAVY OREASE BAMES IN PLAC1, ROOTS L&A.CKRELD RUNBACK BXCMIVE SOLIDS FLOODED SOLID CARRY0V-ERl".-...-..-- OrKER EXPLAIN systvm Pumpcd by CUMMhNTS. CUN I LN I'S I"KANSYbRKED 1-0 0 n��r'tkit�lr!#t�°fit r�NCommonv�r�alth; of Massachusetts • ;.n+{ ��,w +<Y Ifo '•�. r,ity/Town o�NORTH ANDOVER MASSA#�dSfTT ;p r o System Pumping Record Form 4 JAN 2 2 2007 DEP. has provided this form for use by local Boards of Health. They§yptgm�P, utrpp6ng�Roc rd must be submitted to the local Board of Hoalth or other approving authority .LTl DEPARTMENT A. Facility Information -�-.important: =,,•.When filling out 1. System Location: foirns on the computer, use only the tab key Address to move your�.(%Q�C�/Z/ cursor - do not . City/Town , use the return key.:,,2. System Owner: Name . Address (if different from location) Cityfrown 1 Zip Code StatZi Code Telephone Number B.Pumping Record r, 1... Date -of Pumping ^ Date 2. Quantity Pumped: Gallons Type of system:. ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑'. Other (describe): 4. Effluent Tee Filter present? ElYes If yes, was it cleaned? ❑ Yeo 5.- Condition of System:' OF S�z Signature of Hauler Date ��— http://www.mass.gov/dep/water/cipprova.lslt5forms.htm#inspect t5fomA.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealthjqfyassac usetts City/Town of0 System Pumping Recor Form 4 DEP has provided this form for use by local Boards of Health. Other information must be substantially the same as that provided here. B 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. 5. Condition of System: Good 6. System Pumped By: �%ves Envifonm9 Nam Vehicle License Number Nam Vehicle GCA )i ay-) ' Company 7. Location where contents were disposed: Ipswich Water Treatment Plant Signature of Hauler 1pswich, MA 01938 Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System Location: forms the computer, use / �. only the tab key to move your Addre s RCO'( T'n And OV,,,/ ` M q o cursor - do not use the return City/Town State Zip Code key. 2. System Owner: �( (' Name Address (if different from location) Citylrown State Zip Code 9-79- 6R6- 76 IS Telephone Number B. Pumping Record a 9 _p � 1. Date of Pumping Dat9_ 2. Quantity Pumped: �a�oC>OO 3. Type of system: ❑ Cesspool(s) [✓Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes F? No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Good 6. System Pumped By: �%ves Envifonm9 Nam Vehicle License Number Nam Vehicle GCA )i ay-) ' Company 7. Location where contents were disposed: Ipswich Water Treatment Plant Signature of Hauler 1pswich, MA 01938 Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts w City/Town of NORTH ANDOVER, MASSACHUSETTS -- System Pumping Record Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. iQ iermn ., DEP has provided this form for use by local Boards of HeaIth. TINE% EDping�Record must be submitted to the local Board of Health or other approvi g authority. II A. Facility Information 1 System Location: 10 Addr ss �z City/Tow 2. System Owner: {� Name Address (if different from location) City[Town B. Pumping Record TOWN OF NORTH ANDOVER HEALTH DEPARTMENT t4 & s. State Zip Code State Zip Code Telephone Number 1. Date of Pumping Date tleQ 2. Quantity Pumped: Ga��� 3. Type of system: ❑ Cesspool(s) [Septic 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 Na e Vehicle License Number Company 7. Location where contents were disposed: Ipswich Water -- Treatment Plant )swlchi MMA 01933 Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of &ECEIVE System Pumping Record NORTH ANDO E Form 4 NOV - 9 2010 DEP has provided this form for use by local Boards of Health. Other form l �pA bes information must be substantially the same as that provided here. Before sltl►g_ i� P local Board of Health to determine the form they use. The System Pumpin the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. State Zip Code ur to State ----- -- Zip Code ---" - Telephone Number B. Pumping Record 1. Date of Pumping Date 1 a 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ZI No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: VA Name Vehicle License Number Company 7. Location where contents were dispos%d: Signature of Hauler _ ' I y' �� v1�1• Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System Location: forms on the �O �G S 4— computer, use only the tab key Address to move your cursor - do not City(Town use the return key. 2 System Owner: r - Name — Address (if different from location) ------ — --- City/Town State Zip Code ur to State ----- -- Zip Code ---" - Telephone Number B. Pumping Record 1. Date of Pumping Date 1 a 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ZI No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: VA Name Vehicle License Number Company 7. Location where contents were dispos%d: Signature of Hauler _ ' I y' �� v1�1• Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1