Loading...
HomeMy WebLinkAboutMiscellaneous - 925 FOREST STREET 4/30/2018Important: 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 ANDOV Form 4 RECEIVED um 06 zoiz )WN OF NORTH ANDOVER HEALTH DEPARTMENT A but the DEP has provided this form for use by local Boards of Health. Other forms may be use , 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: •Ore} 1 Address City/Town 2. System Owner: Name Slate Zip Code Address (if different from location) - ----- ------ -- State Zip Code City(fown q-7 _79. - Telephone Number _- B. Pumping Record ---1.©'�---- 2. Quantity Pumped: Gallons 1. Date of Pumping pate 3. Type of system: ❑ Cesspool(s) IVSeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): - -/- 4. Effluent Tee Filter present? ❑ Yes [� No If yes, was it cleaned? ❑ Yes � o 5. Condition of System: 6. System Pumped By: JimQ I An -- - - -- ' vin - ---- - ----- � b -b7 - --- - , r- - vehicle License N�ber N m tvel EM Qo) MV) I Company 7. Location where contents were disposed: - - bate' Si 64'(4 of Ha e _ .._. Signature of Receiving Facility Date 15form4.doc• 03/06 System Pumping Record • Page 1 of 1 _CN, Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDO 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. OF WITH AA1DOWR LTM DEPARTMENT City/Town Zip Code State up coae _q2 % C-9 Telephone Number B. Pumping Record 1. Date of Pumping D� . 2. Quantity Pumped: Gauons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms on the 1. System Location: computer, useonly the tab key to move your Address cursor - do not zv—, f7`Y1L�--- — City/Town State use the return key. 2 SystemOwner: h Name Address (if different from location) — - --- -- -- -- City/Town Zip Code State up coae _q2 % C-9 Telephone Number B. Pumping Record 1. Date of Pumping D� . 2. Quantity Pumped: Gauons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 '1`0 WN 0 JYS'T-EN" PUMPING sYsrBLi ............. I ............... A D 0 �RE ss Lis A DAT -1 OF pVMNQ; OCT 0 7 2005 v, ER S Yq TE �c-j� '-*t"sFOIIL; No__ . Y�31' ... )Vpuc I 14A rUKb C)p 3eRy,(�9-- �Uvrltl- u t—N L)tlzidA � 0000 c �otqv z I KQQT3 8XQU$rVS $0Lro0AKAYQny, ONER EXPLAIN V u Type: Emergency Cesspool: W Date of Pumping:� System Pumped By: Contents transferred to: Contents Disposed at: Date: Commonwealth of Massachusetss Massachusetts System Pumping Record Location Routine Yes Wind River Environn►enta/, LLC of System/Other Comments Pumper Signature: Dep Approved from - 12/07/95 Form 4 -- System Pumping Record Septic tank: No =Yes Quantity Pumped: %06ko Gallons Permit #: I e cu to �nQ C rr O � O n v 0 n c � 3 a � o n D p' y n I � v z D v 0, Q cfl s X30, I � 3 o � u 3 3 0 a M p � m v L m 7 � ) C 1 "L 'a r O � H m j -Of D a c� c c� rr i 4 o' 3 m a I cu to E4 oN / /o S • 16 185 New Boston Street /o-, 44 Woburn, Massachusetts 01801 (617) 938.1037 RF.D. *3 Manchester, New Hampshire 03103 (603) 4348725 4L.o9 21'79 34,1y ' �- �I�QESrr SugSve�AC� AISPos�IL .Sj/S r'�M . . i v✓ Ti4, A/ /N in/ 1,VV r,4N ,e aT' v - /o 7 r ,�J / MIV D -80x /A/ Ir8.27 of I/VV D' 847Yovr w / /JA ,y /vg. �9 ZOr ���ES ST' //�/V 84N a INV 194N y t /,,-,7,70 fo,e INv e41V '0 _ /D�'�9 !_/`I SQ UAC?E f U164)6,eS ivy/ '64N 4 R4ti 5 /r/V /A/ V ENp - /07-17 /o& . 95 � DiPRETE • MARCHIONDA & ASSOCIATES INC. j/v FNlU { /oto • 4 9 ENGINEERING A PLANNING CONSULTANTS oN / /o S • 16 185 New Boston Street /o-, 44 Woburn, Massachusetts 01801 (617) 938.1037 RF.D. *3 Manchester, New Hampshire 03103 (603) 4348725 Lor a l3 4-4, PC, 7 .6- r, 1 gZi Fti LND 3� 3� 4G. "Y' Z7.71 Foe4545 577` ^UgSvE'�/�G 1�/SPoSAG .SYS r€M 1,V✓ 7-.4,Ve /N / t>R. iN /N✓ T.4Ne ov7- _ /o A 37 /tl / / MIV D -Box /A./ - /c8. ?7 /ve /NV D- 80Y OV'i ZOr /c_0R6-S 7- Jam% //k/V 94 Al /A/V 84N /NV 841V '� 3 /DG' /09 V\ UA,E E f U/G U 6le S i vVB4N 4 lC4. 17 /NV g4N3 ¢ d 5 �Ip 5, GG / //= � / IZ /N V ENQ / /07.9 7 1M„1 cA/t, " qs DiPRETE • MARCHIONDA & ASSOCIATES INC. d /0&.,i? ENGINEERING A PLANNING CONSULTANTS I,v„ !.. �i 185 New Boston Street RF.D. A, '� - /o5, 44 Woburn, Massachusetts 01801 Manchester, New Hampshire 03103 ,.,/1/ (6Q3) 434-87251 O tt77 P North 1;nriover, i,,,ss. Street No r_;.'-,. r.. s Lot No T oc/Subdiv. PI and a.�ner Inves ti6at,or- +1` Observer SOIL PROFILE Dk-CFS _ ?.r:Icv 3•Elev 4.Elev 0 - 0 - ---- 0 0- _ - �k�7 TiE:s to T� Pits 2 2 — 2 6 � - 9 o 10 Io - - - 10 r'1 uvatiun Pit 2 Strt Sa to, !Ll' - � A�� -- - .�. JifE'S >p of -I):( -)p of 6 i •,e -- -- - - - - -- - - ' -.18t, •{111 )p id qA1- --- - i - Board of Health !1cr;,X; ,�.n&ver,MaBs APPR 04ID DATE Provided: SUBSURFACE DISPOSAL DESIGN CHECK DIST f DISAPPROM DATE Reasons: LoT j Title V FAIL CK .. ' Reg 2.5 The submitted plan must show as a nin i mtms a) the lot to be served -area, dimensions lot #, abutters blocation and lag deep observation holes -distance to ties c location and results percolation tests -distance to ties d design calculations & calculations showing required leaching area (e) location and dimensions of system -including reserve area f) existing and proposed contours g) location any last areas vithin 100' of sere disposal system or disclaimer -check wetlands napping (h) surface and subsurface drains vithin 1.00' of sewage disposal system or disclaimer (i) location any, drainage easements within 1.00' of ses-age disposal system or discla r—er-P1anning Board files ( j) knee sources of eater supply within 200' of se�_ge dispo�l a _ system or disclainer - E (Q-lDcation --of ax}- proposed �,-e11 io serve lot-_lOJ! from leaching facil (i location -of tater lines on pmper_ty 10' from leaehi g facility (m). location of benchmark._ (o)_ garbage disposals: (p), no PVC to be used in construction- - _ (q)" profile -of system -elevations of basement, plumb, pipe, septic inn}:, distribution' box -inlets and outletst-distribution field piping and CtLer elevations (r) maximam ground water elevation in area se„fie dis_�osal er em -� (s) plan amst be prepared by a Professional Eng;.neer or other professional authorized by lasr to prepare such plans Reg 6 Septic Tanks (a) capacities -150%, of flow, vater table, tees, depth of tees, access, pining 1(b) cleanout �(c) IA' from cellar ;all or ingro aid s -3 -*i- �9 PO -01 -- --- (d) 25' from subsurface drains Reg 10.2I I Distribution -Boxes____ (a) s ope greater than 0.08 Reg 10.4 1 ( b) suV Shbsurfacp Jiesign Check List Page 2 FAIL I CK Leaching Pits Leaching pits are preferred where the installation is possible Reg 11.2 a) calculations of leaching area-minimam 500 sq ft 11.4 b) spacing 11.10 [c) surface drainage 2% 11.11 d) cover material e) 2' x2I x4a splash pad f) tee at elbow g) no bends in pipe Brom d -box to pipe Leaching Fields teg 15.1 a) no greater than 20 minutes/inch jb� area-mininrx 900 sq ft 15.4 cconstruction of field 15.8 d) surface drainage 2 % 3.7 e) 201 from cellar call or inground s,,4mxrdng pool Leaching Frenches - a) calculations of Teaching area -min 500 sq ft b) spacing -4 ft min 6 ft with reserve between c) dimensions d) construction e) stone f) surface drainage 2% Douahi.11 Slope a) -slope y x= to be shown) b) y/x X 150 = (to be shows) ris 1a) approval b) stand-by power .. Board of Aealth North Anc over,Haae. M SEPTIC SISTER INSULLATICK CHECK TAST easiest LOT"i r AVATICH� Ob FAIL •1 .55,yy 1. Distance Tot a. Wetlands b. Drains C.. Well 2. Water Line Location 3. No PPC Pipe 4. Septic Tank a. _Tess -_Length & To Clean Ont Covers b. Cement Pipe to Tank On Bath Sides of Tank . 5. Distribution Box a. Covers k Box - No Cracks b. All Lines Flowing Equal Amoimts c. No Back Flow 6. beach Field or Trench a. Dimensions b. Stone Doth c: Capped Inds d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e.Cemxmt Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. -Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location -4th Regard_to Perc Test d. Elevations e. Water Table BO RD OF HtALTH Town of Yorth Andover.Mass. , Permit rr Date APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drill a well ('V�. Application is made to install (_) a pump system. Location: Address --,d 6- ...Lot ## Owner AddAs , if -Well Contractor 404Z:4 1 Address Pump Contractor WELL CONTRACTOR Address (To be completed at time of pump test) Type of Well z �� i Diameter of Well Depth of Bed Rock F Was Seal Tested? Yes (V) ; No { ) Depth of Well Z s �— Depth to Water /D Well used for Size of Casing_ Depth casing into Bed Rock Date ofTesting Well Ended in What Material�� Delivers- % Gals.Per 1,1in. for 4 h --urs Drawdown feet after pumping hours at GPM Date of Completion 'y 7 / nature-A%ell ontractor- PUMP INSTALLER- (To be filldd- in before - installation) - Size & Name -Pump _ Pump Type Used [•'ater Pump Delivers=- GPM = = Size of Tank Pipe Material Used in Well: Cast Iron ( ) Galvanized ( ) Plastic*(—) 1 -'ell Pit (_) or Pitless- Adapter ( ) Was sleeve used to protect pipe? --Yes (_) NO{_) Type or Name ;•:eli Seal Date o'lE 1.1 e P�-nP ..,•:ti:�:'ia::'r;'�P:ti;':YiY;:i`,iii3Y' ,r'ii;i',•7r. ri5ri�5�ii`:.ii -...,i.;.,,;r:r,t,i,r��„ir=.-.,rx-„ Date ['later analysis report submitted to -Board of Health Date'release given to owner of record & Bldg. .Insp- Health Inspector -4- . I `SUR SE�J� �' r�ff WELL & PUMP CO. RT. 28 WINDHAM, N. H. 03087 [603] 898-4232 • [617] 887-5888 ELM SQUARE BLDRS TEL. PAID. 1 ELM 50 ANDOVER MA 01810 LOT NUMBER OR SAMPLE LOCATION: LOT #8 WATER TEST RESULTS 4 APR 84 HARDNESS 119.7 (0-50 REC STANDARD) IRON .6 (0—.3 REC STANDARD) MANGANESE 0 (0—.05 REC STANDARD) HYDROGEN SULFIDE 0 (0—.01 REC STANDARD) Ph(ACIDITY) 6.5 (6.5-7.5 REC STANDARD) TURBIDITY 0 (0-20 REC STANDARD) CHLORIDES 30 (0-150 REC STANDARD) COLIFORM BACTERIA 0 (iy REQiIRED STANDARD) •iE' ..E' .{C .f."iE..3E"n .lE' # # # ?. '"." # X #'�: i{ iY'SF #'K # #':4' #'3�"ff"�"3: 'i'C'� # # #'�'Y-'K' # # # # # # #'if' #'YS' # # # # CHARGE FOR CHEMICAL & BACTERIA TEST *# $25.00 #•�'#3f##'�f••�'##•"r. #.••ir•k #'�'#'� # •K •�'r•�C"X"� •k #####34'###•Ys-�C ########.'1F####### ABOVE TESTS ML -ET REQUIRED STANDARDS AND BASED ON THESE, WATER IS SAFE FOR HOUSEHOLD USE AND HUMAN CONSUMPTION. THERE ARE OTHER LESS COMMON MINERALS WHICH CAN AFFECT - QUALITY OF WATER. Pumps e Submersible a Jet e Centrifugal e Cellar o Sewage Tanks Filters e Softener o Iron . Charcoai "�eutralirer Cartridge Water Testing Pump Parts Motor Controls Water Softener Sa Resin Cleaner Rust & Stain Remc Potassium Permanganate Plastic Pipe & Fitt Lawn Watering Systems Water Heaters e Solar . Heat Pump • Electric o Energy Saviq Wells Drilled o Driven e Dug Gravel Chemical Feeders Tank Alarms & Controls Hoist Service Portable Pump Pu Emergency Service Goulds Aermotor - Jacuzzi Red Jacket Fairbanks ,'Ooi�,e Wayne Aquatron Well -X -Trot v •.ri i ' oro i'• 8 riW.. , ? H W f; .ri N 0:fa `y� 4J 0 44 el •x 04,04 0 u � 2 to N f0 . • '1 f 0.'1 N o NA 4 N b �' 0 E tT 0 •� t4 i•% .� �Y H b` a p W � V] t0 f� cn cn cn N N ,� a� .. to N •.� P4 a 4J t: v •.ri . �i t.f 4 %• i'• 8 riW.. , ? H W 0:fa `y� ul •x 0u �` u � 2 '1 o 4 t� i•% �`.. �Y H b` .i . p W � V] t0 f� A N (A a� rW b to N •.� P4 �` rn ani a 0 H •,•1 4 ro b a � � Io N 44 b 0 b •,j ?/ u /O 41 N W H 14 R O u b 0 fd 0 0 0 0 N 4J '•4JN O bu N -A d m -ri •.I b 14 ya acro a) 4) a° 0 w E• N Z E+ N FORINI 4 SYSTE-'1i PLJJMPD�G RECORD 107 Forest St. Middleton, MA 01949 774-2772 Conunonwealth of M ssachusetts ,.Mass.achusetts fem r cord yst em Ua------'""`— ).Stem ocatton Date of Pumping:. Quantity y Pu �1y Q Pumped' ?al1.ons Cesspool: NO Yes ❑ S"004eptic Tad*-: Igo ❑ Yes System Pumped by: License W: Contents transferred to: Date Inspector CURRIER SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON, MA 01949 (978) 774-2772 11 CO MONWEALTH OF MAS SYSTEM OWNER: SYSTEM LOCATION: 6,1 DATE OF PUMPING: QUANTITY PUMPED: CESSPOOL: NO 0 YES SEPTIC T SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED T0:_ l f x2 DATE: 04 INSPEC OR: 'moo _ SYSTEM PUMPING RECORD GALLONS NO 0 YES E3 -- s It> System Owner Type: Em Cesspool: No Date of Pumping: System Pumped By: Contents Transferred to: Contents Disposed at: Date: Commonwealth of Massachusetts Massachusetts System Pumping Record System Location Routine Yes Wind River Environmental, LLC Condition of System/Other Comments Pumper Signature: Dep Approved Form - 12/07/95 Form 4 -- System Pumping Recor Septic Tank: No = Yesl `; Quantity Pumped: t ®p) Gallons Permit #: DEC rO�r y vFNOR OEpPUTiv1��T -C\- Commonwealth of City/Town of System Pumping R Form 4 assac usetts ecor 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. /'1 City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) A0016" p6d Date 2. Quantity Pumped: Gall&s ❑ Cesspool(s) Septic Tank El Tight 4. Effluent Tee Filter present? ❑Yes ❑ No 5. Condition of System: If yes, was it cleaned? El Yes G� � D `6 `l � State Zip Code State Zip Co Telephone Number Tank ❑Grease Trap 6. System Pumped By: Name Vehicle License Number Company Ipswich ,pater 7. Location where contents were disposed: T1'@atrl"lE?r1t Pant �StN Ir,o.Atir•h A/ie nio': ❑ Nonl:to— Hs - Signature Signature of Receiving Facility t5form4.doc• 03/06 Date Date System Pumping Record •Page 1 of 1 A. Facility Information Important: When filling out 1. System Location: forms the 6(e computer, use only the tab key to move your Address \ ►� ( f��V`(�U� `1 cursor - do not use the return , City/Town key. V �'� 2. System Owner: Name Address (if different from location) /'1 City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) A0016" p6d Date 2. Quantity Pumped: Gall&s ❑ Cesspool(s) Septic Tank El Tight 4. Effluent Tee Filter present? ❑Yes ❑ No 5. Condition of System: If yes, was it cleaned? El Yes G� � D `6 `l � State Zip Code State Zip Co Telephone Number Tank ❑Grease Trap 6. System Pumped By: Name Vehicle License Number Company Ipswich ,pater 7. Location where contents were disposed: T1'@atrl"lE?r1t Pant �StN Ir,o.Atir•h A/ie nio': ❑ Nonl:to— Hs - Signature Signature of Receiving Facility t5form4.doc• 03/06 Date Date System Pumping Record •Page 1 of 1 cSIV 2011 TRNOTER O�WMEN H -C-N Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER Form 4 Important: When filling out forms on the computer, use only the tab tcey to mOVe your cursor . do not use the return key. ' �I 15form4.doo• 03106 DEtS 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 Heafth 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 WR 15.35'1, R. Faoiiity information I. System Location: r Address City own ..••..._- State •� ._._ ..__.. Zip Code 2. SystemW-1ncRr: y Name Address (if different from location) --•- •• City%Town.,.. _.. _.._.._ .... .. __. _.- �. .Sten: ,..�..� ._._.. . —.... - -- •-- , Zip Code Telephone Number B. Pumping Record 1, Gate of Pumping 3. Type of system: 2. Quantity um P ped: Ga1t� " ❑ Cesspool($)tic Tank ❑ Tight Tank ❑ Grease Trap Q Other (describe): .... 4. Effluent Tee Filter present? ❑ Yes a45-r If yes, was it cleared? ❑ Yes Pbio 5. ConditionPped : 6. System P Name ��....�� ...�...._ .— . r---^ veh(cic Lt nye umber Company•--•--"-,...... . _ .-- 7. Location where contents were disposed: .... •.� - -- -- '� ..... __ ._.... I. W1N'T.F... --- -• - - —I:�W: W}TSP; .-_..._...... - _ Signature of Hauler 5i lure of R ��-"•�"'"` _ Date System pumping Record - page -, of i