HomeMy WebLinkAboutMiscellaneous - 939 JOHNSON STREET 4/30/2018 (2): Commonwealth of Massachusetts
= City/Town of .
System Pumping- Record
y,
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.
A. Facility Information
1. System Location: Le o , Left / Right rear of house, Left/ right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address qS� n 2 I
City/Town State
2. System Owner.
VIP
Zip Code
Name' A Y 1 —
Address (if different from location) CT
CitylTown State/'V `p Code •.. . I
Telephone Number l i
B. Pumping
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
l }
Date ' � 2. Quantity Pumped: canons '
Cesspool(s) Q4eptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes
" 5. Condition�ttSystem: � I
6.. System Pumped By:
7.
Neil. Bateson
Name
Bateson Enterprises Inc-
Company
ncCompany
were disposed:
Waste Water
If yes, was it cleaned?
❑ Yes ❑ No.
F5821
Vehicle license Number
41
Date
t5form4.doc- 06/03 System Pumping Record • Page 1 of 1
TOWN OF • Itncfoqrr
SYSTEM PUMPING RECORD
DATE: I a _ q, - ,P
JAN -22M
J
SYSTEM OWNER & ADDRESS
Till G(11 ( v...
cm 3-6�V�6c)A-
SYSTEM LOCATION
(example: left front of house)
v t. . �D A X 6(
DATE OF PUMPING: b r)_ QUANTITY PUMPED: 1 o (n GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: j D
YSTEM OWNER & DRESS
(example: left front of house)
froj l Out
DATE OF PUMPING: 1 QUANTITY PUMPED t z5(DO GALLONS
CESSPOOL: NO � YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ."/
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO:
0
Conunonweal t of INassachusetts
&Iag.)6assachusdIs
System Pumping Record
�ysletn Uwner
l aAIWI/ `
Date of Pumping: ��— > 9--Drc�
Cesspool: No Yes LI
System Location
�39 --'rokws�0L,\ 3�
Quantity Pumped: / 7 `—gallons
Septic Tank: No Yes
System Pumped by: Faredea grO&VI ded License #
Contents transferrred to : Greater Lawrence Sanitary District
Date:
Inspector -
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END FIELD
i
Board of Health
North An4oVerXHaa8.
�PCNID DATE'
M
BzMC SISTEK
INSTALLATICK CHB05 LISP
DATE
&-nnsl
nim
LOT
�- 1. Distance Tot
a. Wetlands
b. Drains
Co. Well
Water Line Location
3- No PPC Pipe
Septic Tank
a. _Tees -_Length Ec To Clean Out Covers.
b. Cement Pipe to Tank- On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
or b. All Lines Flowing Bqual Amounts
/ C. No Back Flow
Oe 6. Leach Field or Trench
a. Dimensions
b. _ Stone Depth
c. Capped Ends
d. Clean Double Washed Stone
r
7. Leach Pits
a. ons
b. Sto Depth
c. ash Pads
do ees
e. Cement Pipe to Pit - Both Sides
t�. 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 with Regard -to Pere: Test
i d. Elevations
/ e: Water Table
Bp;,rd of Health
APPROM DATE
Provided:
Title V
Reg 2.5
Reg 6
Reg 10.2
Reg 10.4
SUBSURFACE DISPOSAL DESIGN CHECK LIST
LOT
DISAPPROM DATE
Reasons:
FAIL OK
e submitted plan must show as a ndm ml m:
the lot to be served -area, dimensions lot i ,abutters
b location and log deep observation holes -distance to ties
c location and results percolation tests -distance to ties
gn calculations & calculations shoring required leaching area
—` ation and dimensions of system -including neserve area
eXI–Asting and proposed contours
to on any vat areas within 100' of sewage disposal system or
sclainer- check wetlands mapping
(h) surface and subsurface drains within 100' of Be, disposal
system or disclaimer
i) location any drainage easements i4thin 7001 of se-�,sge disposal
system or diselai_n.er-PZa-ming Board files
(j) kno= sources of nater simply within 2001 of serge disposal e
system or discla.iner
(k ' cation of my proposed trell to serve lot -1001 from leaching facili
1) cation of j,-a.ter lines on property -101 from robing facility
m cation of benchmark
drive -ways
garbage disposals
no PVC to be used in construction
q) profile of system elevations of basement, pleb, pipe, septic ianr,
distribution box inlets and outlets, distribution field piping and
Over elevations
r) ma Yt n �m ground nater elevation in area sewagedist sal system
j plan must be prepared by a Professional Ragineer or other
professional authorized by law to prepare such plans
Septic Tanks
a) capacities -150 of flow, water table, tees, depth of tees,
� access, putping
p) cleanout
C) 101 from cellar wall or inground s --ng pool
d) 251 from mabsurface drains
Distribution Foxes
a) -slope gr eater than 0.08
b) stop
SOIL PROFILE & PERCOLATION TEST DATA
North Andover, Mass. Street No 3 c 1A'►J SV *-3 Lot No
hoc/Subdiv. " Pland Owner t...&"oyEST
Investigator Observer
SOIL PROFILE DATES
l Al.ev 2. Elev 3. Elev 4. Elev
527 �83
n
I T"s s
-Z%>Ne-y
`.1hItiDy
4A&vS-"—
Benchmark
Elevation
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
Location
Datum
PERCO;,ATION TESTS
DATES `("t 1 e-7 0-718S
0
1
2
3
4
5
6
7
8
9
10
Ties Pt�sTest
Pit Number 1 3`�Z 2 31�3 3
Start Saturation
Soak -Minutes
Start
Drop of 3 " -Time
Drop of 6" -Time
Mams.lst 3" drop
Mins.2nd " Drop
Percolation
TOWN
SYSTE
DATE: `o
F �NORTH AND
PUMPING RE,
P�0'vv:'-' Lc�-
q3� 3,kASII� sk
RD
NOV 19 2004
TOWN OF Nlop--
HEALTH X `r,
(example: left front of house)
�-�- �- 0
DATE OF PUMPING: _ 10 QUANTITY PUMPED I S Cc') GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE I EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: ` L- S - 't� V
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
Date of Pumping: Quantity Pumped: (�� gallons
Cesspool: No�P Yes ❑ Septic Tank: No ❑ Yes( -
System Pumped by: 64&d" eVnided License #
Contents transferrred to ; Greater. Lawrence Sanitary District
Date: Inspector;
m
Commonwealth of Massachusetts
Pa 4Massachusetts
system Pumping Record
System O) Vljer
- �l 4AAe,l)-V— .
Date of Pumping: U--
Cesspool:
No �.'�" Yes 1.1
System Location
9 S q Jo� 1vVsv� 5-�-
Quantity Pumped: t,5`6ti gallons
Septic Tank: No U Yes
System Pumped by: va%4,e License #
Contents transferrred to : Greater Lawrence Sanitary District
Date:
Inspector:
A