HomeMy WebLinkAboutMiscellaneous - 95 CARLTON LANE 4/30/2018 (2)� �,
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t5form4.doc• 06/03
Commonwealth of Massachusetts nr-torIVED
City/Town of MAY 20 2013
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPA;zra' J -r
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: Left�ront ofJlou�s� 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
e �,b t �(
Cityrrown State Zip Code
2. System Owner.
Name
Address (if different from location)
Cityfrown
B. Pumping Record
1. Date of Pumping
3. Type of system. ❑
State Zip Code
�'��-tea
Telephone Number
4--�- L3 eve
Date 2. Quantity Pumped: Gallons
Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f S stem:
_ i J
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ere content4 were disposed:
GLS. _ Lowell Waste Water
ply)).
luleq j Date l
System Pumping Record • Page 1 of 1
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FORM U - IAT 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: s ��1rY1 L5f3'I�I�Ny Phone
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s)
Street Jl A/L �JN �� St. Number
************************Official Use Only************************
RECOMMENDATIONS 9F TOWN AGENTS:
Date Approved 2
h5
Conservation Administrator Date Rejected
Comments
Town Planner
Comments
Food Inspebtor-Health
Septic Inspector -Health
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
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TO: �'
FROM:
NORTH ANDOVER, MASS.
BOARD OF HEALTH
June 6
19 83
DESIGN ENGINEER Re: Soil Absorption
Sewage Disposal
System
This is to certify that I have inspected the construction materials of
said disposal system at lot 30 Carlton Lane
Site Location
North Andover, Mass. _
^�l.�r�
The grades and construction materials are ed in the plans and
specifications dated Feb. 23 19 81!§-JAE June 6 19 83 .
f V PLACE uxlc.
Reg Prof . En ✓40nitarian
•1C a� SRPTIC SISTEK
idover T�.aae.
--� INSULLATILIi CH1rK LIST - LOT
DATE DISARPHUM EXCAVATICN 01 FAIL
,. eaecnst ,
l nJD.�. C-iP�oitiS -
CK
I.
"Distance Tot _. -.
<.
a. Wetlands _
b. Drains -
c. `Well
2.
Water Line Location
_
3.
'.No PPC Pipe -:
optic Tank
-•
a. __Tess --Length do To Clean Out Comers _.
_
b. Caveat Pipe to Tank - 0n Both Sides of Tank
5.
Distribtution Box - -
a. Covers k Box - No Cracks
b. - All lines Flowing Bgiial Amounts
c. No Back Flow
6.-
Leach Field or Trench
a. Dimensions
b. Stone Depth
c* Capped Ends
d. -Clean Double Washed Stone
7;:
Leach Pit
a. ions
b. Sio a Depth
c. sh Pads
d. eas
e Cement Pipe to Pit - Both Sides
. Clean Double Washed Stone
8.
No Garbage Disposal•
9.
-7 nal Grading Inspection
10.
Barricading Covered System
11.
As Built Snbnitted -
a. Lot Location
b. Dimensions of System
c. Location -4th Regard -to Perc Test
d. Elevations
e: Water Table
Boards of Health
North Andrer,Mass
APPRMM,Qeg)D TS
Provided:
SUBSURFACE DISPOSAL DESICK CHECK LIST aa
LOT vy
DISAPPROPED DATE
Reasons:
Title V
Reg 2.5
FAIL
OK
The submitted plan must show as a minimums
a) the lot to be served -area, dimensions lot #,abutters
b location and log deep observation Cde�-distance to ties
c location and results percolation teats -distance to ties
design calculations & calculations showing required leaching area
(e) location and dimensions of system-ln�luding reserve area
f) existing and proposed contours
location anF wet areas idthin 1001 of sewage disposal system or
disclaimer -check wetlands mapping
(h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i) location any drainage easements within 1001 of sesage disposal
system or disclai.uer-Planning Board files
(j) known sources of seater supply within 2001 of sewage disposal e
system or disclaimer
(k) location of mW proposed well to serve lot -1001 from leaching facility
1) location of nater lines on property -101 from leaching facility
(m) location of benchmark
(n) driveways
garbage disposals
no PVC to be used in construction
(q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Mer elevations
r) maximum ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
,r
✓
----(g)
--,
--r
—
11.7
---(o)
Reg 6 Septic Tanks
a) capacit es- 50% of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
�P(e) 101 from cellar wall. or inground swimming pool
) 251 from subsurface drains
Reg 10.2 Distribution Boxes
✓ (a) Mpe greater than 0.08
Reg 10.4 b) snap