HomeMy WebLinkAboutMiscellaneous - 11 CHERISE CIRCLE 9/1/2015 FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary `Y
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.
****************ADDlicant fills out this section********* ********
APPLICANT: � � (�JhJ C Phone _71f 03
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LOCATION: Assessor's Map Number Parcel
Subdivision W'J K 2)I 14 Lot(s)
Streeter C/rn,C�-� St. Numberf
Use Only************************
RECOMMENDATZO 5 OF TOWN AGENTS:
Date Approved
Conservation A m.nistra nor Date Rejected ,
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector-Health Date Rejected
Date Approved
Sep-ic Inspector-Heal-:^. Date Rejected
Comments
Public Works - seeder/water connections_/._,,__4( -�-�
- dr.veway permits
Fire Department
Received by Building (.=_sector Date
i
Town of North Andover,Massachusetts F.—N '
BOARD OF HEALTH
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19 ��
Fc, ,n DISPOSAL WORKS CONSTRUCTION PERMIT
I
Applicant W"
' NAME ADDRESS TELEPHONE
Site Location �2-2'
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Permission is hereby granted to Construct( or Repair( )an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S.No.
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AA
CHAIRMAN,BOARD OF HEALTH
Lam'
D.W.C.No L2
Town of North Andover,Massachusetts Eo�m wo.s
BOARD OF HEALTH
O• DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicart-- l'A= ,(s rmn nXA r t P.l—,C Test No.
Site Location SAT — yL
Reference Plans and Specs.,(�h A r'c�'n/]A<1 a n 4
ENGINEER DESIGN I DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health. /y�—
Y CHAIRMAN,BOARD OF HEALTH
7.
1.
Fee Site System Permit No C.S 7
Rim.. iF .,...
Commonwealth of Massachusetts
= City/Town of NORTH ANDOVER
System Pumping Record cu lvcuai[InvncYVbum
4VIi.:�J.CF f UI F MIS l'IVIL.14 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 within 14 days from the pumping date in '..
accordance with 310 CMR 15.351,
A.Facility Information
Important.When
glling cutforms 1, System Location:
on the computer,
use only the tab
key to move your Address
curs not NORTH ANDOVER Ma
se the return
key GityROwn state Zip Code
k
2. System Owner i-
0-)b rI
Name
rman
Address(f diffe t from location)
Cty/TOwn slate Zip Code
Telephone Number
B.Pumping Record )
1. Date of Pumping cltrr>e. f9r—" 2.Ouantity Pumped Gallon s Is Soo
-
Dafe
3. Type of system: ❑Cesspool(s) [�Septic Tank ❑Tight Tank ❑Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present?❑Yes❑ No If yes,was it cleaned? ❑Yes❑No
5. Condition of System:
7'V
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Sawart's Pre-treatment Plant,20 So.Mill Bradford,Me 01835
Signature of Mauler Date
signature of Receiving Fac 1Iy Data
t5form4.doc-03106 System Pumping Record•Page t of i
A14(4h>9Nz6Uer 12.6.4.
)�6 Main Sf ST�ART�S SEPTIC TANK SERVICE
A/e/!h A ncnve� 47 RAIIRDAD STREEP
BRADFORD, MA 01835
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MMMY REPORT FOR WM OF rU0 1-9"noelyer
DATE ADDRESS GALIDNS '
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Commonwealth of Massachusetts
" Clty/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record mu:
be submitted to the local Board of Health or other approving authority,
A.Facility Information
mponeno
when filling out 1, System Location:
P—on the /
computer use
nlmove lab keY Addre
o o
City/to
cursor.do not
use the return wn
zD coos
key. 2. System Ownec
____._.
-4, ---._
Ad
dress(II dnfeent hom tl -_"
Telephone Number -
B.Pumping Record
1. Dale of Pumping Data 66 2.Quantity Pumped: G-,----
y � ceoona
3, Type of system: ❑ Cesspool(s) k-Septic Tank ❑Tight Tank
❑ Other(describe):
4, Effluent Tee Filter present?❑Yes NO If yes,was it cleaned? ❑ Yes❑No
5. Condition of System: r,
6. Sy em Pumped By: '..
ameLL�J._._ --
Vehicle License Number - ---'
_I� CJ_ lQ �q!�Y✓lJ.
Company
7. Location where contents were disposed:
81 slurs of Hau �—'--- --
...---
http 11www.mssa.gowdep/water/ provais/t5torms.hlm#inspect
t 51orm4.tlo6 06103
System Pumping Record•Page I of