HomeMy WebLinkAboutMiscellaneous - 60 DEER MEADOW ROAD 10/5/2015 i
Commonwealth of Massachusetts
_ City/Town of � � �� ''/J'?
System Pumping Record
� I.�:� P���o-�i�w�ie��Ir�s��i�«� I��c�e
r
Form �..� � ���,.���r..�m�i e�w� r�u I
DEP has provided this farm 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/Right front of house, Left/Right rear of house, Left/ igstde o house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ,�• � � ,� ,�, � � � '
City/Town -; State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Sw��' l ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 13'ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M-filo If yes,was it cleaned? ❑ Yes ❑ No J
5. Conditio Kyoc stem:
..
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc 'on-w'e contents were disposed:
G.L S. Lowell Waste Water
Sign to a Haule Date f
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
1
Commonwealth of Massachusetts
City/Town of
System u i Record
Form.4
r0vm a�o l aws a M4DOV�:�u����m,
DEP has provided this form for use by local Boards of Health. Oth �Crir a dd" �2 he i
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 front of house, right front of house, left side of house, Ight side'of house Left
rear of house, right rear of house, left side of building, right rear of building, under ec .
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State + C Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [:]-1qo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: V\' �
-�
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
. Vuo'f Lowell ste ter
Sigler Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of 11,11 7, 7 T- 1\�
a y stem Pumping Record
Form 4 H ,f AY ? 2010
DEP has provided this form for use by local Boards of Health. Other f r gf wqAbWqQyV&
We
information must be substantially the same as that provided here. Be mith 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 side of hodgZ�kiht'��Jdeof hoq— , Left front of house, Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address 1 4 4
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town St at Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 9--Se—p�tic Tank ❑ Tight Tank
r-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes o yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
D Lowell Waste Water
�Igrptute of Haul Date
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
RECEIVED
Form 4
'I Syay
DEP has provided this form for use by local Boards of Health. Other ormsjr#*_b6 6a� fit th
information must be substantially the same as that provided here B ore using this form, check ith your
local Board of Health to determine the form they use.The System P m pipg,�I3 l§8 mitted to
r EAL1"H DEPARTMEN'f' I rr
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left fron e> rd r, left si of house Right front, right rear, right side of house.
forms on the
computer, use
only the tab key Address
to move your 02,
NC
cursor-do not Cityrrown State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) Q-S'e
ptic Tank Fj Tight Tank
Other(describe):
4. Effluent Tee Filter present? E] Yes [El No If yes,was it cleaned? Yes No
5. Condition of System-
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
7
Date
YnPalureof H u r
tign
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth ®f Massachusetts
City/Town f RE EF
System Pumping Record JUL, 2 2 2008
5
Form
�auvr:�:l :e. �trio � fi � rvli�
DEP has provided this form for use by local Boards of Health. Othe torrrls may but th
information must be substantially the same as that provided here. Before using this farm;'chec 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
Important:
When filling out 1. System Locatiory
forms on the
computer, use
only the tab key Address CS✓
to move your .✓�,
cursor-do not Cityrrown " State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip CojcLe
Telephone Number
B. Pumping cr
c -1141:1 f �
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes El No
5, Condition of System: v .�-.�. u
V\0 4z-
6. Systern Pumped By: y
Name Vehicle License Number
Company
7. Location ere contents w isposed:
Signat a ler (f Date
t5form4,doc<06/03 System Pumping Record<Page 1 of 1
i
1
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f
r
7'
TOWN OF
SYS'T'EM PUMPING RECORD
RECEIVED
DATE:
F U .
VET
SYSTEM OWNER. & ADDRESS SYSTEM LOCATIO
(example: left front of house)
LA,
�1 o .
r �010 t
DATE OF PUMPING: QUANTITY PUMPED : GALLONS
i
CESSPOOL: NO YES SEPTIC T NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TOO: .L. .1) Lowell Waste
I
TOWN OF NORTH ANDOVER 1
SYSTEM PUMPING RECORD
� l l'E,,Yi OWNER & ADDRESS SYSTEM LOCATION
f (ex�imple: lef, franc or house]
t2d,
"
I
U \TE OF PUMPING: QUANTITY PUMPED 1, fL C,� LL(?��
�tii'OOL: NO 1 � YES SEPTIC TANK: NO YCS
—
� ATURE OF SERVICE: ROUTINE "' EMERGENCY
! lI>FRV:�T10NS:
GOOD CONDITION FULL TO COVER
HEAVY CREASE BAFFLES IN PLACE _
ROOTS LEACHFIELD RUNBACK _
EXCESSIVE SOLIDS FLOODED _
SOLIDS CARRYOVER _ OHER (EXPLAIN)
i
)TL'M PUMPED BY: -
� I
UNTENTI TRANSFERRED TO: _
NORTH ANDOVER
DATE CUSTOMER DESTINATION EST GALLONS
4/1409 SUS INSPECT LOWELL 1500
60 DEERMEADOW RD
ACTION-KING ENTERPRISES, INC.
Livingston Street
Lave% MA 01852
.. � 77
r.
r
�r
Pagel
Commonwealth of Massachusetts
Massachusetts
Svstem Pummina Record
System Owner System Location
-A6 r
.Date of Pumping: Quantity Pumped: gallons
Cesspool: No Yes ❑ Septic Tank: No ❑ Yes
a
System Pumped by; Vd&dese 0 ` .<a. License#
Contents transferrred to : rater Lawron s a District
Date: Inspector:
q
Commonwealth of Massachusetts .,
u
City/Town of
k
System Pumping Record
Form 4
DEP has provided this form for use�by local Boards of Health. Other for
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/Right front of house, /Righ ea of hour., Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address ._. ,
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Citylrown ' State Zip Code
r"
Telephone Number
t
B. Pumping Record
CIN
1. Date of Pumping t 2. Quantity Pumped:Date �Pum p Gallons
3. Type of system: ❑ Cesspool(s) .
esspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition of System:
u\. � c
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca,ion�here contents were disposed:
GCAHaule Lowell Waste Water
Sign t e Date
t 5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts i
z G J
City/Town of
System Pumping Record TOWN ff'NOMH ANDOVER
Form 4 ua -4'%RTME
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 RSystem Location: Left/Right front of ight side of building, Left/Right front of building, eft/wRlht read of ' Left/righ s def house, Left/
g building, Lin er deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
tL
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) R"6eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 13""'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition System:
NO tA,
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wher contents were disposed:
CU L S. Lowell Waste Water
SignAtufe 4 Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
s Commonwealth of Massachusetts
City/Town of
"f "'e ;w
System Pumping Record
Form 4
�N
y..
ANDOIA R.
DEP has provided this form for use by local Boards,of Health. he rd must
be submitted to the local Board of Health or other approving authµority. .
A. Facility Information
Important:
When filling out 1. System Lti3On'
forms on the � �l
computer,use
only the tab key Address
to move your
cursor-do not
use the-return City/Town State Zip Code
.key.
2. System Owner:
Name
Address(i(different from location)
City/Town State
i Code'
Telephone Number
B. Pumping .Record
Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight.Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [A-10 If yes, was it cleaned? ❑ Yes'❑ No
5. Condition of System
C) I /�
6. System Pumped By.
Name Vehicle License Number
Company .. -
.7. Locatlo-,where content
were ' posed:
Sign ure uler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06103 System Pumping Record-Page 1 of 11
Town of North Andover
Community Developnient and Services Division
Office of the Flealth Department
M• �1
400 OSGOOD STREET
' � pPoAY6D
North.11nclover,Massachusetts 01.845 ����ocaeu���
Susan Y.Sawyer,R1 HS/RS
Public Health Director (9'78}688-9540-Phone
(978)688-8476-Fax
Date:June 6,2005
Address:60 Deermeadow rd,North Andover,MA 01845
Re: Application for: Addition&Deck
Dear:Mr.&Mrs.Mukerjee
Your application for an addition and a deck at 60 Deermeadow rd.has been reviewed by the Health
Department. The application was denied on,.lane 6 2005 for the following reasons:
L X Missing information
2. X Passing Title 5 inspection of septic system required
3. 11 Location of structure not acceptable
4. LI Undersized septic system
To address the problem(sl:
If#1 is checked, please supply:
a, .Floor Plan of exisfin art d ro osed addition—all rooms
hm ed plot plan show irr house se rtic s stern and pfflposed pMLect In scale
If#2 is checked:
o Have lire se tie s stern
i s cte b a certi red Title S iris ecfar to deterrrtirre t/pe si e o tl:e s stern
a»d
m
whether it is outirr �roverly° "„µ
b.
If#3 is checked: t s a .
a. Relocate the project � �
If#4 is checked: GI
a. Provide additional information proving that the existing septic system meets current capacity
requirements. Please consult an engineer to determine the flow capacity of the septic system.
Please feel fi•ce to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Mic ele E.Grant
Cc: Building Department
File
BOARD OF APPEALS 688-9541 BUJIDING 688.9545 (_'UNSERVA'PI()N 688-9530 NURSE 688-9543 PLANNING 688'9535
pCK-, , " e-\0t ( 0 10q IT-
Vo
e N CMG S-�, �� �{ �T•�ZS�ri
FORM U - LOT RELEASE FOR r -- —�
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.
1 APPLICANT FILLS OUT THIS SECTION
APPLICANT M4 MR5 In 6,Kr:- Z.1"�� PHONE lrr' 175-C-'gam'
LOCATION: Assessor's Map Number PARCEL_
SUBDIVISION LOT (S)
STREET _/zo 0e�1C 10,69 00 A P ST. NUMBER �,e)
OFFICIAL USE ONL
A ZTNS TOWN A
CONSERVATION ADMINIS BATOR DATEAPPROVED
DATE REJECTED ,
COMMENTS 4) 44AM s,
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD NSP CTOR-HFAI T DATE APPROVED
_..DATE REJECTED
SEPTIlb INSPECTOR-_HEALZH DATE APPROVED a j
DATE REJECTED S
COMMENTS
f 9,, - mm
Ginn.�
3
PUBLIC WORKS -SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
i
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
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Town of North Andover, Massachusetts Form No. 1
I NORTH
BOARD OF HEALTH
O �1.EO 16 •yO
O� �l 19
0 yd N m
r � Z A
1'_-
�QAO Pc APPLICATION FOR SITE TESTING/INSPECTION
RATEO 5
9SSACHUS��
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer NAME ADDRESS TELEPHONE
Test/I nspection Date and Time ! /� 7
CHAIRMAN, BOARD OF HEALTH
Fee Test No.
S.S. Permit No. s°G D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts Form No,a
BOARD OF HEALTH
f NORTH J(,,/
Z.tiA �-'Gam•°
19
g9SRATpRP��,�J DISPOSAL WORKS CONSTRUCTION PERMIT
SACHUSE
Applicant
NAME %�,, ADDRESS TELEPHONE
Site Location G�� 30A
: Permission is hereby granted to Constructor Repair ( ) an Individual Soil Absorption
: Sewage Disposal System as shown on the Design Approval S.S. No. J
C I INAN, BOARD OF HEALTH
1Y�
Fee D.W.C. No. ��
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MORTGAGE A SURVEY PLAN
LOCATED IN v cM. : a
SG°ALE-I" Vin' D47-E. a,
,�L.GILES RL.S
/!NORTH AN VER, M 6
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145.Lo
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r ON
TO i �I J .9 IrS T/TL E"/ SU rev=1�►.�
THIS LOT/S LldX IN A FLOOD HAZARD ZONE.
CERTIFY THAT THE OFFSETS SHOWN ARE FOR ME PURPOSE
sc
v17FSETS SHOWN OF DETERMINING ZONING CONFORm/TY 1 ,
CONFORM TO THE
OR NoN c GNS
ZON/NG BY LAIC OF h `lf/° �
AND RE NOT TO E USED TO ESTABL ISH
. _ ,< Pl?oPERT Y LINES. -t 121 f3,7
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NOR 7-1-1 ANDOVER, MASq
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T/'A7"" ;r//E OFFSETS SHOWN ARE FOR ME
PURPOSE
OF'FSFr,9 SHOWN OF DEMR /N/N ` ` �
. O'N/NCB' �`t 'N�"t�F�I�I/rY
CON-C-ORM TO ME OR NON CN�"t / `"Y WH�"N CON " C/ 'M,
"01VING BYl A W OF AND A L-"NOT TO BE USED D 7 0 E-9 TABL.ISI.1
BCARD OF
( r -sops 0 WELL
P4 F4
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a If«
Lrd Of Health SEPTIC SZu
)rth Andovar,M�s . INSTALLATICK CHECK LISP LOVJ
P OVED DATE DI SAPPr�C7J�D X AVATZC�i 0K F7�ZL
_Lco
l_0115 ea ins Y
OK
1. Distance Tot
a. Wetlands
17' b. Drains
/ c.. Wolf
2, Water Line Location
3. No PVC Pipe
?�. Septic Tank
a. Tees -_Length & To Clean Out Covers
b. Cement Pipe to Tank Cr' Both Sides of Tank
5. Distribution Box
a. Covers do Box - No Cracks
b. All Lines Flowing .Equal 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 Pits w
as Dimensions
b. Stone Depth
c. Splash Pads
d. Toes
e« Cement Pipe to Pit - Both Sides
f. Clean Ruble Washed Stone
8, No Garbage Disposal
�• q. -Final Grading Inspection
" 10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
e. Location with Regard_to Pere Test
d. Elevations
e: Water Table
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OFFSErS SHOWN / . f G O'NSP " ", o `; a SUCH
CONFORM 7" THF USE /5 FOR DE DER A NA 7-101V OFZOA(IIVG
ZONING 9 Y L A W OF CONFORMIrY OR NON CONFORMIrY
. WHEN KEN
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