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Home My WebLink AboutSeptic Pumping Slip - 781 WINTER STREET 5/17/2016 Commonwealth of Massachusetts y 1. i City/Town of Y W System Pumping Record ` � rF � Form 4 DEP has provided this form for us&by local Boards of Health. Other forms may"bb'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 t f ontsatlu tsO 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 Cityrrown State "Zip Code 2. System Owner: Name' Address(if different from location) City/Town ' ty State � Zi - _. Telephone Number B. Pumping Record 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 L-3—No If yes, was it cleaned? ❑ Yes ❑ No " 5. Condition of� t 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Lo tion v)th re contents-were disposed: GLLS. Lowell Waste Water Sign t e Haule Date t5form4.doc•06/03 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts 1 lugCity/Town of System Pumping Record 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: Left d"61 ht front of house t eft/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 Cityfrown State Zip Code 2. System Owner: Name Address(if different from location) city/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Dat r 2. uantity Pumped: Gal ans 3. Type of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank I ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes N o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: p 6. System Pum ed By:A Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: G S� Lowell Waste Water Sign t e Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 TOWN OF NORTH AN'DOVEP, ' SYSTEM PUMPING RECoKu) SYSTEM 0 ADDRBSS Sys I ZM LOCATTnN DATE OF PVWNQ; „ �QUANTiTY PUMPED: /ze hq1 ..r VIwNr ..n...n.o..... ...•V•v..•n .��.. ... .. .,. VbSSPOOL: NO YES .,.: Stlpcic I'arik: NU N...,NN,.... . N6 rvu OF SERVIce., Kou'r NR.., ►l`"�MERUGNCY ``UIiSERVATIUN9; .w, voO�co rDrrlvN FULL'M(DOVER I HSAVY 4>rjws DAPPLES IN PLACE, ROM RUNG _ BXCUSYVE SOLIDS FLOODED A( K „ SOLID CARRYOVER,N..N...OTHER EXPLAIN sy•tom Pumpcd by ••�;= °�. .x .,..,. VUMMENTS. l �,:vN PEN'I'S rKANSr'ERP,51) I'0 f F � 2 S NOV ,-* 2004 TOWN OF NORTH ANDOVE'k SYSTEM PI MP`IN RECORL) ,. 't,..,' L)A UL �y 9 i f / In,[Gik U1 SY7ST` .M LOCATION M U WNFR& AC�DRESS 5 .S TF �p DATE OF PI,IMPIN(): —.,,�'�._ .,�-.�,..�.. ,,. ,. 4?I.IANTITY AIJMPED:.. � 1 CLSSPUUL; NC? " Y48 Saptic '1'arak; NU YES NA rUKE OF SERVICE: FtfJU'I"INk �lrth;RCl�;N4'1` ._ �)t�S�RVA'CIUNS; J 000D CONDITION FULL'ro COVER HEAVY ORE,ASE BAFFLES IN PLACE ROOTS LEACHMELD RUNBACK EXCBS$'IVE SOLIDS _ FLCJODI?D SOLID CARRYOVER,.., OTHER EXPLAIN , Syauom Pu,n}�cd by Sg/w Af f t,'CaMMF,N'I'S. 1 1 CUNI'l::N"I'S I'KANSYtaRKBD I'0 II l l TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD STEM OWNER & ADDRESS SYSTEM LOCATION -_-- �, .. (ex„ample, left front of house) U \'I,E OF PUMPINC; QUANTITY PUMPED AdA/� LLt�ti� t I100L: NO YES SEPTIC TANK: NO YES i f `I URE OF SERVICE: ROUTINE EMERCENCY u lh(:R Y:\TI ONS: GOOD CONDITION. FULL TO COVEk HFAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK . CXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER O�HFR (EXPLAIN) ..� � �TLM PUMPED BY: CU,I"df:NTS: I'S TIZANSFCIZIZED TO l I i f K"tA "+� k��rG� fx rhtral'r�st,�l aII1,'t ( (r 41 f.ir A�� + V k r " a.. !A r'jx f."', y a 4h' " r♦`MMr 1 .., ; r I u ! Pf t t��{�a�' ' S�+ �.��;`1st{rnI r Orr �'� ��,k} fI r;'t• 1 ,1�r(�i� r '. h i r�` L�"1 �J 4�{ lh'� k",hJ""+'rJ ( 1 Y Y 5! r it tnY�"•I>'1 t M r� �{ �f +tw�, -3 n +ww" j,` Do X1-1 p, RECORD � � 1 *�1 � s ,,,*i" L �wrT } r 4 � '�'.`r y'flt�P N�, ,+. !ny r �•, i rr f `a'1 r�� `�� 1 ,f 4 r .. �� .1 )`�I� pry a1c�f j J„ �r f fYx 1 4j^( ......, " r A 1 j � �� " 'KEM IIYM '"'.T V�TJ .. low,110-fruit 4 h�'1+f'Y(?��yr� �� 1 h Jx~ ��rl�,('`��,��y { ��; ,s,r� .^t tr r..,• X ..� � .. t rSSt++�e�tAl�fflh n" h ��I d r �„,,, OM"" '��S .''" �r�r�wll•`�A! �r�d�(y, �(..`"`",:«,,-.. jj rya..rYa e 1 ^^�?F'�' ." ✓ ;•+ �lk#� ttf ►t'7rY�! JPUMPED ' GALLONS �Y �rL�,d�� q�i it},•, 4 :1 ��'�IIIIIIA. r^T11�""" DIY 4c ♦�: N/'► �Z/'� YES !�1/,� ( S T '*�#C�11; ��+I tr1 '�✓,rrt „%mow"”' � � ,. r 1,w �+1E+�''Ci,�j�Cy 11,l, 1a j ,� -- D' ; �,rq,Pnear rrt('��J1�1y'Yjt�♦ �''P'�' T �� .,. ,.. r ,. • 1tOOTS` ' , �......,,..,, 11"FLES IN pLAC ......... E1 M1 k+"i � 111 I it �SWX SOLIDS : '""'.""".,, LFA�LD RUNBACK 1114 41 FLOODED OTIMRr �� 2^5W(��6!I r.`!i!}it�lf,f�;�y(I tist,+F}�•�i��( n( �� rrtf, tr rt:{�xi r ',. t". '"s,`�J reyr ,�� 1 1 ( t y t'W"'1"".yl 7r i � • "��t�� W r�„ Y� n rp'.s+r t '1•'; /.wt'',' , Plht�?r4}rr I➢� , r •.� �'�.� � s,r �`•P��r��%Pry,h�,,. �� 1V' 1 r e,�., , 't .� ♦.' , 1 ,[ 1.rr, .'�` � 'N rx�r' ,H � g10 M f ' r 1 �. , #. .r r ire ;•�, r Itt r�,. e�,i�r�7yi�tl�syr,�` T^ y a' t r.. . ( rr n,F 1 t. r } I ,.I I • H,) /��''M "•7 k ifj,:'�1 1A�1?7.a C'r �h1 ' ��i.., 1 �M1 � +I r !ta 1 1 p ca f 'C s r.n5 s !{JW<j,i n 1 "(, �r�� '.N�� 3 - c , , FORM U'- LOT RELEASE FORM ► oPc � t INSTRUCTIONS: This form is used to verify that all necessary approvals/permits frc r Boards and Departments having jurisdiction have been obtained. This does not relieUE the applicant and/or landowner from compliance with any applicable or requirements_ *****************************APPLICANT FILLS OUT THIS SECTION****** APPLICANT YG �. �+✓�'�l�� PHONE' >G� . LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT(S) / `� STREET ST. NUMBER. ` i CIAL USE RECD► ENDATIONS +4 TOWN AGENTS: ONSERVATION ADM►NIS ATOR DATE APPROVED rZI 11 jjljj DATE REJECTED COMMENTS s 1 f TOWN PLANNER DATE APPROVED DATE REJECTED - - -------- COMMENTS OOD INSPECTOR-HEALTH DATE APPROVED j I DATE REJECTED ��8EP"TIC INSPECTOR-HEALTH DATE APPROVED. " DATE REJECTED ' COMMENTS Neel Cv f r o n c PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9W jm ❑ Stewart's Septic Service ❑ Andover Septic ❑ Stratham Hill Septic ❑ Roto-Ran (978) 372.7471 (978) 475.2593 (603) 772-5548 (978) 452-902 20 South Mill Street,Bradford,MA 01835 Date of a ice i - PAY FROM THIS BILL Customer Name: _ / A ? Service Location: 74-_ Phone: Septic Tank Pumping and Cleaning Contact: "Done the Right Way'. f , Billing Address: y / City: o e Y Zip: f Special Instructions ❑ Completed J ❑ Incompleted Reason: / Pe QPM Services Rendered (AA f(1 Vacuttm-Pumping Op�rVations Drain Cleaning l; Septic Tank Good Condition ❑ Main Line ❑ Drywall ❑ Leechfield Runback ❑ Toilet Bowl ❑ Leech Pit/Overflow ❑ Riding High ❑ Kitchen Sink ❑ D-Box (liquid level ❑ Bathtub/Shower ❑ Pump Chamber ❑ Full to Cover ❑ Vanity ❑ Grease Trap ❑ Excessive Solids ❑ Floor Drain ❑ Catch Basin Top/Bottom ❑ Vent ❑ Portable Toilet ❑ Use No Powdered Soap ❑ Sewer Jet Cl Other ❑ Heavy Grease ❑ Other Qty: ❑ Roots Footage: Size: � L) Suggest Electric ❑ Under 1000 gallons 6.'1000 gallons ❑ 1500 gallons Rootering ❑ 2000 gallons ❑ 3000 gallons ❑ 4000 gallons ❑ Van Called ❑ 5000 gallons ❑ Other ❑ Other Misc. -7 y CJ ❑ Digging Charge ' * L) Backhoe ❑ Inspection ❑ Location ft./in. ❑ Consultion `S' /f ❑ Certification: P/F ❑ Service Call ❑ Estimate Reason: ❑ Labor ❑ Portable Toilet Rental ❑Pump Repair ❑ Waiting Time ❑ Baffle ❑ Repair * Digging Charge is Per Driver ❑ Chemical Treatment � )�f l ,c-7 Discretion ❑ Other Description of work Recommendations 1. Terms of kyrrierrit Parts Vacuum Pumping Drain Cleaning NET 1 V DAYS Yr. Month Yr. Month Tax Terms&Conditions ❑ Cash ❑ Check ❑Credit Discount Total 1. Not responsible for damage beyond curb line. 3. 1.5%per month will be charged to accounts past due. 2. All complaints shall be reported within 48 hours. 4: The purchaser agrees to pay all cost of collection. j l I Customer Signature Serviceman 7,f = ❑ Rag ANDOVER SEPTIC 47 Railroad Street ROTO-R" Nature of Service ❑ N/C (978) 475-2593 Bradford,MA 01835 (978) 452-9022 Reg.Maint. ❑ Emergency ',Q-Day ❑ Night a`e of Service PAY FROM THIS BILL I Customer Name. Service Location i Phone. Septic Tank Pumping and Cleaning Contact: "Done the Right Way" Emergency 24 Hour Service - 7 Days a Week Billing Address: City: Zip:'1/1- Special Instructions . Completed "❑ Incomplete Reason: Per: AM/PM Services Rendered ! Vacuum Pumping FGood rvations Drain Cleaning/ _01 Septic Tank Condition O Main Line D Drywell ' eechfield Runback ❑ Toilet Bowl ❑ Leach Pit/Overflow ❑ Riding High ❑ Kitchen Sink ❑ D-Box (liquid level) ❑ Bathtub/Shower ❑ Pump Chamber ❑ Full to Cover ❑ Vanity ❑ Grease Trap ❑ Excessive Solids O Floor Drain Top/Bottom 1--) Catch Basin El Yard Drain ❑ Use No Powdered Soap El Portable Toilet ❑ Vent Heavy Grease ❑ Sewer Jet ❑ Other El O Roots »� /- Qty: � O Other Size: O Suggest Electric Footage: O Under 1000 gallons 6-11000 gallons O 1500 gallons Rootering ❑ 2000 gallons ❑ 3000 gallons ❑ 4000 gallons ❑ Van Called ❑ 5000 gallons O other ❑ Other Misc. -' ,1C 1 Digging Charge _ ❑ Backhoe n El Inspection ❑ Location O Consultation ❑ Certification: P/F ❑ Service Call ❑ Estimate Reason: 11 Labor El Portable Toilet Rental ❑ Pump Repair ' ❑ Waiting Time ❑ Baffle O Repair M _ Digging Charge Is Per Driver ❑ Chemical Treatment % Discretion ❑ Other _ Description of Work Recommendations Terms of Payment Parts Vacuum Pumping Drain Cleaning NET 15 DAYS Tax Yr. Month Yr. Month Discount Terms & Conditions ❑ Cash Q Check ❑ Credit 1. Not responsible for damage beyond 961b line. p g Pa Total t 3. t.59G per month will be charged to accounts past due. + - 2. All complaints shall be reported with n p8 hours/ 4. The purchaser agrees to pay ail cost of collection. L/` i ,� Serviceman Customer Signature 1 t J i Y n Reg ANDOVER SEPTIC 47 Railroad Street ROTO-RA Nature of Service ❑ N/C (978) 475-2593 Bradford, NU 01835 (978) 452-9022 Reg. Maint. ❑ Emergency ❑ Day ❑ Night Date of Sery tce PAY FROM THIS BILL Customer Name: r Service Locatioh M1 / -L Phone. Septic Tank Pumping and Cleaning Contact: "Done the Right Way Emergency 24 Hour Service - 7 Days a Week Billing Address: City: % Zip: Special Instructions ❑ Completed ❑ Incomplete Reason: Per. AM/PM Services Rendered Vacuum Pumping Observations Drain Cleaning Septic Tank ❑ Good Condition ❑ Main Line ❑ Drywall ❑ .Leechfield Runback ❑ Toilet Bowl ❑ Leech Pit/Overflow ❑ Riding High ❑ Kitchen Sink ❑ D-Box (liquid level) ❑ Bathtub/Shower ❑ Pump Chamber ❑ Full to Cover ❑ Vanity El Excessive Solids ❑ Grease Trap ❑ Floor Drain Top/Bottom ❑ Catch Basin ❑ Yard Drain Use No Powdered Soap❑ Portable Toilet El ❑ Vent ❑ Heavy Grease ❑ Other ❑ Sewer Jet Qty. ❑ Roots ❑ Other _ Size: ❑ Suggest Electric Footage: Under 1000 gallons,yA 1000 gallons ❑ 1500 gallons Rootering ❑ 2000 gallons El 3000 gallons ❑ 4000 gallons ❑ Van Called ❑ 5000 gallons ❑ other ❑ Other Misc. ❑Digging Charge ❑ Backhoe ❑ Inspection ❑ Location ❑ Consultation El Certification: P/F • Service Call ❑ Estimate Reason. ' • Labor! ❑ Portable Toilet Rental ❑ Pump Repair • Waiting Time ❑ Baffle ❑ Repair ' Digging Charge Is Per Driver ❑ Chemical Treatment Discretion ❑ Other Description of Work Recommendations Terms of Payment Parts Vacuum Pumping Drain Cleaning Tax i r`Y Yr. Month Yr. _ Month NET 15 DAYS i Discount 'Terms & Conditions_. ❑ Cash ❑ Check ❑ Credit t Not responsible for damage beyond curb line. 3. 1.5%per month will be charged to accounts past due. Total 2. All complaints shall be reported within 48 hours. 4. The purchaser agrees to pay all cost of collection. Customer Signature Serviceman I