HomeMy WebLinkAboutSeptic Pumping Slip - 49 ORCHARD HILL ROAD 12/28/2016 Commonwealth of Massachusetts
MEWED
City/Town o
SyMem Pumpling, �. �. . �
Up— — T ENT
Form
DEP has provided this fora for use=by local Boards of Health. Other forms may be'used,but the
information rest be substantially the tame 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.
1. System Location: Left/Right ront of House, Left/Fight rear of house, Left-/right side of house, Left
Right side of building, Left/Rig !on 6 ul in l Left/Right rear of building, Under deck
Address
city/Town State Zip Code
2. System Owner:
Flame`
Address(if different from location)
city/Town M State ip de
c 2�
"Telephone Plumber
i
q In r
I. Date of Pumping Date . Quantity Pumped: fail®ns
. Type-of system: El Cesspool(s) S eptic Tank D Tight Tank
Other(describe):
4. Effluent'Tee Filter present.? Yep o If yes, was it cleaned? E Yes 0 No,
' S. Condition of system:
6: System Pumped By:
Nell.Sate son - F5321
!dame Vehicle License Plumber
Sateon Enterprises Inc
Company
;i ,
t 7. Location where contents-were disposed:
' 4 S: Lowell!Waste Water
` Sign a Houle Date
form4.doam 06/0 System bumping Record Page 9 of 1