HomeMy WebLinkAboutSeptic Pumping Slip - 125 WINDKIST FARM ROAD 5/24/2017Co monwealth of Massachusetts
City/Town of .
yste P• pi ecor
Fo 4
TOWN OF NUFt Fi ANUOVER
HEALTH DEPARTMENT
DEP has provided this form for use.by local Boards o 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.
E
MAY 2 4 2017
A. Facility, I formation
1. System Location: Le RI ht f o f board; 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
2 5 IA) i v\Jk...1
City/Town
2. System Owner:
Address (if different ro Iocaff
City/Town
Stet
3 IS
Zip Code
Telephone Number
Pa:!
I I 11
pi
I II
c
1. Date of Pumping
3. Type -of system:
Other (describe):
4. Effluent Tee Filter present? 0 Yee
. Condition of System:
Ncip ;1" / i,e
rd
4- 2z, -
Date
2. Quantity Pumped:
Gallons
Cesspool(s) Ect Septic Tank E3 Tight Tank
If yes, was it cleaned? 0 Yes ID No,
6: System Pumped By:
Nell Bates -on.
' Name
Bateson Enterprises Inc
Company
7. Loos w ere contents were disposed:
GL. S. Lowell Waste Water
F5821
Vehicle License Number
t5form4.doo- 06/03 System Pumping Record • Page 1 of 1