HomeMy WebLinkAboutMiscellaneous - 1004 SALEM STREET 4/30/2018N
QO
�cso
Commonwealth of Massachusetts c
City/Town of
System Pumping Record, 2014
Form 4'=,Ma�maVlR.
MR
WALJ" ANT
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 / Right front of hous, Le Right r`of ho Left/ right side of house, Left/
Right side of building, Left /Right front of bul Ing, Left / Right rear of building, Under deck
Address
C90
City/Town State Zip Code
2. System Owner.
Name
Address (if different from location)
Cityrrown state Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: canons
3. Type of system', ❑ spool(s) ❑ Septic Tan Tight Tank
�ther(desecAbe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No:
" 5. Condition of System:
6. System Pumped By.
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Loca�e contents were disposed:
Waste Water
F5821
Vehicle License Number
Date
t5form4.doa 06/03 System Pumping Record • Page 1 of 1
PRINTED BY: Pamela DelleChiaie - PLEASE LEAVE IN PRINT-OUT TRAY....... THANK YOU.
DelleChiaie, Pamela
From:
Sawyer, Susan
Sent:
Monday, December 13, 2010 8:20 AM
To:
'Tom Trowbridge (E-mail)'
Cc:
DelleChiaie, Pamela
Subject:
FW: Health Dept
Attachments:
PETITION FOR VARIAN CE-Nov..docx
I reached out last week and got this response. I have not spoken with her yet however as I have been off. I think first off
she needs to request an extension to the Jan meeting or she needs to appear. I will send her that info. right now.
She makes this difficult. If she did the Title V and it failed, we would have the teeth to get it done in 2 years without any
extra agreements. Without it we could enter into this attached agreement I suppose.
Questions: In your opinion
Does the board want to give the full 2 years only?
Does the board want to have milestone requirements such as have an approved plan done by the end of 2011? That way
it doesn't get pushed off?
From: cmhenriguez@aol.com Lmailto:cmhenriquez@aol.com]
Sent: Wednesday, December 08, 2010 3:26 PM
To: Sawyer, Susan
Subject: Re: Health Dept
Susan -I was going to call you tomorrow. We have not heard from Manzi at all,Bateson cleaned septic said it
would not pass title five as per his opinion. Therefore I will request sometime maybe to may 2012 to install new
system. Please advise. I have been so busy but we can talk about how to proceed. I am available tomorrow
working at house. Thanks. Carmen
Sent from my Verizon Wireless B1ackBerry
From: "Sawyer, Susan" <ssMer@townofnorthandover.com>
Date: Wed, 8 Dec 2010 14:53:02 -0500
To: 'CMHenriquez@aol.com'<CMHenriquezgaol.com>
Cc: DelleChiaie, Pamela<pdellechgtownofnorthandover.com>
Subject: Health Dept
Hello Carmen,
I am putting the agenda together for the meeting on the 16ei. Have you made a decision?
Can you give us an update and if you need an extension, please submit a request if one is needed by tomorrow. The agenda is closing.
thx
Susan
Last month's decision
Larry Fixler made a motion; to authorize Susan Sawyer to sign the building permit application with a requirement that the applicant
find a means to address the stated failing subsurface disposal system by the December 16, 2010 meeting of the BOH. Dr. MacMillan
seconded the motion. All members were in favor. The motion was unanimously approved.
I OF 2
DelleChiaie, Pamela
KA
PRINTED BY: Pamela DelleChiaie - PLEASE LEAVE IN PRINT -BUT TRAY THANK YOU
Stman Sawyzt
Ju0iP.ic NeaM I)Iud"
1600 Vagead sttet
W420, unit 2-36
.✓Vodh andc+m, Ma 01845
a9ke 978 688-9540
faux 978 688-8476
All email messages and attached content sent from and to this email account are public
records unless qualified as an exemption under the
[ http://www.sec.state.ma.us/pre/`r)reidx.htm ]Massachusetts Public Records Law.
Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more
information please refer to: hftp://www.sec.state.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
2OF2
DelleChiaie, Pamela
PETITION FOR VARIANCE
I, CARMEN M. HENRIQUEZ LOPEZ, being the owner of the premises identified, as
1004 Salem Street, North Andover, Massachusetts, Assessor's Map 104D, Parcel
210/104.D-0031-0000.0, and recorded with the Middlesex North Registry of Deed in
Book 03 08 1, Page 0064, hereby request that the North Andover Board of Health, grant a
variance in accordance with 310 CMR regulations, to permit the continued use of a septic
system which is failing, and facilitate the immediate replacement of a roof and
construction of a second floor master bedroom addition, as indicated in the building permit
application, prior to the completion of the upgrade to the septic system or to connecting to the
town sewer system. It is hereby agreed that the connection to the town sewer system or the
installation of a new septic system should be completed by the owner on or before November 30,
2012, pursuant to 310 CMR Section 15.305(1) which allows the owner to upgrade the system
within two years.
CARMEN M. HENRIQUEZ LOPEZ
OWNER
1004 Salem Street, North Andover, MA 01845
DR. THOMAS TROWBRIDGE
CHAIRMAN, BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MA
Sawyer, Susan
From: Sawyer, Susan
Sent: Thursday, November 18, 2010 7:12 AM
To: 'tat.boh@comcast.net'
Subject: recommendation
Regarding 1004 Salem St.
Consider this proposal
1) Require one of the following before Dec. meeting
a. Conduct a Title V inspection
i. If passes, the matter will be closed
ii. If fails, next month at BOH mtg.
1. Provide proof of intended purchase of sewer access and an proposed agreement for a
time line for tying in
2. Provide proof of contract with a septic designer and a proposed timeline for
repair/replacement of system
2) Determine terms, and instruct the Health Dir. to sign the bldg permit on Friday, Nov. 19`h (Possible specify the
type of time that would be acceptable to the Board.)
3) Continue the request until Dec. meeting
Sumn Sawyn
J uric WeaPtPc Joked"
1600 Uoyaad Sheet
JW420, 20, unit 2-36
✓ odh Clndaa", ./KCl 01845
mice 978 688-9540
fax 978 688-8476
All email messages and attached content sent from and to this email account are public
records unless qualified as an exemption under the
[ http://www.sec.state.ma.us/pre/preidx.htm ]Massachusetts Public Records Law.
1
l oOtt
Sawyer, Susan
From: Sawyer, Susan
Sent: Wednesday, November 17, 2010 8:37 AM
To: 'CMHenriquez@aol.com'
Subject: RE: request
Please call me this morning and we can discuss this. This is how I explained it to the Board. You have verbally told me
that you agree the system is failed. Remember the pumping slips and the age of the system. It is concerning. Usually we
have the owner have a Title V inspection to confirm this, and you still can. Our list of inspectors is on the website. They
must be licensed with us. You can still do a title V inspection if you wish. If the inspection fails, we are in the same
position as we are now.
To All,
I will be placing an additional request on the Board meeting. More details to follow.
As an introduction;
Carmen Henriquez Lopez, owner of a single family home at 1004 Salem Street, has submitted a building permit
application. The Health Department reviews building permits to be sure the addition does not pose a problem
with the septic system per the state code.
http://csc-ma.us/PROPAPP/servlet/PrintablePDF?Linkld=1518211 &Temp=Temp.pdf&CommunilyCode=210
The owner is aware that the septic system is about 50 years old and is in basic failure. Her request is to make a
legally binding agreement with the BOH to allow the construction of a second floor and roof repair prior to
upgrading the septic system.
Ms. Lopez states the roof is in need of repair and that winter is fast approaching, she wants to get it done now.
She has chosen to add a room above the existing 6 room home and needs your approval to allow it to be done;
with a binding promise to upgrade a failed system within a specified period of time.
Normally, there is a procedure.
1) review of building permit application
2 )if the determination is that the septic is undersized or in failure per Title V
3) then the owner hires an engineer; conducts soil tests, submits a design for a new system.
4) When the system plan is approved by the Health Dept, the addition and repairs are often done at the same
time. Or an agreement is made to complete the system ASAP.
In this case there is no engineer, no soil tests, no Title V failure, no plan submitted and no approval. She wants
to address the board to allow this agreement due to the nature of the need for an immediate roof repair. She will
have an agreement available for signature by the Chairman if the Board deems her situation and her proposal
positively. I have recommended this course of action as it is very late in the season and she has a hardship. Of
course the approval is yours to decide. The. BOH's concern to consider is that the owner MAY not complete the
repairs of the septic in the time agreed upon and that the BOH will have a non-compliant system and have to
take action against the owner.
Thank you
The hand written attachment will be replaced by a'-ngal document. The other is a copy of the building
application for her addition.
Susan
i
From: CMHenriquez@aol.com [mailto:CMHenriquez@aol.com]
Sent: Tuesday, November 16, 2010 6:03 AM
To: Sawyer, Susan
Subject: Re: request
Susan,
I am a bit confused about this. If I am not showing any more than 7 rooms total, which is what the house was originally,
since we made 3 bedrooms into two a few years ago, and now with the second floor addition it will once again have 3
bedrooms, why is this considered an expansion.
Are you telling me that I have to record a restriction on the deed
In a message dated 11/15/2010 4:47:32 P.M. Eastern Standard Time, ssawyer@townofnorthandover.com writes:
Here are a couple of ideas. The deed restriction attached is not a draft it just shows the type of
agreements that can be made.
Because you need a building permit, I requested a Title V inspection. You admit the system is likely
failing and are asking not to have to conduct that inspection as required
You are requesting a variance to this .... (of course the board may require you to do the inspection, no
guarantees)
15.301: continued
5) A system shall be inspected prior to any change in the type of establishment, or increase in
design flow, or prior to any expansion of use of the facility served for which a building permit or
occupancy permit from the local building inspector is required. If the system is a cesspool, or if the
system is failing as set forth in 310 CMR 15.303 or 15.304(1) or is a significant threat to public
health, safety, welfare and the environment as set forth in 310 CMR 15.304(2), then the system
shall be upgraded prior to the change in the type of establishment, increase in design flow or
expansion of use of the facility. Prior to an increase in the design flow to any cesspool, or to any
system above the existing approved capacity, the cesspool or the system shall be upgraded in
accordance with the standards applicable to new construction. Whenever an addition to an
existing structure which changes the footprint of a building with no increase in
So assuming they accept your determination that the system has failed ... you are asking to do the
construction of the addition prior to the completion of the upgrade per this section. And Basically
"continued use to a system in failure" until a time you request.....
310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION
15.305: Deadlines for Completion of Upgrades
(1) If a system is failing to protect public health, safety, welfare or the environment as set forth in
310 CMR 15.303(1) or 15.304(1), the owner or operator shall upgrade the system within two years
of discovery unless:
2
(a) a shorter period of time is set by the local Approving Authority or the Department based upon
the existence of an imminent health hazard; or
(b) the continued use of the system is permitted by the local Approving Authority in accordance
with the provisions of an enforceable schedule for upgrade. Bases for continued use include, but
are not limited to, proposals to connect to a sanitary sewer or shared system. A fiscal commitment
to the sewering plan or shared system plan, together with an approved facility plan where
appropriate, proposing connection or replacement of the failing system within five years, and an
enforceable commitment by the owner to perform interim measures (for example, regular
pumping) shall accompany any such local approval. Such approval shall expire in five years or
upon the failure of the applicant for such approval to meet interim deadlines set forth in the
enforceable schedule for upgrade and the plan. The Department may by specific written approval
authorize the local Approving Authority to allow a longer period of time, where the municipality has
provided the Department a proposed implementation schedule for design and construction and
has made a demonstrated financial commitment to the construction schedule. The Department
may revoke any'such approval if the approved schedule is not met.
Carmen, if you made the agreement and then did not follow through the form below is what the Health Dept
would likely send you. I sent this just for your information while you think about making this difficult decision. I
cannot tell you how much the entire septic system will cost, but it is up to you whether to offer to install it at a
later date.
Form 8 - Enforcement Order Form
Revised June 2003.
For use by local Boards of Health in local enforcement actions.
Filing Options: MS Word Form 51 KB I PDF Form 12 KB
Just an FYI -----
15.022: Duty of Compliance
Except as otherwise specified, the duty to comply with the provisions of 310 CMR 15.000 with
regard to any system shall be upon the owner(s) and the operator(s) of a facility served by a
system, jointly and severally.
Sumach Swmpt
Y ub& MeaM Ohect n
1600 V igmd Skeet
53W 20, unit 2-36
r odd Qndaaen, .MQ 01845
affice 978 688-9540
lax 978 688-8476
All email messages and attached content sent from and to this email account are public
records unless qualified as an exemption under the
4
L�- -� ax- or�-
Err 0 S y�
-i-o r e -p l e -z cc Sep 4l c o(z- Colv,,JE-c-4 7o
E Fo
(V o 4 AwjoVE-n, )4 CA o w �i c� ��.
1�11 /�/ 9110
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 2v—c-�,
SYSTEM OWNER & ADDRESS
04
SYSTEM LOCATION
(example: left front of house)
lcpback o�
DATE OF PUMPING: QUANTITY PUMPED fl GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER _
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
Commonwealth. of Massachusetts REC�1��
City/Town of
System Pumping Record, NOV - 3 2006
�y Form 4T NEqCT N�RTy
N CEPgRA DoveR
DEP has provided this form for use by local Boards of Health. The System u eco d must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When filling out 1. System Lo ation: ^�
forms the
computer, use _
only the tab key Address
to move your not
cursor - do not i
use the return CityfTown State Zip Code
.key.
2 System Owner.
Name
Address (d different from location)
Cityfrown Stat11 e
e � /
Telephone Number
.B. Pumping Record
1: .Date. of Pumping (.
p g Date Quantity Pumped: canons
.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-'
❑ No
5. Condition of System.
O
y o 0 0
p
;4ic oo�
N
C �
O
� �
L
m
�
v
c
�
a
d
Z
N 't co
000
a1
V
O V M
—
2
J
J
o -
.-
O
a
d
w
S
a
=
w
a
o
m
o
a
d
d
o
o c�
0
m
p
a
m
d
N
V
`
c
c
w
w
Q
m
a
40
U LU
Cil NC
-
a (n W
E
;
CQNK�S :TRANSFERRED, TO:
TCvVN OF NO,^.TH ANDOI, _R/
1 1
BOARD OF HEALTH
�4AY ' 4 2fl01
�+fitt� 1 i,
h 'err .. 'i�*hlilF�.i'• .�..f
as t
a a
DATE:,
,
SYSTEM OWNER & ADDRESS
SYSTEM LOCATION
(example: left front of house)
�enftq U.eC
lU6
/UQ�
OF PUMPING: 7 OJ
QUANTITY PUMPED %4_ GALLONS
DATE
CESSPOOL:. NO v YES _
SEPTIC TANK: NO _YES
r' NATURE OF SERVICE:, ROUTINE EMERGENCY
t
4 OBSERVATIONS:
`GOOD CONDITION
FULL TO COVER.
HEAVY GREASE
BAFFLES IN PLACE
ROOTS
LEACHFIELD RUNBACK
EXCESSIVE SOLIDS
FLOODED
SOLIDS CARRYOVER
OTHER (EXPLAIN) _
t ref. t t` 1 SYSTEM PUMPED BY:.
COMMENTS:
HI'7 irk �tl ;
CQNK�S :TRANSFERRED, TO:
TCvVN OF NO,^.TH ANDOI, _R/
1 1
BOARD OF HEALTH
�4AY ' 4 2fl01
�+fitt� 1 i,
h 'err .. 'i�*hlilF�.i'• .�..f
Commonwealth of Massachusetts
%o- 4J, Massachusetts
System Pumping Record
System Owner
Date of Pumping: r� —
Cesspool: No Yes [ ]
System Pumped by: 64&44W
System Location
Quantity Pumped: (OM—gallons
Septic Tank: No [ ]
License #
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
JAN 3 1
Yes [+----
f
System Omier
/t,� ,I 4t", 7_
Dale of Pumping:
Cesspool
No Septic. `tttik Ntt des , r
System lluitiped by:
Nt
pit'., .
('oiiiiiion�ve�lllt l}f iVtas9i#Cftt)seils
t�RK.
J�� Massacrlt a s0tl
lAd
.Dale:
'�,
�Rr¢dd� ,fin1 cd¢d,_
.x• Lieelt�e�# � �- �
Re+Qort1 >
P 4;'
r
System I'utnr�rr
Ear
4 a
Y
r, kgr'Kit
E
Systein Ludtrliun
g TAtr
r.a�
No Septic. `tttik Ntt des , r
System lluitiped by:
Contents tiausferrrod to a areele
_ t 61 T.
y�
'3.�
a t � a- a Fs'l• E Eiek''At}
.Dale:
'�,
�Rr¢dd� ,fin1 cd¢d,_
.x• Lieelt�e�# � �- �
E •.
- - i p
Contents tiausferrrod to a areele
S
+� b i
y�
'3.�
a t � a- a Fs'l• E Eiek''At}
.Dale:
y
• �' } M
- - i p
s yr'x `9 7x sfy
y7s
iia rFe'. ! ; ! 1.
E ark. `2 s ' 91st
air j txJ �YiEl
yfCon moI weaI111 of MassachuseM
I 6
Massacltusetis
jysten Puippit!g Record
Sysleiu Owner
9-��O
Dale of I'uuiping:
Cesspool: No M' Yes (..
System Location
(luaiility Pumped: l 3-� gallons
Septic 'Tank: No H yes 1—�
Systetu Pumped by: arejea Fartnhiijed License #
Consents Iranslemed Io: greaser arAcreltce a a )std _ _
Dale: ----..._
Inspector:
Jcommonwealth of hlassacl�usetl§ TOWN OARD OF HEAD Hi1�F
Massachusetts a
n
4
1
System pgMpinq Record
Form 4 -- System Pumping Record
Commonwealth of Massachusetss
: Massachusetts
System Pumping Record
Owner ISystem Location
10+ it itL_'3t
IOU street
V tth Andov, r. KA 111j45 I
1401th Andovor laA U11A,
t .7,.1 rU1.4141 (97o) 6u1-44,11
Type: Emergency Routine
Cesspool: w Yes Septic tank: Mo Yes
Date of Pumping: a Quantity Pumped:/_QU06alkms
System Pumped By: Wind River Environmental, LLC Permit #:
Contents transferred to:
Contents Disposed at:
Wa M
Date: Pumper signature:
Condition of System/Other Comments
Dep Approved from - 12/07/95 13JC 2 ,
TOWN OF NORTH ANDOVER c- _oRT,���l,.2_t�i .
SYSTEM PUMPING REC00 R -Dr"
APR -72003
�l l EM OWNER & ADDRESS .
Ile'
SYSTEM LOCATION-
(ezamPle: left front of house)
U:�'I E OF PUMPING; V �� QUANTITY PUMPED % GALL()�l
V /
;. PO0L: NO YES SEPTIC TANK: NO YES
V
� ATURE OF SERVICE: ROUTINE EMERGENCY
t1ll. FRV;1TIONS:
GOOD CONDITION,
HFAVY CREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
i
>1 . 'TLM PUMPED BY:
� U M M FNTS:
UN I'NTS tRANSFERRED TO:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
O�HFR (EXPLAIN)
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD,
D .A I I
� STEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
c4 51�
G..
U,\'I'E OF PUMPING /S� QUANTITY PUMPED /,—�Z CALLONS
C. I:S.SPOOL: NO (V YES SEPTIC TANK: NO YES L�
'.ATURE OF SERVICE: ROUTINE IJ EMERGENCY
(m.SFRV.�\TIONS;
GOOD CONDITION
HEAVY CREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
PUMPED BY:
C'U 1I lyl ENTS:
�:UNTENTS TIZANSFEIZRED To:
FULL TO COVER
BAFFLES IN PLACE
LEACH FIELD RUNBACK
FLOODED
Y, HEIZ (EXPLAIN)
t.
TOWN OF NORTH ANDOVER
SYSTEM PUMPIN RE C OR_p:._.,'
.-32603
i1 STEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)__,
O Lxci
/O&q Sc
U:\"1'E OF PUMPING: 1 0''> QUANTITY PUMPED G'AL.L0.',
f. I:.�.SI'UUL; N0 YES SEPTIC TANK: NO YES
NATURE OF SERVICE; ROUTIN .EMERGENCY
tali.>rRVAT IONS:
COOD CONDITION- FULL TO COVER
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSI-VE SOLIDS FLOODED
SOLIDS CARRYOVER O�HER (EXPLAIN)
i
PUMPCD'BY.
C'U )-1'YI F -NTS:
TRANSFCRIZED 'TV:
...I ; .... .... ".. . . ... ....... ...
TOWN OF NORTH At$
I / 11A SYSTEM PUMPINQ J(E
SYSTEM UWNER & ADDRESS--�'
/z,v �
A /0) -
DATE OF PVM?fNo:
)VER
ORI)
7 15 TEM LOCATION
_QUANTITY
(-b3SPOOL: NO ESS00C NU, YES
NA rURE OF SERVICE: ROUTINE,
DEC 0 7 2004
GOOD CONDITION ... .I��'Tyj COVER C= NORT 7.
.HEAVY ORWEBAFFLES IN PLACE.ROOTS LWMELD RUNBACK
BXCUSIVE SOLIDS_. FLOODED
IOUD CAKRYoV'ERl_....,_. OTHER EXPLAIN
SY*t*m Pwnpcd by
Ice-)
CUMMENTS.
............... . . . ......
�.uN mm's
w
m
"41
c
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD',
DATE:
ADDRESS
(example: left front of house)
ro
DATE OF PUMPING:'— 1 — ' QUANTITY PUMPED GALLONS
CESSPOOL: NO e ---YES SEPTIC TANK: NO YES /
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: 6' '
Commonwealth of Massachusetts
City/Town of
System Pumping Record RECEIVE;
Form 4
=_ � � p g 2009
DEP has provided this form for use by local Boards of Health. Other fo ms m e used, but the
information must be substantially the same as that provided here. Befo ers��g�uth your
local Board of Health to determine the form they use. The System Pu pings aer at�a�ar3O't��Tab itted to
the local Board of Health or other approving authority.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
A. Facility Information
1. System Location: Left froCleft ar, eft si of h use. ht front, right rear, right side of house.
Address L4 73—�—
City/Town State
2. System Owner:
Name
Address (if different from location)
City/Town
y -, 0-'z—
Zip Code
Stat �^ —4gL6
Telephone Number
B. Pumping Record 7 —10:�
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: Cesspool(s) eptic Tank Tight Tank
C1 Other (describe):
4. Effluent Tee Filter present? E] Yes _ PTINO If yes, was it cleaned? [I Yes [j No
5. Condition of
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locaf a contents were disposed:
O.L.S.D Lowell Waste Water
F 5821
Vehicle License Number
re of Hdulbr Date
t5form4.doc° 06/03 System Pumping Record ° Page 1 of 1
Commonwealth of Massachusetts
City/Town of
w° System Pumping Record
kta, SyeY`
Form 4 DEC 4 2010
DEP has provided this form for use by local Boards of Health. Ot � F T r the
information must be substantially the same as that provided her"'.-
ck 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, right side of house, eft
�ai of'fious ight rear of house, left side of building, right rear of building, under deck.
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State
Zip Code
State���� � C de
relephone Number
Ca --a �
Date 2. Quantity Pumped
Cesspool(s)Septic Tank
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes D -No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. , Locati here contents were disposed:
.L.S. Lo II Waste r
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1