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HomeMy WebLinkAboutMiscellaneous - 103 BRADFORD STREET 4/30/2018N o W W Commonwealth of Massachusetts City/Town of . System Pumping. Record Form 4 S DEP has provided this form for usezby 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 ef�t / ''Pdub o hous , Left / Right side of building, Left / Right front of building, Left / Right rear of buMing, Under ec Address City/rown \ State Zip Code 2. System Owner. Name* Address (d different from location) RECEIVED Cityfrown JUL 13 2015 t stat �'—tO Y�Code TOWN OF NORTH ANDOVER HEALTH DEPARMEMIT B. Pumping 1. Date of Pumping 3. Type of system: ❑ 4. �`-q-0S — 2. Quantity Pumped Septic Tank Date Cesspool(s) Telephone Number i Gallons ❑ Tight Tank ❑ Other (describe): Effluent Tee Filter present? ❑ Ye .,s l- NO If yes, was it cleaned? 5. Condition ofst m: '��4- �. 6.- System Pumped By.- Nell. y: \V� Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. LocationAybere contents were disposed: L S. Lowell Waste Water Sign a Haul Date ❑ Yes ❑ No, t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts01 REC7RED City/Town of System Pumping Record Form 4 TOWH 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 tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health of other approving authority. A. Facility Information 1. System Locatio 'Left side , Right side of house, 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 City/Town G State Zip Code 2. System Owner: Name Address (if different from location) City/Town State (QZe 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 If yes, was it cleaned? ❑ Yes ❑ No 5. Conditiop ofj�ysteVm: 6. System Pumped By.- Neil y:Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G. L. Lq*eJl-11Vaste Water Signatur$ of t5form4.doc• 06103 F5821 Vehicle License Number uate & —4q'—1 eq System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record JUL 14 2014 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use- by local Boards of Health. Other forms may a 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 rig id of hous , Left/ Right side of building, Left / Right front of building, Left f Right rear of b ding, Under ec c Address City/Town state Zip Code 2. System Owner. , Name Address (d different from location) CitylTown ' State p Code Telephone Number B. Pumping Record "7 1. Date of Pumping 2. Quantity Pumped: _� Date Gallons 3. Type of system: ❑ Cesspool(s)eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes, No 5. Condition ofp System: � tv-.A�� I 6 j.{ Gi�LC 6. System Pumped By. - Nell y:Neil. Bateson Name Bateson Entemnses Inc - Company 7. Loca ' re contents were disposed: GL S• Lowell Waste Water t5form4.doc- 06/03 If yes, was it cleaned? ❑ Yes ❑ No. F5821 Vehicle License Number Date System Pumping Record • page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts RECEIVED i City/Town of System Pumping Record JUN Q 9 2008 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPAR'T'MENT DEP has provided this form for use by local Boards of Health. Other for ay -be ,but the information must be substantially the same as that provided here. Before using this for;, 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 . Address e/ ` „4 Citylrown State �ef Zip Code 2. System Owner: Address (if different from location) Cityrrowm B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State& S 6 Zip Cade Telephone Number Date 2. Quantity Pumped: Gallons Cesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 9-- o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: v--\ &)c �-� ��—X-k 6. System Pumped By: Nam � Vehicle License Number Company 7. Location re contents mere d' ed: Date t5form4.doc- 06/03 System Pumping Record a Page 1 of 1 TOWN OF NORTH AND SYSTEM PUMPING REi DATE: eS DATE OF PUMPING: CESSPOOL: NO NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: ElfECEIVED RDNov-92n ToHEALTH DEPOPITARTMENT R SYSTEM LOCATION (example: left front of house) PUMPED O��fGALLONS SEPTIC TANK: NO — EMERGENCY YES FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: B. Pumping Record fi: Dat e,of Pumping nate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [I'< If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Syst� 6. System um ed py: 'Name Vehicle License Number Company _ 7. Location ere confer re osed: Sign r of auler http://www.mass. gov/dep/water/approvals/t5forms:htm#inspect t5form4.doc• W03 Commonwealth of Massachusetts RECEIVED City/Town of I JUN 1 1 2007 - System Pumping Record �Y Form 4 TOHE�LTHJDEPARTM TORTH ER DEP has provided this form for use by local Boards of Health.. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When filling out forms on the 1: System Location: computer, use only the tab key to move your Address (r — cursor - do not use the: return City/Town St to Zip Code key. 2. System Owner: Name Address (if different from location) tLl State/) /^ 5 Zip Code: City/Town Telephone Number B. Pumping Record fi: Dat e,of Pumping nate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [I'< If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Syst� 6. System um ed py: 'Name Vehicle License Number Company _ 7. Location ere confer re osed: Sign r of auler http://www.mass. gov/dep/water/approvals/t5forms:htm#inspect t5form4.doc• W03 TOWN OF SYSTEM DATE: (P10-05 SYSTEM OWNER & ADDRESS G RECORD SYSTEM LOCATION (example: left front of house) JUIN 2 0 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT c� ok DATE OF PUMPING: (a-(0-6 S QUANTITY PUMPED: -1 sC3 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE T EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D_/ Lowell Waste Commonwealth of Massachu[rdst4it5AL%MPA11ftEfvrm! RECE, 11, V E City/Town of 1117 1 a JUL Og 2011 System Pumping Record Form.4 UL toil H® OF HEALTH of NORTH ANGOVE DEP has provided this form for use by local Bomay be used, but the information must be substantially the same as that provided here. a ore 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 Loc 'on: Left front of house, right front of house, left side of house, right side of hous ear of Ouse ' ht rear of house, left side of building, right rear of building, under deck. Cityrrown State Zip Code 2. System Owner: A Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record r 1. Date of PumpingDate ~ ~ C Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System:—kj ; 1 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Locaf er ntents were disposed: G.L.S.Q. owellAJllaste�ater t5form4.doc• 06/03 F5821 Vehicle License Number — zy— t Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEIVED F City/Town of ' JUL O g 2011 W° System Pumping Record ,M Form .4 4UL MI. OARD OF HEALTH DEP has provided this form for use by local d Fb s may be used, but the information must be substantially the same a 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 hous<n ht font of hou left side of house, right side of house, Left rear of house, right rear of house, left sl t rear of building, under deck. City/Town State 4 Zip Code 2. System Owner: Name Address (if different from location) City[Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Date Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? es ❑ No 5. Condi ion of Syst m: 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Location where contents were disposed: G.L.S. . LowellAJVaste 10dater Stat Zip Code -a36� Telephone Number — 2. Quantity Pumped: Septic Tank Js-'-�--� Gallons ❑ Tight Tank If yes, was it cleaned? Da sus No F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 til BO R® OF HEALTH DEP has provided this form for use by local Board 01 y be used, but the information must be substantially the same as that . g 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. RECEIVED JUL 0~g 2011 A. Facility Information 1. System Location a fr � nt of house ight front of house, left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. City/ I own , State Zip Code 2. System Owner: Name Address (if different from location) City[Town State �p Zip Code S— Telephone Number B. Pumping Record �l 1. Date of Pum ping p g Date Quantity Pumped: 3. Type of system: F]�� Cesspool(s) Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes d No 5. Condition of System: 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company o4 Vn J. 7. Location _where contents were disposed: Of I -�� Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No M F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of W° System Pumping Record Form .4 JUL 22 t5form4.doc• 06/03 RECEIVED DEP has provided this form for use by local Boards oi 14011001MOM information must be substantially the same as that pr .� local Board of Health to determine the form they use. The System Pumping the local Board of Health or other approving authority. L 0 8 2011 ) OF HEALTH used,. but the is form, check with your rd must be submitted to A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of hous4, .Left) ar o , right _rear left side of building,right rear of building, under deck. Cityrrown State Zip Code 2. System Owner: 1 Name Address (if different from location) City/Town State C `p Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: canons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight.Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ .Yes No Ifes was it cleaned? y E] Yes ❑ No 5. Conditiotl of System: ��- 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. SLowell where contents were disposed: AJV,aste Water Of F5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form .4 �M SV BY`•� DEP has provided this form for use by local Boards of em information must be substantially the same as that pro det local Board of Health to determine the form they use. T e the local Board of Health or other approving authority. RECEIVED R E C E I V EDj-U—Ll 8 2011 6WADFHEA 0used, buT H W@ l eK form, check with your rstem Pumpinq Record must be submitted to A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of house, eft a o ouse fight rear of house, left side of building, right rear of building, under deck. City/Town State 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Zip Code State Zip Code Telephone umber Date �d` ( 2. Quantity Pumped; Cesspool(s) /Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑Yes Iql No 5. Condition of System: 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company T Locati�o where contents were disposed: L. I—()off Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of MassachusettsRECEIVED u City/Town of W° System Pumping Record JUL 0 8 2011 RECEIVED ,M Form .4 DEP has provided this form for use by local ardsMe I ��e �ALTHthe information must be substantially the same a thathe�reBefo using this form, check with your local Board of Health to determine the form t OTIM ing Record must be submitted to the local Board of Health or other approving th TH DEPARTMENT A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of house, Left rear of house, h r ar of hous ,left side of building, right rear of building, under deck. 2 PO4 .. f.. O UqC City/Town State Zip Code System Owner: Name Address (it different from location) City/Town State ¢¢ Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 40 �2.uantity Pumped:DateGallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [V No 5. Condition of System: 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Location where contents were disposed: If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 IR14; tj ;in 91! L. it U51f L 0 TOWN OF IU° vl JO Vf (- SYSTEM PUMPING RECORD w; •fir ,_- . ,`r,{ DATE:-&-d-q"6:; :; !; li - 3 2003 SYSTEM OWNER & ADDRESS aVA, [ o S (S (4�' 'j SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: _.aa+ P QUANTITY PUMPED: GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: ,, TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: -Li-© P -- SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING:/e,-4�9,QUANTITY PUMPED GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONT ENTS TRANSFERRED TO: T F[T-TT W CC.. f m c I0 Q a� 0 O 0 m 0 O. L L V 421 C c N O E c 3 .0 GGQ O 1- O Q � E I U O O C O QU E L ro 0 c m I c 0 .N E E O u c 0 :- ra L V) c 8 U I O m C C ru d, I ro R1 w - O cc O I O >L O_ Q O O n DORM U TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION ASSESSORS MAP .SUBDIVISION LOT(S) PERMANENT ADDRESSASSIGNEDB�Y. D.P.W. STREET © �12' a /l2PPLICANT PHONE C'�TE OF APPLICATION TOWN USE BELOW THIS LINE PLANNING BOARD A/ Iv TOWN PLANNER CONSERVATION COMMISSION CONSERVATION ADMIN. DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED BOARD OF HEALTH DATE APPROVED `� 3 HEH S NITARIAN DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS V'IFIRE DEPT. WP RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from.the compliance of any applicable Town requirement or Bylaw. OFFICES OF: APPEALS 13LJII-DINCY CONSERVATION HEALTH PLANNING o` �.IORth, Town of m ;< r NORTH ANDOVER 'Ss+cRus�s4 1)I\'151()N OF PLANNING & COMMUNITY DEVELOPMENT Building Inspector. KAREN 11.1. NFLSON, DIRECTOR 120 Mein Street North Andover, Mi)SSi)C11USe,t1S 0 1845 (61 7) 685.4775 4-12-88 re: proposed addition 103 Bradford Sig. This office has no objection to the proposed 17 by 23 foot 1 room addition as described by George Malmberg. Sincerely, Mike Graf Health Dept. OFFICES OF APPEALS. BUILDING CONSERVATION HEALTH PLANNING OF NOR rN 9 Town of m { D .� NORTH ANDOVER �' �'O•' :. off::.`, g �SS4CHUS DIVISION OF PLANNING & COMMUNITY DEVELOPMENT Building Inspector KARFIN 1 LP. NI-_LSON, IDIRECI`OR 120 Main Street North Andover, Massachusetts 01845 (617) 685-4775 4-12-88 re: proposed addition 103 Bradford St. This office has no objection to the proposed 17 by 23 foot 1 room addition as described by George Malmberg. Sincerely, Mike Graf Health Dept. ..:zt\ ,r APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPAT'tVWT--NORTH ANDOVER, MASS. Standard Const. Bradford. St. I hereby make application for a permit for a sewage disposal installation at wri--- ,Dr_adford St._, . I will install this system in accordance with all the lays of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further., I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inchest and. will maintain a minimum grade of 1% until. 10 feet preceding the septic tank where the grade shall not exceed 2%. T will install a concrete septic tank of �00 gal- in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s),of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with open joimted,bell and spigot Ackron pipe at�least 4 inches in diameter and laid in a series of trenches, the bottom of which will provide a minimum of 150 lineal () feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3A to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling 'the trench, 2 inches of gravel or stone 1/811 to IN' (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single the line will exceed 100 feet in length and in any case., two lines of the wi;l be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the in- stallation will be less than 100 feet from any private water supply.. 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I fwrther officer, asprovided below, and to incorporate any additional requirements tha may be attached to the permit. Plot Plans must be submitted with application. DATE Signatur of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andoverp Massachusetts. DATE Sig tune of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE ./ �ij r__.......r.. Signature of Inspecting Officer Percolation Test Garbage Grinder _�_ BOARD OF HEALTH TCWN OF NORT i A MOVER, MASS. n 3oa�" I. NAF" ,� . �.. �:� : ^'; fi t: 'G.-�.r4-�s- DATE t .<�t l.r .i /A' 2. ADDRESS .A .° : LOT N0. �; TEL 3. NO. OF BEDR001,6 . b3. DEN YES . NO.. 4. GARBAGE GRINDER YES . . . . NO.. 060 5, SHOW DIPI NSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LIMS 7, SHOW DV ENSIONS OF LOT 8. SHOW LOCATION AND SIZE CF SEPTIC TANK CR, CESSPOOL 9. NOPE LOCATION AND DISTANCE OF WELL FROP,2 SEVIERAGE SYSTEM 10. SHOW LOCATION CF BROOKSt STREA 5, DITCHES, LEDGE OUTCROP, ETC. 11, SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL -FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD HE READ CAREFULLY. - iUIL�i N' JAJlL.�/ A l..�il A.��.r c.......+�•�:�. Coritwoiw vealth of hl"NAficltusetts Massachusetts TOWN OARD OFHHEALTH ANDOVER, ' ► �l ' 1 lecur �2 7 1995 1ulll t s�le►�� �� 'MMel - s enI oca ion Datc of Pumping l Z " i ✓ � � �uattllt; l'uinl�eJt � � v Cesspocil: Mj ,L7f Yes �rnitr 't'n.,l' ►�'� a Yes System Pumped by: License Contents transferred Ir: Date -_ inspector TOWN OF SYSTEM P DATE: �- ca PING RECORD ..� ov SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of ho� ) ,- Cali Y -k 0 D � DATE OF PUMPING: &—W—QUANTITY PUMPED: GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES V NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D V Lowell Wast Commonwealth of Massachusetts RECEIVED City/Town of JUS 012013 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT DEP has provided this form for us&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 housLe /rig side of house Left . / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address City/Town 2. System Owner. Name Address (if different from location) City/Town 0 State Zip Code State, � A ' Zio Code 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 No. 5. Condition off System: 6. System Pumped By: Neil Bateson Name Bateson Entemrises Inc Company 7. Location wherkcontentss were disposed: G L Sal . Lowell Waste Wi If yes, was it cleaned? ❑ Yes ❑ No, F5821 Vehicle License Number Date & W& -S' � n t5fomt4.doc- 06/03 System Pumping Record • Page 1 of 1