Loading...
HomeMy WebLinkAboutMiscellaneous - 120 LACONIA CIRCLE 4/30/2018 (18) E s}�, �SV t r A 11-1 MASSA _ � � OU •1� r7 r.,fi�t���s ,y� RM RECEiv,-j prnvlded�hts form for use by local Boards of Health. Th syat4tgpwm In ftecor must be.submitted to the:r iocal'6oard of Health or other approving auth rity J tNp�l ., .. p .'.., , . A. Faciiity InfmiationI I owN 0(=NORTH ANDC3W R �y*tan�ortant:; W AL7H DEI'ARTMPNT j�r•Y ra►►np out 1. : System Locatlon•:' : only the tab key Address to move your cursor.do not use the return CityRown ,, --� :+ �„ ♦ State i7p Code, System Owner ' - : Address(if different front 1 ca&on) Chy — /Town . Sts �. Tele r. -Jp Code3 Telephone Number umping R c rd .{ {. .1 •,J ' w} 1 SVS J k,123 V Date of PtimpinQ 1, . © 2. Quantity pumped: c 3, Typ@ of system .: Q Cesspo6l(s) ueptlo Tank Tight Tank :Other(describe), • : -- -- Effluent Tee Filter present? .© Yes, too if yes,was It cleaned? [� Yes•. talo `f r C' idltldn of Sysif" t'" � ti c � tr , a.,, Ir .i. +• + J 8. Sy eft Pumped By' �CAoW Vehicle t.kenie Number j a ti iu�r rit'F 4' rta� 't• if. 9,t.4 XS'41'f�Y'1'•(f; ,•Yi� '/:� I(A •� p ' •,5;. .J.rYj"��^',�"!`l.�Jif.•baiy�,tr :.Iv.;.r,�t •:Pr'C'' 1 SL Q^1 7t;- Ma : Locatlontwh8re cortentsyuere dlposed; y Gtr + f G 8r�F(S �.1,_ fes,• ,t-, r,{.b ,t �L. - :�•. �;•G:.�- f k r' c • store acrbr,�• . Date httpJ/wwvv.mass• �ovide• atierfa rovaIM5forms.htm#iris ect p f • 1 t t5farrrvt.doa•t78/03 .. .. . System Pumping Record•Page o L4