HomeMy WebLinkAboutMiscellaneous - 120 LACONIA CIRCLE 4/30/2018 (28) 11 }fc% 1 - t711 �t
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MA n R ; TH ANDOVER MASSACHUSETTS
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DEP,has prov(ded this form for use by local Boards of Health. ThEtyYu
REC
in Record must
be submitted to tha.local'Board of Health or other a rovin i
7. approving 0�7
A: Foc1Il� Infgrnjat1Ol� TOWN OF NORTH ANDOVER ,
HEALTH DEPARTIVIENT
ImRortant,
�,:r YVtian'filum out 1 :: System location
forms on the
computer,use
only the tab key Address
to move your-w
cursor•knot � ��D _ jjy ( -
use the return City(Town State
Zip Code.
key, 4 t t l b j 2 System Ow
ner >:. r
+ Nams
All Address(If different from location)
Citylfown State p Zlp Code
Telephone Number
,' Yr pumping Record r
r Date of Pumping Dat 2. Quad Pumped:
Gal on
3, TYpe of system ❑ Cesspool(s) t<J Septic Tank ❑ Tight Tank
❑'Other(describe);
, Effluent Tee Filter present?.❑ Yes No if yes, was if cleaned? ❑ sem^No
r ; ;Condition
of's
r
, r `
,
8 sy a�n Pumped By
/Vehicle Ucenge Number
I( t �� ,,�1vI,•G,,,ll
Company;
J` .
< 7 location where:contents were dlposed:
r ,
,
S(�nature of Hauler: � t.
Date
:http//www.mass.goV/depJwater/approvals/t5forms,htm#inspect
t5form4 doc+06/03
System Pumping Record•Page 1 of 1