HomeMy WebLinkAboutMiscellaneous - 1472 SALEM STREET 4/30/2018 (2) 1472 SALEM STREET n S
210/106.A-0149-0000.0
1
I
TOWN OF P-
SYSTEM PUMPING RECORD
(3va;d GF 10RI H A""
BOA, HEXi-
DATE: 3
9 203
SYSTEM OWNER& ADDRESS SYSTEM LOCATIONIr_-. --
(example:left front of house)
DATE OF PUMPING: QUANTITY PUMPED : 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: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: '
Commonwealth of Massachusetts
Massachusetts
i
System Pumping Record
System Owner System Location
c (- iE
Date of Pumping: l "l Quantity Pumped: (�allons
. ❑ Yes
No Yes ❑ Septic.Tank. No
Cesspool: ,
P
System Pumped by: t�S`el ¢Qo�C �iN' �xP� License# ,
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspectors`
i
. i
I
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: o
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
S
k
o
DATE OF PUMPING: '2"4 QUANTITY PUMPED t � GALLONS
/ V
CESSPOOL: NO �/ YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE JEMERGENCY
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: TOWN OF ( RjANDOVF-r"�/
9
Pi",% r 2001
CONTENTS TRANSFERRED TO: rp
r LZ 0-4=!V'�-
Commonwealth of Massachusetts
City/Town of I OCT 1 2 2006
System Pumping Record
Form 4 TO''VVN OF NORTH ANDOVER
.••,•. HEALTH DEPARTMENT
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 1. Systel Locate
fom the
computer.
r,use
only the tab key Address [ / r
to move your ( `--t'
cursor-do not III i
use thereturn Cityrrown State Zip Code
.key. .
2. System Owner: L
Name
Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. .Date of Pum in
P 92. Quantity Ped:
Date
um P Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight.Tank-
❑ Other(describe): _
4. Effluent Tee Filter present? ❑ Yes D 0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
1
v�
6. System m ed
Name
Vehicle License Number
Company -- .
7. Location ere contents were ' posed:
Signatur of ul r Date
h.ttp://www.mass.gov/dep/wat r/. pprovals/t5forms.htm#inspect
t5fonn4.doc•06/03 SystemPumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping in Record ��� ��
y g
Form 4 �= JUN 3 0 2008
DEP has provided this form for use by local Boards ofsed, but the
information must be.substantially the same as that prov��• form,check with your
local Board of HeaA to determine the form they use.T em Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use ll
only the tab key Address r 1'�
to move your �C
cursor-do not Citylrovwn State Zip Code
use the return
key. 2. System Owner:
Name
i
Address(if different from location)
City/Town State Z�pCode
Telephone Number
B. Pumping Record
1. Date of Pumping Date . Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [.ate' If yes,was it cleaned? ❑ Yes ❑ No
t 5:-. Condition of System:
✓� l
�. 6. Sy*M P�p@d
Nam Vehicle License Number
Comp
7. Locatio ere conte r s isposed:
Sign r au er Date
t5form4.doc•06/03 System Pumping Record o Page 1 of 1
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FORM U - LOT RELEASE FORM
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1 INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT 4- LIM. PHONE b �
LOCATION: Assessor's Map Number U PARCEL l `7
SUBDIVISION LOT (S)
STREET/ / ��ri " ST. NUMBER
OFFICIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS: �C) o
C NSERVATION A MINISTRATOR DATE APPROVED l
DATE REJECTED
COMMENTS
'110
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSIDE
TOR-HEALTH DATE APPROVED _
rE8TOR-HEALTH
DATE REJECTED � jSE WN DATE APPROVED � � i
DATE REJECTED ' I! ??R '
, 5 2000 I,
COMMENTS1a ^fa;°,
F,UILIE ING DEt
PUBLIC WORKS - SEWERIWATER CONNECTIONS -
I
DRIVEWAY PERMIT
FIRE DEPARTMENT
.JIENT}
RECEIVED BY BUILDING INSPECTORDATE
Revised 9197 jm
77 .
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