HomeMy WebLinkAboutMiscellaneous - 15 WOODBERRY LANE 4/30/2018Vi
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COMMONWEALTH OF MASSACHUSETTS
North Andover
BOARD OF HEALTH
Little Neck Clambake Co.
NAME
NUMBER
BHP -2014-0642
FEE
$0.00
DATE ISSUED
June 07, 2014
6 Collins St. SEABROOK, NH 03874
-------------
ADDRESS
IS HEREBY GRANTED A Food Est. - TEMPORARY -CATERING
TEMPORARY CATERING PERMIT
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires June 08, 2014 unless sooner suspended or revoked.
RESTRICTIONS: Meal service for 60
NOTES: Contact: David Fyrberg
HOURS ACTIVE: Bickley event, 15 Woodberry St. North
Andover Mas..
------------------------------------------------------------
BOARD OF
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BOARD OF HEALTH CHAIRMAN
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06/02/2014 11:22AM FAX9782835577 ---s ,, _ NORTHERN OCEAN MARINE
N04TH AMM–VER HEALTH DEPARTMENT
:CATERING REGISTRATION APPLICATION
Name of Caterer
Address of Caterer (, Co �, i r,r
Licensed Business Facility
Catcdng Permit Number
Street
City/Town -
X10002/0007
o'3 B rlt{
Tel. # of caterer ( 603)
Supervisor for caterer ]DOW'A
IF C
Location (street address) of
Facility, building or hall where
Meal will be --served
Zip
Date of Cvnccrion 0&161 Estimated 4 of meals to be serviced %a
Fun(
Norte Andover Health Department
Attn: (Catering Permit Application
1600 Osgood Street; Suite 2035
North Andover, MA 01845
Phone: 978.688.9540
OR—SCAN & MA TO: headthdept(a�townofnorthandover.com
Signature of applicant caterer
TideMOA\� AP -r --l o-;4 uatc
FORM MUST BE RECEIVED BY THE, NORTH ANDOVF,R H -Ci ALTH DEPARTMENT
OFFICE NO LATER THAN SEvp- 7 DAYS PRIOR TO FUNCTION
A uitturih ]NI,(;,L. Cttftpter I. ll. Section S. Chapter 94, Section 305A 105i'AZ 595.021
DU NUT WRITE BELOW nUS LINE – EOR ANDO E PAR ENT USE ONLY
Date received Reviewer
M
Received Time Jun. 2. 2014 11:24AM No,0683
BOARD OF HEALTH TEL. 688-9540
NORTH ANDOVER, MASS. 01845
APPLICATION FOR SOIL TESTS
DATE:
7tRO
LOCATION OF SOIL TESTS: 1,S 1,00012 i,3r,"'9v L�� /G�. _w&uF2
Assessor's map & parcel number: 1-m,4P 0.3P fH-✓'c�� /W �`
&�OWNER: lSeoG�
ADDRESS: I� l,��ot�k'�'s✓ G-�Jti"r
ENGINEER: N, �� .reg
TFL. NO.:
178— 66
^176
CERTIFIED SOIL EVALUATOR:
Intended use of land: residential subdivision, single family home, commercial
Repair testing C Undeveloped lot testing
N. A. Conservation: Commission Approval:
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM:
1. Proof of land ownership (Tax bill, deed, or letter from owner permitting
tests)
2. Plot plan
3. Fee of $275.00 per lot for new construction. This covers the minimum two deep holes
and two percolation tests required for each disposal area. Fee of $75.00 per lot for
repairs or upgrades.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional- Engineers can design septic
plans.
3. At least two deep holes and two percolation tests are required for each septic system
disposal area.
4. Repairs require at least two deep holes and at least one percolation test, at the
discretion of the BOH representative.
5. Full payment will be required for all additional tests within two weeks of testing.
6. Within 45 days of testing, a scaled plan (no smaller than V-1 shall be submitted to
the Board of Health showing the location of all tests (including aborilst )�
7. Within 60 days of testing soil evaluation forms shall be submitted. 80 RD of HLA LTwEf?/
JUL 12,999
WOOL eE �y
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TO: NORTH ANDOVER, MASS Jk U E 19 77
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System I nspection
This is to certify that I have inspected the construction of the said disposal system at
4-07— WO U /p S/ L/¢/V North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19 .
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SOIL PROFILE & PERCOLATION.TEST,DATA
Town/City. N6.&Street U)000 t�'' Lot No.
Loc./Subdiv.Liz—Plan Owner 0-110
A)
Investigator D Observer
p 50_1L PROFILES -DATE
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1' leve •' Elli.•,_„_, 34 Elev.,r 4'Elev._
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Benchmark
Elevation
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Datum
Percolation Tests, -Date d
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Pit Number
2
3
4
5'
6
3
a� 7
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9
10
2 3 4 5
Start Saturation
Soak -Mins.
Start Test -Time
1Ca
Drop of 311 -Time
1
:3
Drop of 6" -Time
1:2)
Location
Datum
Percolation Tests, -Date d
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Pit Number
1
2 3 4 5
Start Saturation
Soak -Mins.
Start Test -Time
1Ca
Drop of 311 -Time
1
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Drop of 6" -Time
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Notes & Sketches on Back Frank C. Geglina.s & Associates, North And.
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160 Sylvan Street
Danvers, MA 01923
September 28, 2007
Building Inspector
Town of N. Andover
,/ \/ \/ \/ \/ \/ 1 Telephone: 978-646-0097
Structural Design & Sales Fax: 978-646-0087
www.mcbrie.com
RE: Framing Inspection Affadavit
-15 Woodbury Lane -
N. Andover, MA
Please note that McBrie LLC has reviewed the framing as installed on Friday September 28, 2007 for
the proposed addition at the above referenced project.
It is our opinion that the new framing, as installed, is complete & according to our plans &
specifications and is adequate to support the proposed structure loading.
If there are any questions or concerns, please do not hesitate to contact our office.
DR" J.
Brian J Kavanaugh, P.E. KAVAMMM
Structural Engineer / Managing Member stlalx' M'-
10:41142
C Wocvm ws and SeamgsWrian MyDmwwnU McBneVn ection logYWickkyRe=k xe.doc. Page 1 of I
WILLIAM F WELD .
Governor
ARGEO PAUL CELLUCCI
Lt. Govemor
COMMONR'EALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF- ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617-292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
•'rce,-
;�� �J0 dress of Owner:
Property Address. ^•Q /dDate of Inspection: 0 � p . (If different)
Name of Inspector: iL9 Jj A.) Y pt/c ��}
I am a DEP a, roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name::�
Mailing Address: /7"t 4
Telephone Number: �'7 2jo 2 f
TRUDY CORE
Secrew)
DAVID B. STRUHS
Commissioner
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
eeds Further Evaluation By the Local Approving Authority
Edo
vFi Inspector's Signature: A Date:
The System Inspector s all submit a copy of this inspection rep rt to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the..'system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
r
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of- Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows!substantial infiltration or exfiltration; or tank
failure is imminent. The system will pass inspection if the existing septic tank is'eplaced with a conforming septic tank
as approved by the Board, of Health. TC`'�/�' tE NRfffH ANDOVER
BOARD OF HEALTH
(rwiaod 04/25/97) Papp 1 of 10
DEP on the World Wide Web http:/Nvww.magnet.state.ma.uS/dep.
JUN 1 01999
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
d� CERTIFICATION (continued)
Property Address: AU 41
Owner: 4s 4
] Date of Inspecti
0'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: A�
P Y r
Owner: it+�
Date of Inspection:
'7-7'
DI SYSTEM FAILS:
Y u must indicate either "Yes" or "No" as to each of the following:
1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Its+
ljy
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surfacewaters due to an overloaded or clogged SAS or
cesspool.
r Static liquid level. in�the distfibation" =box;above outlet invertdue UI an. overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
V% Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. .
_ Any porton of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
ltd Any portion of a cesspool or privy is within a Zone I of a public well..
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
EI LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public-health acid safety' and the'environrnent''because one=or more of the following conditions `exist.
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a,surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring.the system and facility into full compliance with'the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department.foi further information.
(revised 0.4/35/97) Page 3 of 10 r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
�er
jj 140
Property Address:
Owner:?
Date of Inspection:
f`7
Check if the following. have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes 0
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
�► r z As -!built plansalhave been.. obtained andgexaJk mined. ,Note if they are not available with.N/A
The facility or dwelling was inspected for signs of sewage back-up.
./� The system does not receive non -sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
40 The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub -Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
— Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
I
(revised 04/2S/97) Page 4 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1W
Owner: 4? �i�
Date of Inspectio�n:Q
FLOW CONDITIONS
RESIDENTIAL:
Design flow: O g.p.d room for S.A.S.
Number of bedrooms:
Number of current residents:!
Garbage gn •:der (yes or no):_&W
Laundry connected to system (yes or no)
Seasonal use (yes or no):—J&i0
Water meter readings, if�v ilable (last two (2) year usage (gpd):
Sump Pump (yes or no): fl
r.. , ; ;;.. w
Last date of#occupan4i=4)1
Y f ' t)
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)
Non -sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last ;date of occupancy:
OTHER: (Describe) _
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or
If yes, volume pumped: 0 allons
Reason for pumping
- TYP�TEM
Septic'tank/distribution boz/soil iabsorption system . ' .ar^ ' 04- V W-
Single cesspool
y; Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: c�
Sewage odors detected when arriving at the site: (yes or no/10
(zevimod 04/1S/97)
Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
1TEM INFORMATIO (continued)
Property Address: IV
Owner: Auoio
Date of Inspectio :
or
BUILDING SE ER:
(Locate on site plan)
�M
Depth below grader
Material of construction: _ cast iron _ 40 PVC _ other (explain)
Distance from Rrwate water supply well or suction Imf-
Diameter _X
Comments: (condition of joints, venting, evidence of leakage, etc.)
Comments:
(recommendation for pumping, condition o
Jjinlet and outlet tees or bafflesjdepth of liquid level in relation to outlet i
integWy/evidence pf leakage, etc.) iVn� s /N Oy"C '✓ �i3f/„�
GREASE TRAP:
(locate on site plan) a
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97)
n
Page 6 of 10
TANK:
SEPTIC
(locate on site plan) `
�t
Depth below grade:
t"� x
Material of construction: concrete _metal _Fiberglass _Polyethylene
—other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance
_ (Yes/No)
Dimensions: o
Sludge depth:_ s�
Distance from top of slydge to bottom of outlet tee or baffler
Scum thickness:
Distance from top of scum to top of outlet tee or baffler +'
Distance from bottom of scum to botto outlet tee or baffler
How dimensions were determined:
Comments:
(recommendation for pumping, condition o
Jjinlet and outlet tees or bafflesjdepth of liquid level in relation to outlet i
integWy/evidence pf leakage, etc.) iVn� s /N Oy"C '✓ �i3f/„�
GREASE TRAP:
(locate on site plan) a
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97)
n
Page 6 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
tr(.+pf►lt w SYSTEM INFORMATION (continu, )
Property ddress:
r'
tOwner: (/,Q
Date of Inspections
SOIL ABSORPTION SYSTEM (SAS):
(locate onsite plan, if possible; excavation not required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: ell
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, nurrbe.r, dimensions Y,n
overflow cesspool, number: k
Alternative system:
Name of Technology:
Comments:
(np,te conditipn of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of 'cesspool:
Materials of construction:
-Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: S
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: _
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(reviaad 04/2S/97) Page a of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:r01j
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection).
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions
Capacity: gallons
Design'flow: ' gallons/dav 14;:.
Alarm level! 'f t Alarm ri workngcorder Yes; `'r No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
1 .
DISTRIBUTION B(A: f ./
(locate on site plan) j`''
Depth of liquid level above outlet invert:F1 /1CW 74-0
Comments:
PUMP CHAMBER-
&# -(locate on . site plan) y r
� -
Pumps in working order: (Yes or No) 4
v Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/15/97)
Page 7 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYS.TkV INFORMATION (continued)
Property Address:
Owner: C eL r} N
Date of Inspection:
Depth to Groundwater / Feet
Please i *tate all the methods used to determine High Groundwater Elevation:
Obt ed from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
etermine it from local conditions
r
Check with local Board ldf,health 4= F `
ti
Check FEMA Maps
Check pumping records /s
4eck local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
(revised 04/25/97)
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Page 10 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
441i ZSV INFORMATION (continued)
Property Address:
Owner:
Date of Inspe ion:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
1
e
(revised 04/25/97)
1
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Page.9 of 10
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Please forward us as much of the following information that is possible;
1• Type of system
2. Hoe � Ga1/7g
3.
7rw-�-X4, vo-�
Location,-
Maintenance records and date of last pumpi g out
ti r ( G�
I
Documentation of repairs and reconstruction
6. Site conditions
7. Builder of systemecr . /"
8. Engineer who approved%
— Site
— System
9. Installation Procedure
1.0. Problems
Ir
SEPTIC SYSTEM INSPECTION FORM
ADDRESS IIS- W66a,-
DATE INSPECTED '
PROPERLY FliNCTIONING? b N
WEATHER CONDITIONS
COMMENTS:
bA i E C i:ALi i Y TES &-`' ?ESL
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
p � I Nature of Service
�b REy SP iE fi
Reg. Maint.
NIC(,
Emergency
ANDOVER SEPTIC PUMPERS " � Day d Night
"Pate eryi2k PAY FROrill ink#IS BILL
Customer Name: W j
P.O. Box 4173 B Station
Service. Location: Andover, MA 01810
�.''� n�-�(✓G ...: (.• ri � �j � ,fiTr.l 1, . � �� '
Phone:(508) 475-2593
1-
/o/�/ r -
Contact: Professional Septic & Drain
Billing Address:
Locally Owned and Operated
City: zip: Emergency 24 Hr. Svc. — 7 Days
Special Instructions + ':
Per: n a'
AM/PM
Services Rendered
F
Completed
❑ Incomplete Reason:
Vacuum Pumping — ..
d'
Septic Tank
❑ Drywall
❑ Leech Pit/ Overflow
❑ D -Box
❑ Pump Chamber
❑ Grease Trap
❑ Catch Basin
❑ Portable Toilet
❑ Other
Qty:
Size:
❑ Under 1000 gallons 1000 gallons ❑ 1500 gallons
2000 gallons ❑ 3000 gallons ❑ 4000 gallons
❑ 5000 Gallons ❑ other
Misc
❑ Digging Charge
❑ Location
❑ Service Call
❑ Labor
❑ Waiting Time
Digging Charge Is Per Driver
Discretion
Observations
Drain Cleaning
❑ Good Condition
❑ Main Line
Leechfield Runback
0 Toilet.Bowt--
Riding High `"
M
O Kitchen Sink
(liquid level)
❑ Bathtub/ Shower
❑ Full to Cover ----.,ti
Erdessive Solids )
❑ Vanity
❑ Floor Drain
y
x G7
Top % Bottom ._, ..
"� `'' "
b Use No Powdered Soap
�7 _-
Yard Drain
��
Chi
❑ Vent ��L l•! t
�°' (' l.: a`r`t' r
❑ Heavy Grease ❑ Sewer Jet r7
❑ Roots ❑ Other G
❑ Suggest Electric Footage:
Rootering 1(0 ❑ Van Called /
❑ Other '
❑ Backhoe
❑ Consultation
❑ Estimate
❑ Portable Toilet Rental
❑ Baffle
❑ Inspection
❑ Certification: P/F
Reason:
❑ Pump Ropair
❑ Repair
❑ Chemical Treatment
❑ Other --
Description of Work
Recommendations
Vacuum Pumping Drain
Yr. Month _
forms & Conditions 1 ❑ C
1. Not iesponsible for damage beyond curb
2. All complaints shall be reported within 48
I the undersigned agree to all terms and
Customer Signature .
t t 11 Terms of Payment
Parts
nth r T i 1 5 DAYS Tax
� r q
Ch t I Credit - ' ti
Of—
rltr3. 1.5% per month will be charged to accounts past due:
f
4. Ttie purchaser agrees to pay all cost o[collection. ^° I
Serviceman
�l �0
Dr.T�:7
LOCATION:
Eno ' VVI T NE S. --
FE=COL ^,TION
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LOCATION:
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I I[IV iCE ST, 1JR T _D
Onim
onwealth ®f Massachusetts
City/Town of POI1 lq-l-�dove K
-1
Svstern Pumping Record
Facility Informatione
System Location:
A
JUN '14 2010
ANDOVER
address
Ur
City/Town
State zip cone
System Dinner:
Rame: Y
dress `ifdifferent from location of pump)
W"i
State Zip c-,ZI
q 35 7 - IP, q
Telephone Nurnber
Rec®lyd
Date Of Purnping �/o
Quantity Pumped /L 00 s all.
Type of System -,,\(--'Septic Tank Grease Tra
p ®cher (what,
System Ramped by:
—�)a
company: ROOTER -MAN 12 East Dracut Rd.,1Vlethuen, MA 0 1844
ecation where contents were disposed:
Signature of Hauler ) /I d-� �
Bate