HomeMy WebLinkAboutMiscellaneous - 154 ROCKY BROOK ROAD 4/30/2018 i 15ROCYW ROD �
1009 o a d0.A-0062-0000.0 --
0�
MAP # vl U LOT # -
PARCEL # STREET -_..__.._.
CONSTRUCTION nES
HAS PLAN REVIEW FEE BEEN PAID? NO
PLAN APPROVAL: DATE ��� / � APP. BY_
DESIGNER: -sr,0ab PLAN DATE: . _
CONDITIONS ��Ci/��'I��
WATER PLY: OWN WELL
WELL PERMIT
WELL TESTS: HEMICAL DATE APPRUVED._.�_.._._._.__
BACTERI DA T E F1PPRUVEU _
BACTERIA II ATE AF=PRUVEll�__ _
COMMENTS:
FORM U APPROVAL: APPROVAL TU ISSUEYES' NO
DATE ISSUED BY
CONDITIONS:
FINAL APPROVAL: .
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NU
OTHER - YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL:
DATE:..Z BY:
�E_ �GY�ZM_�NSSg4�AUQCI ...
.•a.�. . .�•I., i ,_. _ �,i.. y. :l.. ` y ..:' K.. • !. ,ilk. moi-. 'K j. ,,P.�f� 3 1.. •',' -
x IS THE INSTALLER LICENSED? t '� �� _ . YES NO
<: TYPE OF- CONSTRUCTION: ; _ REPAIR
NEW CONSTRUCTION: ,... CERTIFIED PLOT PLAN REVIEW YES NO
i CONDITIONS OF..APPROVAL YES NO
z (FROM FORM U)jl
f
+ `,ISSUANCE OF DWC PERMIT f NO
2 DWC PERMIT. N0_ _i ,INSTALLER: �SC�ooD
BEGIN INSPECTION YES 0:
:`:EXCAVATION . INSPECT-ION: ; NEEDED:
PASSED BY
CONSTRUCTION INSPECTION: NEEDED=
AS BUILT PLAN SATISFACTORY: YES:
` APPROVAL. TO BACKFILL: DATE: BY
'`
FINAL • GRADING APPROVAL: DATEl BY
'.•,, FINAL CONSTRUCTION APPROVAL: DATE: BY
Commonwealth of Massachusetts.. 7ECEE®
City/Town of Q13
System Pumping Record
Form.4 TOWN OF NORTHANDOVER
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/ i ar of ho , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
city/Town State Zip Code
2. System Owner: t
Name 1.
Address(if different from location)
City/Town State
Telephone Number
B. Pumping Record
OD
1. Date of Pumping Date 2. Qu ntity Pumped: Gallons
3. Type of system: ElCesspool(s) Septic'Tank ❑ Tight-Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No.
" 5. Conditioq ofSystem:
6. System Pumped By.-
Nell
y:Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ince
Company
7. Location where contents were disposed: .
j G.i_S. Lowell Waste Water
4Signa Haule Date
I
t5fomt4.doc•06/03 System Pumping Record•Page 1 of 1
I
Commonwealth of Massachusetts
City/Town of DECEIVE®
System Pimping.Record JUL 16 7.01.5
Form 4
TOWN OF NORTH ANDOVER
pWii D ��AR�MENT
DEP has provided this form for use-by local Boards of Healtf ier rms 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 tont of Nous �L� J ear of Nous , Left/right side of house, Left/
Right side of building, Left/Right front of t eft Ight rear of building, Under deck
Address
Cityrrown state Zip Code
2. System Owner. 1
Name*
Address(if different from locafion)
Cityrrownip Co
' g
Telephone Number
t
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons Y
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No:
5. Condition o Sy tem-
�w
6.. System Pumped By.
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc•
! Company
i
7. Lo 4rentents-were disposed:aL S: Lowell Waste Water
Sig Date `
06rm4.doc•06/03 system Pumping Record•Page 1 of 1
1
Commonwealth of Massachusetts RECEIVE®
City/Town of
System Pumping Record SED 5 Zu 12
Form 4 TOWN OF BMORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided.this form'for use by local Boards of Health. Other orms 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, LeftjRi ht rear , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
9 9 9 9.
Address
Cityrrown C State "\Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State n ,,, ` de
Telephone Number V
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-19eptic Tank ❑ Tight Tank
❑ Other(describe):
I
4. Effluent Tee Filter present? E] Yes No If yes,was it cleaned? ❑ Yes ❑ No
j 5. Conditio of ystem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7Z'sSige
ntents were disposed:
Lowell Waste Water
e Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
�. I
Commonwealth. of Massachusetts RECEIVE
City/Town of
System Pumping Record APR 2 4 2006
Form 4 TOWN 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 ocal Board of Health or other approving authority. .
A Facility Information
.Important:
When filling out 1 System location: l -
forms on the
computer,use
onmo a tab key Address ��
to move your
cursor-do not
Qityrrown Zip Code
use the return State
key.
2. System Owner:
Le. vkA
Name
Address(if different from.location
CiblT
own
stat
Zi Code
i 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 :resent?
p El Yes L. 1V0If yes, was it cleaned? E] Yes ❑ No
5. Condition of System:
�C C �c
6: ,System Pu ed�By
Nam —
e
Vehicle License e
cense-Number
company
--
Y
Z. locatio here contents were disposed:
S gna re.o -auler
Date
hftp://www.mass.g e
/water/approvalt/t5forms
htnAnspect
t
5fo
rm4
.doc•06/03
System Pumping Record-Pagel of 1
DATE Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
FEE lvD' PERMIT # / 71;' DATE RECEIVED
APPLICANT ��;� �cCry ASSESSOR'S MAP
ADDRESS PARCEL #
LOT #
ENGINEER
STREET
�. �S(�
ADDRESS C���rc ,�� �U/Tc= /UA D6r/Fle
PLAN DATE REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED
� '���"195� �'.D.1� ���v hyo� TCS �✓�/g �� �a� Testi /c
PLAN REVIEW CHECKLIST
ADDRESS /.l0T 7 r _�6�66/C ENGINEER
GENERAL / /
3 COPIES (/ STAMP LOCUSL/ NORTH ARROW 6 CALE
CONTOURS (/ PROFILE c� SECTION c/ BENCHMAR ,&f0'
PERC INFO ✓ ELEVATIONS WETS. DISCLAIMER t--� WELLS &
WETLANDS t,-' WATERSHED? DRIVEWAY!/ (Elev) WATER LINE i_�
FDN DRAIN SCH40 TESTS CURRENT? /G:5
SEPTIC TANK
MIN 1500GL// . 17 INVERT DROP GARB. GRINDER/LZ (+200% EDF)
25 ' TO CELLAR C" MANHOLE TO GRADE ELEV GW
D-BOX
SIZE # LINES FIRST 2 ' LEVEL STATEMENT
INLET 43.67 - OUTLET 143 , ,17 (2" OR . 17 FT) TEE REQ 'D? AA9
i
LEACHING
MIN 660 GPD? L,,� RESERVE AREA FROM PRIMARY? �� 2% SLOPE
100 ' TO WETLANDS ✓ 100 ' TO WELLS v 4 ' TO S.H.GW L---'
35 ' TO FND & INTRCPTR DRAINS 325 ' TO SURFACE H2O SUPP Com.
4 ' PERM. SOIL BELOW FACILITY9 MIN 12" COVER Ll_*� FILL? (25 '
if above natural elev; 10 ' if low) BREAKOUT MET? c�
TRENCHES /
MIN 660 gpd SLOPE (min . 005 or 6"/1000' ) v >31COVER?-VENT
SIDEWALL DIST. 2X. EFF. W OR (MIN 61 ) IS RESERVE BETWEEN
TRENCHES? (,Z IN FILL-A MUST BE 10 ' MIO- ' 411 - PEA STONE?_k
I
BOT t36 d X LDNGSIDE 416D X LDNG� = TOT
(L x W x #) (62/2H2) (DxLx2x#) (G/ft2)
Copyright O 1993 by S.L.Stare
i
i
I
RECEIVED
'roWNa,F NaRTH AND`jv JUL - 62005
UA 11 SYSTP-M PUMPINQ MCO
q.. -
TOWN OF NORTH ANDOVER
5YSTSM ADDRESS HEALTH DEPARTMENT
LOCATION
u
i
DATA OF PVMMNQ,,
QUA N71TY PUMPM
NA rVK4 ow sL,
UbUAVA-nc®N&
OOOD CONDITIONHRAIY� C'L�Y�R
YY fl $ «Kom ® BAPYLES IN P
t,A `.
LWHy'BL(? RUNBACK
LR?C Y0K� .-ODER EXPLAIN
<•ut�t��Nr�.
P NSYtARLL) ►'cf
i
j
9
-711 k
SYSTEM COQ
UAT TJ7:-1 -a/
,�Y5fOWKER chi -AD-I-- SS -------
_______--_- �
IjY AO"c7' �6a 61e-
Ali 4Aec, "Aw
DATEO INS
CESSPOOL NO YES SEPTIC TANK NO YES
NATURE OF SERVICE: R(5U.'INp o/EMERGENCY
OBSERVATIONS-,
GOOD CONDITION FULL TO COVER
ROOTS _ LEACHFIELDRUNBACK
EXCESSIVE SOLIDS- FLOODED
SOLID CARRYOVER- OMER EXPLAIN
SYS'T'EM PUMPED BY
CON"I'E'N'E `I`RANSFERRED,TO
05/11/2000 15:57 5083736611 STEWART/ANDOVER PAGE 01
A16( . ANn6i/er Q•a 4.
131 pin ,S f RTS SEPTIC IPM SERVICE
Marlin 47 RAIIItM STREEP
A �'��� SOME=, MA 01835
t.lwu 1 L l6/-Cap� 'i
978-372-7471
inS
Motes cip
Y RMKM PCR TUM CIp �
ADERM
_ 6dd 7
310
93 she"woo,o
I o�a �/Q,►� /a od
ram
1
�t
1
l4do
Isdd
1�
An /9„
Sum ooyIOl f
Ll 49 ,
1
7 c r7,d le s x,C f
I '
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: zlg e9Z
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
Z eP7)0�1,�IS (example: left front of house)
6z4 15ro- 6,L4d'
/)v
DATE OF PUMPING: QUANTITY PUMPED GALLONS
CESSPOOL: NO De' YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE_ C EMERGENCY ?
i
i
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: LA&YIL
COMMENTS:
CONTENTS TRANSFERRED TO:
I
i
O R TT___I I
1
own of �or _ Andover
No. 11::(o -
Zo ^= North? �
Andover, Mass., s1 • I4T 199}-
CCC HI CHF_WICK I
BUILD
l BOARD OF HEALTH
Food/Kitchen
. . PERMIT TO C
' • Septic System _ /n
BUILDING INSPECTOR
THIS CERTIFIES THAT............................ ..�..C #21s " . d .................
' Foundation a 1+kq-el
has permission to erect......W� .............. buildings on XoT*7- ....
t �S42
to be occupied as..Sl N.kt ...ItoPrw�!.. .. ..I�. .wC�.LtN(�-..W .. -C� ... G!�IV ........ Chimney
provided that the person accepting this permit mall in every respect co form to the terms of the application on file in Final t
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY PLUMBING INSPECTOR
=VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA. 114.8-S. B.C. ou /r/;/v9
i
pb Final
PERMIT EXPIRES IN 6 MONTJDATEFEE PAID
UNLESS CCONST R UCTIOI'l ~I/-\.I� 1S ELECTRICAL INSP_EC OR
�Oug �A? ` IZ
`'#SMIT,fOR FRAME/BUILDING
• Service
,�/�� jr/ BUILDING INSPECTOR Final _ r
.DATE.._,..__—�FEE PAID V:...�. _
Occupancy Permit Required to Occupy .Butilding GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
p Y P Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. f
Burner
PLANNINGKe(-' FI AL CONSERVATION ,V`� FINAL Street No.
Smoke Det.
SEWER/WATER FINAL (!k-*-; SJ-7 DRIVEWAY ENTRY PERMIT I *_
Town of North Andover, Massachusetts Form No.3
NORTH BOARD OF HEALTH
\) .np'/- ��y(J /� `�
p� 19
p � I
'°•,., "� DISPOSAL WORKS CONSTRUCTION PERMIT
9SSACNUSES
Applicant_�'U- OS5 m&
NAME ADDRESS( TELEPHONE
Site Location �l 1 # �� L-�U O l� •
Permission is hereby granted to Construct Kor Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
"
CFTA1RMAN,BOARD OF HEALTH
Fee. D.W.C. No. �c� �o
Town of North AndoveF, Massachusetts Form No,s
MpltTp BOARD OF HEALTH
D
* s Y
DESIGN APPROVAL FOR
SSACHUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant `�6,A) o SGoO,n Test No.
' Site Location T 7 ✓�OC4 Y 7SAL>
Reference Plans and Specs. Qs6 ooh
• ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
CHAIRMAN,BOARD OF HEALTH
• o�
: Fee- 0,/,Q • Site System Permit No.
I �
is
'TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
{
I
l
DATE: ,A T �_�.-I��. 1, I��I ' '� � •
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
(example: left front of house)
d e a n ccp out
1 `� �lJGc t/ rd6
N r'�
t.
f, PATE OF PUMPINGQUANTITY PUMPED GALLONS
t ,
~CESSPOOL: NO, X,_ YES SEPTIC TANK: NO YES
4'' '' NATURE OF SERVICE: ROUTINE . EMERGENCY
F OBSERVATIONS:
GOOD CONDITION FULL TO COVER.
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
Ic
SYSTEM PUMPED BY; '' l
y s S..,�.y m t,,^ 1 ° 'jy,+—_r..G � «:�--�•—.+.:'_ �T�.°x�l� ar�+e.or�+�.
vaf5y}ltd tji
R � .
fi
COMMENTS.'
fc�v IV OF IV
qq
I. r.�l� c4
TRTO::
�►NMRREI) TO. ' �41
� /���[ �✓vl�� �c�
'T U
zn ._
DIVERSIFIED
CIVIL' ENGIN ERING
CERTIFICATION
Property -Location: Lot `7 Rocky ,Brook Estates
Town•, / State': . NorthAndover; MA
Plan Reference DCE' Dwg No 1026
I, Peter- G.' Parent, 'a Civil Engineer; duly "licensed
`as �such• n th'e Commonwealth of Massachusetts,`.
'here by `der tify that 'I',have' person
ally inspected-the
'constructed".sub'surface- sewage 'disposal-°sy'stem, thown
do ,.the" referenced plan, and further certify .- that
the system; as constructed, generallyconforms; "
within acceptable. enginee'ringq., 'tolerances to that
"of' the record` . plan,:. and complies with the
,provisions of 310 CMR 15:00
(N OF M
A
S ,
PETER 9PyGM
= PARENT v,
No.`37846
IST
Peter G. ' Dc
rent Date.
359 Littleton Road, Westford, MA«01886 (508) 692-0939
P Q':_Box 880;:Methuen;.MA 01844,-(50
.8) 687-71_61'_,
NORTIy �I
O «ao
4-0 BOARD BOARD OF HEALTH 55,
� O p f'
�•.°,,,,° -t5� 120 MAIN STREET TEL. 682-6483
CNUNORTH ANDOVER, MASS. 01845 Ext. 32
August 8, 1994
Dear Mr. Lemonias:
As of this date, Lot #7 Tanglewood Road in Rocky Brook
Estates has been tested for groundwater elevations and has had
percolation tests with acceptable rates for the siting of a
subsurface disposal system. Design plans have yet to be
submitted to the Board of Health for review.
Sincerely,
Sandra Starr, R.S.
Health Administrator
cc: Karen Nelson, Director, Planning & Comm. Dev.
File
i
TOWN OF NORTH ANDOVER M
SYSTEM PUMPINC RECORD _
Ig 2 2003 I
1'EM OWNER & ADDRESS SYSTEM LOCATION
(exMPle: lef( front of house)
41, -
74
U:\Tc OF PUMPINC: - (QUANTITY PUMPCD 1600
:. 1.--SPOOL: NO �ES SEPTIC TANK: NO YES
� w
i
ATUKE OF SERVICE: ROUTINE EMERGENCY
fflhPRYATIONS:
COOD CONDITION. NULL TO CUVCIZ
HEAVY CREASE BAFFLES IN PLACERUOTS LEACHFIELD RUNBACK . �
CXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER 0 HFR EXPLAIN
>1 .>'I'Lm PUMPED BY:
I
I
UN I l.'.NTI tRANSFCIMED To:
1
, I
Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
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 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
Important:
When filling out 1. System Location: Left fr t, left ear, eft s' a of ouse Right front, right'rear, right side of house.
forms on the
computer,use
only the tab key Address r �( f
to move your. �: ^�`tom/ p"v
cursor-do not citylrown State Zip Code
use the return
key. 2. System Owner:
• r ,
Name
_ Address if different from location
Cityrrown State _-fp Cede
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: Cesspool(s) eptic Tank Ll Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes No If yes,was it cleaned? Yes No
5. Condition of System:�
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatiqo wh re contents were disposed:
L.S.D Lowell Waste Water
0�j
igna ure of H u r Date
t5fonn4.doc•06/03 System Pumping Record•Page 1 of 1
IC\- Commonwealth of Massachusetts
I s "I ED
City/Town of
System Pumping Record JUN 15 2007
Form 4
94
TOWN OF NORTH ANDOVER
EALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health.Other forms m H ,
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
Important:
When filling out 1. Syste Location:
forms on the
computer,use
only the tab key Address n ,
to move your ,!V w
cursor-do not
use the returnCity/Town Stat Zip Code
key. 2. System Owner:
-� Name
1�1 Address(if different from location)
Cityrrown Zip Code
f
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑-*§e—ptic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
I
5. Condition of System:
-S" l
6. Systr F�fBy
Name Vehic a License Number
Company
7. Location ere contents we disposed:
C__.X/J �u
-� --
Sign re H user Date
t5fomi4.doc•06/03 System Pumping Record•Page 1 of 1
i
f�
Commonwealth of Massachusetts
City/Town of . :'QED
r .
System Pumping Record
Form 4 LT
UN 3 0 2008
OF NORTH ANDOVERDEP has provided this form for use by local Boards of Heaerlbr i'� , but the
information must be substantially the same as that provideefore 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.
L.
A. Facility Information
Important: ,
When filling out 1. SystL m LO 10
forms on the
computer,use
only the tab key Address I � M
to move your c ,i
cursor-do not Cityfrown State Zip Code
use the return
key. 2. System Owner:
gas
Name
ILS Address(if different from location)
Citylroevn State„ � v pp(C�ode
Telephone Number
B. Pumping Record G
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 LI-Wo If yes,wras it deaned? ❑ Yes ❑ No
5. Condition of System:
6. Syste P�"mped By
Name Vehicle License Number
Company
7. Location ere contents disposed:
Sign rrrTauler Date
t5fom14.doc-06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts LRE City/Town ofEDSystem Pumping Record D*70Form 4
DEP has provided this form for use by local Boards of Health. Other forms
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'ouother approving authority.
A. Facility Information
1. S _ cation: Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of hou Right rear of house. Left rear of building. Right rear of building.
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location) j
City/Town Stade Code
Telephohe.Number
B. Pumping Record
1. Date of Pumping
p g 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. Condi 'on of System-
6.
stem-6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati re contents were disposed:
L.S. ow Waste Water
Signatur o a r Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
s'^.`^�. ...
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3
F 1+
'Y •�e� 'i 1�.4.Vii. i`, ^'.�.f.. 1 - �
...... .w. ..,.... _.. ... �..t
C\- Commonwealth of MassachusettsRECEI
.. 3-
City/Town of
System Pumping Record 11UN 14 2011
Form.4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. er or s a e sed, 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 front of house, right front of house, left side of house, right side of house, Left
rear of house ri rht e o hQus , left side of building, right rear of building, under deck
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingD�-�o . 2 '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:
(eJ
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
G.L.S. Lowell ste ter
` (o �o2 - j 1
Signa u of auler Date
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