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HomeMy WebLinkAboutMiscellaneous - 162 BRADFORD STREET 4/30/2018 162 BRADFORD STREET et 1 210/061.0-0051-0000.0 `\ l 1 i I i, i i 1 Commonwealth of Massachusetts City/Town of System Pumping Record SUN 3 0 2014 � Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use-by local Boards of Heal Merfami RECEIVED � Commonwealth of Massachusetts City/Town of NORTH ANDOVER SEP '12 2313 } System Pumping Record TOWN OF NORTH ANDOVER Y HEALTH DEPARTMENT Form 4 M 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Locatiorx:--, on the computer, Md' use only the tab 6' lU' key to move your Address cursor-do not NORTH ANDOVER Ma use the return City/Town State Zip Code key. 2. System Owner: Name — mnm Address(if different from location) Citylrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date i►'/"V a 1 2. Quantity Pumped: Gallons w0 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stew rt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Sign re4OHauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED _ City/Town of JUN. 0 3 2013 System Pumping Record OWN OF NORTH Form 4 T HEALTH DEPARTANDOVERMENT 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 hou , L I rea of hou , Left/right side of house, Left/ Right side of building, Left/Right front of'+ , inging, Left I ar of building, Under deck Address [ r7? City/rown State Zip Code 2. System Owner. Name Address(if different from location) City/Town States, C ` G�'en Cod e Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ElCesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No. " 5. Condition o�f S stem 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lti re contents were disposed: 7L S. Lowell Waste Water SignAtufe qt Haule Date t5form4.doc•06/03 System Pumping Record.Page 1 of 1 1 • eLY:i= f`ran � �yjd f �,er /c;± s rage i + uy 9 frp%'it y �kc✓o$`� ] 1 i , h �?fi, ,y} 7 ,,r��tf'4'•P✓22ri)'S"'..�`� L .t Y- 1 la achusetts A t /Tovn .Q •NORTH ANDOVER, MASSACHUSE S r. 5 stem,Pu`m .ing.' Rec© �'d SAN 2 Form 4 , K v �i✓ .,, '.. NDR�H pND NOF D�pP.ftTME.• ..i .' DEP Th� has provlded this form for use by local Boards of Health, W ystem P� Record must be submitted to the.local Boa d r f o Heal th or other approving a Or p p . 9 tY• A .Facility Information ;moi-_ImMrtant. .: , :::� �•.�Vherifil�n9 out-.::::,;1...; System Location:'�.,.�.`_; :. . forms: computer,use only the tab key Address to move your �: i�i'� �•f� cursor!.O not ` use the rstum CltyrTown State Zip Code i key: }`yT 2 System Owner " r Name Address(if different from location) Ci fro wn Ste Zip Code Telephone Number 6. Pumping Record"",. ,a • 1 Date;of PumP•in9: Date 2. Quantty Pumped: G Gallons 3 Type of system ❑ Cesspool(s) eptic Tank C] Tight Tank i �❑ Other(describe):• , 4 Effluent Tee F(Iter present?.❑ Yea., N� If yes, was it cleaned? ❑ Ye 5 Condition of System• /IIfp t 6 Me Pumped ByG i Name x Vehicle Ucen a Num <' ber r ilx� Via.Ir Y,r`i Jif.':��' I �tl K./�/,W�, •�vl// /'/// ' Company.. VI J 7 Locaflon where contents were dl;3posed: l 1} a, , t,; .:.:•.:Signature of hauler.:>, Date httpmass.gov/dept.wateNapprpV41s/t5forms,htm#Inspect t5fom>4.doc tM/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of NORTH ANDOVER MASSACHUSETTS System Pumping Record wForm 4 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. System Location: forms on the (c computer, use a r7L �f V� only the tab key Address to move your cursor-do not use the return City/Town State Zip Code key. 2 System Owner: ISI Name Address(if different from location ` IVBD City/Town State - Zip Code MAY 1 1 2006 7 Zo,P5 Telephone Number TOWN OF NORTH ANDOVER T PP 'TNIENT B. Pumping ecorr ._ 1. Date of Pumping D U 2. Quantity Pumped: - allonG s 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: 6. System Pumped By: Name ehicle License Number V � 2� Company 7. Location where contents were disposed: dD CS7 S' nature of Hau Date http://www.mass.gov/dep/water provals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 ..1i::5�hi.J'�+'(�11/�1;I,��•li�'1.,,,4�•�i�••ll'YItiI��NG�•:• .t+'�•'�. • :a?.,•Lt•"�,Y(�;'r:„{{,int:i�;'x.7,7�.r�,T°r'�';,5�'�:�.1.�:`. �4,.� ... :.:<.r+,✓'i \;I. RECEIVED DEC 0 6 2005 .► •tib�, • . ... TOWN OF NORTH ANDOVER TOWN U U K.I `h 1` HEALTH DEPARTMENT V- i't/// T 5Y ,q PUMPING Rp , UA (k A DOR.Ess fav �'t�sPQOL; N YUJ„ NO or 004b CON01'!'IVN 1'v U. r u t ci> ax RZAYY Ossa e mumu nLJQ4 00 $OLygytg_ .. or trR i�14M ,. CPO. t'VMM�NTs. , Y Z� RECEIVED TOWN OF NORTH ANDOVE UA 11 10 3 ..Q� SYSTEM PUMPINQ "co JUL - 6 2005 TOWN OF NORTH ANDOVER SYST OWNER & ADDUSSHEALTH DEPARTMENT SYSTEM LOCAT10N oo+ DATE OF pt1WNQ �v -�. .._Q �N Y P ..�.._ vrfpED. Sdaxic Tank; NU Yf NA ruKb Qfj 3f:AYiCf: FtUU'ifNE, _ ^ �M RUf:NC 1 0b3aAVA,n0N3: OOOD CQNvaloN FE,JI_L ryi CovER KRAYY OILBA38 _.� BA,FYLBS IN FLAQL, RoOT$ w L3ACMPLo RUNBACK SXCB8SIY6 SOL109 _ FLOODED -SOLrDCARXYOYER-__.OTKER EXPLAIN t'UMMENTS. UvN!'fN'f'� t'K.4NSF'f:kR6;[) f'tt .T01FN /FNORTH ANDOVER BOARD OF HEALTH Location Permit # Food Service $ Retail Food $ Limited Retail $ Seasonal $ Disposal Works Insta s $ Disposal Works Co ruction $ Soil Testing 1/ $ Design Approval Permit Dumpster Permit $ Burial Permit $ Swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ Well Construction Permit $ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License $ Suntanning Establishment $ offal/Trash Hauler $ Other $ 7 , 50 Health Agent White - Applicant Yellow - Dept. Pink - Treasurer BOARD OF HEALTH ; NORTH ANDOVER, MA 01845 Tr :�iF r�c�R A ,�� 978-688-9540 1K,"'D of HE i APPLICATION FOR SOIL TESTS' DATE: Z— 0-t? MAP &PARCEL: (e t.__ _Mme. 5�1 LOCATION OF SOIL TESTS: L 1JJKA10E-Or--W OWNER: l1 L'V EA 12:V V TEL. NO.: �� / �j�� �'�✓ ADDRESS: ENGINEER: DAU t✓1 iECK- W6n�1,. TEL. NO.: � '1 t; G57 ?C CERTIFIED SOIL EVALUATOR: moi. L-L, r2LI Intended Use of Land: Residential Subdivision a Family H Commercial Is This: Repair Testing: ` Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of$425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$200.00 per lot for repairs or gpgrades. (If time is not critical, fee for repairs is $75.00) 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 1"A 00') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval: Date Received: Check Amount: Check Date: MT NAYMAivCMP Job No. 9 ie7E5 50-0 0� � LO' 11 • LOrr 12 lw .�' yt LC710 141 �C NRtJ IN THE SOWN OF BOXFC7RD BDXE.'1 t o NORTH ANUMM— Odw f/ f l W .} OF t �•� o PAut, J 7 rI 1 BRADFORC S1' Lc too MORTGAGE LOAN INSPECTION This plan was not prepared from an instr:;ment survey. Offsets and distances shown should not LOCATION: be used to establish property lines. W QNTH a rjr M MA This plan is intended for mortgage.purpcses2 " SCALE: - 5P DATE: r19.� only. NO ESSEY, I certify that the structure shown or: this a REt31STRY� Plan W6 In conformance with the zoning TITLE REFERENCE: .- i,92a setbacks in effect at the time of construction. PLAN REFERENCE: i certify that the parcel shown is IS 07 -- Located within a flood hazard area'as dep cted COREY & DONAHUE. INC. on FEMA Flood insurance Rate Maps for a Cambridge Ro d,wAbum.MA 01801 Community No: 250098 BOARD OF HEALTH NORTH ANDOVER, MA 01845 f _ ' 978-688-9540 ' a i APPLICATION FOR SOIL TESTS` d0 DATE: 0 MAP &PARCEL: Wit , LOCATION OF SOIL TESTS: l,. 1 iD r'ciez OWNER: 'I C 1?E i,) I� tom`+ TEL. NO.: T ) j ADDRESS: IG Z,- 61--it-Atr� ►'Z>^ � ENGINEER: (.i1'IiU i►-I�� ���G�f TEL. NO.: 2g4 CERTIFIED SOIL EVALUATOR: 7��. t,t� t2i1 Ftzg�w Intended Use.of Land: Residential Subdivision ' g e Family H Commercial Is This: Repair Testing: `� Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of$425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$200.00 per lot for repairs or Lipgrades. (If time is not critical, fee for repairs is $75.00) 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 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line Conservation Commission Approval: -Date Received: Check Amount: Check Date: T i r M , NAYMAfV CMP glob No. 9IS76G 44,x'00 RFs � L07 12 LCT 10 rr Ki V && tN T.Fi ,OWN OF BOXFC7RD . r i tN OF PAUL BRADFORC S LAW TAVI UQ-(; This pian was not prepared from an instr:iment This LOAN INSPECTION survey. offsets and distances shown should not LOCATION: be used to establish property lines. This pian is intended for mortgage.purpcses SCALE: i = 5C` DATE:_2Wls::' only. 1 certify that the structure #iF�2shown or this Q REGISTRY' � 7 Plan - �N in conformance with the zi ening TITLE REFERENCE: setbacks in effept at the time a construct;on. PLAN REFERENCE: p` I certify that the parcel shown is within a flood hazard area as dep ted COREY & DONAHUE. INC. Ea�lneers b Surveyors on FEMA Flood Insurance Rate Maps for 198 Cambridge Rand,Woburn,MA 01801 Community No: APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. e eby makp application fo a permit for a sewage disposal installation at ,r L- . I will install this system in ac- cordance with all the/laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of /� in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe anlaid in a series of trenches, the bottom of which will pro- vide a minimum of / �o lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single the line will exceed 100 feet in length and in any case, two lines of tile will be .installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE /,I / ign ure of Appl} ant I hereby issue the above permit for the oard of Health of the Town of North Andover, Massachusetts. DATE Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as describe DATE r /'7 / k Signature of Inlpe ting Officer Percolation Test Garbage Grinder BOA'�D OF HEALTH -'OWN OF NORTH ANDOVER, MASS. 4.5 I _ r CS ri Go ' � I� .l- /5v � 1. NAME !_ R e U /Z DATE /0/ ±Z// 10, 2. ADDRIK".., L.o 7 /l R A J"J /�O FR-b S7-. LOT NO. // TEL. NO. CF BEDROOMS If DEN YES NO L--- 4. GARBAGE GRINDER YES NO L-- 5. SHOW DIMENSIONS OF HOUSE t� 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 4- 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL /v o G I 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM No W e!/ 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. NNo ff e 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE I,- NOTE: NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. .. • 1y _ � BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS SEWAGE DISPOSAL DATE 21_ NAME OF APPLICANT RArnn norpnrAtinn LOCATION T,Qt #I-1- Rradf'ord Street Address of lot no. BUILDING: Dwelling 3[ Other SYSTEM: New____l Repair GENERAL DESCRIPTION OF LAND high SUBSOIL: Clays Gravel Sand PERCOLATION TEST 11 minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK 1,000 gallon capacity. LEACH FIELD 180 lineal feet of drain pipe. P William J. D is oll, Engineer Board of Heal h Address- 6&4f)G6?o, sT Title of Fide Page of Date File Open: Date file closed: Doc Document/Action Title Date.of Refer to other Purpose of Docume�nt/Action and notes action Document/ document/ Num. Action De artrnent i Board of Appeals — Board of Health — Plannang Board — Conservatiion Commission — Building Department Gy UD/ ii/-UUU IJ:J/ :DubliI bli JIt/JAK,I/ANVUVtK PAUE ui A164 YqNwver g.o. 4. )Jl� o,n Sf ART'S SEPTIC 39M SMIC2 Ne il47 RuIRM gPREET A ne�o✓�r . MA 01835 U..uI L t6/-pp N 978-372-7471 "MM cr j ? Y RJWM FM Tom, OFDM 47[1ti f s _ Gdd 310 L(I I t7 ,4,-e- 93 7 ,4e- 'S3 She,-ujoon IVY ys,� o e- .SS/Q.,,� �6 oa meg P I�ov /97 err 1 +� gr,� v /4�e ^� t M- 1 �5n��� 5 AI A(- ti}i � tjt.'^`, TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD f FqXZIyY,rJ 91,-r>,2�yt,r7 E w�.rf }, ?`tel ,� ''Arb'����ry1 i�F �y{�r�i��rl.l:i>k}•91tj�i,�'te i�, i '1r.. - .. .. ., SYSTEM OWNER &ADDRESS SYSTEM LOCATION T)q (example: left front of house) y�' '� 1 � ''E,P ,+;u�N r � n l J U fi / ✓�!�C.E AV Ifx;'�'t •�*�l�t'� � �A t aF K � 17+�1a����1��`QF1���f+� •d�+..f 14�'r�'t'3ft'�'+��"xraSl. 4P'S't",'.. '°dIc v. �r i 5 risn�'a "'"""c t.. , iF.i.;, ,.-.. - ., . .. .�i _ ._.. 5 r t OF PUMPING; 501 QUANTITY PUMPED;,GALLONS H 7 '�xl ���� +Y f t, tnun , jjP rr NO SEPTIC .. YES—_... TANK: NO YES m —7.; t a 1,�,{fr +ffihf13aS''•f�h a } Q f n r _ i a .� MATURE OF'SERVICE;: ROUTINE, } _ ✓ EMERGENCY �y�tN i c} r rt}q �ri e rlfrr n q '�'f'���� ��1�"������i�l''�`>a�' }Irl�„��i` � I ��t � ��^° . .... ... . .. , ...: . . .. • " gQ V a r. , T ATIONS:. GOOD FULL TO COVER HEAVY GREASE BAFFLES IN PLACE _ ROOTS . LEACHFIELD RUNBACK „ r �'''i `i., .try' �.., EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER--� ! � OTHER(EXPLAIN) r IN� It PU XPEDt J1. Lle- � 4�� +.� I s r r ,.• r � Nr `tr P f ,i i rh d r "d4A Ika� r'1 e r r l 4r tlf 7 [TS TRFERRED TOO: - o,( plf t 1ir'! '"izl 'j Iry• is , y S _ „ R 8 � �r�4�� '�h�M•t�F ���a i� k�4�3Y1�'t�Jt I, 1+dirr t1f4_.k �,� � ,��. ` ! {. , jowl, � r5 ��`� �eC�t�Vi•�r�r' �tt'r'`Er f�'�ji j � > { 1: 9t -.� ��•� , — m. its u k. >T����i5,d-�acC�4}�f'ji'•«t ( '�s'�i 1 !' ,f-r� �,P ,tt'1�� .f., :�f 1. f .. �� TOWN OF NORTH ANDOVER C-- W'j-libb� I�oRTF"A,.,,,: SYSTEM PUMPING RECORD ' BOP.r�of DATE SYSTEM OWNER&ADDRESS SYSTEM LOCATION � f /o a- ,ap-q .Q/ � 6u t DATE OF PUMPING. b' 3_ ._QUAN 11TY PUMPED: CESSPOOL: NO._3L,---YES_....__._.._.._ Septic Tank: NO YES NATURE OF SERVICE: Rt01.J"PINE , ._.)(__EMERGENCY OBSERVATIONS': GOOD CONDITION FULLTO COVER HEAVY GREASE ___. BAFFLES IN PEACE V ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS~ ^_FLOODED SOLID CARRYOVE. �OTHER EXPLAIN Systcrn Pumpcd by COMMENTS: CONTEN'T'S TRANSFE RLD TO _ RECEIVED TOWN OF NO 'H ANDOVE: . OCT 0 5 2004 SYSTEM PU TNQ R.EC;ORL. DA I ` v� TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER & ADDRESS SYSTF,M LOCATION .e DATE OF PUMPING: / p pI.IANTITY PUMPED: �'�SSP(X)L: NO�✓ YES,. SOPuc lank: NU. NA rUKE OF SERVICE: KOUTI.NE.. EMER0EN0' ObSERVA rlONS: / 000D CONDITION FULL TC) COVER A, HEAVY GREASE BAFFLES IN PLACL ROOTS _ LEACHPIELD RUNBACK CXCUSIVE SOLIDS..__«_ FLOODED SOLID CARRYOVER._..........OTHER EXPLAIN Sy.tcm Pumped b7 Lso/."C�/C� __ tea._.�.:. x'1'1."/.1.. . CSf. . ,�3ra�rr'' •-na. UMMENTS. CUN VEN l'J MANSF'I~RRED 1-0 L�� �1 AW.V. Commonwealth of Massachusetts Form 4--System Pumping Record Massachusetts System Pumping Record AUG - 7 2007 System Owner System Location TOWN OF NORTH AN[ C 'ER ,F._ r : it r+nid i . 1 ! . r : , j, L .t. t rr• H ALTHDEPA�TNIE� F Type: Emergenc Routine Cesspool: No Yes Septic Tank: No YesE � Date of Pumping: /v Quantity Pumped: DCS Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments Dep Approved Form-12/07/95 Commonwealth of Massachusetts RECEIVED City/Town of NORTH ANDOVER MASSACH J System Pumping Record 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 local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. Zea stem Locati�on:r/y�►� forms to the [ l l Vllj n7)1-1_� , �4 computer,use _ only the tab key Address to move your I Coo ret use the cursor-do return P not City/Town State Zi Code key. . 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping �—V/o Date V 2. Quantity Pumped: Gall V U 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: 6. System Pumped B 11477 ame U Vehicle License Number &011c- slaw<- - Company 7. Location where contents were disposed: r C JLA� gnature of Hauler Date http:/twww.mass.gov/deptwater/approvals/t5forms.htm#inspect t5fonn4.doa 06/03 System Pumping Record•Page 1 of 1 i