HomeMy WebLinkAboutMiscellaneous - 167 GRANVILLE LANE 4/30/2018 167 GRANVILLE LANE
210/106.0-0061-0000:0
I
Commonwealth of Massachusetts
_ City/Town of .
V S stem Pumping-Record MAY 7 ?��
p 9
I
y AVER
4 No
F NORTH
ANR
FQIITn TOW IMENT
>•• ` � pEPAf�
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H
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 usin .this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
P 9
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left M
1 t re�Ffe-a—rodf
, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left lgbuilding, Under deck
Address
Citylfown State Zip Code
2. System Owner.
PD�Ouj 14\
Name
Address(if different from location)
CitylTown ' State � rZin Code
Telephone Number
3 i `
B. Pumping tZecord .
1. Date of Pumping Date 2. Qu ty Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank El
Tight Tank
❑ Other(describe): /
4. Effluent Tee Filter present? ❑ Yes ❑'NO IfN
es,was it cleaned? Yes o,
Y ❑ ❑
5. Condition of s m:
(0J-4?,k V\1
6: System Pumped By.-
Nell.
y:Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatiowwhers contents were disposed:
a S: Lowell Waste Water
«- s-
Sign it HaullwU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
RECEIVED
Commonwealth of Massachusetts
a City/Town of JUN 14 2013
System Pumping Record T0, cw
Form 4c >
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
1. System Location: Left/Right front of house, Left/ fight rear 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
Cityrrown C9 State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown State//'^/�s Zip Code
�.Y I (Cle
Telephone Number
B. Pumping Record
1. Date of Pumping C� 2. QuantityPumped:Date p Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a-No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Conditio of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company .
7. Locatio ere contents were disposed:
G.L S. Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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t y�c
t._
Permit No-
Department of Fire Services -----
()ccupanc', and I cc C heckcd
BOARD OF FIRE PREVENTION REGULATIONS I Key. 9:05
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
t,
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INL PRINT I,% l;\,k OR TYPE,ILL IIN-/'•(/V/`If 110N) Date:
('its ur i own t& Al---y J1' Svc I a /he In.yp c-for- r►/ li'itc.c:
I!: 14ti, ,tppliratiun the undcrsl>;rted gives notice of his or her intention I-Iert'orrm the clecirical %cork described beltm.
f. wation (Street S Nuinher) � / (l�u H U�. J _ xw— _
Owner or I cnaut -- — v� � -- Telephone No.
0-A ner's Address
C-
1% ,his permit in conjunction with a building perniii? 1 es ❑ No L (Check Appropriate Box)
Purpose of Building z tAitityAuthuriiation No. f7Z_y � �F:ststing tiers ire cas olts (herheatl �_� l'nell;rd Fc^- s'tio, of meters
New tier,ice -- -- An►ps / --Volts 0%et•head ❑ T;ndgrd ❑ No.of Meters
Number of Hecders and Arnpacity
Date..........................� C'y ,,,r,r,• t,,.,) %., ,,,r„.,t,,,t ;r.,' r,. ,,,,,; ,.. t, --
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' ?o`"'�•D�,� NOF NORTH (;eneraturs
K A
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Batter.” Units
PERMIT FOR WIRING
FIREALARMS No_ r}f Ione.
CHUS tt`� 'o. of )etrction ane
Initiating Deices
No.of Alerting 1)e%ice%
This certifies that S 7
•�t e ontaincil
T—
has permission to
perform ....,/, �' 7t' in
111tctection/Aler(ing1)e► •�
... .......... ..� - /.,..
' / ,. �G�i►nrc► a
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7:......... a S� r
......:. I L Connection�►cai'L } Other
wiringin the ,•l.�•N sccur;t� �aems:* }
building of....../ .. J. i
/ No.of )e*.ices or F:e uicalcnt
Mass.
................
... Data V4'irin�:
..................�.........................::. ,North Andover,
'" rf No.of 1)es ices or F: uic:►Icnt I
Fee-->�............. Lic.NO�yf� ,�, /�/ >' clecommunrcatron. `irtnt
. :'`�...... No. of Uc�ices or F: uicalcnt
ELECTRICAL INSPECI`OR /yL
Check # I/ 'y
8860 J,.rr,'�1. ,;r �r. „•r1r ,,. •, t%r.' L„�a,,,,, �, r• .
� nit ipai pl,}i1:, 1
ill 'cif-( flit}% 10—md upon Lotn},lctt,m
I101-111 tncc of t:fertl,ca! X%mk nta\ „1,i unk:—
Iltc Iicllt'+l'l }?ti t It}C, plotIt of iii htlil; ttttillril l” If1C1111}III, -,coll1l)Ivlt:d t,l,t'rallon C:0%L ;l_i' (}I 11� 101,111Itf1J! t'L}tii%Jlc';+t !ht.'
cclt11it:, that etch cuccra i.1 cc- .Inti ha, r011hiled prvot of ,atitc It) 111 }?until i„usia oit—icc.
t 111.4 h i )\1 1\1t RA%ek 1. — I3(+�}) ❑ t)tIII.R �_� f`ipccilj 1
I cerfilt•, rnrder Nfe paiffc and penalties nJ perjury, that the ia(nrrnalion tiff Nii., application is true and complete_
F 111�1 N ��1!•:: �._.�__ S.� 4 //` �__�c�r�-�_-• _—_—..___---- _ i.i( . 10.: j
(accmcc: �, ��_ Signature
c ✓._ Lam._. l% f.•.
11!1'; nrtilt'!i,rrr.rrrilody-iutr.r
------
yY '�u.:----
�cetl+,tt .tail t onlract,tr I is en e required ti>r till, %%ork: ita p}yahlc. clttcr the Beer,% number!tete.
ON' ER"s iNSI RANCE LVAIVER: I ant amilrc that the I.1ccmcc glut, trr,r intra the• Iiiihilitc nt,tsranc�t,ner t_t n{,rntJllt
rryulrcll h� I.,tt !ic n1c .i_Ilalurc I.104m. } }tcrthc cc: ice lhl> Icylli-cmcrt I ;tan 01i 1,01C k vnct❑i t,tc11cl L- t,ccnrr J_ctI
t)H neri Agent _
tii�natur: 'Telephone No. /'F R.1tlT /''EE. S l
i
�LN Commonwealth of Massachusetts
R �
City/Town of I
System Pumping Record JUN - 5 2006
Form 4
.. • TOVVN OF NORTH ANDOVER
HEAT TH DEPARTMENT
DEP has provided this form for use by local Boards of Health.. ptng ecord must
be submitted to the local Board of Health or other approving authority. .
A Facility Information
Important:
When filling out 1. System Location:
forms to the _ p^ �.;, ,�
computer,use C.� e— " �L-�
only the tab key Address r Q
c move your /Y /r
cursor-do not �+`�°
use the�return Cityfrown tate Zip Code
key.
2. System Owner.
Name
lel Address(if different from location)
City/Town State ffZip
s�Code
Tele one Number
B. Pumping Record
I. Date.of Pumping Date 2. QuantityPumped:
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. Condition of System:
6. System PumpedBy
y
Name ��r� Vehicle License Number
Company --
i
7. Locatio ere contents were ' posed:
�� U>
� I
Signa re a ler Date
http://wWw.mass.gov/dep/Water/approvalS&/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
TO ♦1 1\ OF
SYSTEM P TMP NG RECO ,'� `-`���`�
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
WA
(�` 11CV
6��q
DATE OF PUMPING: (A`r a `t QUANTITY PUMPED : 00C> GAL ONS
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: G.L.S.D Lowell Waste
BUTTERWORTH & O'TOOLE, INC.
P.O.BOX 8294
SALEM,MA 01971-8294
ADJUSTERS/APPRAISERS
FOR INSURANCE COMPANIES ONLY
TELEPHONE(978)741-5731 FAX(978)740-9109
December 03 , 2003
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING DEC 9 QQ,�
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B '-
TO: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
City/Town Hall City/Town Hall
ADDRESSES
North Andover, MA 018451 North Andover, MA 01845
RE: Insured--. David and -Lorraine- Brown
Address : 167 Granville Lane
North Andover, MA 01845
Policy No. : H0021025
Loss of : 11/29/03
File or Claim No. : 031-2162
Claim has been made involving loss, damage or destruction of the above
captioned property, which may either exceed $1, 000. 00 or cause Mass. Gen. Laws,
Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws,
Ch. 139, Sec. 3B is ,appropriate, please„ direct it to the attention of the writer
and include a reference to the captioned insured, location, policy number, date
of loss and claim or file number.
If no reply is received from your office within ten days, we will assume
you have no liens of any type against this property and we will recommend to the
insuring company that this claim is paid.
Vicki Gardner
Adjuster
BUTTERWORTH & O'TOOLE, INC.
P.O.BOX 8294
SALEM,MA 01971-8294
ADJUSTERS/APPRAISERS
FOR INSURANCE COMPANIES ONLY
TELEPHONE(978)741-5731 FAX(978)740-9109
December 03, 2003
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
TO: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
City/Town Hall City/Town Hall
ADDRESSES
North Andover, MA 01845 North Andover, MA 01845
RE: Insured: David and Lorraine Brown
Address : 167 Granville Lane
North Andover, MA 01845
Policy No. : H0021025
Loss of : 11/29/03
File or Claim No. : 031-2162
Claim has been made involving loss, damage or destruction of the above
captioned property, which may either exceed $1, 000 . 00 or cause Mass. Gen. Laws,
Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws,
Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the writer
and include a reference to the captioned insured, location, policy number, date
of loss and claim or file number.
If no reply is received from your office within ten days, we will assume
you have no liens of any type against this property and we will recommend to the
insuring company that this claim is paid.
Vicki Gardner
Adjuster
A) L401a� /
TOWN OF
V
SYSTEM PUMPING RECORDr, ~,
� V
a
DATE:��1 1 JUN 16 2003
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:left front of house)
4
DATE OF PUMPING: ,off r3 QUANTITY PUMPED : (b 0 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:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: (3 �1
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: ( �i3 �� QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEP IC 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:
COMMENTS: Boll, ��'
CONTENTS TRANSFERRED TO: 6;, 2-- S_ 1� -
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 02 0 02
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
Owv�.
1, - - -e-
DATE OF PUMPING: — QUANTITY PUMPED t000 GALLONS
J /
CESSPOOL: NO YES SEPTIC TANK: NO YES ✓
NATURE OF SERVICE: ROUTINE J 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: __ _ _! Sri✓\����Cl�
COMMENTS:
CONTENTS TRANSFERRED TO: J
Address /'�� ��N V��-�� �xlTitle of Fi'.le Page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes T
action Document/ document/
Num. Action Department
Board of Appeals — Board of Health — Planniing Board — Conservation Commission — Building Department
� G�
_r 1
1. Commonwealthy91of Massachusetts
JYy\
, Massachusetts
System Pumping Record
System Owner System Location
/;foW A
1
Date of Pumping: Quantity Pumped/n,
Cesspool: No,-P� Yes [I Septic Tank: No [] Yes
System Pumped by: V44F4" License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
Commonwealth of Massachusetts
Massachusctts
stem Pumping Record
System Owner System Location
i
Date of Pum ping: Quantity Pumped: IWO gallons
Cesspool: No Yes Ll Septic Tank: No U Yes
System Pumped by: erad4le 5drevMae4 License#
Contents transferrred to : greeter Lawrence Sanitaty Qlskict
Date: _ _ Inspector:
I
r
('�►� i��iun venhll o Mss�ncbugetls
I v
Mll93AchUS8tt9
5_ysle�>Ii�vutil p fig 11 rd
5yslc,u Owuct ------ Syslem Lucnli�iii
t6
LIK
r
�)e�e ur rw„ ,ing: Clunidity Humped: / gallons
Cesspool! No Heplid lo' k: Nil .) Yeh
Syslenl Pumped IT Vdteddd 6,4010 ttdM LIc�1�stl
Cnnienls li��isle�ited lu : ;''eals`t�'r�naae gettl�rtt Uishlcl - - — 1
DRIB: __--_ �flsifeulutr ,
I
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' Cluuulnu11�N111� i,t Alal�Itrllu�eil� ' + ,
. 1 NlgseuCllue�ItE!---TM,=�7,• �rl�OetERf
130
• � � MA`I 30 1996 .
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j � � �.1=�•� i • ' SII
ocill"n ^'
las�tatrru�rne ,
"
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1 I;
Dale for 1101ltlltlid
3
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7
�,'t,�lgluutl Ru �� 1'er � firldit' 'I'dwl+ '. ti+.s
CL "eS n 1 Lla se'N�
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(:UIIIlflll.U011lttlfed ilia
Mot
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WA91
TO: NORTH ANDOVER, MASS C C` S 19 '7-c
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
L d 7— /3 C—/k/4 N V1 Ile L%t Iyxf North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
/4 bt Cr- % 19
� pF h1q;sq
Ieg. , ogibb r.`/Re` :unitarian
sso C00%
130,
13
Lo
zo 5 c a.L i. A/6,
1
Ar
0 F MAssq
A
JOSEPH ti
1-'
":n. Guo
n.,
Cl ST
FS"ip{ALrh
M
X 5-rIMG
I
4 -
1
�y. �/ 65.09
TOWN OF NORTH ANWnR NORTH ANDOVER BOARD OF HEALTH
REPORT OF PERC TEST
_
ADDRESS OF SYSTEM! 'Ile zn, 4 DATE 71-
NAME
1NAME OF PROFESSIONAL ENGINEER CR SANITARIAN CONDUCTING TESTS
NAME OF LOT OWNER 6eQ. rr ADDRESS JL/ems cJ G
.v o(J e4
SHOW APPROXIMATE LOCATION OF PITS ON SKETCH ON REAR OFAS SHEET
Total
Soil Log: Topsoil :Subsoil _ De the & ys Water Level Pit D th
E�
33 1976 Time to Time to
Perc Tests D th Saturation Time Drop 12" - 91' Drop 9" - 61,
r
Other Considerations: /_�!(/� �%i ✓ I`'C' /�j
Recommendations: E's�"G�/ Cc ,1'7CJ� '✓ ,� ��,•��
,ILS G✓°� -
f
Signature
lazC.��O� Gel doC/fU G� G�
s00
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DQA-1 Ai
-- - _ ---- _ -- , _ a P20PO.SEb ' SUBSU�2FAGS SEtt/ACaE , I)Js54L cSTEM
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ale
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BRB�GR1ltt'
+ 8,� f .� 3 ::ter f � �/ �t), r�0aool
C. /. r G. �� 4E ¢983 r
• „"' DEs/G Al DATNALA
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gal
'RME _ • r T MATE • 4041 $'.A Z>
_ 6p,2'• $El.UAUE FLOW FS
SEPrle 'T"AAlk . 11- 'nP c o.c!'
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DATE -3-?�
t TOP
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WATE'�2 TABLE
GOGA T/D
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FORM 4- SYSTEM PL11PL\G RECORD
TOW ER/
80ARD�O HHEAL,?4{
Commonwealth of Massachusetts
, Massachusetts C � 3 ,
System Pumping Record
SN-stem %-,•ner SN,stem Location
LaAep
Date of Pumping: C - Quantity Pumped: l gallons
Cesspool: No Yes ❑ Septic Tank: No ❑ Yes
Sstem Pumped by- � � License #:
Contents transferred to:
Date Inspector
SFr arr 40 v,A"
t OPAIDL,
9
i
TOWN OF AvA
d
SYSTEM LIMPING RECO
RECEIVED
DATE: (S'O JUN 2 0 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
S( Owv-\
�ac� 66�
�CZANJ I Ili
DATE OF PUMPING: l 5 0 QUANTITY PUMPED : loco 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: G.L.S.D Lowell Waste
Commonwealth of Massachusetts ---�--�-
City/Town of REE ``rt `
� System Pumping Record AUG 2 200
r` Form 4
OWN OF NORTH P,N1r)rA" '
DEP has provided this form for use by local Boards of Health. het�otRfiSy die used;-tut the
information must be substantially the same as that provided he . e ore 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
a ty
Important:
When filling out 1. SystemLocatioft:
forms on the
computer,use ` ,� f
only the tab key Address
to move your �J'v"`�u "t r (fv
f �l
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
&�
Name
Address(if different from location)
City/Town State p Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Ga►►ons
3.
Type of system: ElCesspool(s) .-Septic Tank E] Tight Tank
Y
❑ Other(describe):
i
4. Effluent Tee Filter present? ❑ Yes 9-11o' If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Civ
6. System Pumped By:
p� \1 P�"�
Name Vehicle License Number
Company
7. Location w e contents ere ' sed:
Sig ur auler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
<CN Commonwealth of Massachusetts
City/Town of
LRE �'VE
w' System Pumping Record 2 5 2008
Form 4
EARTM��ERDEP has provided this form for use by local Boards of Heal , 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: ��--t--,f� �� k6`!�e
Location-
forms on the
computer,use
only the tab key Address ! � ��
to move your �l
cursor-do not Cityfrown State Zip Code
use the return
key. 2. System Owner:
Name
ISI Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): �,_�
4. Effluent Tee Filter present? El Yes LT tvo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System um By:
Name �---� /J Vehicle License Number
Company --
7. Location ere nten isposed:
-Signatur.oeoulor Date
t5form4.doc^06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts RECEIVED
City/Town of �� a2j4fl
System Pumping Record
Form 4 MM*FMMTMA=VBR.
WAL�ilHil
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 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. System Location: ide-ofhous fight side of house, Left front of house, Right front of house,
Left rear of hou e, Right rear of ho . Left rear of building. Right rear of building.
Address
Citylrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State
Telephone Number
B. Pumping Record
1. Date of Pumping � �vly Z. uanti Pumped:
p g Date Q ty Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Condi * n f System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati a contents were disposed:
L."er
ell ste Water
6-> y-._ I 0
Signat Date
t5form4.doc•06/03 System Pumping Recons•Page 1 of 1
Commonwealth of Massachusetts
City/Town of ��
System Pumping Record
Form.4 OUN i 4 zu11
TOWN 0. �7
DEP has provided this form for use by local Boards of Healt . Otto o sp l u , but the
information must be substantially the same as that provided ere. g T 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 hoy� ar of hous , 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 Stat f� Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L�1- O If yes,was it cleaned? ❑ Yes ❑ No
5. Conditio of ystem:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
.L.S. Lowell ste ter
Signa u of auler Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
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
1. System Location: Left/Right front of house, Left t"rear of hour Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address t6 l
Cityrrown State Y Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown State6o�� �rZi de
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date 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 Sste
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo _ h ntents were disposed:
G.L S. Lowell Waste Water
Sign a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1