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HomeMy WebLinkAboutMiscellaneous - 230 FOREST STREET 4/30/2018 230 FOREST STREET 021 0/106.A-0038 0000.0 �-_ Commonwealth of Massachusetts z City/Town of . System Pumping-Record Form 4 b� 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/ i ht fr ,, Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address O 3� O City/Town State Zip Code 2. System Owner. Name Address(d different from location) City/Town State _ Zip Code ; Telephone Number t B. Pumping Record �. 1. Date of PumpingD _ 2. Quantity Pumped: / Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yens DIKO If yes,was it cleaned? ❑ Yes ❑ No; 5. Condition of eml � ` 01- ` l 6: System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L S'. Lowell Waste Water Sig Haul Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts -- City/Town of R �����W System Pumping Record MAR J 'i 2014 Form 4 TOWN OF NOR iii ANDOVER HEAt.TH DEPARTMENT , DEP has provided this form for use=by local Boards of Health. Other forms may bused;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/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address 15�Vrl - a 4 City/Town State Trp C [iAToy12014 e 2. System Owner. TOWN OF NCR i Fi ANDOVER Name HEALTH DFPARTMFNT -� Address(if different from location) CitylTown ' State_^ � , dpi�Code Telephone Number B. Pumping Record -� is 1. Date of Pumping Da 2. Quantity Pumped: —, Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank F1 Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No. 5. Condition pfd( C/ 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio �5re contents were disposed: O Lowell Waste Water Sig cf HaullerU Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 i Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: James Miller Property Address: 230 Forest Street Policy Number: HP1687312 Date/Cause of Loss: 10/29/2011, Storm Damage/Electrical File or Claim Number: 25722-JD Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Justin Daniels On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. 4&inature and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 0 ,Lor #8 �I b€1716ti 50'x` � I �S-$VlcT 50'150' {� ----83 ---— o / K� ft? I t� o ZNVfleT Dgs/41V ASUuicT �. -rANK - /N 6 � l �i�•�lL. � 3�' •`l� N a r ;C •.2 36 38 di a, FNt) or / 71z£N CH l06 ��� ,v� a•� R, *4';a� AM 6/1 t r 1 ��JL7,E Sr CE er/;7;f -T l' 7- ?i!E aj)L plj-9, Glc/ -7,Y/Z 7CC���QTY lS Lr>--47E7l AS SPcwf-1 o%l 7:2 4// /ft` 40 Gi�MPLIE3 W rf1 77-1E 20QlU(�, SET a40�-- 0E:g0 f2:E-- MF.PTs of THE Towu OF MOZ+4 ar-t7oVa j. :r r-(JP77�Ee Cae2rFr 71047- rWE A&c.414E nr� utu� GEOTECHNICAL CONSULTANTS �6 JJoT [OCA rMp /W 0 Fl.00p -r4A IP OF MASSACHUSETTS, INC. 799 Turnpike Street 6/8/84 ��" `'� J�� NORTH ANDOVER,MASSACHUSETTS 01845 Board of Health r SEPTIC SISTEK North LOT' INSTALLATICK M DI AVATI Ob FAIL (•� DATB PH_OPS ' .1 easonst *1 FAn OK e .i 1. Distance Tot a. Wetlands b. Drains c.. Well 2. Water Line Location 3. No PVC Pipe 4. Septic Tank a. _Tees -_Length & To Clean Out Covers. b. Cement Pipe to Tank on Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing tea• Amounts c. No Back Flow 6. Leach Field or Trench a. - Dimensions b. Stone Depth c - Capped lads d. Clean Double-Washed Stone' 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cement Pipe to Pit - Both Sides f. Clean DoubYe Washed Stone 8. No Garbage Disposal $� V 9. -Final Graffi Inspection 10. Barricading Covered System j0 # ll. As Built Submitted a. Lot Location b. Dimensions of System c. Location -Ath Regard-to Perc Test ' d. Elevations Water Table 4_ r BoarAd-of Health N a r tf: :'n do ve r,Ma s s SUBSURFACE DISPOSAL DESS GN CHECK LIST `���,,��,,.., r -LUT 8 irc' ' . .n APPROVID D� VED DISAPPRODATE - Reasons: Proviso• v f ., _ I � �� - •- Yom' - r Title V FAIL CIE Reg 2.5 The submitted plan mist ahow as a n nin'uml the lot to be served-area,dLmensions lot #,abutt.ers blocation and log deep observation hof es-di sttance to ties results percolation tests-distance to ties d design calculationlocation and s & calculations requite arach3mg area location and dimensions of sps g ) existing and proposed contours g) location any wt areas ..thin 100' of se age disposal system or disclaimer-check wetlands napping (h) surface-and subsurface :dr2ins _vithin 100'-of sewage disposal system or disclaimer- -_ ,i) location' any- drainage easements thin 1DOt of stege dispospl systems or disclail-m-er-Planning,nn�.-Board files- (J) kno= iles_( ) know sonrc es of meter supply -within 2001 of se-p--ge di spo sale _ stem ordisclaim to _erne 1o�l or fi om Leaching facil --.-- 1— -�- _ (k)_-3:ocation�f-any-proposed %,e - 11. .s _ (1)_�ocation=_of meter lines on property-1 -Irom.leaching facili y� -- _ F4 (m) .location-of benohma.rk� : _ (o)- garbage disposals ."y- _ (p) no PVC Ao be used in construction—-- 1 i e s tic ,tangy: (q) profile-of system-.e1 evations of basem ts;-p- -- , p. P �_ _ � distribution-box- inlets and-outlets,- is distribution f`f eld=pip g d l - Ot,.Ler- elevations - - (r)., naa3aam_grojmdxater--elevatiaa_in area-sezage-dis�sal--stem -- (s) elan roast be prepared-by=a Frofessionai-Sagineer or -other- _.- professional--authorized _by lasuch.-to prepare sucplans-- - Reg 6 Septic-Ta_n�ks (a) capacities-150 of f1o�;,-meter table,_ tees, depth of tees, �! access, ping I(b) cl eanout pool d) l0 ' from cellar-_ iz..11 or in.ground �i-�--�g d) 25' Prot subsurface drains - Reg-10.-2 rains - Reg-10:2 _ Distribution-Boxes----- (a)_ Boxes___(a)_ s ope greater tnan 0.08 -� Reg-10--4 x SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No �R- FaP.��T �' L�-� v Lot No 8 Loc/Subdiv. Pland Owner Investigator 4GO. dews-OUT. Observer MSQ- SOIL PROFILE DATES 1.kev 2.Elev 3.Elev 4.Elev l 0 A 0 0 0 1 - T� S 1 -T-i s 1 1 • Tiles P�s est 2 2 2 2 3 3 3 3 4 4 4, 4 5 5 5 5 6 6 �+oY 6 6 -nit 7 'eGFUss.c... 7 Rewsel... 7 7 ►.�o o w 8 8 8 8 9 9 9 9 1OL 10 . 10 10 Benchmark Location Elevation Datum PERCO TION TESTS DATES �Z 1. g3 [� / 8'`3 Pit Number 1 2 3 4 Start Saturation 1.00 'l% '5 S Soak-Minutes 1-6-o ar �p Drop of 311-Time Drop of 6"-Time 17 15' Mdsms.lst 3" drop 0 3a , Mins.2nd " Drop Percolation Z �� .o. �Q z5 FoQE ST wEt'S c..1v SE loo' JAI s Pumps b� © 0 Submersible WELL PUMP CO. oJet 9 RT.28 WINDHAM, N.H.03087 0 Centrifugal J' 0 Cellar SE�� [603]898-4232 0[617]887-5888 o Sewage Tanks Filters o Softener 0 I ro n B.-` R CONST TEL a NO. 0 Charcoal 477 ANDOVER ST 686-3653 0 Neutralizer ANDOVER MA r71 81(i _ 0 Cartridge Water Testing LUT NUMBER OR SAMPLE_ LOCATION: #w Pump Parts Motor Controls HATER TEST RESULTS �0 MAY 84 Water Softener Salt : 2r: �raa Resin Cleaner HARDNESS 51 .3 (0-50 REC STANDARD) Rust & Stain Remover IRON .02 2 (0-m.3 REC STANDARD) Potassium MANGANESE 0 (0-.05 REC STANDARD) HYDROGEN SULFIDE 0 (0-.01 REC STANDARD) Permanganate Ph (ACIDITY) 7.2 (605-7.5 REC STANDARD) Plastic Pipe & Fittings TURBIDITY .3 (0-20 REC STANDARD) Lawn Watering CHLORIDES 10 (0•-150 REC STANDARD) Systems COLIFORM BACTERIA 0 (0 REQUIRED STANDARD) Water Heaters NITRATES 0 (0-10 REC STANDARD) 0 Solar NITRITES 0 (0-10 REC STANDARD.) ODIUM 0 (0-150 REC STANDARD.) 0 Heat Pump ;. : aitirrar3ik & :�aitrk �r3r �e �tfi# c�t43ek :�## 0 Electric CHARGE FOR CHEMICAL & BACTERIA TEST #* $25.00 0 Energy Saving a: Wells o Drilled ABOVE. TESTS MEET REQUIRED STANDARDS AND BASED ON THESE, 0 Driven MATER IS SAFE FOR HOUSEHOLD USE AND HUMAN CONSUMPTION. THERE ARE OTHER LESS COMMON MINERALS MHIC:H CAN AFFECT 0 Dug QUALITY OF MATER., 0 Gravel Chemical Feeders Tank Alarms & Controls Hoist Service Portable Pump Puller Emergency Service Goulds Aermotor Jacuzzi Red Jacket Fairbanks Morse Wayne Aquatron Well-X-Trol Town of North Andover,Mass . _Permit # �� Date . /v --J_ APPLICATION FOR WELL & PUMP PERMIT Application is he-teby made for permit to drill a well ( ) . Application is made to install (_) a pump system. _ Location: Address Owner Address_471;" _AA)ve6� 5�, /�, Tel . Well Contractor f��i , i Address lel . �'' �_ Pump Contractor _4,1 _Address �d WELL CONTRACTOR (To be completed at time of pump test ) Type of .Well Well used for Diameter of Well �` Size of Casi-ng Depth -ems Bed Rock � Depth casing into Bed Rock Was Seal Tested? Yes V ) No (_) Date -of Testing Depth of Well �© IJe]-1 Ended in What Material Depth to Wa ter (j _ _ Delivers- ,5 Ga 1 s . Per Min . for 4 h:Du-rs Drawdown-),2& feet after pumping__hours at �C"� GPM Date of Completion ---� - -- -- —--- - - .-_ i� Sipnat e I'Deil Contractor-------- • PUMP INSTALLER- (To be filled -in before installation) Size & Name- Pump_--- ---- --= ---- -- -- ---Puii-jp Type Used Eater Pump Delivers=- GPM Size of Tank Pipe Material Used in Well : -Cast Iron ( ) Galvanized ( ) Plastic ( ) Well Pit (_) or Pitless- Adapter ( ) Was sleeve used to protect pipe? Yes (_) NO( _) Type or Name l•Dell Seal Date .i�i '-2 h it N i�(Yr'ii'il'}f iii':� i' -t2 ii ,. ,. •.„ „ „ , ,. - - _ - = Date ('Dater analysis report submitted to Board of Health Date release - given iD owner of record & B7-dg. Insp Nea7_th Inspector � Commonwealth. of Massachusetts �� =-J' '=� \\j City/Town of I MAY 0 3 2007 VjSystem Pumping Record Form 4 TOWN OF NOR-H ANDOVER HEM H DEPARTiMENT 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 fining out 1. System Location: forms on the c ;y computer,use only the tab key Address c move your cursor-do not City/Town use theiretum St a Zip Code key. 2 System Owner: Name Address(if different from location CityfTown State Zi Code Telephone Number B. Pumping Record 4. J. Date of Pumping -p. g Date 2. Quantity Pumped: canons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe) 4. Effluent Tee Filter present? ❑ Yes ^LAN . If es was it cleaned? Yes. Y ❑ No 5. Conditio f System: , 6. SysteT Pp kd B Name Vehicle License Number Company .7. Locatio here content ere d ed: . p Signalur of au r Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5fomi4.doc-06103 System P.- Record•Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (exam le: left front of house) DATE OF PUMPING: (1UANTITY 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: TOv�N OF N OR Ate©OVER/ COMMENTS: BOARD OF HEALTH _ "V I A 2nni P^T' , CONTENTS TRANSFERRED TO: TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: t4, lt SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house �0 5 I� DATE OF PUMPING: `� QUANTITY PUMPED l �7`� GALLONS CESSPOOL: NO r 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: COMMENTS: T om OF NOR APR 2 6 2001 j CONTENTS TRANSFERRED TO: I'gmm nw altl of Massachusetts /v , Massachusetts System Pumping Record System Owner System Location rL Date of Pumping: 3 Quantity Pumped: (-�gallons Cesspool: No � Yes L..) Septic Tank: No Yes System Pumped by: Fctrederf Srea7 tided License# Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector _ V t•c,n�i iNti nliir uh MA4�ar;hu��ti� . m �• ,� Qpt4l�M���Irltu��tt� i S�4t�r�� t.►tvitc� - SySIEiN ttAlltiN i '— � �rr�irUly !'U�iih�t�i �� �Alidlif . i t"pat�i►c�l: No I�✓ (_.� . tHi� lllk: Nr� lJt tcl----= : sy�ttr�r I►��irr1,��1 bye �rt�'�dd�t �i�� +l�� t,1��ttA��!: � . P t:rlNlpi�l� Irnrrat�+tt�ti Ill . f3f��t�t I�iwt�Hef���i��,�/li���'r�C•RrS..'��Yan'M• w,w✓-NrV.���PkWYI t i !a•t 4 i t• Address 2� 0 Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes: action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Department Commonwealth of Massachusetts .e- �� , Massachusetts System Pumping Record System Owner System Location Date of Pumping: . Cd Quantity Pumped: gallons Cesspool: No F4 Yes ❑ Septic Tank: No ❑ Yes System Pumped by: 64"" 45d&O't" License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: TOWN OF SYSTEM PUMPING RECORD a � 32003 `, DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) y"Ut(_ DATE OF PUMPING: QUANTITY PUMPED : (7 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_j Lowell Waste i ' . RECEIVED TOWN F ,1�► - � S STEM PUMPING RECORD R 25 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DATE: SYSTEM OWNER & DDRESS SYSTEM LOCATION (example: leftfront of house) o - �- _'6 J S DATE OF PUMPING: QUANTITY PUMPED : r_c'Q-_tD 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 LEACIff I 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 1 System Pumping Record APR 2 8 2008 lug Form 4 TO\ IN ur r.ORTH ANDOVER. DEP has provided this form for use by local Boards of Health.Other fo -46wa& 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: forms on the computer, use only the tab key Address to move your cursor-do not Cityfrown State Zip Code use the return key. 2 System Owner: Name ISI Address(if different from location) City/Town State `S Code Te ephone Number B. Pumping Record V-D-3-0& 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 No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of � tom. �.., 6. SystemPu pecLBy: dJ� 6 �� Name Vehicle License Number Compan 7. Location re cgntentre sed: Sign re uler Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of APR 2 3 2009 System Pumping Record TowNOFNORTHAlvoavER Form 4 HEALTH DEPARTMENT DEP has provided this form for use b local Boards of Health. Other forms rms ma be used but the � P Y Y , 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 front, left rear, left side of hous Right fro; 'ght rear, right sid of hou e. forms on the computer,use only the tab key Address ` to move your. cursor- not use the return Cityrrown State Zip Code key. -- 2. System Owner: Name Address(if different from location) City/Town Stag J �� \�-.ZWde 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 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. Location where contents were disposed: L.S.D Lowell Waste Water / LP ~C igna ure of H Or Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts ! = City/Town of r a° System Pumping-Record Form 4 OR 4 2010 DEP has provided this form for use by local Boards of Health. *,* t the information must be substantially the same as that provided he eck with your local Board of Health to determine the form they use. The System umping ecor mus a submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of housSj Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) Citylrown State 01 Zip Code r Telephone Number i B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filterresent? p ❑ Yes 0'No If yes, was it cleaned? E] Yes ❑ No 5. Condition of System: 6. System Pumped By: .Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company i; 7. Locaf ere contents were disposed: .L D Lowell Waste Water g toe of Haul r Date t5fonnjt doc•06/03 { System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of a System Pumping Record , � � �M SVey`� Form 4 tIAR 3 01011 DEP has provided this form for use by local Boards of Health. Other forms bPRWRYM v information must be substantially the same as that provided here. Before u in 1heWjP* � ur local Board of Health to determine the form they use.The System Pumping Record must IT M to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of hous r�buildiing., ft side of house, right side of house, Left rear of house, right rear of house, left rear of building, under deck. 71Z City/Town State Zip Code 2. System Owner: Name Address(if different from location) Citylrown Str ode Tele-phone Number B. Pumping Record 1. Date of Pumping p g Date �eptic ty Pumped: Gallons 3. Type of system: ❑ Cesspool(s) nk ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Lo ere contents were disposed: (2,L-.SD ell Waste r MUU Signatur H ler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 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�fron:tof hous Left/Right rear of house, Left/right side of house, LeftRight side of building, Le t front of building, Left/Right rear of building, Under deck Address a3 0(44A X4-U,�'-0-r Cityrrown State Zip Code ' 2. System Owner. �J l Name Address(if different from location) CitylTown State 8� Zip Cede 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 present? ❑ Yes 3 No If yes, was it cleaned? ❑ Yes ❑ No. " 5. ConditioSystem- 6. yste\�Jl� 6. System Pumped By: Neil Bateson F5821 RECEIVED Name Vehicle License Nuf EU] Bateson Enterprises Inc Company APR 1g 2013 7. Locatio here contents were disposed: WN OF NORTH ANDOVER HEALTH DEPARTMENT G.L S. Lowell Waste Water Y I SignAtufe I Haule Date t5fonn4.doc•06/03 System Pumping Record•Page 1 of 1