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HomeMy WebLinkAboutMiscellaneous - 25 HOLLOW TREE LANE 4/30/2018CN Commonwealth of Massachusetts _ City/Town of System Pumping Record Form 4 1. °014 �RBCEW2 MCD _ `- iii 6 � �� TOWN OF 14 "% HEALTH t�A DEP has provided this form for uses by local Boards of Health. Other forms maybe LseE, uuf 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 1. System Locatio . L Rig ront of ho , Left / Right rear of house, Left / right side of house, Left / Right side of bul i'Id'n'g, Left / Right front of building, Left / Right rear of building, Under deck Address City/Town State Trp Code 2. System Owner. Name Address (If different from location) City/Town State Zi Code Telephone Number i B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): 2. Quantity Pumped: C Date p Gallons —T Cesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 5. Condition of 6. System Pumped By. - Neil y: Neil. Bateson Name Bateson Enterprises Inc Company 7. Loca ' re contents were disposed: �. $. Lowell Waste Water 3 If yes, was it cleaned? ❑ Yes ❑ No, F5821 Vehicle License Number — q- (&.-ly - 11 Date t5f6rm4.doe- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEIVE V City/Town of , 203 k, System Pumping RecordForm 4 'GOWN (}'i' NORTH 9-11 K 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: ee igh vont of hou , 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(a,---- vv- Cityrrown State 2. System Owner. Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ —P Z- � -r- -- ( - e� Zip Code State CZ.i� Code /, �� 1 Telep`fione Number Date 2. Quantity Pumped: Gallons Cesspools) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ YesNo If yes, was it cleaned? 5. Conditipn �qf �J�y 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location a contents were disposed: S. _ Lowell Waste Water F5821 Vehicle License Number &�- - C -I Date ❑ Yes ❑ No. t5form4.doc• 06/03 System Pumping Recons • Page 1 of 1 <�'\ Commonwealth of Massachusetts F City/Town of System Pumping Record RECEIVE® Form 4 %1M SV Oy`0� pUU 1 [U11 DEP has provided this form for use by local Boards of Health. Other fors may be used, but the information must be substantially the same as that provided here. Befor tltl�ldi your local Board of Health to determine the form they use. The System Pump ed to the local Board of Health or other approving authority. A. Facility Information 1. System Locatio front of hous ight front of house, left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. I W UaAAVP11 jC)— City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record a-&,V,k 1. Date of Pumping 3. Type of system: ❑ Date Cesspool(s) /VV1.y/ .may✓\-//C�l�'� �i �_/l JI//� Telephone Number — 2. Quantity Pumped: Gallons eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ANO If yes, was it cleaned? ❑ Yes ❑ No 5. Conditi n of System: n . ' � ! � U fyoi ,nom `ei�J `� 6. System Pumped By: Neil J. Bateson 7. F5821 Name Vehicle License Number Bateson Enterprises Inc. Company contents were disposed: t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts 4E -E'VE® City/Town of NOV ID 5 2007 � System Pumping Record Form 4 [�'-a'�-'ALTH OF NORTH ANDOVER DEPARTMENT 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: forms on the computer, use only the tab key Address to move your cursor - do not CitylToNvn use the return key. 2. System Owner: Name from location) 1�1 Address (if different Pt, � (-ems State Code City/Town Stat�CJ Zip -7 0 ode Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date 2. Quantity Pumped Cesspool(s) Septic Tank 4. Effluent Tee Filter present? ❑ Yes No 5. Conditiory.p oust tek)QJ rA . - . ��J.+ Name Company 7. Locati erercontetwerposed: l �v Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 P, Commonwealth of Massachusetts City/Town of System Pumping Record. Form 4 DEP has provided this form for use by local Boards of Health.. The be submitted to the local Board of Health or other approving autho A. Facility Information .Important: When fining out t. System Loction: forms on the. V computer, use only the tab key Address to move your <- cursor - do not y own Cit /T use the return State Zip Code key. ` 2. System Owner. Name Address (if different from. location) CityFrown State kj ��e(vCode' � Telephone Number SEP 2 5 2006 HEALTH Myo B. Pumping Record I. Date of Pumping pate 2. Quantity Pumped. Gallons I Type of system: ❑ Cesspool(s) tic Tank ❑ Tight,Tank ❑ Other (describe)` 4: Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condition f System: (&j. . ef 6. SystemPu 119 p By Name Vehicle License Number Company -- . 7. Location re contents Q disp : http://www.mass t5form4.doc• 06103 als/I s.htm#inspect System:Pumping Record • Page 1 of 1 ,A SYSTEM PUMPING RECORD DATE: q-aTaCL SYSTEM OWNER & ADDRESS F "Q5 V TE�d�FN OF NORTH AN.,�,•, BOARD OF HEAD H OCT 1 2002 SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: q sZ - o c - QUANTITY PUMPED: l © 8 C7 GALLONS CESSPOOL: NO YES EPTIC TANK: NO Y YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: 5 Q� o7S /� GLQnu 1`r�e.. Zel FROM: NORTH ANDOVER, MASS BOARD OF HEALTH DESIGN ENGINEER 7 19 Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at LG % Q //a��O t ,QC,L L /�/�/� North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated q// z 19 7. . U nitarian DATE: TOWN OF /v °�&P.r!- -- SYSTEM PUMPING RECORD,; ' r,..`�1tz SYSTEM OWNER & ADDRESS a.5 �t6w7vtre- t11 - SYSTEM LOCATION (example: lei front of house) tA �;6V4— 6' Douse DATE OF PUMPING: l 0 QUANTITY PUMPED : �G ONS CESSPOOL: NO YES S PTIC 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 v Lowell Waste DATE: TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD �5 (fouj -Ver Lv\ (example: left front of house) 0 6-ttSC c DATE OF PUMPING: ib -'i 6-0( QUANTITY PUMPED I o66 GALLONS CESSPOOL: NO / YES NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: SEPTIC TANK: NO YES EMERGENCY FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: 2ooi "'TOWN OF NCRTH ANDOVER REPORT OF PERC TEST NORTH ANDOVER BOARD OF HEALTH ADDRESS OF SYSTEM DATE r, 9 7 NAME OF PROFESSIONAL FNGINEER. OR SANITARIAN CONDUCTING TESTS NAME OF LOT OWNER ����,,�,�, ADLRESS SHOW APPROM4ATE LOCATION OF PITS ON SKETCH ON REAR OF THIS SHEET 2/0- 7�Tftl Total Soil LSubsoil Depths & TvDes WatPr T.PirPl Pit Dr -nth �'17 Time to Time to lo Perc ests Depth Saturation Time Drop 12'l - 911 Dron 9" - 6" 41, 1 Other Considerations: � ® 40 4f0100, h Recommendations: / f Signature •stem uwner Date of Pumping FORM 4 - SYSTEM PL11PL\G RECORD Cotnmonwealth of Massachusetts , Massachusetts System Pumping Record system Location Quantity Pumped: t x000 Cesspool: Igo , ties ❑ SPntir Tant•- Nlr% ❑ Yes [� System Pumped by: License #: Contents transferred to: . Date Inspector TOWN OF SYSTEM DATE: ` q - o q SYSTEM OWNER & ADDRESS a. S �; 10 W 7r -c -c G RECO RECEIVED SEP 1A 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM LOCATION (example: left front of house) j- , OV6-- o h01,6--(— DATE OF PUMPING: ® QUANTITY PUMPED: O O U GALL NS CESSPOOL: NO YES SEPTIC TANK: NO YES J NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.Dy Lowell Waste Commonwealth of Massachusetts CitylTown of - ECE'IVED System Pumping Record Form 4 S E P 2 8.2009 M DEP has provided this form for use by local Boards of Healt1202 f .�j j. but the information must be, substantially the same as that provided ,check with your 41 local Board of Health tQ, determine the form they use. The System Pumping Record must be submitted to the local Board of Health or=oMer approving authority. A. Facility Information ��' 1. System Location: Left side of house, Right side of hous�,� Pft front of house ight front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. A Address City/Town 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State -IF\,,- �-c::�) Zip Code Statel/^ G �� B Telephone Number Code C (� Date Quantity Pumped Cesspool(s) ®-Septic Tank C� Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes [-No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: V, � 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L.SD Lowell Waste Water Signature of Hauler �r Date t5form4.doc• 06103 System Pumping ReFord •Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record AUG 2-6 2010 Form 4 M s TOWN OR NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other forms M ALTM D P NT 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 or -otter approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, eft front of house Right front of house, Left rear of house, Right rear of house. Left rear of building. Ig rear of building. Address A'-- 5 Cityrrown State 2. System Owner: r G Name Address (if different from location) Cityrrown B. Pumping Record R.- (740 1. Date of Pumping 3. Type of system: ❑ 4 Date Cesspool(s) Zip Code State , Zip Code Telephone Number — 2. Quantity Pumped �epticnk Gallons ❑ Tight Tank ❑ Other (describe): , Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No Condi��on�of System: / 1 � -- U u�(- V 1 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Loca iefflw-erg contents were disposed: G.L.S. D Signature F5821 Vehicle License Number Date :--I ? ---10 t5form4.doc• 06/03 System Pumping Recons •Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record N 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. RECEIVED AUG 21 20.12 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT t5form4.doc• 06/03 A. Facility Information 1. System Location: Righ ont of hous 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 Cityrrown 2. System Owner. Name Address (if different from location) City/rown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code State^ � � Z' Code Telephone Number Cho` Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Leo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L1S _ Lowell Waste Water iuleq I Date It System Pumping Record • Page 7 of 1 ViIlk' " W h Q � 4 � v 2 v v a W V W O Q LU QQ � J \ W � Q V o Q Q •J O ViIlk' " W h h W Q W � 4 � v 2 v W h h W Q W � 4 � v 2 v O I OZ 1S47, -1P7o1r SS�9fi r f o' 4 .11 u