HomeMy WebLinkAboutMiscellaneous - 26 TURTLE LANE 4/30/2018 (2)_C_\ Commonwealth of Massachusetts
4 City/Town of North Andover
Systern Purn;ping Record
;wy Form ,+
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AUG 0 4 2014
TOWN OF NORTH ANDOVER
HEALTH 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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
,� ( T r-�-e la n P
Address
North Andover Ma 01886
City/Town
2. System Owner:
Name
Address (if different from location)
State
Zip Code
City/Town State Zip Code
_f
Telephone Number
B. Pumping Record
looO
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 20 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No lf.yes, was it clearied? ❑ Yes ❑ No
5. Condition of System:
6. 3ystem Pum ed By:
n2y
ame I Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
§nature of Hauler Date
Signature of Rece cility
Date
t5form4.doc• 03/06 /' System Pumping Record • Page 1 of 1
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filling out forms
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VQ
Commonwealth of Massachusetts
City/Town of A�c►1-4+1. An haver
System Pumping Record
Form 4
RECEIVED
tJtY -14 2913
IrOWU or- r.107r. f Ar�-
HEA'—TH MP .qT,
DEP has provided this form for use by local Boards of Health. Other -for nv may,be bstd but1t e
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
1. System Location: /
Address
aDe
Newbury_ Ma
City/Town State Zip Code
2. System Owner:
D Ick
Name
Address (if different from location)
Newbury
City/Town
State
Telephone Number
B. Pumping Record qh
1. Date of Pumping Date 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
EX SO 114
6. System Pumped By:
Name
Stewart's Septic Service
Company
Zip Code
10odg/
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signatul'e of Hauler
Signature of Receiving Facility
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
ow
TYPE OF SEWERAGE DISPOSAL
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Public Sewer ❑
Tobacco Sales ❑
Well 11
Food Packaging/Sales ❑
®
Permanent Dumpster on Site ❑
Private (septic tank, etc.
Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
er r Signature of A ent/OvmSignature of contractor
Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMMENTS
/ _ CONSERVATION
DATE REJECTED
L■
DATE APPROVED
DATE REJECTED DATE APPROVED
COMMENTS W G 1 V/k • 1/ a w/ t ► l loo / w/ 1 k, wa
DATE REJECTED DATE, PROVED
4/7/,P 7
HEALTH ❑ `" /
COMMENTS ��, z��� 4�, _
v may-. , �' � i L a'�- A'- aX
FIRE DEPARTMENT - Temp Dumpster on site yes no
Fire Department signature/date
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature tit Date Driveway Permit