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210/038.0-0109-0000.0
Town of North Andover, Massachusetts Form No. 1
BGARD OF HEALTH 7
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At...ss.Al APPLICATION FOR SITE TESTING/INSPECTION
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Applicant
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Engineer
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Test/Inspection Date and Time 2
Al RM N,BOAPDOF HEALTH
Fee Test No.
S.S. Permit No. /lo d D.W.C. No. C.C. Date�� Plbg. Permit No. ��J
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DESIGNER 'S CERTIF'ICA'TION
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This is to certify that the subsurface sewage disposal system
installed at L,j 7` (s' JAIlVdy SDA , Subdivision Lot No.
Town Trot No._ and Town trap No. has been installed
in strict accordance with the plans and specifications approved by
the AvOsamm Board of Health. This certification includes the location.,
grades and materials of all components of the systema
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Dote: This must be delivered to the
Board of health within 48 hours
following the approving Inspection. y�
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DISPOSAL _. � 1Ht1i.above-irvu+er tablwr
•SYSTEM PROFILE
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SEWAGE DISPOSAL 5YSTE1,
BATESON WERPRISES, INC. 'LOCATION : *,32 BAN NAN DR/V E
ARGILLA RD. NO. ANDD VER, /`14, 0/yly5
ANDOVER, MA 01810 O W N F R : ��FPH: l'AiyELA x020
DAT.E ; DEC. 2 1999 lVoT 7o SG9��-
Commonwealth of Massachusetts RETE ®
City/Town ofi . t ,
System Pumping-Record TOV'<<R OF N0RTHAHDOVER
Form 4 HEALTH DEPARTMENT
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DEP has provided this form for usez 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
I. System Location: Left/Right front of douse, Left/ rear of house Left/right side of house, Left 1
Right side of building, Left/Riglit front of building, Left/Rig t rear of building, Under deck
Address
3&, Bav�ooc,,
Cityfrown State - Lip Code
2. System Owner.
Name'
Address(t different from location)
Citylrown state Zip Code
Telephone Number
.B. Pumping Record
LI -k (:::� - 75
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system. ❑ cesspool(s) Teptcank
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 - F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo re contents-were disposed:
G.L S: Lowell Waste Water
Sign a Haul paw `
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