HomeMy WebLinkAboutMiscellaneous - 336 SHARPNERS POND ROAD 4/30/2018t
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SEPTIC SYSTEM INSTALLATION
I
`� r 0�l
CONDITIONS:F�
Is the installer licensed?
NO
-MR
Type of Construction:
NEW
90
New Construction:
Certified Plot Plan Review
YES
(01
Floor Plan Review
YES
Conditions of Approval from Form U
YES
Issuance of DWC permit:
YES
NO
DWC Permit Paid?
g
NO
DWC Permit # (
Installer:
Begin Inspection:
YES
NO
Excavation Inspection:
Needed:
Passed: By:
Construction Inspection: J
Needed: `/ — ?2
As Built Plan Satisfactory: / r
YES:
Approval of Backfill: Date:
Final Grading Approval: Date:
LM
Final Construction Approval: Date: By:
Certificate of Compliance: Approval: Date:
-. J.
0
Lot & Street "J ��°'`4r x�kr-) �J Map/Parcel
CONSTRUCTION APPROVAL
Has plan review fee been paid: YES AIA- NO Permit# 126
3
Plan Approval: Date: AIA Approved by:
Designer: /Vt Plan Date:
Conditions: r 0.,J i
Water S ly: Town Well
Well Permit: Driller:
Well Tests: Chemical
Bacteria I
Bacteria II
Plumbing Sign -Off:
Comments:
Form "U" Approval
Date Issued
Conditions:
Final Approval:
Date Approved
Bat,e Approved
Date Amoved
Wiring
Approval to Issue
By:_
YES NO
All Permits Paid? YES NO
Well Construction Approval? YES NO
Septic System Construction Approval? YES NO
Certification? YES NO
Other? YES NO
Any Variance Needed? YES NO
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
It
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
A. Facility Information
1. System Location:
Address
� ,,lA /Amr-1
-----
CitylTown
2. System Owner:
Name
Address (if different from location)
City/Town
State ---
Zip- -
Stat
Tele one umber
B. Pumping Record tt��
1. Date of Pumping 2. Quantity Pumped: / goo
Date Gallons
3. Type of system: ❑ Cesspool(s) CKSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --- --- ---- -- — --
4. Effluent Tee Filter present?Yes No If yes, was it cleaned? Yes ❑ No
5. Condition of
6. System Pumped By:
Name l
IA
Company
7. Location where contents were disposed:
Signature of Receiving Facility
Vehicle License NumVer'
INWIP.
Ipswich, MA.
Date If
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
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 mus# 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. 00T L 8 2013
A. Facility Information
1. System Location:
OF ijC.H kADOV'ER .J
I-TALTH [)F-PAP'WNT
I -X->1142 r rc_d veal-
AdJess�
City/Town State Zip Code
2. S7t"ZamOner:
Name
Address (if different from location)
City/To,vn
Stat Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat 2. Quantity Pumped: 01)
Gallons
Q
3. Type of system: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --- — --"- - —
4. Effluent Tee Filter present? Pyes ❑ No If yes, was it cleaned? MYes ❑ No
5. Condition of Systerg:
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
6. System Pumped By:
p
Name
Vehicle License Number
Company
G'L'S.D.
7. Location where contents were disposed:.
North Andover, NA.
Signature of Hauler
Date
Signature of Receiving Facility
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER,
System Pumping Record
Form 4
MASSACHUSETTS
RECEIVED
QCT 0 4 1009
DEP has provided this form for use by local Boards of Health. The Systern Pumping Re ord must
be submitted to the local Board of Health or other approving U[t6RNt(YF NORTH ANDOVER
HEALTH DEPARTMENT
A. Facility Information
Important:
When filling out 1. System Location:
forms on the 1) ?
computer, use J iqnrs i
only the tab key Addr ss
to move your '
cursor - do not
use the return City/Tow
key.
2. System wner:
Name
Address (if different from location)
CitylTown
B. Pumping Record
a�
State
ON".
Zip Code
State Zip Code
Telephone Number
1. Date of Pumping Date 0�2. Quantity Pumped: Gallons, v
3. Type of system: ❑ Cesspool(s) [?J�Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? Z_"Yes ❑ No If yes, was it cleaned? pl-'Yes ❑ No
5. Condition of System:
Csoo a
6. System P` ped
Na e Vehicle License Number
Company
7. Location where contents were disposed. G.L.S. .
__. ---
.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#insect
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
a� City/Town of NORTH ANDOVER, MASSACHUSETT
-
System -Pumping Record
_ Form 4
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 _CEIVED
A. Facility Information
SEP 15 2006
Important:
When filling out 1. System Location:
forms on the( TOWN OF NORTH ANUOVE.R
computer, use , 32 b S A erl,, f Jq y Ct HEALTH DEPARTMILNT
only the tab key Address
to move your ^^ a� r— j4A A jj QQ U
cursor - do not City/Town- J State Zip Cod 7
use the return
key. 2. System Owner:
r� C E .- A d — -- ----
Name
Address (if different from location)
City/Town 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? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
-- U �t -- —
6. Syst m Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Sig atu of Hauler
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
TOWN OF NORTH ANDOVER SEWAGE. DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( ) constructed;
(') repaired;
by O 1 nd et "rl
located at
e
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit # , dated — with an approved design
flow of gallons per day. The materials used werd in conformance with those
specified on the approved plan; the system was installed in accordance with the
provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees
substantially with the approved pian. All wort{ is accurately represented on the As-bu;lt
which has been submitted to the Board of Health.
Bed inspection date:
Final inspection date:
Installer:
Engineer Representative
Engineer Representative
Lic.#: Date: Z ��/
V.
INSPECTION CHECKLIST FOR SEPTIC SYSTEMS
Yes NO Initials
A. Bottom of Bed
1. Excavation to proper depth
2. With trenches, sides of excavation are beneath B horizon
3. Edge of excavation specified distance from foundation, etc.
Comments:
B. Retaining Wall
1. Wall height and width as specified
2. Waterproofed
3. Wall minimum 10' to leaching facility
4. Wall meets specifications of plan
Comments:
C. Building Sewer
1. Pipe diameter minimum 4"
2. Schedule 40 pipe
3. Watertight joints
4. Inlet to tank cemented
5. Slope minimum 0.01 or 1/8" per foot minimum
6. Pipe properly set on compact firm base
7. Pipe laid on continuous grade in straight line
8. Cleanouts precede all change in alignment and grade
9. Manholes at any 90° change
10. 10' minimum offset to water line
Comments:
D. Septic Tank
1. Level
2. 1,500 gal minimum
3. Gas baffle present on outlet
4. Manhole to grade
5. Manholes over center and each tee
6. 3-20" manholes
7. Inlet tee minimum 12" under invert
8. Outlet tee minimum 14" under invert
9. Outlet line cemented
10. Air space 3" above tees
11. 2" - 3" drop from inlet to outlet
12. Pipe set
13. Compact base with 6" of 3/4" crushed stone under tank
14. Tank is watertight
Comments:
Yes NO
E. Pump Chamber
1. If separate from tank, compact base with 6" of 1/4" stone underneath
2. Minimum 2" pipe to d -box if gravity system
3. 20" access manhole
4. Tank level
5. Watertight
6. Tank size agrees with plan specification
7. Manhole to grade
8. Check valve and bleeder hole present
9. Alarm in building on separate circuit
10. Alarm functions
11. Manual operating switch
12. Pump delivers liquid to d -box
Comments:
F. Distribution Box
1. D -box level
2. Minimum 0. IT' (2") drop from inlet to outlet
3. Minimum 6" sump
4. Outlet pipes show equal distribution
5. Compact base with 6" of stone beneath box
6. Box is watertight
7. All lines cemented with hydraulic cement
8. Schedule 40 pipe -
Comments:
G. Soil Absorption system
1. All stone double -washed - 3/d' - 1 %"
- pea stone
Bucket test done?
2. Minimum 2" of pea stone above distribution lines _
3. Minimum 6" stone beneath pipe _
4. Distribution lines capped or connected together _
5. Grading meets 3:1 slope _
6. Minimum of 9" of fill graded over system
7. Toe of slope stops minimum 5' from edge of property; if not, then swale.
Comments:
H. Leach Trenches
1. Minimum 2 trenches
2. Length of trenches agree with plan. (Max. length 100')
3. Width of trenches agree with plan - Minimum 2% maximum - 4'.
4. Vent present if <50 feet or specified
5. Distance between trenches minimum 4' and maximum of 6'
6. Minimum distance between trenches 10'
7. Pipe slope minimum 0.005 or 6" per 100'
8. Depth of trenches below outlet invert minimum of 6".
Yes NO
9. Pipes set on stable base.
Comments:
1. Leach Field
1. Maximum length of field 100'
2. Pipe slope minimum 0.005 or 6" per 100'
3. Separation between pipe 6' maximum
4. Pipes connected at end
5. Separation between adjacent fields 10' minimum
6. Pipes set on stable base
7. Maximum 4' separation from edge of field to first line
8. Minimum two distribution lines
9. Maximum perc rate 20 mpi
Comments:
J. Leaching Pits
1. Minimum inlet pipe 4"
2. Pits of concrete
3. Sidewall between 12" and 48" wide
4. Access manholes on each pit
5. Pipes cemented with hydraulic cement
Comments:
K. Final Grade
1. Slope over soil absorption system minimum 0.02
2. All system components covered by at least 9" soil
3. Cover soil free of stones larger than 6"
4. Grading slopes away from dwelling
5. No areas over system that may pond
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
property at ,3 3(1 f"�-id Rd relative to the application
of T) - B�6n dated for plans by
date wi revisions a e _
I understand the following obligations for management of this project:
and
1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor,
project manger, or any other person not associated with my company schedules an inspection
and the system is not ready then item two shall be applicable.
2. As the installer I am required to have the necessary work completed prior to the applicable
inspections as indicated below. I understand that requesting an inspection, without
completion of the items in accordance with Tile 5 and the Board of Health Regulations may
result in a $50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first. Installer must request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or
verbal OK from engineer must be submitted to Board of Health, after which installer calls for
inspection time. Installer must be present for this inspection. With pump system all electrical
work must be ready and able to cause pump to work and alarm to function.
c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be
on site.
3. As the installer I understand that persons or companies not associated with my company may
not perform the work required by my company to complete the installation of the system
identified in the attached application for installation. I further understand that work by others
unlicensed to install septic systems in North Andover can constitute reasons for denial of the
system, and/or revocation or suspension of my license in the Town of North Andover plus
significant fines to all persons involved.
4. As the Installer I understand that I must be on site during the performance of the following
construction steps:
a) Determination that the proper elevation of the excavation has been reached.
b) Inspection of the sand and stone to be used.
c) Final inspection by Board of Health staff.
d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other
components.
5. As the installer I understand that I am solely responsible for the installation of the system as
per the approved plans. No instructions by the homeowner, general contractor, or any other
persons shall absolve me of this obligation.
Undersigned Licepsed Septic Installer
Date: 6�
r
Disposal Works Construction Permit # i
NORTH{
OL
O p
M = �
• off+ •
SS�CMUSE
Applicant
Town of North Andover, Massachusetts Form No.3
BOARD OF HEALTH /rl
DISPOSAL WORKS CONSTRUCTION PERMIT
Site Location �i
Permission is hereby granted to Construct ( ) or Repair (Y an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
d rri-Y
CHAIRMAN, BOAR TO FI&A L
Fee
D.W.C. No. vz'�
FEE
COMMONWF-ALT14®F MASSAC14USETTS
Board of Health, &. A&er MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
LocationY34
Owner's Name - d / 16
Map/Parcel#
Address gwn�I' O/!qR Id
Lot#
Telephone#
Installer's Nam
Designer's Name
Address OZr J
Address
Telephone# e
Telephone#
c
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Number of sheets
Name of Soil Evaluator
Revision Date
Date of Evaluation
The undersigne ees�prXj
ve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees of toin operation until a Certificate ofjCnpliace has been issued by the Board of Health.
Signed Date �%e
Inspections
No. COMMONWEALTH EALTH ®F MASSACHUSETTS FEE
Board of Health, &�:` if , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer (- �lsl.C!"��7 s% /iilil, ��ld� /j/!�
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No
COMMONWEALTH OF MASSAC14USETTS
Board of Health,
M
DISPOSAL SYSTEM CONSTRUCTION V PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. , dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health
FORA14 t SYSTEM P A1P'G RECORD
- 1
of Massachusetts
Massachusetts
ystem LOMLIVII
Date of Pumping:/v��O�,
Quantit} Pumped: ------gallons
Cesspool: No ❑
System Pumped by: 4
Contents transferred to:
Yes ❑ Septic Tank: No ❑ Yes ET --
Date
Inspector
License #:�
0 THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0
107 Forest St.
Middleton, MA 01949
(508) 774-2772
C
�x%
FORM 4 - SYSTEM PUMPING ORD
of Massachusetts
Massachusetts
�vstem Pum,�i_n Recard
stem Utii,'ner l Q
kc6e'r
9 ?s--'s-S-0 3
system Location
Fc6 n4- .
Ih b e-4wee✓1 Ffo4
Of\ ?\,tCc� -- S(Gt t
(a�b6C-F- 8 Fifc COSI
Date of Pumping:
Quantit)' Pumped: gallons
Cesspool: 1\o ❑ Yes ❑ Septic Tank: No ❑
Yes
System Pumped by: CC) ( C ('e C
Contents transferred to: ( QA 441
License #:..
Date 7— 9(�F
Inspector ;0 rc/-c
• THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY •
• Farm 4 -- System Pumping Record
Commonwealth of Massachusetss i
Massachusetts
System Pumping Record
i Owner System Location
Type: Emergency Routine
Cesspool: No Yes Septic tank: No [—]Yes
Date of Pumping: — .l Quantity Pumped: '� &allonss---"���***--���
System Pumped By: Wind River Environmental, LCC Permit #:
Contents transferred to:
Contents Disposed at:
Dep Approved from - 12/07/95
Commonwealthof assac usetts
l City/Town of
System Pumping Recor
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 within 1r -tom -ft date in
accordance with 310 CMR 15.351.��Vb7
A. Facility Information SEP 16 2008
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
nem
1. System Location: LHE
N OF NORTH ANDOVER
33k
I ALTH UEPAR rl_®
��G��ne�s i�oncl Imo,
Address
Nol�h Anjovic'f
City/Town
2. System Owner.-
Name
wner:Name "
Address (if different from location)
City/Town
B. Pumping Record
Me,
State
O)S,q-
Zip Code
State Zip Code
9'79- a58 - URN
Telephone Number
1. Date of Pumping g_ a6_ Uz' 2. Quantity Pumped: /Soo�
Date Gallons
3. Type of system: ❑ Cesspool(s) [j]Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? WYes ❑ No If yes, was it cleaned? 2"Yes ❑ No
5. Condition of System:
Goof
6. System Pumped By:
J." �all�n� 7L09
Name Vehicle License Number
Wtnj
Company
7. Location where contents were di
Signature of Hauler
Signature of Receiving Facility
t5form4.doc• 03/06'
3 eZ) J--""
Date
Date
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
�N City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
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—
Important:
When filling out
forms on the
computer, use
A. Facility Information
1. System Location:
LAA
�� 5th/ gW:X—s
4
N O V
I
T'D ;
0 2 2007
`
only the tab key
to move your
Address
�i ��
–
,�/� /L
/'1
cursor - do not
use the return
City/Town
/"t
State
Zip Code
key.
0
2. System Owner:
_ ELCnl GT-AMAL_7[�>_
Name
Li
—
—
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
�?/2_1 U
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 System:
Q
System Pumped By:
--
Name Vehicle License Number
Company
7. Location where contents were disposed:
W WT'P
—ft -to
Signature of Haule Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
�1 Commonwealth of Massachusetts --D
City/Town of
System Pumping Record NORTH ANDOVER CirT -0 2Oil
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may besTO N g NORTH ANDOVER
information must be substantially the same as that provided here. Before using this.i ktJ�__u„MENT
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 — - - Important:
When filling oul 1. System Location:forn
he
computer,sc 3 6 Srtrar�nef� �Gt7t� ~� only the tab key Address
to move your �rJ( Qn�Q fGr �,A
- da not
use the return cityrrown r State zip Code
i
use the
key Z System Owner. ('�,�jj
Name.._. E tcf) ,-1 zq(�,f(aj
Address (i difterent from localion) - -
CityRown _ — State – Zip Code
6a7 _
Telephone Number
B. Pumping Record
1. Date of Pumping 9/1aJ i' — 2. Quantity Pumped. /�
Dale ,_,/ Gallons
3. Type of system. ❑ Cesspool(s) M Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe) -
4. Effluent Tee Filter present? yes ❑ No If yes, was it cleaned? Oyes ❑ No
5. Condition of System:
- -- C"Mj -
6. System Pumped By:
_,Jim Glla4 _ ----
�N me Vehicle License Number
�d �,�cr- Envi�ohm��ar
Company
7. Location where contents were disposed:
Signature of Hauler _ iK Date - -
Signalure of Receiving Facility Date
151arm4 doc" 0 106 System Pumping Record - Page t of t
Commonwealth of Massachusetts
sU
of
System Pumping Record NORTH ANDD
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
4012
TOWN OF NORTH ANDOVER
y�L:TH DEPARTMENT
A. Facility Information
1. System Location.-
Address
ocation:Address
-- -'.V�(H'-- _....
City/Town State
2. System Owner:
Name
Address (if different from tocatiort)
City/Town
B. Pumping Record �j
7. -1-/� - ��- 2. Quantity Pumped: /
Date Gallons
3. Type of system: ❑ Cesspool(s) [�pbc Tank ❑Tight Tank ❑Grease Trap
Other (describe): - —
4_ Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No
1. Date of Pumping
Zip Code
State Zi Code
Telephone Number —
5. Condition of System:
6. System Pumped By
Name �
Company
7. Location where contents were disposed:
Signature of Hauler
Signature of Receiving Facility
Vehicle License Number
Date. -- o
il
Date
l5form4.doc- 03106 System Pumping Record - Page I of I