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HomeMy WebLinkAboutMiscellaneous - 340 BRADFORD STREET 4/30/2018 (2)N O W ca O O N m om m o I W fi Commonwealth of Massachusetts City/Town of System Pumping Record 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. A. Facility. Information 1. System Location: Left/ Right front of house, Left/ Right rear of house, Left right'side of house, eft / Right side of building, Left / Right front of building, Left / Right rear of building, Address T3 O City/Town State Zip Code 2. System Owner. Name Address (if different from location) City/rown State Tip Code Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system- ❑ ❑ Other (describe): Data 2• Quantity Pumped: Canons Cesspool(s) 34eptic Tank El -right Tank 4. Effluent Tee Filter present? ❑ Yeas [3'No If yes, was it cleaned? ❑ Yes ❑ No. 5. Condition of t� Zc A„ n � t/`. 411� 6. System Pumped By.- Nell y:Neil Bateson Name Bateson Enterprises Inc- Company nc Company 7. Loc where contents were disposed: 09 G. S. Lowell Waste W, F5821 r Vehicle License Number t DEC H'2013 TOWN OF NQRTh ,-o,- J% c_Fi HEALTI ! Data t5fom4.doe- 06/03 System Pumping Recons • Page 1 of 1 a 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 OCT 2 3 2008 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. A. Facility Information 1. System Location: Left front, left rear, left side of house. Right front, right rearright side of house. Address_ �► o City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: r Ej Other (describe): Stag G e &"4P7 e Telephone Number Date 2. Quantity Pumped: Gallons Cesspool(s) _ eptic Tank 0 Tight Tank 4. Effluent Tee Filter present? M Yes 0-N-0, If yes, was it cleaned? Q Yes 0 No 5. Cond1 inn of System: � 1 c)S_,,(:::j l 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L.S.D Lowell Waste Water of F 5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts CE VED City/Town of S E 14 2007 System Pumping Record y� Form 4 TOWN OF N RTH ANDOVER HEALTH DL' ARTMENT Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ILEI ILC -11 DEP has provided this form for use by local Boards of Health. Other forms may be u but the information must be substantially the same as that provided here. Before using this form, eck 'th your local Board of Health to determine the form they use. The System Pumping Record must miffed to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Address "'— �, 40 (t'>r Cityfrown 2. System Owner:, Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State –I Zip Code State � � Zip Code Telephone Number Date 2. Quantity Pumped: Gallons Cesspool(s) otic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes � If yes, was it cleaned? ❑ Yes ❑ No 5. Conditipn,of Syste�m,�� YYj►v)� Vehicle License Number 7. t5form4.doc• 06103 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of I �" System Pumping Record 006 Form 4 SEP 14 2 �y DEP has provided this form for use by local Boards of Health. The SVtfi' iF011%p ng Resor must be submitted to the local Board of Health or other approving autho i,-. � I 1 A. Facility Information Important: When filling out 1. System Location_: formthe computer, r, use v� 1 only the tab key Address to move your i cursor - do not use theretum Cityrrown key. 2 System Owner: Name Address (if different from loc, CityfTown W ..V Zip Code State Zip Code 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. Condit* o of System:�- 6. Systemu d -6y \s? a� Name Vehicle License Number Company -- . .7. http://www. t5fonn4.doc• 06/03 A/' H V— 0 v n d �i 1 i f � c � I0 E Q 7 V t0 i O � O � L Q f L L UCl 40 f C 1 O E C .-+ U '6 Q C i R C � I v H C � O C Q O Q -D L EYi U O O C r m TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: I-caQk (example: left front of house) t S DATE OF PUMPING: QUANTITY PUMPED 10 O- L GALLONS CESSPOOL: NO /YES SEPTIC TANK: NO YES v/ NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY - COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) 0 CONTENTS TRANSFERRED TO: • L- ` TOWN OF N, ;VJO\f� SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS 'NOA-1 ayvtD r SYSTEM LOCATION (example: left front of house) 14 J)adL j ko ug— DATE OF PUMPING: QUANTITY PUMPED: (� c7 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE f 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: i L S' �'. CONTENTS TRANSFERRED TO: `7" TOWN OF-- FJ°� SYSTEM PUMANG RECORD RECEIVED DATE: - 51-o SYSTEM OWNER & ADDRESS �0 �fQd�vd SYSTEM LOCATION (example: left front of house) SEP - 3 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT (), — Lo ut DATE OF PUMPING: t QUANTITY PUMPED: 0 0-0 GALLONS CESSPOOL: NO f YES SEPTIC TANK: NO 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: G.L.S.D J Lowell Waste STATEMENT' Tel. (508) 475-4786 Bateson Enterprises Inc. 111 Argilla Road • Andover, Mass. 01810 Aug;. 12 19 -93— F- -I Mr. Joseph Mangano 340 Bradford Street ' North Andover, Ma. 01845 L J To insure proper credit please return this stub with your remittance. AMOUNT s 135. 00 DATE DESCRIPTION AMOUNT 8/11/93 Pumped Septic Tank $135.00 Bateson Enterprises, Inc. - Andover, MA 01810 SEPTIC SYSTEM INSPECTION FORM ADDRESS �� DATE INSPECTED j PROPERLY FUNCTIONING? N WEATHER CONDITIONS COMMENTS: WAVER QUALITY i'ES! Eb n lzesocrs? DYE TEST PERFORMED? Y N DATE? SKETCh: WATERSHED RESIDENTS QUESTIONNAIRE 1. Name r d ri ej a 2. Street Address to 14 5�� UA�1 Y- 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool �' septic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ;M111 yes ❑ no ❑ do not know 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years 11-20 years ❑ over 20 years ❑ do not know 7. Has your se wa a disposal system been rebuilt or repaired? El yes no ❑ do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? $. annually ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never 9. Have you had any problems with your sewage disposal system? ❑ yes. no If yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine —j— dishwasher garbage disposal dehumidifier drain sump pump toilet roof/pavement drains shower/bathtub �- 11. Please state the brand a d type (liquid or powder) of detergent you use for: dishwasher 00 clotheswasher 12. Does your property have a lawn? yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/2 acre 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. How often do you fertilize your lawn? No. of applications per year V Season(s) of the year 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: —W15n* ❑ Check here if your lawn is maintained by a professional landscape contractor. s t �h111u11anry nllll uC h�aaaa�liu:tellla flow 1�yA1�111 � 11YIl�'1 __.^ -- WIP 1)( 11111111411". i� t `�-- � � � 1����►Iu y 1�u11y�ed: l �-'t��uuu� �'aA�11u111 HIP I`'� �'�A � � Sepik; J Nnk Nu l) 1'es 81010I11 by: j'(Ire4ofs e#&011 O I.Icellea # .--------_-.--- l'�m1a1dR 11A11s1�111Fi! It1 � �!u!!!�-1,�r�uul�l�-hlhll�►lt-1�!!�!�! __-- - Ills peclul : _- - — - -_. TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: ✓ 1 SYSTEM OWNER & ADDRESS SYSTEM LOCATION Kaj'14- c�Aka (example: left front of house) 19 2001 ' DATE OF PUMPING: QUANTITY PUMPED C GALLONS CESSPOOL: NO /YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: 6 - FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) Commonwealth of Massachusetts City/Town of W° System Pumping Record ,M Form 4 �'Jv 7f(.1 TOWN OF NORTH ANDOVgR DEP has provided this form for use by local Boards of Healt 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 L Address\ - �-" -4 e 0 - �-- k 0 J': -:-, � City/Town 2. System Owner: ! �L OLA, Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code State � iQ Cpde Telephone Number Date 2. Quantity Pumped Cesspool(s)eptic Tank i OcwD Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: � V\- (-6 6. System Pu By: _� _ A�d �-s-;Fs-a-1 Name Vehicle License Number Company 7. Location where contents were disposed: GICS.D. � owdll WasteMater Signature Date C')—C�-,-s — (v t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massach City/Town of System Pumping Record Form 4 M OF-CEIVED OL 1 3 0 2009 L TOW OF R�Ur� r,NDOVER DEP has provided this form for use by local Boards of Heap r„ pther,fotTlas_zmay a used, but the information must be, substantially the same as that prow dem here. a ore using is 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 other approving authority. A. Facility Information 1. System Location: Left side of hous Ri ht side of house Left front of house, Right front of house, Left rear of house, Rpt rear pf(housqe. Left fear o uilding. Right rear of building. Address City/Town 2. System Owner: A Name Address (if different from location) Cityrrown B. Pumping Record State Zip Code State Zip Code 011-00-1 Telephone Number 1. Date of Pumping t ©— (S_ 2. Quantity Pumped: � ©o () Date Gallons 3. Type of system: ❑ Cesspool(s) Ell -Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes LK No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: IM 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Loca�tionn where contents were disposed: G.L.S.D� Lowell Waste Water J 'e ( F5821 Vehicle License Number 1 c)- l ':3�- v Signature of Hauler Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEIVED W° System Pumping Record Form 4 NOV 12 2�12 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other forms6A§%:UWMEMT 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 / Igh side of ho eft / Right side of building, Left / Right front of building, Left / Right rear of building, Under Address <3 + -.4L&", Cityrrown State Zip Code 2. System Owner: nA Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): StateZi Code e- ,-a�� Telep one Number Date 2. Quantity Pumped: Gallons Cesspools)Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: t 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locatio ere contents were disposed: G.L S. Lowell Waste Water F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record •Page 1 of 1