HomeMy WebLinkAboutMiscellaneous - 340 SUMMER STREET 4/30/2018J
�
Lot & Street `
r� � � � � Map/Parcel
CONSTRUCTION APPROVAL
Has plan review fee been paid: YES NO Permit# / 0 0 3
Plan Approval: Date: ,2/9 Approved by:_,,"
Designer: / f k e jly) /ICA::� Plan Date: / -1�
Conditions:
Water Supply: Town
Well
Well Tests: Chemical
Bacteria I
Bacteria II
Plumbing Sign -Off:
Comments:
Well
Driller:
Date Approved
Date
Wiring Sign -Off:
Form "U" Approval: Approval to Issue:
Date Issued By:
Conditions:
Final Approval:
All Permits Paid? YES
Well Construction Approval? YES
Septic System Construction Approval? YES
Certification? YES
Other S
Any Variance Needed? YES
FINAL BOARD OFPE LTH APPROVAL:
DATE: �
APPROVED BY: - 1
NO
NO
NO
NO
NO
NO
NO
SEPTIC SYSTEM INSTALLATION
Is the installer licensed?
Type of Construction:
AYE SR NO
NEW) REPAIR
New Construction: Certified Plot Plan Review
��
r
Floor Plan Review
e,`YESJ
w
i
•
SEPTIC SYSTEM INSTALLATION
Is the installer licensed?
Type of Construction:
AYE SR NO
NEW) REPAIR
New Construction: Certified Plot Plan Review
��
NO
Floor Plan Review
e,`YESJ
NO
Conditions of Approval from Form U
YES
Issuance of DWC permit:
S NO
DWC Permit Paid?
YES
NO
DWC Permit # Installer:
..
,;.v r -
----J�
-S;�
Begin Inspection:
Excavation Inspection:
Needed:
- .E,Z El PAPP
Construction Inspection:
Needed:
S
jg NO
% 0,4
-:� Approval of Backfill: Date: Z/ld )QCT By:��
`�
Final Grading Approval: Date: 42 Y f By:
Final Construction Approval: Date: By: 7
Certificate of Compliance: Approval: Date:
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE:
12/09/99
This is to certify that
the individual subsurface disposal system
constructed (x) or repaired ( )
by
William Sawyer
at
Lot 2 Summer Street
has been installed in accordance with the provisions of Title V of the State Sanitary Code
and with the North Andover Board of Health regulations as described in the Design
Approval Site System Permit # 1003 dated 2/24/98.
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
Board of Health Inspector
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AS BUILT PLAN ToP Pr-.�-I^r�,
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SUBSURFACE DISPOSAL SYSTEM
LOCATED IN 0
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SACHUSE
Town of North Andover, Massachusetts
BOARD OF HEALTH
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Form No. 2
/ �g
Applicant aoPC6-y �%CV�LD�/L��/�% Test No.
Site Location G� .
Reference Plans and Specs.
ENGINEER U DESIGN DA
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 100 3
Commonwealth of Massachusetts
_
p 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 / i ht front o —sa' 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
og ls
City/rown state Zip Code
2. System' Owner.
Name
Address (d d'rfferent from location)
Citylrown ' state Zip Code
q 7- � 4�,6
Telephone Number
B. Pum -ping Record
1. Date of Pumpingdate 2. Quantity Pumped: Gallons -?
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yep No If, yes, was it cleaned? ❑ Yes ❑ No;
5. Condition ofd
s: System Pumped By: MAY 7 2014
Neil Bateson F5821
Name Vehicle License Nt mTAVVN OF
Bateson Enterprises Inc HEALTH DEPARTMENT
Company
7.
contents were disposed:
0orm4.doc- 06/03 System Pumping Record • Page 1 of 7
Commonwealth of Massachusetts
City/Town of
° System Pumping Record
Form 4
s+°
DEP has provided this formlor use by local Boards of Health. Other i
information must be substantially the same as that provided here. Be
local Board of Health to determine the form they use. The System Pu
the local Board of Health or other approving authority.
RECEIVEu
JUL = 2 2012
y be used, but the
your
:d to
A. Facility Information
1. System Location: Left / , De-ftl-Right.rear of house, Left / right side of house, Left /
Right side of buildi eft / Right front of building, Left / RI t rear of building, Under deck
Addr ss',7 t✓ V� U
City/Town State Zip Code
2. System Owner. 1
Name
Address (if different from location)
City/Town Stat�jp
��_3 �s e
C
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qu ntity Pumped: Gallons
3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. ConditiSystem:
6. System Pumped By:
Neil Bateson F5821
Name
Bateson Enterprises Inc
Company
7. =L_Q
re contents were disposed:
Lowell Waste Water
fVO.t
Vehicle License Number
Date
t5form4.doc° 06/03 System Pumping Recons ° Page 1 of 1
TOWN OF NORTH ANDOVER�� 's�oa'';
SYSTEM PUMPING RECORD
c�9
r t
� MAY 12
2003 1
DATE:
a
SYSTEM OWNER & ADDRESS
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: � I Li i2 QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC 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: ��-A- - I AA -en
COMMENTS:
CONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System 00 constructed; ( ) repaired;
by
located at " a. - S- T'S' 1 &Qr 21
was installed in conformance with the North Andover Board of Health approved plan, System
Design Permit #10v 3, dated a o� - %g- , with an approved design flow of L1140
gallons per day. The materials used were 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 plan. All work is
accurately represented on the As -built which has been submitted to the Board of Health.
Installer: `rp l Lic. #:
Design Engineer,5DM-.��)Colt�
r i
DEC — g I;a
J
Date: t'
Date: II - l714(
AS -BUILT CHECKLIST
P/
LOT NUMBER, STREET NAME
ASSESSORS MAP & PARCEL NUMBER
LOT LINES & LOCATION OF D WELLINGS
. /
LOCATION & DEMENSIONS OF SYSTEM,
INCLUDING RESERVE
v
TIES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
y
- ELEVATIONS OF DISPOSAL SYSTEM
v
TOP OF FDN ELEVATION
LOCATIONS OF WELLS, DRAMS, WATERCOURSES
W/N 1 50' OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
—�
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
STA2\9 & SIGNATURE
L% PERVIOUS AREAS -'DRIVEWAYS, ETC.
(/
NORTH ARROW
FINAL CONTOURS
LOCATION & ELEVATION OF BENCHMARK USED
LOCUS PLAIN.
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: 1_1 iIq C/
CURRENT INSTALLER'S LICENSE#
LOCATION: & 4 a- Z _! ooAg/n e
LICENSED INSTALLER:
SIGNATURE: TELEPHONE#
CHECK ONE:
NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
$75.00 Fee Attached?
Foundation As -Built?
Administrative Use Only
Yes__; / No
Yes No
Floor Plans? Yes No
Approval �__._ Date-. 9
•-
Y
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*APPLICANT FILLS OUT THIS SECTION*
APPLICANT L✓� �„� , 7� A'i 't -4 y. 4 (�
LOCATION: Assessors Map -Number
SUBDIVISION
STREET
PHONE
'.v
PARCEL
LOT (S)
ST. NUMBER �5
*********-*******-******** 0 F F I C IA L USE ONLY**
RECOMMENDATIONS OF TOWN AGENTS: -
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
Q �,4,(A (,v
TOW LANNER-'
f�
COMMENTS
FOOD INSPECTOR -HEALTH
C IN ECTOR-HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
M
LIC WORKS - SEWER/WATER CONNECTIONS
PUB ll I1 .11
DRIVEWAY P RMIT
FIRE DEPARTMENT(O/L
RECEIVED BY BUILDING INSPECTOR
DATE
PLAN REVIEW CHECKLIST
ADDRESS % cZ 5L,IMMeZ 57-, ENGINEER MG--,Pe1 M%4G,C
GENERAL
3 COPIES STAMP LOCUS NORTH ARROW ✓ SCALE
CONTOURS PROFILE � Sc) SECTION L--� BENCHMARK L, --'SOIL &
PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS
WATERSHED? -AZ&/ DRIVEWAY WATER LINE V FDN DRAIN M&P L-,--'
SCH40 TESTS CURRENT? SOIL EVAL
SEPTIC TANK /
MIN 150OG V .17 INVERT DROP GARB. GRINDER/t/O (2 comps +200)
10' TO FDN .L,--' MANHOLE ELEV GW ## COMPS. GB
D -BOX 2
SIZE ## LINES FIRST 2' LEVEL STATEMENT v�
INLETS 3. 94-- OUTLET 7 ( 2" OR .17 FT) TEE REQ' D?
LEACHING I /
MIN 440 GPD?`' RESERVE AREA �4' FROM PRIMARY? 2% SLOPEC---
100' TO WETLANDS �� 100' TO WELLS. 4' TO S.H.GW (5'>2M/IN)
20' TO FND & INTRCPTR DRAINS L--- 400' TO SURFACE H2O SUPP.�-
4' PERM. SOIL BELOW FACILITY MIN 12" COVER ILL? �5')
BREAKOUT MET?
TRENCHES
MIN 440 gpd SLOPE (min .005 or 6"/100')_z SIDEWALL DIST. 3X EFF.
W OR D. (MIN 6') C% RESERVE BETWEEN TRENCHES? IN FILL? L. MUST
BE 10' MIN. 4" PEA STONE?_Z VENT? 0/L (>3' COVER; LINES >50')
BOT PD + SIDE 'f2 -6-` X LDNG % = TOT M ?41
(L x W x #) (DxLx2x#) (G/ft2)
Copyright 0 1996 by S.L. Starr
'y'� 5^• sift. .l� I tW a!a •s «•V! � t• t
iR{:...�u ..,.2' •"'a.•»j j•,jG l:t= "��Y.. '.•J%c.',� �
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7 I � `-�s'ys/�,_ . l:Jil�l ,J I_(✓ ' Yi J4�J . i.:i.K '� �-i y s t.
_ yrs. ry 4Z = �r i� 1� /e `� 64BS .5� �5�'' z :r,; 1 ,
— _ i J � �t.t.--k.r � t' r
C6.6 I ria ss I iA'ie
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CGL? S� . i�TS_TD
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LOCA
#-,,410 -2 �5-"
NEW PLANS:
SEPTIC PLAN SUBMITTALS
$60.00/Plan
REVISED PLANS: YES $25.00/Plan
DATE:
DESIGN ENGINEER:
When the submission is all in place, route to the Health Secretary
NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
FEE:PERMIT ## DATE RECEIVED is ICT
APPLICANT MAP PARCEL -44+46
ADDRESS LOT #
ENG. M&UIMACC ST.
ADD.
PLAN DATE REV. DATE
__. CONDITIONSOFAPPROVAL
APPROVED DISAPPROVED
REASONS FOR DISAPPROVAL:
FORM 11 SOIL EVALUATOR FORNI
Page I
Date....
No. ...................................... Commonwealth of Massachusetts
WoM AWWVMR, Massachusetts
a
Performed By: Dv..f:. M-SWE� ................ ....
Witnessed ....
By: ......................... . .....
...
................ I
............................................................................................
............................
..........
.....................................................................................................
Lmdo AMM OF
L. I z CV M H e- V, 51—.
5
Poe: -nom or -r.m.*36 PAV-.
New construction Fr Repair - 11
owwa NM. dor4ol
M*W. am 5e) "P(A-( 091%ld
Tekpbm I HIST14 V f- W, H A - 6V044
Published Soil Survey Available: No El Yes
Year Published ...j4I Publication Scale .11.15. .640 Soil Map Unit
Drainage Class ..C� ......... Soil Limitations ......... SfNgjge!� . ........................................ (t . A!ZVTA.y-4
Surficial Geologic Report Available: No ❑yes
❑
Year Published 777777— Publication Scale ..................
GeologicMaterial (Map Unit) ..... . . . . . ............................................................................. . ..................................................
777— ..................................................................................................... .... ......
Landform ......................... I ........................................................................
(�' 2��
Flood insurance Rate Map:
Above 500 year flood boundary No ❑ Yrz
Within 500 Year flood boundary No Yes
❑
Within 100 year flood boundary No Yes El
Wetland Area:
National Wetland Inventory Map (map unit) ....... OAJ ...... S., -W . ...... ................
.................
Wetlands Conservancy Program Map Imap unit) 7 .........................................................................
Current Water Resource Conditions (USGS): Month XV4W-V'
Range Above Normal El Normal I Below Normal El
Other References Reviewed:
a
* 12-3
* I-ZLj
I,ORNI t I - SOR, EVALUATOR FORM
Page 2
Deep Hole Number 1.41J.'N Date:.07�1�91 Weather
Location(identify on site plan) ....5 - RAW . . ........................... f ........ ................. ........... ......... ................................................
Land Use Slope (%) ..Za-. Surface Stones .....i=E W..... .......................................................
Vegetation. ............................................................................... .............
Landform...... NQ.M.114f� ........................................................................................................................................................................ ......................
Position on landscape (sketch.on the back) ............... I ..................................................................................
Distances from:
Open Water Body .......W 4feet Drainage wav�SO f7 feet
Possible Wet Area 1.0 .. :tfeet Property Line .....1.U......+... feet
Drinking Water Well -10.0.t feet Other ............ . ......................
DEEP OBSERVATION HOLE LOU
Depth from Surface
(inches)
Soil Horizon
Soil Texture
(USDAI
Soil Color
(Munsell)
Soil Mottling
Other
(StruS
ctuto to Boraulders,
%tones,
Co, Gvel)
AP
F-S.L.
LOA M,(
5Y 6,13
9+\'/'
SN 6113
AP
2216\11231(0
22 11" 96>11
6 ?AV,
5\/613
5\12 q ho
-H� fZ
Parent Material (geologic)..... I-
.
................................................... Depth to Bedrock: ..WA............
pel3th to Groundwater: Standing Water in the Hole: Weeping from Pit Face:
Estimated Seasonal High Ground Water: 30.hw.
I
FORA, 11 - SOEL EVALUATOR FORM
Page 3
❑ Depth observed standing in observation hole ................... inches
❑D pth weeping from side of observation hole
inches
Depth to soil mottles 3P1..Z`I inches
❑ Ground water adjustment .. feet
�—
Reading Date Index well level ...................
Index Well Number 9
Adjustment factor'".- Adjusted ground water level ........................................................
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system?
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on (date) I have passed the examination approved by the
Department of Environmental Protection and that the above analysis was
performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017.
Signature
FORM 12 - PERCOLATION TEST
COMMONWEALTH OF MASSACHUSETTS
WoM RLJWVf!�IZ , Massachusetts
Site Passed Site Failed ❑
Performed By: 1,6S 601) I N
Witnessed By: giz �o�OLO
I
...................................................................................................................................
Percolation Test
Date: ........
6..I,STime:
R-11 ...................
Observation Hole #
P (Z3
Depth of Perc
,, ,,
SO + ZO = 5-0
,,� ,,
3� t zoo = S;& I,
Start Pre-soak
1:11
l'-ILl
End Pre-soak
Time at 12"
1'Z9
Time at 9"
l 'qC)
3Z{
Time at 6"
5-7
1:L43
Time (9"-6")
Rate Min./Inch
Site Passed Site Failed ❑
Performed By: 1,6S 601) I N
Witnessed By: giz �o�OLO
I
...................................................................................................................................
TOWN OF
SYST:
DATE:
SYSTEM OWNER & ADDRESS
C0(
G RECORD
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: _ ' 0 QUANTITY PUMPED : Q v GALLONS
J /
YES SEPTIC TANK: NO YES a/
CESSPOOL: NO S
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 Lowell Waste
J
Commonwealth of Massachusetts --,EE1
City/Town of .�
¢
� System Pumping Record T701�vl,�
G 13 2007
Form 4
M , NORTH f,NLDEP has provided this form for use by local Boards of Health. Other fou.'At3tTitfhe
information must be substantially the same as that provided here. Before using this form,, che%k wl�nn h 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
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
r�rrn
1
System Location:
C1 V
Address
Citylrown
2. System Owner:
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
State
' ?-4C)
Date
Zip Code
State � 9Z' Cod
Telephone Number
2. Quantity Pumped:
Gallons
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:
6. System Pumped By:
Name Vehicle License Number
V In
Company
7. Locationwlnere conteqLsNwe)disposed:
c.i 46 of ai dar Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
MERRIMACK
ENGINEERING SERVICES INC.
Engineers * Surveyors • Planners
66 Park Street
ANDOVER, MASSACHUSETTS 01810
(508) 475-3555
Fax (508) 475-1448
To 50APD Or HEAL -CH
TOw��'p psa,� -Cs C}f `F `': Y FI
WE ARE SENDING YOU ❑ Attached 1 ❑ Under separate
>
❑ Shop drawings ❑ Prints
❑ Copy of letter ❑ Change order
❑ Plans
DATE 1
t
JOB NO.
ATTENTION
S'A >kbS iZQ
RE:
LOTS 1 4 Z SL,H m(5512 S T ::
❑ Samples
the following items:
❑ Specifications
COPIES
DATE
NO.
DESCRIPTION
l
t2-2q-�7
1
SDI L 15VAL.. • CvT00
1
12-28- q'
600,
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THESE ARE TRANSMITTED as checked below:
For approval
❑ For your use
❑ As requested
❑ For review and comment
❑ FORBIDS DUE
REMARKS
❑ Approved as submitted
❑ Approved as noted
❑ Returned for corrections
19
❑ Resubmit copies for approval
❑ Submit copies for distribution
❑ Return corrected prints
❑ PRINTS RETURNED AFTER LOAN TO US
COPY TO
SIGNED: UF—s
r
If enclosures are not as noted, kindly notify us at once.
Commonwealth of Massachusetts
City/Town of ,
\\ J_
System Purhping Record DECEIVE®
Form 4 0 2009
OCT 3
DEP has provided this form for use by local Boards of Health. Oth r forms may be used, bgt e
T ynua
information must be, substantially the same as that provided here. p aAh k with your
local Board of Health tQ determine the form they use. The System u ust be submitted to
the local Board of Healthmoth r approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of hous ht front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address
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: ❑
❑ Other (describe):.
Statgr� _Zip Code
Telephone Number
(0rD-6 -d 9
Date 2. Quantity Pumped:
Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes BITO
5. Condition of System:
Y\ t'?-) Cj_A
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where. contents were disposed:
Lowell Waste Water
Signature of Hauler
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
to -& --�
Date
t5forrn4.doc• 06/03 System Pumping Record • Page 1 of 1
r
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
4ev.
rerun
Commonwealth of Massachusetts
City/Town of No andover
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 awthority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
Address
No Andover Ma _
City/Town State Zip Code
2.
Name
Address (if different from location)
City/Town
V State
Zip Code
Telephone Number
B. Pumping Record
r
1. Date of Pumping Date Quantity Pumped: Gallons n
3. Type of system: ❑ Cesspool(s) • eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped
By: %. J
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01
Signature of Hauler
Signature of
e
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1