HomeMy WebLinkAboutMiscellaneous - 385 FOREST STREET 4/30/2018O w
Q� w
�1' T
D 0
o m
CAcn
cno
o m m
o m
o �
�j
Commonwealth of Massachusetts
City/Town of
System Pumping RecordREC
�IV®
Form 4
DEP has provided this form for use- by local Boards of Health. Other forms ay be uAd; but-the0
information must be substantially the same as that provided here. Before u Iriothisjopm, check with your
local Board of Health to determine the form they use. The System Purn >� c. b71m""' "4iUbmitted 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, rig side of house Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
LQ
Address (if different from location)
City/Town state&
de
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
Date 2. Quantity Pumped:
Cesspool(s) eptic-Tank
Gallons —�
❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes F1 No:
'6. Condition of " m:
6: System Pumped B;5
L)C��
Neil Bateson
Name
Bateson Enterprises Inc -
Company
7. LocabopAvhere contents were disposed:
aL S -M Lowell Waste Wi
s l
F5821
Vehicle License Number
t5fomt4.doc• 06/03 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.
`..v( 786
renes
http://www.
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER,
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.
A. Facility Information
1. System Location:
3m-
Address� 9
City/Town
2. System Owner:
Uve- U%
Name
Address (if different from location)
City/Town
B. Pumping Record
HA-
State
(DC,9- gs''
Zip Code
State_ es ` Zip Code
Telephone Number
1. Date of Pumping Date 2• Quantity Pumped
-1.
Gallons
3. Type of system: ❑ Cesspool(s) ❑optic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑-lqo- If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: t
ri c�' � \
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
htm#inspect
� — (7-0
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
r
ys�Jt�4,x' liF'ruJt.
V-1
k+[Jii 19-11 1 ,fid '. r+ ) t r r
�•µ.� S�.} :I t1ji Tr r "Alf.a,'7MN Al t j6 �I 1'1�'�0 ���I 1 F':1xvr
I R A. }( (•1 r�d,�? 1 r Gl �, 4 s A"' • i 'f r� , °•S r'
t. �,ty Ji sy W"i. A Nirlf i%t' St •� 1
• 'ai y
r 1 'G ��,1 �''.�. ��iC.�•u `Ali y�ixtl !''�iY� ,/,.1 it, i � S • • s F ' ,j�"S !+I. ' � '� r ' •
g��S�ft
,�y+k
�Krfly�' t(Te'"l+,t:_l q tJ! r f 'y., 11 r} •
rr ' .!' t,A S'�r`'' ' i fd � 5.•jt" ,�tJ
j �' !��i irl'< t} A � Mt.v �''4��jFl;I.`�71"f+, .,�},n;��i�• �` , .n• r ti�1 s� r %S%
`P -F1i' } �rx Jl't !1'' M, r �X •.,. Aj. -7;.. ,1 k ry. a 5t1 r, ,
7 t_)
F�� f
iM• ilia +� v h 1 S • t � f '� . C
.
ANDOVE
d SX(`��hL�w R
Y., . L �j�/1 PUAVING 'RECORD
-n
+riff•,. .r •:.' ri /1 .._,r
1,
:ss
r7r
•�'';1Virh�Ylyr ti v rt �i 1�! € !{} r i. .a j t'r 1" �L. 1.,• .
ifyS') •1 i,yr 4 {�,. 1 , t'ihY t X � + '�„•" k•N, -
t
ti 17 •4F1,I.r,1y .'��.j * Y ...r.f f! 't y, Y' 1 I� id E t'Jy r t .r•'..
a.s'. gill ,il• .rdowQ ': 7
f' ���i�,'+� O�ER � •+> of ,,°y ASI F} ,,+ ` ; •
�.Ir'ti t • ..
� �1r , a,`4 i 'a4: R S S LpCATI
orf r ON
�:. � �• :1�t't fi�oot
of bo
•. ��� : ' rpt ,, ,_ • � � 11m)
+ . ' ki + t _1�r+�SKY(,1+tai p1 r; �� � � ���� trr • 1
#Jt It y r' r y r
• f!,srA F. �' •', t S r• wifClf,a °o � •
� + t
tr jC75„ P.
Y f".,lo-now
P le.p y 3a+ If l a r I �iRy i f r. •"'+
RT• �+P. ^
41I .. S '�S• f Q�i�� LT'�Llf
VMPEDl Qd�GUJ
/ lj 1ifrt ' ” JJtUr•'�Sd�,M1E,r,+.N y' f � t p _� NS
} (`�. f^,� Lam• � CC� r�r' 'i F1
NO'"""-iS+I�
'IC TANK NO
01
VV. 't ' 1 ::. ,€.' r.! i'�,! 4y FY .'1.�� �' - q. .i t • J•n f
4� s'�" Jf tl r(-+,i�`a I :.' f' p ,• :AO*u .-, ry. {��.��,•!t..'.
• RdERGENCY
:+ • ����'VF�'�1t5�i14+r�1•�ll�:f[M}'R'��tt {Et *t,r tir] r. �.�,,�,.� , .. �f� .
Y'4�!1!ONC� r s
o,
FULL TO
COVER
a V t
'�"„yMi •($��.tt i .: tlt OOTS !�►
y,,. �.I�PFLES IN PLACE
f C r� 't EErt�•�.�.71 m SOLIDS bT�.ji�
. , Jfr AVL A
SODS CARRYOVER "...I.”. FLOODED •�.��
I ::fi�rrf .. .off .
If
• f of iI`+"1
It
•t."t�rly'''vn�tuj: ,,fr Z'lvq
1 .�r
F .lit
r eY�,{I tk �'•.I��Sd?, X, 1+ait.h"#
r ee
dt rye/Ilkiiiiiiiiiiii p,
t 1
�r
S�llspr7pi, t!+{ 7�Ra11[R` ( ,k • '.t �r fN y VV --
' :l'•a .o `ri "!•I� ^���r€p 1:�'(ilf�7'it,'�l�r� 1A 4JV�1,1y�e �f1,}f *:• .,
,j,f v + ' . } h yh �, f r ry , i1� ,•r1 MMM��� '" i'1) 1 I� ,1 .jt f tl �'� i .
r
, ,. ftr�j�r.+�`r','r�x}7.J 4 � t t{Y�t�r �L"''S' r/� . i � --•• — ...16 ,
TOwN OYNORTH ANDOVE
gvM 0,� JioRfo
W r HE" f,
SYSTEM P
UM.PINGRECO j
SYSTEM
WUATION
:1-19 Afrout of house)
0
ANAMA.- ��QVANTrry Pumpim
1006 GALLONS
OLO NO''
SEPTIC TANK: NO YES
0 .... .... ....
EMERGENCY
T� 7"0tll
001,
MAN
I
•
rlf, OD
�FGO
FULL To COVER
HEAVY GREASE
ROOTS. BAFFLES IN PLACE
-ANNLEACYOULD RUNBACK
EXCESSNESOLIDs.
TEED#Q�MSCARRYOVER(ExPLAN)
r EX ll I Y�
RAI
140
47 0,- Ca
,'A
i
-Z"
0�
E
10—
z
us
1
00
o
0
-7�
o It
z<
3.1 w
—10
O
CR
CD
E
m
c
j
IQI
"J
'N
5,
cc
�NN
"'t
Ln
(6 trz
co
m
O
T
N
c)-4-
Lo
I
co
I
r--
co
a)
OPil