HomeMy WebLinkAboutMiscellaneous - 518 SALEM STREET 4/30/2018 (2) i
518 SALEM STREET
38.0-0105-0000.0 - ----------------------- - - -- -
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i
I
Commonwealth of MassachusettsCEI ED
City/Town of
S stem Pumping-Record
YS 1014
Y TOWN OF NORTH ANDOVER
�~ Form 4 HEALTH DEPARTMENT
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 houseA@,// ig rear of ho , Left./right side of house, Left/
Right side of building, Left/Right front of b . ng, Left/ Ig rear of building, Under deck
Address Sa_4e/ "O`n
City/Town state �S Zip Code
2. System Owner. /
Name
Address(d different from location)
Citylrown Stat �� _fZiR Code ;
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system. ❑ Cesspool(s) Septic Tank El -right Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YeANo If yes, was it cleaned? ❑ Yes [3 No
5. Condition f
6. System Pumped By.
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GL Lowell Waste Water
t �C
Sig Haul Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
I
Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record AUG 13 2008
k9i
Form 4 TOWN OF ti'v'RTH ANDOVER
HEALTH DEPARTMENT
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
Important:
When filling out 1. System LOcati
forms on the
computer,use
only the tab key Address
to move your `"eA.,A�a4
cursor-do not
use the return Gityrrown State' Zip Code
key. 2. System Owner:
as
Name
1 1 Address(if different from Dation)
Cityrrown State i ` e ip die
17
Telephone Number
B. Pumping Record
LS�
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 f�f4o If yes, was it cleaned? ❑ Yes ❑ No
5. Con 'tion of Syst ��� e J
6. Systenj Pu ped J�y.
Name I (C Vehicle License Number
Company
7. Location a Conten s Isposed:
LM'
Signature fHaM Date
t5form4.doc^06/03 System Pumping Record^Page 1 of 1
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 hou , L Rig rear f ho . , Left/right 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
Address(if different from location)
City/Town ' State e I � < Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qua 'ty Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No;
5. Conditionlof System:
6. System Pumped By: R CiLf f'L:D
Neil.Bateson F5821
NameVehicle License Number I
Bateson Enterprises Inc
ConpanyTOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
7. Lo a contents were disposed:
Cy S'. Lowell Waste Water
Sign Haul Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts ED
City/Town of
System Pumping Record JUL 012013
Form 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for uselby local Boards of Health. er orms 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 hous�Rig ear of hous. Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address -
'Y"��
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State 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:
6. System Pumped B
Y Pe By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
I•-S.S. Lowell Waste Water
SignAtufe Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
I
Commonwealth of Massachusetts
City/Town of L ,
System Pumping Recordr � �U1Z
Form 4
DEP has provided this form for us&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 LocatioO�Le /Right front of house, Left/Rig f , Left/right side of house, LeftRight side of bu , Left/Right front of building, Left/Right rear of building, Under deck
Address Sc:?A-�— <S A
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qua umped: Gallons
3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If es was it cleaned? Ye
y ❑ s ❑ No.
5. Condition of Systerr>,: -
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo re contents were disposed:
Ca.., S. Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth.of Massachusetts
City/Town of I DEC 18 2006
System Pumping Record
Form 4 TM, )AVER
HEALIn mt-NT
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
Important:
When ruing out 1. System Location-
forms
occation forms the
computer.use
only the tab key Address
to move your
cursor-do not /
Gity/Town Zip Cade
use the return State
key.
2. System Owner.
Name
pcio Address(if different fromaocation)
Cityrrown
State Zip Code
Telephone Number
B. Pumping Record
fi: _Date.of PumpingDate 2. Ouantity Pumped:
Gallons
i
.3. Type of system: ❑ Cesspool(s) .[Septic Tank- . El Tight Tank
❑ Other(describe).
4: Effluent Tee Filter present? ❑ Yes DINO If yes, was it cleaned? ❑ Yes: ❑ No
5. Conditi n of Syste
iA-
6: System Pumpkl By
r.
Name V
ehicl
e-License Number
Company .
7. LocatI here cont` is disposed::
Signa'' re f: uler Date
h.ftp://wwW.mass.gov/de ateri4optovait/t5forms.htm#inspect
t5form4.doca 06103 System Pumping Record•Page 1 of 1
Commonwe lth of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
Date of Pumping: �`� �� Quantity Pumped: 14�_-I`��allons
Cesspool: No [.] Yes [] Septic Tank: No [] Yes
System Pumped by: 64&40* License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
a
a
Cotnnionwealth of Massachusetts
TOWN OF NORTH ANDOVER/
x i Massachusetts BOARD OF HEALTH
o }
System Pumvinu Record ' —�--- -----
Systent Owner System Location
uantit Pumped: allotns
Date of Pumping: . C: , Q y g
I
Cesspool: No Yes U Septic Tank: No U„ Yes
System Pumped by: 641004 License#
P
Contents transferrred to : Greatet Lawrence 8aiiltarV District
Date: inspector:
i ',
FORM 4- SYSTEM PL11PM RECORD
� o
Commonwealth of Massachusetts
Massachuset
System Pumping Record
system Owner Systern Locatjon
SQ�zva-
J
Date of Pumping: -( � Quantity Pumped: ZhZ) gallons
Cesspool: No Yes ❑ Septic Tank: No ❑ Yes El
System Pumped b.': —
License
#:
Contents transferred to: �'
Date Inspector _
TOWN OF wer
SYSTEM PUMPING RECORD
DATE:_
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
j
5 �
DATE OF PUMPING: QUANTITY PUMPED : 1000 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE__z 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: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
T OF K, lhv'K
SYSTEM PUMPING RECO"
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
cAct` A0 (e"mple:left front of Loose)
6'cy, 6us--c
DATE OF PUMPING: QUANTITY PUMPED : Q c0 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
7
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIWIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
coNTENTs TRANsFERRED TO: G.L.S.D Lowell Waste
Commonwealth of Massachusetts RECEIVED
City/Town of APR 2 9 2009
a System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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
Important:
When filling out 1. System Location: Left fron , lefty ear, ft s' a of hous . Right front, right rear, right side of house.
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
CitylTown State6g_, 9,/ Zip Code
Telephone Number
B. Pumping Record
q
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: 8 Cesspool(s) _ eptic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes B-N-0� If yes, was it cleaned? Yes No
5. Condit! n of System-
_
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location._where contents were disposed:
L.S.D Lowell Waste Water
7Y F-o,3
��
igna ure of H Or Date
t5form4.doc•06/03 ' System Pumping Record•Page 1 of 1
Septic System Information
518 SALEM STREET
Printed On: Wednesday,August 13, 20
System ID: BHS-2002-1394
General System Information Latest Permit Information
Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench
Design Flow: One TWO Capacity: Number:
Design Flow Provided: Minutes per inch: Width: Width:
Total Flow: Depth: Length: Length:
Seasonal: No No Depth to Water: Diameter: Leaching:
Grinder: No No Soil Type: Depth:
Laundry: No No
Hauling/Pumping Listing Quantity
Type System Type Pumped Pumped By Transferred To Disposed At Date Pumped allons
Routine Septic Tank Bateson Enterprises 12/16/2004 1000
Routine Septic Tank Bateson Ent GLSD 12/04/2006 1000
Comments: tank flooded&runback from SAS
Routine Septic Tank Bateson Ent GLSD 08/08/2008 1500
Comments: tank flooded&rn back from S.A.S.
GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Page 1 of 1
Commonwealth' of Massachusetts RECIIIV
City/Town of SEP 29 2010
System Pumping Record
FOCIII 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health ouoW0.approving authority.
A. Facility Information
1. S do : Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of ho ight rear of house. Left rear of building. Right rear of building.
Address
Cityrrown State V Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State �/ 3Zip Code
Telephone Number Y
I
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 L0 If yes,was it cleaned? ❑ Yes ❑ No
5. Conditi n of Syste
-( r �
a,4 4A (f Ljv, hie
71
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio here contents o tents were disposed:
P
G.L.S.D 17 LowjAftste Water
Signature o0afier I Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
ICN Commonwealth of Massachusetts
City/Town of
System Pumping Record REUINVIED
Form 4
DEP has provided this form for use by local Boards of Health. Othe forms may be used, but t
information must be substantially the same as that provided here. B f fyM ffitfd,M , � with your
local Board of Health to determine the form they use. The System Pert _bmitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of house, left side of house, right side of hou4 a
ar-Of. a ght rear of house, left side of building, right rear of building, under deck.
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State^� � �j rZjp Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) QIs�ptic Tank, ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition pf System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location nowpH
e contents were disposed:
.L.S. WasteApter,--)
Signatur gf '� r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
I
Commonwealth of Massachusetts RECE EC
_ City/Town of
System Pumping Record DEC - 8 2011
Form 4 TOWN OF NORTH ANDOVER
`�M s HEALTH DEPARTMENT
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 hous� Ig rear ,f hou , Left/right side of house, Left/
Right side of building, Left/Right front of bul d'I ing, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zi 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 resent? Yes o If es was it cleaned? Yes No
p ❑ � yes, ❑ ❑
5. Condition of System:
I
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
LS. Lowell Waste Water
Sign
Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
I
' G
Commonwealth of Massachusetts RE.0IVSD
City/Town of JUN2U12
System Pumping Record
,�
Form 4 MOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 Locatio . Ight front of house, Left/RighffjEo Left/right side of house, Left/
Right side of buirdfing, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State ��� � `Zjo 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? E] Yes D'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. Locatio—nwhese contents were disposed:
Lowell Waste Water
SignAtufe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1