HomeMy WebLinkAboutMiscellaneous - 526 WINTER STREET 4/30/2018 (4)I�
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Commonwealth of Massachusetts
City/Town of
System Pumping- Record
Form 4
a+
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. e Rig o house, eft / Right rear of house, Left / right side of house, Left /
Right side of bud ng, Left / uildirig, Left / Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner.
Name
Address CO different from location)
Cityfrown Code
a.•' Telephone Number
Pumping Record
1. Date of Pumping
3. Type of system: ❑
Date
Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 9— No
5. Condition
6. System Pumped By:
7.
— 2. Quantity Pumped
ptic Tank
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No:
Neil. Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc
Company
contents were disposed:
t5fomi4.doco 06/03 System Pumping Record • Page 1 of 1
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Form No. 4
Town of North Andover, Massachusetts
BOARD OF HEALTH
19 q1
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (j()
INSTALLER
at 53tfl W �n�-CX S-�—r-c InJ-, Yl a . A n�y2
SITE LOCATION
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No. dated 19 .
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
BOARD OF HEALTH ENGINEER
�- -
c -
5 : FORM U'- LOT RELEASE FORM �� i
INSTRUCTIONS. This form is used to verify that / 1`A kv,4 �_
Boards and Departments having jurisdiction have been obtain da This does notits rrorii�
the applicant and/or landowner from compliance with an Y applicable licable or requi ements.Ve
**************************APPL.ICANT FILLS OUT THIS SECTION
APPLICANT_ I� PHONE 2-1' `7 2-6
LOCATION: Assessor's Map Number , 4 PARCEL_
SUBDIVISION
STREET -63 9
CONSERVATION ADMINISTRA'
COMMENTS
TOWN PLANNER
COMMENTS
.TH
SEPTIC INSPECTOR -HEALTH
COMMENTS
LOT (S)
ST. NUMBER
ONLY �►*****
ENTS:
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE -REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTO
Revised 9197 jm
TE
I
LON
�1
3
X
X
t� OD
i
i
p .. or.
HRH Construction
Scope of Work
538 Winter St. N. Andover.
overview:
Construct a 14' X 16' room addition with attached covered 14'X i0' deck at the rear of 538 Winter St. per the
attached plans.
Demolish the existing three season room and exterior stairs and remove the existing sliding glass door between
existing dining room and new addition and case out opening•
The new room will be built off sono -tube footing type foundations.
Exterior of new addition will be sided to match the existing house as closely as possible.
New addition roof will be three tab, 25 year shingles, color to match existing as closely as possible.
&M new Malvin Integrity IDH3660 windows and one ISD6068 OX door with removable grills and screens will
be installed per the attach plans. hLo `Mao 5 (L1 FM
New floor and ceiling of room will be insulated with R25 insulation c/w vapor barrier and new walls will be
insulated with R19 c/w vapor barrier.
Interior walls and ailing will be Sheetrocked ( blue board) and plastered New floor will be Oak hardwoods
sanded and varnished to match existing hardwoods in dining room as closely as possible.
All new interior trim to be standard 2 %s" colonial door and window trim and 3 %i" baseboard either pre primed or
stain grade per homeowners choice.
Exterior deck will be 2" x 6" pressure treated decking with a standard 2" x 2" picket railing with new Pressure
treated stairs.
Ceiling over deck area will be 1" x 6" Tongue and Groove Pine.
Electrical:
Outlets in new room to code.
1 exterior outlet on deck.
1 fan box in new addition and 1 in ceiling over exterior deck -
2 flood lights of rear of new addition.
1 able and 1 phone jack in new addition.
1 cable jack in existing kitchen.
-rz Z, a -,: � W b —
TOWN OF NORTH ANDOVER
PUBLIC HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01845
Sandra Starr
Public Health Director
July 9, 2003
William D. Hope
P.O. Box 5164
Andover, MA 01810
Re: Application for replacement of 3 -season room and new deck
Dear Mr. Hope:
Telephone (978) 688-9540
FAX (978) 688-9542
Your application for a building permit at 538 Winter Street, North Andover has been reviewed by the Health
Department. The application was denied on July 9, 2003 for the following reasons:
L. X Missing information.
A scaled plot plan no smaller than 1 "= 40' must be submitted showing the dwelling, the existing septic tank,
the proposed addition/construction along with a floor plan sketch of the entrance to the new room, and the
exact placement of sono -tubes relative to the septic tank.
2. Passing Title 5 inspection of septic system required
Location of structure not acceptable
To address the problem(s):
If #1 is checked, please supply
Flirt oor plan of existing androosed addition —all rooms
b. Certfiedc wz h�s�t ..�Pl
If #2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and
whether it is operating properly: OR
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Reviewer
Cc: Building Department
,,'file
TOWN OF NORTH ANDOVER
PUBLIC HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01845
Sandra Starr
Public Health Director
July 9, 2003
William D. Hope
P.O. Box 5164
Andover, MA 01810
Re: Application for replacement of 3 -season room and new deck
Dear Mr. Hope:
Telephone (978) 688-9540
FAX (978) 688-9542
Your application for a building permit at 538 Winter Street, North Andover has been reviewed by the Health
Department. The application was denied on July 9, 2003 for the following reasons:
1. X Missing information.
A scaled plot plan no smaller than 1"= 40' must be submitted showing the dwelling, the existing septic tank,
the proposed addition/construction along with a floor plan sketch of the entrance to the new room, and the
exact placement of sono -tubes relative to the septic tank.
2. Passing Title 5 inspection of septic system required
Location of structure not acceptable
To address the problem(s):
If #1 is �checked, please supply
L./ Floor plan of existing and ro osed addition all rooms
b.d , t 1 y showtng house, sptss em c 0 0`�1J ' se
If #2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and
whether it is operating properly: OR
b. Tie-in to municipal sewer
If #3 is checked:
Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Reviewer
Cc: Building Department
File
TOWN OF NORTH ANDOVER
PUBLIC HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01845
Sandra Starr
Public Health Director
July 9, 2003
William D. Hope
P.O. Box 5164
Andover, MA 01810
Re: Application for replacement of 3 -season room and new deck
Dear Mr. Hope:
Telephone (978) 688-9540
FAX (978) 688-9542
Your application for a building permit at 538 Winter Street, North Andover has been reviewed by the Health
Department. The application was denied on July 9, 2003 for the following reasons:
1. X Missing information.
A scaled plot plan no smaller than 1"= 40' must be submitted showing the dwelling, the existing septic tank,
the proposed addition/construction along with a floor plan sketch of the entrance to the new room, and the
exact placement of sono -tubes relative to the septic tank.
Passing Title 5 inspection of septic system required
Location of structure not acceptable
To address the problem(s):
If #1 is checked, please supply
Floor plan of existing and fro osed addition all rooms
b.xtrfiedp) o�,zot Y:�pQed BrJo has soal
If #2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and
whether it is operating properly: OR
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Reviewer
Cc: Building Department
File
DelleChiaie, Pamela
From:
DelleChiaie, Pamela
Sent:
Wednesday, July 09, 2003 10:55 AM
To:
Starr, Sandy
Cc:
Griffin, Heidi; Lagrasse, Brian
Subject:
538 Winter Street
Hi Sandy,
Received a call from Dave Hope of HRH Construction. He submitted a Form U on 6/17/03 for 538 Winter Street, which
requires septic sign -off. Can you please review for signoff in the next couple of days? Please call Dave to follow up at
978-314-7263. No septic file was found in the file, but Form U was submitted with plans. I will put in your misc. review
inbox for review.
Pamela DelleChiaie, Health Dept. Assistant
Town of North Andover
Community Development & Services
27 Charles Street
North Andover, MA 01845
pdellechiaie@townofnofthandover. corn
Tel. 978-688-9540
Fax 978-688-9542
FORM U - LOT RELEASE FORM Y 3 ss�
INSTRUCTIONS: This form is used to verify that all necessary. 1 r �u�fi�e�C
Boards and Departments having jurisdiction have been obtain da Th s doses not from
the applicant and/or landowner from compliance with any applicable or requirements.not relieve
*APPLICANT FILLS
APPLICANT
LOCATION: Assessor's Map Number '� 7
SUBDIVISION �?
STREET v 0Ji A'fd
--->!"'c---'�
CONSERVATION
COMMENTS
TOWN PLANNER
OFFICIAL USE ONLY
DATE APPROVED
DATE REJECTED
LOT (S)
ST. NUMBER
DATE APPROVED
DATE REJECTED
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE -REJECTED /' 3
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECT
DATE
Revised 9W jm
L+ x-26
HRH Construction
Scope of Work
538 Winter St. N. Andover,
Overview:
Construct a 14' X 16' room addition with attached covered 14'X 10' deck at the rear of 538 Winter St. per the
attached plans.
Demolish the existing three season room and exterior stairs and remove the existing sliding glass door between
existing dining room and new addition and case out opening.
The new room will be built off sono -tube footing type foundations.
Exterior of new addition will be sided to match the existing house as closely as possible.
New addition roof will be three tab, 25 year shingles, color to match existing as closely as possible.
&W new Marvin Integrity IDE3660 windows and one ISD6068 OX door with removable grills and screens will
be installed per the attach plans. hi o `RA3o swqa&ts
New floor and ceiling of room will be insulated with R25 insulation dw vapor barrier and new walls will be
insulated with R19 c!w vapor barrier.
Interior walls and ceiling will be Sheetrocked ( blue board ) and plastered New floor will be Oak hardwoods
sanded and varnished to match existing hardwoods in dining room as closely as possible.
All new interior trim to be standard 2 %i" colonial door and window trim and 3 %a" baseboard either pre primed or
stain grade per homeowners choice.
Exterior deck will be 2" x 6" pressure treated decking with a standard 2" x 2" picket railing with new Pressure
treated stairs.
Ceiling over deck area will be 1" x 6" Tongue and Groove Pine.
Electrical:
Outlets in new room to code.
1 exterior outlet on deck
1 fan box in new addition and 1 in ceiling over exterior deck.
2 flood lights of rear of new addition.
1 cable and 1 phone jack in new addition.
1 cable jack in existing kitchen.
Heatin .
Extend existing baseboard heat zone from dining room into new addition.
Paintin .
No painting or staining of any kind is included.
Allowances:
The following allowances are included in the total contract price of $35, 6Zo and may be combined, added, and
or subtracted per the homeowners wishes to a total of $T2114 - (50
Electrical: $1500.00
Heating: $1750.00
Door / windows $4041' W
Total: $7,950.00
Miscel,Ianeous•
HRH Construction will provided an on site dumpster for the duration of the project.
All waste, scraps, cat offs etc. will be placed in the dumpster for removal upon completion of the project.
The site will be kept clean and swept daily, however, the homeowner understands that due to the scope and nature
of the work some mess and some dust contamination of non work areas is inevitable.
No changes to this scope of work or contract will be made without a signed change order.
The total contract price includes regular permit fees, however, them is no allowance for any engineering,
architectural, or similar services that may be required by the building dam, nor does it include any
allowance for mecungs with any board such as the historic commission, wet land, or board of health, etc.
RM C N U O -DATE: �.Z�t
Commonwealth of Massachusetts
City/Town of
System Pumping Record a X013
Form 4 -; V, V%
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 LocatioPRig ont�ho 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
City/Town W State Zip Code
2. System Owner.
Name
Address (if different from location)
City/Town State/,I
V
de ,
Telephone Number
B. Pumping Record
1. Date of PumpingDate 2• Qua Pumped: Gallons3. Type of system: E]Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? E] Yep ffNo If yes, was it cleaned? ❑Yes ❑ No.
5. Condition of System: r
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
contents were disposed:
,!fD-- '�) I,_j
t5fom4.doc• 06/03 1 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
} System Pumping Record RICEI�'
Form 4 tflflt''
1M yVev`'VW 9Vii
DEP has provided this form for use by local Boards of Health. irlt� OthLz'jNJERfi6&.b%RLWubmifted
ms may be used, but he
information must be substantially the same as that provided here.NL YF -h k with your
local Board of Health to determine the form they use. The System to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location:Qrof nit o^ f ho right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System O*ner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
State,,,,, Cs `1p Code
Telephone Number I(
Date 2. Quantity Pumped
Cesspool(s)eptic Tank
Gallons
❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition S Stem:
6. System Pumped By:
Neil J. Bateson
F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. 1-9patio ,wt\ere contents were disposed:
G.L.S.
q 'C),;) C>
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
-�x
Commonwealth of Massachusetts
REC E®
City/Town of I
OCT 2 4 2006
System Pumping Record
-
,.
TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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 filling out
forms the
computer. use
1. System Location:
only the tab key
to move your
Address
cursor - do not
use theretum
Cityfrown State
Zip Code
key.
2. System Owner:
Name
Address different from focation
(if
City/Town State-�Zip
Code:
Telephone Number
System Pumping Record • Page 1 of 1
TOWN OF Jul • �hnt�o�e�
SYSTEM PUMPING RECO
DATE: 6-;kO5
SYSTEM OWNER & ADDRESS
paftj
IVED
SEP - 7 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTEM LOCATION
(example: left front of house)
llc--n- ;o�+ � wus-e—
DATE
OF PUMPING: (� — o`� �� QUANTITY PUMPED: $;Q Q-0 GALLONS
CESSPOOL: NO YES PTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED To: G.L.S.D V Lowell Waste
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 'I-II-st�-
OWNER & ADDRE
(example: left front of house)
� 3 1 W,,,4tr 4 -
DATE OF PUMPING:—0;LQUANTITY PUMPED GALLONS
CESSPOOL: NO /YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO:
� Commonwealth of Massachusetts
City/Town of 410$ R
System Pumping Record
Form
4NOFNpP�R
10 N -TN
DEP has provided this form for use by local Boards of Health. OiFier 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 Locatr:
forms on the
computer, use
only the tab key Address \X5�
to move your
cursor -do not Cityrrown a Zip Code
use the return
key. 2. System Owner.
Name
Address (if different from location)
Citylrown State Zip Code
i�;. a
Telephone Number
B. Pumping Record
l
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. Condition onnf��Sy tem: �� l� � �
V \ j/ `'CEJ 4-c.;c�
6. System Pumpd By:
l �
Name
Company
7. Locatio ere contents
• L ��-
Vehicle License Number
Date
t5form4.doc> 06/03 System Pumping Record . Page 1 of 1
D'Agata, Donna Mae
From:
DelleChiaie, Pamela
Sent:
Thursday, August 14, 200310:00 AM
To:
D'Agata, Donna Mae
Subject:
FW: 538 Winter Street
----Original Message ----
From: DelleChiaie, Pamela
Sent: Thursday, August 14, 2003 9:53 AM
To: Griffin, Heidi
Subject: FW: 538 Winter Street
----Original Message -----
From: DelleChiaie, Pamela
Sent: Wednesday, July 09, 2003 10:55 AM
To: Stan-, Sandy
Cc: Griffin, Heidi; Lagrasse, Brian
Subject: 538 Winter Street
Hi Sandy,
Received a call from Dave Hope of HRH Construction. He submitted a Form U on 6/17/03 for 538 Winter Street, which
requires septic sign -off. Can you please review for signoff in the next couple of days? Please call Dave to follow up at
978-314-7263. No septic file was found in the file, but Form U was submitted with plans. I will put in your misc. review
inbox for review.
Pamela DelleChiaie, Health Dept. Assistant
Town of North Andover
Community Development & Services
27 Charles Street
North Andover, MA 01845
pdellechiaie@townofnorthandover.com
Tel. 978-688-9540
Fax 978-688-9542
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Commonwealth of Massachusetts
Dill City/Town of
System Pumping Record
Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
,aan
DEP has provided this form for use by local Boards of Health.
information must be substantially the same as that provided h
local Board of Health to determine the form they use. The Sy:
the local Board of Health or other approving authority.
AUG - 6 2007
Isedt the
Foiin, check with your
must be submitted to
A. Facility Information
1. SysteT Locati
Address
Citylrown State V Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
e
state
6S _
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 B'lVo—' If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
r\CX ��
91
Syste Pu By: 1
Marne � ��VehiGe License Plumber
T ---, -S - &'-� I
Company
7. Location ere cont w e sposed:
lrJ� t A
Date
t5form4.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.
�1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
RECEIVED \
JUL 16 2009
v
TORE O H OE ARTM R D"NT
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 a fro , left rear, left s' a of hous . Right front, right rear, right side of house.
Address l5'3 (s— L
City/Town State
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: El
El Other (describe):
Date
Zip Code
State�^ Zip Code
Telephone Number
2. Quantity Pumped
Cesspool(s) v Septic Tank
Gallons
Tight Tank
4. Effluent Tee Filter present? 0 Yes y No If yes, was it cleaned? [I Yes [j No
5. Condition of System:
6. System Pumped By:
Neil Bateson
F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
of
Lowell Waste Water
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachus
City/Town of System Pumping RecordJUL... 2010Form 4
TOJ�."R'C8-"V—ED
OF NORTH AN OVER
DEP has provided this form for use by local Boar ft ay be used, but the
information must be, substantially the same as that provided here. e g 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 of- 4r approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of hous eft front of house?Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address p 1 1 V
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: ❑
State �� = Zip Code .
Telephone Number
--C)
Date 2. Quantity Pumped: Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
5. Condition of System:
f/c) ( 1 --
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locati ere contents were disposed:
G.L. S. D p2 A Lo"Y)Waste Water
Signature
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
Date
t5form4.doc- 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
M yv
E
OCT 16 2012
TOWN OF NORTH ANDOM
_ HEALTH DEPAR'r,,brr
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:CeORig rant of hous , eft /Right rear of house, Left /right side of house, Left /
Right side of building, Left / l ding, Left / Right rear of building, Under deck
—",— �) 3 � Ujl u� L�1—
City/rown State
2. System Owner.
Name
Address (if different from location)
City/rown
B. Pumping Record q —6 (— k
1. Date of Pumping
3. Type of system: ❑
Date
Cesspool(s)
Zip Code
State 3a qp� de
Telephone Number r
— 2. Quantity Pumped;
Septic Tank
C�
Gallons
❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes alqo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition 9f stem:
" ""j C ��� wak \ V�-
6. System Pumped By:
Neil Bateson
7.
F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
contents were disposed:
Lowell Waste Water
t5form4.doc• 06/03
System Pumping Record •Page 1 of 1