HomeMy WebLinkAboutMiscellaneous - 55 FARNUM STREET 4/30/2018 (2) `T
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� Commonwealth ®f Massachusetts(
assachusetts
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R"'--_,CEj
Town ®f NO Andover
14
roSystem 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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted t(
the local Board of Health or other approving authority wit n ng date in
accordance with 310 CMR 15.351. �� rC
A. Facility Information ,JUN 10 2014
Important:When
filling out forms 1. System Location: TOWN OF NORTH ANDOVER
on the computer, C HEALTH DEPARTMENT
use only the tab 15 L nr
key to move your Address
cu sor-do not No Andover
use the return Ma
key. City/Town State
� CZip ode
Y'r-
2. System Owner:
Name
recon
Address(if different from location)
City/Town State Co
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallghs
3. Type of system: ❑ Cesspool(s) Septic 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. S
.yLJOPumped By:
Name
Vehicle License umber
Stewart's Septic Service
Company
7. Location where contents were disposed:
Ste rt's re-treatme nt, 20 So. Mill Bradford, Ma 01835
auler
Date Ile
Si lure of Receiving Facility Date
t5form4.doc-03/06
System Pumping Record»Page 1 of 1
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DOVER
H MASSA HURT
Syst n of
Pumping Record:. DEC 16 2010
Form TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. T I I 6 two must
be submitted to the local Board of Health or other approving authority.
X Facility Information
out 1, System Location:
forms on Ua
computer,us.
only to tab key Address
to mew your Y a
Cursor• R kntL
do not , Wgwn State Zip Code
up the return
key' 2, System Owner
Name
�..i Address(tf different from location)
state Zip Code
Telephone Number
/00 6. Pumping Record
2. Quantity Pumped:
1. Date of Pumping Date G ons
3. Type of system: ❑ Cesspool(s) IBJ Septic Tank ❑ Tight Tank
❑ Other(describe):
4, Effluent Teo Filter present? ❑ Yes C] No If yes,was It cleaned? ❑ Yes ❑ No
5. Condition of System:
00(ic/
0.' Sysj4m.Pumped By:
L
( Vehicle Uoense Number
Ali -J— CC.
7. Location re contents were disposed:
rn
tura of Date
hdpJ/www,mass.govldep/waterlapprovalsdforms. #Inspect
t5fom*dw 06103 system Pumping Record`Page t of t
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.� ;.0. ;.� ORTH�A�IDOV AC USE
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DEP..ha: rovlded f""i--
p, thh form for use by local Boards'Of Heaith. Th stem Pumping Record muse
be submied to the.local•Board of Health o`r other approving authority.
i
A Facili i'� ti
Info�ron Iv 0 5 1007
,,YVhen[!!lf1�OUt •. System lOCatlOn; TOWN Ur •.W`,I is F. ,IER
of1 � r I EALrFiJ�FHR.• 1JT
MTOU
f •only the tab key Address
to move your
`usi the rotum::%.ot
City/Town State
.�'•IWW r,.11 l.� •':`;''�'. ..•,., •'�:�'`,,�•,. .".'iI •; .... p Code.
•:,err.• :,,;.. y�.2. ,System Owner,' ., „ � .
:J•. ., .�..,vii1l a.i :.'1��;fP� ,I t. Yf�, a`.� n.1y�; a
s' _.•a J: ,;;' :ti';IC'<.Name
Addfess(ir dlrrefent ffom Iocatl0n) ;
CltylTowrti: State' ZIP Cod
Telephone Number
"+Pumplg Re.�ord
•'��i. .,`„ ap't' `:'y.It.k'i:�'.„ d/,i(,c.;::a9�C 1 r
�• 1,, Dato;of Pumping i'
Date 2• QuantJty Pumped:
'T
Gallons
yp.0 pf,system;, Q Cesspool(S) tic Tank
, P
: Tight. . t
❑ Tan
. k
9
.. .. .._ .Other
d
e
s;d:
1
4 Effluen1t'Tee Filter present?.Q Yes No If yes, was It cleaned? ❑ Yes ❑ No
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• .� �::'!;' , Sur � ;1 i
' • :.6-:,:sy Pumped By:
.'t%-• ,. r• .:;l 1.i:'•,+i..: ,,,, .: ' ri. ''�1'i � ,
fir. ry'14a ,7:w4 t�%�J/ 4F�^ ; :. , S.J<•:. ` n �. Vehicle Ucen#e Number
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1t= ; v �fr� /i lLt
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• '':'YJy,,�rt' N"•'•..+7,e'w'•IH'gi�f}I]`r qq, v,., f;,�L�+1�t'II,F�J`'}'.�4`"5.,.1x,1
... vv ,,yy. 'i.,. .ti•,j 4 I ANI'.•.:O:f” ., •� '..
7;:':l.ocatloh.where conterits yuere di;3posed;
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ma
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,••+ .. .r�,''%'� 'r"'••t'' Date
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t5fofrM.doa!06103 stem
SY Pumping Record Page 1 of t
SITNI PUMPINcC ,. c'� SEP - 7 2005
_ _p_ry_ TOWN OF NORTH ANDOVER
5Y��' M o°^fig. AD53_ _ _.._RE5 _J ALTH DEPARTMENT
P5
No, 'l�d� /� rs/�f S fc�e U`F rL
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Tb.WN`0, ' NORITi''AI1jpV
ER
SYSTEM PUM'PI.NC RECORD
, tr
Y .TCM .UWNER & ADDRESS SYSTEM LOCATION
Qe ,;'�...�2..c'G (ez�m�le; Icfr from of hour)
. ,r r1u M
UIGUFPUMhINC; i .
p UANTITY f'UMPQ, D 1CM- c;
r t
UL:'lNO YES SEPTIC TANK: N0 YES
�-----
-NATURE OF:SERYICE; •ROUTINE. MERCENCY
USr'RYATIONS;
GUU;O C.U,NUI1;LON . ,�,_,, rifCUYGIZ•
FIEA'•1'Y:CKkr1SC' .l3AFFLLS' IN 1'lrACl
`R U:O:TS ?: � �_� L E A C H F I C L D I t UN l3 A
CXCESSIYE SOLIDS F1�00.DED
SOI;Ip,S'CARRYOYER IJHER ii~✓Xf'LA.INi
. Syr}v !i l tt��FY,�t�'y„Ns Lr`t.�'�Yn,14r y f}11 Ill tt, .w..�.�"r. lir •r r .1 /
�,' :! Yt v.. y i 5+A��sjJfli ITIaTY y 3 4 11 t•1�+, a� i .t 4:: ! t r ;,1� � r
IIMPUMPCI�.RY .
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: #&.3
SYSTEM OWNER & ADDRESS
SYSTEM LOCATION
> (example: left front of house)
DATE OF PUMPING; /1 �O/ QUANTITY PUMPED
GALLONS
CESSPOOL: NO _. YES
SEPTIC TANK: NO __ YES
NATURE OF SERVICE; ROUTINE
_.,X— EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE FULL TO COVER
ROOTS ------ BAFFLES IN PLACE --
EXCESSIVE SOLIDS LEACHFIELD RUNBACK
SOLIDS CARRYOVER FLOODED
OTTHER (EXPLAIN)
SYSTEM PUMPED BY:
--OMMENTS: TO
�1
----------------
.�
ONTENTS TRANSFERRED TO:
/0
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
�60 l�tu'
,
k
� � C
I�--- --- 3 4'
d a'
fie..
1. NAME . DATE 5,
2. ADDRESS .r .J�. LOT N0. S. TEL. .
3. NO. OF BEDROOTZ DEN YES . NO.. .
4. GARBAGE GRINDER YES oto.. .
5. SHOW DIT:'tENSIONS OF HOUSE X 3 �
6. SHO+17 DISTANCES OF HOUSE TO ALL PROPERTY LINES
'-'7,, SHOW DITMBIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEVMAGE SYSTEM
10. SHOW LOCATION OF BROOKS,* STREATS, DITCHES, LEDGE OUTCROP, ETC.
"11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD HE READ CAREFULLY.
/address g 5���3�2iilUM Sj .
Title of File page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes T
action Document/ document/
Num. Action Department
Board of Appeals — Board of.-Health — Planning Board — Conservation Commission — Building Department
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