HomeMy WebLinkAboutMiscellaneous - 75 JOHNSON CIRCLE 4/30/2018 (3)3. Type of system: [ITiht Tank E] Grease Trap Cesspool(s) Septic Tank ❑ 9
❑ Other (describe):
4. Effluent Tee Filter present? ❑Yes ❑ No .
If .yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
t4eaW V 6Qv-4- coc.er
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record - Page 1 c
t5form4.doc• 03/06
R
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Commonwealth of Massachusetts
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City/Town of North Andover
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System Pumping Record
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Form
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DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
as that provided here. Before using this form, check with your
information must be substantially the same
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
days from the pumping,date in
the local Board of Health or other approving authority within 14
accordance with 310 CMR 15.351.
A. Facility informati®n
Important When
filling out forms
1. System Location:
I
on the computer,
h n 5cn
Y
use only the tab
key to move your
Address
01886
Ma
cursor - do not
North Andover
State Zip Code
use the return
CityfTown
key.
2. System Owner:
(/
a
Name
tum
Address (if different from location)
State Zip Code
Cityrown
Telephone Number
B. Pumping Record
1. Date of Pumping a
Dte
2. Quantity Pumped: Gallons
3. Type of system: [ITiht Tank E] Grease Trap Cesspool(s) Septic Tank ❑ 9
❑ Other (describe):
4. Effluent Tee Filter present? ❑Yes ❑ No .
If .yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
t4eaW V 6Qv-4- coc.er
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record - Page 1 c
t5form4.doc• 03/06
FORM U - LOT RELEASE. FORM
INSTRUCTIONS: This form aPProvals/permits from goa�ssed to verify
have been obtained. and Departments
that all necessary
landowner This does not patents having jurisdiction
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compliance with an relieve the applicant
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APPLICANT: C F0F01-(this section*****************
LOCATION: Assessor's Map umber N 37 Phone 643 q- oz�g
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Subdivision Parcel Z
Street k75 mon/So^1 Lot(s)
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St. Number
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RECO14MENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Town Planner
Comments
Jar J .
th Agent
Comments
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved kel
Date Rejected
Public Works - sewer/water connections---------------
- driveway permit
Fire Department
Received by Building Inspector
Date