HomeMy WebLinkAbout- Septic Pumping Slip - 332 RALEIGH TAVERN LANE 6/4/2019 Commonwealth
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System Pumplang Record
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Form 4 1d'DE['11'1'1`/J1 I I 1JI
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lnformatlon must be substantially the tame as,that provided here. Before using.this form,c*heck,with yotir,
lomil Board of, Healthtl r d must be,submitted to
approvingthe local Board of Health or other,
A. Facility
t
T.
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System L front of house, fight rear of-house, Left, right side of house, Left
Rightside building, Left ht fr6nti d s, Left Right rear df b� ild � Under deck
Addres
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CHY/Tows state Zip Code
2. System Owner.
I
1
Address different from t
City/Town statw Zip Code
_l Numbed
B, Pumpillng Kecord
* Date of Pumping, Date� 2 �� � ity w Gallons
3., Type-of'system: Glesspool(s) [D�-S6j5flc Tank El 'Tight Tank
Other(deiscribe):
Filter4. Effluent Tee nth es No If yes, was it cleaned? S No
NM' Condition of w
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w
.. M .
i
y7St.e
i
6
M1
Pumped
lw
Vehicle l Number
Bateson r
Inc-
and
. L ,wherei
Lowell Waste,WaterNMI 4 FM
FOP
SignAll, HUI Date
t5fbrm,4.dor.,b 06103 System Pumping Record Page