HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 135 LACONIA CIRCLE 7/16/2019 Z�W,��u�Crlu�w0 �i�/ %/ /1�(I�IIIryIII,Irpy(
Commonwealth
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CKt /Town
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System Pump'fng,Record
Form 4
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provided'this foirmll -by local Boards bf, Health. forms a used„b'utl the <<
« All check with your
inform r �s sll the a provided h � r si . s Forl
1 1 Boarda l forte fey use. b � s !n Pumping Record must be submitl
the local Board of Health or other approving authority.
A. Fac[14y.
InforMation
Location:1, System � i i ,� Left I
of Right sideit Rightbuilding, L � r � i� i � r+
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Address
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Ad-Ulf
C rrown « state Zip Code
Owner,2, System
N @ J E
Address,(if different from location)
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F
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CWTOwn « Stag Zip Cod
Telephone
e a
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B. Pumping
Record
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Date ruin
Date Calla ,
r Typel srteff: Ell Gesspooll(s) Septic,Tank E] TightT ank
Other0 (describe).-
4.
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Effluent Tee Filter present?.. Y l No If' ��,� was it.cleaned? Yes E] N o,
5. Condition of System.,,
; System Pumped By.
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Neil.Batetll F5821
N13me Vehicle License Number «
Ina
u
Company
where7. Location n n -were disposed.-,
Lowell Waste Water
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« Date
/
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t5fbffn4.doob 06/03, System Pumpingr