HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 WINTERGREEN DRIVE 11/19/2020 :�L\ Commonwealth of Massachusetts RECEIVED
City/Town of NOV 19 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEF has provided this form for um 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: Left/Right front of house, Left light rear of hous ,Left/right side of house, Left
Right side of building, Left/Right front of building, a Right rear of building, Under deck
Address
City/row� state Zip Code
2. System Owner.
Name.
Address(f different from location)
CitylTown state Tip Code
—?$ l - —7 o C3,P
Telephone Number
6. Pumping Record
1. Date of Pumping Dam I �`� °� 2 antity Pumped: GallonsS�
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? �❑ No
5. Condition of System: I^_ ( r
40-1
6. System Pumped By.-
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locationv"contents-were disposed:
C L S Lowell Waste Water
signiftle qt Haulfflu Date
t5forrn4.doc-06/03 System Pumping Record•Page 1 of 1
�:���
��v
4-
n � �'
• ems.
. _� �_. _
. � S
t �
5
d 3 .� - �--.,x;.;� ,cti�.. a �; _ _:irk '"
y ,.
,.
; .
� ' � - ».
„z�
_ � �.� �_
�'�:t t � �
x �:
'!; - _ r -
:.
' �-^ ,. #:
ri,., _..,,.
" -r .p
- � ..fti
� � , tea,
c ;t. �,
�, .. ,�: �
�; �,
j';
_.�,
1.
. �
8°#"F ...
� � � ... ._