HomeMy WebLinkAboutSeptic Tank - Sprinkler Permit - 151 CARLTON LANE 4/9/2021 WF
Commonwealth of Massachusetts
City/Town of APR 2021
System Pumping Record T m y CQF HEALTH
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 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/Ri ht front of douse} Left/Right rear of house, Left I right side of house, Left
Right side of building, Left tg ron o uilding, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record _
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Duo If es was it cleaned?y ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo e contents were disposed:
G L S. Lowell Waste Water
Sign a LHauioev
Date
t5form4.doc-06/03 System Pumping Record•Page 5 of 1