HomeMy WebLinkAboutSewer Service Connection - Miscellaneous - 318 SALEM STREET 10/3/2023 APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Ma— Z-Z3
Application by the undersigned is hereby made to connect with the town sewer main in Street,
subject to the rules and regulations of the Division of Public Works.
The premises are known as No. �/ C��/�( / Street
or subdivision lot no.
Owner Address
Contractor `2 2— 9 Address
tle v'cO (2 vGri zopi . kie� Aplicant's Signature
44
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PERMIT TO CONNECT WITH SEWER MAIN
The Division of Public Works hereby grants permission tom-��_ L f�
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to make a connection with the sewer main at Street
subject to the rules and regulations of the Division of Public Works..
vision of Public Works
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By
Inspected by
Date
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See back for rules and regulations
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Commonwealth of Massachusetts
City/Town of No.Andover O5ti��3
a System Pumping Record SEQ
Form 4
'M
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information Ciro
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
v2. System Owner:
Name
Address(if diftereWromlocation)
No.Andover MA
City/Town State Zip Code
Telephone Number'
B. Pumping RecordI,Yll,f�/,-2 �? 100D
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s)/ eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
Jo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic 58 So Kimball St. , Bradford,MA
Company
7. Location where contents were disposed:
20 So.Mill St.,Bradford,MA
3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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