HomeMy WebLinkAboutSeptic Pumping Slip - 981 JOHNSON STREET 9/30/2015 Commonwealth of Massachusetts
ry d City/Town of F '4 4 Z W44
System Pumping Record
�nr ,
Form 4 .
®EP has provided this form for us&by local wards 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 i h#'front of , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town �1 State Zip Code
2. System Owner:
Name' 1
Address(if different from location)
f
City/Town ' State l. - Zip Cade ;
.� i4 ( ( �
Telephone Number
B. Pumping Record
}
1. Date of Pumping ®ate 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) Septic lank El light lank
Other(describe):
4. Effluent lee Filter present? Yes o If yes, was it cleaned? E3 Yes 0 No
5. Condition of Sy tern:
6. System Pumped By:
Nell Bateson F5621
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo -ere contents were disposed:
GLL S. - Lowell Waste Water
Sign t e Haute Date
t5form4.doc-06/03 System Pumping Record®Page 1 of 1
Commonwealth of Massachusetts
City/Town of 1: IVED System Pumping Record`���m��� " �������� o�����o��
� _ »_ ��
Form 4
TOWN=0FN0FRTHAN00VER
OEP has provided this form for use bv local Boards of Health. Other forms ENT]
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 3yeban) Pumping Record must bosubmitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
City/Town State Zip Code
_ System Owner:
Name
Address(if different from location)
Telephone Number �
|
�
B. �n�00�-�� �� �
~~^ Pumping-" ^~�~~~^~^ _~ |
/ ^�-i��
1. Date ofPumping Date 2. Quantity Pumped: GuUunm
3. Type ofsystem: [1 Tank F-1 Tight Tank
[] Other(describe):
4. Effluent Tee Filter [] Yes D-No If yes, was itcleaned? F� Yes n No
5. Cond
vualc
0. System Pumped By:
Nei| Bataaon F5821 �
Name Vehicle License Number
8eteeon Enterprises Inc �
Company
7. Loc ion, here contents were disposed:
i0M I
S.
G.L�ST Lowell Waste Water
au
4SIgn tu e Haulev Date
t5fonn4duo06/03 System Pumping Record^Page 1o[1
.1 - q
O
O t 0 �U
SAC HUS���y
PUBLIC HEALTH DEPARTMENT
s
Community Development Division
To: All North Andover Residents with Septic Systems and Garbage Grinders
Please note that due to recent reviews of Title 5 Reports, your property has been identified as
maintaining a working garbage grinder that is being used in conjunction with a septic system.
The Health Department is concerned for the longevity of your septic system.
Garbage grinders are never recommended where septic systems are used, but if they are installed,
the system must be specifically designed to handle the waste from them; your system can not
handle the waste as designed. Please note that continued use of this grinder could quickly cause
a pre-mature failure of your septic system, resulting in a large expenditure to replace it. The
North Andover Health Department recommends that you remove it from your home as soon as
possible.
Some information regarding regular maintenance of your septic system is attached. Please call
the Health Department--at 978.688.9540 if you have any questions, or e-mail your questions to:
healthdeptatownofnorthandover.com.
Thank you for taking the time to consider the impact that your current setup has on your septic
system and`the environment.
Sincerely,
I
Susan Y. Sawyer, REHS/
Public Health Director
/pfd
Enc: Septic System Information: http://www.mass. og v/dep/water/wastewater/dodont.litm
1600 Osgood Street, North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com
d
I
Commonwealth of Massachusetts .®.. . .
..
City/Town of
System Pumping Record
W:
Form 4 1
DEP has provided this form for use by local Boards of elm 4ria ,used, but the
information must be substantially the same as that prov d-ftere."Refore 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
Important:
When filling out 1. System Location: Left front, left rear, left side of house igh Dront, ght rear, right si of hous
forms on the
computer,use
only the tab key ddress
to m y
move your
cursor-do not
use the return Cit y!Town State Zip Code
key. 2 System Owner:
Name
1
Address(if different from location)
City/Town Stat � l 7,ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: Cesspool(s) 4aseptic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? [j Yes No If yes,was it cleaned? 0 Yes Ej No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LQureof contents were disposed:
Lowell Waste Water
r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
I
Commonwealth ��;.
City/Town of , q�
System Pumping Record JUN 09 ?008
Form 4 j
ttwr �s
DEP has provided this form for use by local Boards of Health. Othe rma maybe use �ut th
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
Important:
When filling out 1. System Location:
forms on the
computer,use
to move you
rey Address r
cursor-do not Cityfrown State Zip Code
use the return
Bey' 2. System Owner:
Name
n Address(if different from location)
City/Town State/�,� Code
Telephone Number
B. Pumping Record C -
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 ®'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System umped By: .
Name Vehicle License Number
Company
cont w
7. Location w e re n were osed:
.... � �� , �
Signat of a Date
t5form4.doc<06103 System Pumping Record a Page 1 of 1
1
TOWN OF NORTH ANDOVEP,
uA I'k
SYSTFM PUMPINU R.ECORj:)
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
DATE OF I'UMPtNQ;�..�........,.,............ _.._QUANTITY PUMPED:,-Z
k:ttSSPOOL: No___......YES
...., ....... Sopcic 1'Xnk; NO
NA rVKU OF SERYICE; Rou-nNE �
_ �. .Rh16Ro ENC'Y
0k$SERVA'r 003:
OWD COND!'TIUN PULL. 'iYJ COVER
nAVY 4RP.AEE �►
A.PPI,ES I P "......,. .
'R40T'J N I,.ACC. ...... ����
B� cusiVE SOLIDS m...... FLOODED p RUNBACK
-10LIV CAKRYOYER OTKER EXPLAIN
. Q.. ice�
`'UMMENTS.
1
t.'VN I'EN'I'S rKANSP'ERKBI) I,O
TOWN OF NORTH ANDOVE'P,
U A t'F. P��C ak �a 2�kCa°
SYSTEM PUMPING UCORI)
SYSTEM OWN .& ADDRESS
SYSTEM 1,OCATJC)N
r
DATE OF PUMPINQ: /
_. :..___..._QUANTITY PUMPED.,..,r ?
k:bsSPOOL: NO__,...... yB8_ ..... Septic Tank; NU, YES
t
NA rURU ON SERVICE; ROU'rI.NE.:'.L,k;MI ROENC'1'
ObURVATIONS;
000D CONDITION . PULL TO COVER
HEAVY 0"'A$E EAFFLES IN PLACE
ROOTS LEA,CHFIELD RUNBACK
s BUIVE SOLIDS
SOLID CARRYOVER. OTHER EXPLAIN
sy•tvm Pum d b —,
� r .... .... U/_cam
L'UMMENTS.
'U rh I'S rKANsy6RKBD 1'L1
i
TOWN OF NORTHANDOVER �
SYSTEM PUMPING UCORD j
� 1 I'EM OWNER & ADDRESS SYSTEM LOCATION
(m4mPle. Icf( from of house)
oz
.AW
L) \•I C OF PUMPINC, ( ' �! QUANTITY PUMPED LLC�
F�
�.SI'O0L: NO YES SEPTIC TANK: NO YES
I
ATURE OF SERVICE: ROUTINE EMERGENCY
uI3S('RV;�TIOf�S�
GOOD CONDITION. FULL TO COVEk
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER 4HFR (EXPLAIN) _
i
PUMPED BY:
C U1 ^rlFLATS,
U'\''I'k'NTS TIZANSFEIZIZED TO:
TOWN OF NORTH ANDOVER 5 2(
SYSTEM PUMPING "CORD
DATE: .
SYSTEM OWNER &ADDRESS--- SYSTEM LOCATION
U-r (example: left front of house)
C.)
DATE OF PUMPING: 1()f 1,-)c,-,-JUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LE AC LD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
j
commonwealth of Massacht'se is I
N, 6J.6 Massachusetts 1
.— i
t f'urinain tic®r
System Owner System Location
pp p 4,
C uairtit Prim ed: ec'—"gal lolls
Date of Primping: ? Y p
Cesspool: No Yes L.J Septic Tank: No Yes
System 11timped by: varedrire k ijej License _
Contents transferrred to : Greater Lawrertce zi�ttery Ulstrt�ct — --
Date: _ -- Inspector: