HomeMy WebLinkAboutSeptic Pumping Slip - 31 BRIDGES LANE 1/5/2016 FP,ho {hIa loan rpr Leo �, ;ocol JUN 4: 2009
09 !(100Ip Of IOCaI 8o J pJ peIcI pr npa'; ,mod s�1 dnl a
A, Facillky In(orrrl�llon
HEALTH ,r I NT
,•a J
� 1.J� '„",y��(,�',�•r ;, � ,'i,'l..r,r: •1;',� ,/,;..�•.�.�,' � 51111 '__'.-----
�;i I ,'t :;rr• m Owner, �'• ,
�6r14 a (IIOVfrnnl rcvn 0u4 '
r11a9nOn1 1 ,Jhplr _
umpin ord '
Oayo o!�PurnDlnq 40 �ypP 41 iywism; ' i(s) $ _
la
��+0(h9�1(da3Crfba
MOM Too FII(o('P(P,,wr? 71 Yo9
�, \ ��\�1,i�.'rr,�r'(i(�'�j�;�,Jj�ll�l,.:; ,/ y99 x'81 I; :•9ana`�� `_1 y -,_
1,.. 61l'.Condlllon 4(,;9 m,;,'•J _
'�• ',i ,1f.�,"'` �'I,l%'�i�! t'l;yj�l�f'!P6' oc � /,r}y
q mrPy'mpcd
• ic,
! y1hldl '�Gdnll
�•'� '� •f.r .It {{.•,i Y•li'l,v V�''1 'I' �rI��� li r,
.. . 'r•�f;',i�t,\`,,!.,�J't!,'v!nl��l� (����Z;J,(d.J•f' �1,1��i\lI"il�'"?I', !' / ',..,.......
_ On,�vt18(� gOQ18nlJ' @f9 dl p
"-,,,^� :/^•�,,1.��'�,'+,Sl�niku► PINIV4(yf,�y,,,l...,:,:,, . w fin, 1 �.
• .me3a.poYl d�p�we(e�l epp�4Ya/3/(blorm3.n:m,viny�r�C1
+'.CCh,, , r®d,}��7}t ��`�':�',' /' '•!'rye ;
+�
°.;�; t t I �'1•I I:AIJ�OV ° NIASSA�MUSE
v}t t'`. { y\ J''��Q YJi •;I ,�V���{j'j, �J��Yi�L',S,\✓1�1We��14'Itt,!r I ..
• �I•. ,.i,(t,y,,/�l V�,t(`�y�I'I'„+,Vf����'�flf��{�,l�ryj:a:t.�, .)r 4;, �e.n �4,�.Y�,Il '
,!(;J..F Vl r r� •
`D P,,has pravlded 04'form for use by local Boards of Health, Tho System Pumping Ru;
b5 aubmloted to the IoCal Board of Hoallh or othor approying authorlry, v
A,, Faclll ir�f�rrtlo��
'J;, N v out 1 ; SyStem l.ocatlon
only Use lib key Addrm
Uy1'I'4tilrfl'•, ,\,;::. IIltY•; 04Yn {, ,� ,: .,';'.':•;. ./: Slal1 (,^�
1'..YI Y•,rt.,,mt®wn®r,'CI
.,il'. ,h, �fr�l,�t'I'1/',•j•Ir,�.�' 1.�'�'rl�i.,\ri. `
(I(Moronl rwn iMuon) �"
Two 6, Ca)
Tolophono Number
Cyr \ ',
uCnpll1g'�6�Ot`d
Date of Pumping."""
J '
ping �oolo 2, Quanury Pumped;
ciuo ns
TYPe P a stem' Tank Tight Tank$Oplc,
,
Z',.,,Ocher1(deigd
" \,11.;1';/i%j'..ri.t{
,
V
4I*! E „uo r Tae FII p�urn t' If yes, was It cleans
•,
0 No
m rtl (� se t7 " Yes d?
,stir " ','6,i1';Coridl�lan m
X
l
r r i
' `YI
P.4imped
�,f �• � t r �„r�l, �� '��,s�alC11•f�+W'f+';r'i 'i ,t'''','•tf�v`i'' C-) f
Hr �r;� {,�rtl,ry�'+��P� j�f'�t`� ,Y,c"�..�• .,�1%, , It ti: v'r, ,��T”. hicle Ucen�e Number '
:-r.t I •� \t y'"((�'�'irt' Yli l' �/Y V'I I ,��t' / 1Y1 y1 r �, /
7 V
�',)!�I
tl.oo�l�'J,�,.ra'
F loos on,wn @re
nfs',Were dlyposed;
'I' '.I} I t'L'.�/;1`/IJS •''/I,..i i,J•I<V tt)�,Y?� 4' \.
hUP;/ .m•a�.J 'o'v'/de+two olHaule(,t�/'rant' t ool�
ssr8 {!v✓afar/approVaJslf6(orms,hcmiflnspecc
5y116m Pumping Rocory
Commonwealth of Massachusetts
City/Town of NORTH ANDOVE
RMASSACHUSETTS
S System Pum ping Record
Form 4
DEP has provided this form for use by local Boards of Health. 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
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
Name
Address(if di rent fr
City/Town ZiILCodp'
MAY 1 .1 2006
'j,C)Wl,40F Telephone Number
B. Pumping Record
- el 63
1. Date of Pumping 2. Quantity Pumped:
Dat Gallons
Type of system: ❑ Cesspool(s) F-w Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? F-1 Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: re
6. Sys m Pumped By:
Name
Ve icle License Number
Company
7. Location where Contents were dis used:
C_
Al"
signature auler Date
http://www.mass er/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
'POWN OF NORTH ANIXNE'k
SYSTEM PUMPINO
U A I*h
SYSTR (0) RR SY
of
DATE OF PVMNNQ:
QUA WITY PtJMPFD:,
NA rVRU0V 38RVICP,:
ii�CEIVED.
013SUAVA'nONS:
,SUN 0 3 2,005
OWD conaloN V, PULJ- 1-() COVBR
MIAVY ORBAwt I ANDOVER
BAJBS IN LAC( l'oWN 02, MEN f'
A0073 �,,EALI"H DEPART
LRACHNVJ,D RUNBACK
BXCUSIVU SO1.108 —,– FLOOM
,S0LrDCA"YQy'5X c
),qfER EXPLAIN
ICUMWNTS,
'UN It
,......w.�....�.,,w.,„,,,..».,,,:.., ...,.�........,�.i Boa ..w„�...,.
�a
SYSTEM LOCATION
//C v 5 ".. Tll
DATE, AF umPlN � � /
SEPTICTANK
GOOD C(MIXTION FULL TO COVER
, � I
HEAVY GREASE BATTLES BAITLES IN I..AC;Iil __._..
I1,7CC ESSI" ?SOLIDS FLOODED
SOLID CARRYOW.'R. 0111PR EXPLAIN
SYSTEM PUMPED BY
CONTENTS TRANSFERRED
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
�1 D'I'EM OWNFR & ADDRESS „ SYSTEM LOCATION T�'^
/ (example: left front of house)
U.\'I'E OF PUMf'INC: QUANTITY PUMPED 1 z %' 0,NLLc» �
�.�I'UUL: N0 ' ES SEPTIC TANK: N0 YES
MATURE OF SERVICE; ROUTINE µEMERGENCY
FRY,:\T10NS:
GOOD CONDITION, FULL TO COVER
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK..
CXCESSIYE SOLIDS FLOODED
SOLIDS CARRYOVER Pj7 HEI`Z (EXPLAIN)
cm PUMPED BY: ILI IL / ,
C U,I'vl rNTS:
UNTI:'.NTS 1'IZANSF IT, IZRED TO:
TOWN OF NORTH AN-DOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: / _ QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES . b
NATURE OF SERVICE: ROUTINE _ EMERGENCY
i
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
i
COMMENTS:
I
CONTENTS TRANSFERRED TO:
........................
I
_ Tu"WN 00F NORTH ANDOVER
SYSTEM PUMPING RECORD
•,' as t ��
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
e
rjn
i �'@ G• s
1
GALLONS
f
UANTITY PUMPED :.
,�T OF PUMPING:' . �� .:� Qb ��
` CESSPOOL: NO YES SEPTIC TANK: NO YES
r
1�t,AIJRE OF SERVICE: ROUTINE EMERGENCY
tt
O$SERVATIONS:
'GOOD CONDITION " FULL TO COVER,
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
a EXCESSIVE SOLIDS FLOODED _
SOLIDS CARRYOVER OTHER (EXPLAIN)
STEM PUMPED BY
1} . .. "
`
A
i � 1
i
O.:NIMENTS:_, ti . .. �. .�
r
��rpd}'�j��L
Ar �
s
Fes .�O. .,114
on
r h Yi1 i t t � htu"
)J1 }
j {
d,,,�
li