HomeMy WebLinkAboutMiscellaneous - 1470 Forest Street (4) Ii 1470 FOREST STREET
I - 210/105.6-0003-0000.0
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Commonwealth of Massachusetts RECEIVED
City/Town of � ���°t�� SEP -
System Pumping Record ����
Form 4 T0WN0F80*ORD
0ARI)OFIJEA1TM
DEP has provided this form for use by local Boards of Health. Other forms may be used, but t e
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 t� t
Important: JAN
When filling out 1. System Location:
forms on the TOWN OF NORTH ANDOVER
computer,use 1470 STONECLEAVE RD.
HEALTH DEPARTMENT
only the tab ke, Address ���
to move your -BeOEF9RD rl n /4AD let MA .A49�t' (�/9 yl—
cursor
-do not City/Town State Zip Code
use the return
key. 2. System Owner:
MARY PICARELLO
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumpin8/20/09 1500
Pumping 8/20/09
2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic 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 Pumped By:
Benjamin Shute H79 406
Name Vehicle License Number
J's Septic& Drain
Company
7. Location where contents were disposed:
GLSD
48/20109
Agna
Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Address .l'�Z b �2�i � Title of File
Page of
Date File Open: Date File closed:
Doc Document/Action Title Date of Refer to other Purpose of D.ocument/Action and notes.
action Document/ document/
Num.— Action Department
Board of Appeals - Board of Health - Planniing Board - Conservation Commission - Building Department
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
P APPLICANT: ��ASAWALi- Phone
CATION: Assessor's Map Number ;/C?� Parcel
Subdivision Lot(s) 60 60 0
reet Aeg r f T 7 0 FW St. Number
************************Official Use Only***** * *************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector-Health Date Rejected
-�L�J %1 Date Approved /
Septic Inspector-Health Date Rejected
Comments
I
Public Works - sewer/water connections
- driveway permit
VVZire Department
Received by Building Inspector Date