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Home My WebLink AboutTitle V Inspection Report - 101 GRANVILLE LANE 3/27/2018 Commonwealth of Massachusetts r6 Title 5 Official Inspection car j- Subsurface Sewage disposal System Form ..Not for Voluntary Assessments r,l 101 Granville Lane Property Address Larry Donov.an Owner _ .___._._ ......_ Owners Name information is required for every North Andover MA 01845 02/27/2018 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form, Inspection farms may not be altered in any way. Please see completeness checklist at the encs of the form. Important;When filling out forms A. general Information on the computer„ 19 use only the tab � ) key to move your 1. Inspector: . cursor-do AA rA use the return F2obe of Inspeert ctor __.rick _ __.. _._..._. ...._.. _ ...__ _. ..,._...,_ .__....._, ___..,. _.._._ __ � � � Mkl key, _ Wind River Name_ iro Wind River Environmental � � r� p 46 Lizotte Drive --- - Company Address Marlborough MA 01752 Clty/lawn State Zip Code (800GG 459-1682 SI 13759 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: El Passes Q Conditionally Passes ❑ Fails El Needs Further Evaluation by the Local Approving Authority ..._ — - 02/27/2018 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Boars! of Health or DEF')within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the,approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under 1 the same or different conditions of use. 15ins.doc„rev.6116 'ritle 5 Official inspection Porrn:Subsurface Sewage Disposal System„Frage 1 of 17 � . Commonwealth of Massachusetts "��N� � ��N 0�� =�� mm��N�� m N-��mm � m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1O1Granville Lane Property Address Larry Donovan ----- Owner 6wner'allome |nfonmmhonie North Andover MA 01845 03/27/2018 required ---- �------ page. cuynown 2umoa Zip Code Date ufInspection B. Certification (cont.) Inspection Summary: Check A.B,C'D or E/always complete all of Section D 8> System Passes: | have not found any information which indicates that any cf the failure criteria described in 310 CMR 15.303orin 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: � Stei i d working order E3\ System Conditionally Passes: Fl one or more avatum components aSdescribed in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board ofHealth, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not dehsrmined." please explain. The septic tank is metal and over 20 years old*orthe septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfi|toaUnn ortank failure is imminent. System will pass inspection if the existing tank in replaced with a complying septic tank as approved by the Board of Health. °A metal septic tank will pomm inspection if it is structurally sound, not leaking and if Cedd|oain of Compliance indicating that the tank ieless than 20years old is available. F] Y F] N ND (Explain below): ^ . Commonwealth of Massachusetts "��N� � ��0 0�� y�N��N �mm��w��0��mm N-��mm � m Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 1O1Granville Lane � Property Address L rrD von Owner Owner's Name information is North Andover MA 01845 02/27/2018 requ|�dhxovo� _____� _��_____� page. C|iyfruvm State Zip Code Date nfInspection B. Certification (cont.) Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B\ System Conditionally Passes (oont): F-1Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval ofBoard nfHee|th): F-1 broken pipe(s) are replaced El Y El N Fl ND (Explain below): � n obstruction ieremoved Fl Y F-1 N 0 ND (Explain ba|uw): distribution box is leveled orreplaced Y 0 N ND (Explain [l ThenyateonroquiredpumpingmormUhan4UmesayearduetobrnkonorobstruoK*dpipa/e>.The system will pass inspection if(with approval ufthe Board ofHee|th): El broken pipe(m)are replaced Fl Y Fl N 0 NO(Explain be|ow): F-1 obstruction is removed Y 0 N F-1 ND (Explain below): C1 Further Evaluation hsRequired bvthe Board pfHealth: Conditions exist which require further evaluation by the Board of Health in order to determine if the system iofailing to protect public health, safety orthe environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Fl Cesspool orprivy iowithin 50feet ofasurface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh omo,duo'rev,o//e Title aOfficial Inspection Form:Subsurface Sewage Disposal System'Page 3m1r / . . u� Commonwealth of Massachusetts ��N�� "��'"��N N�� NpN�y� Title �� Official� �mm�� N��mm �-�� mmm ~ �� r�� Subsurface Sewage Disposal SystemForm ~ Nnth>rVo)untaryAnaeunmanta 181Granville Lane Property Address Larry Donovan Owner Owner's Name information i's MA O1845 - mqu�dhxove� '""'"' '""^""e' _ ________ co��own 2/27/2018 3t*m zipCmde o�aof|rmpe��o page. B. Certification (cont.) 2. System will fall unless the Board mfHealth (and Public Water Supplier, if any) determines that the system is functioning in o manner that protects the public health, safety and environment: � F-1 The system has a septic tank and soil absorption system (SAS) and the SAS is within 1O0feet ofasurface water supply ortributary toa surface water supply. El The system has o septic tank and SAS and the SAS is within a Zone 1 of public water supply. F-1 The system has a septic tank and SAS and the SAS igwithin 5Ufeet ofaprivate water supply well. [l The system has oseptic tank and SAS and the SAS ieless than 1OOfeet but 50feet or more from oprivate water supply vve||*°. Method used todetermine distance: ** This eyeham paemao if the well water analysis, performed at a DEP certified laboratory, for fecal � � coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must beattached h/ this form. 3. Other: � D) System Failure Criteria Applicable boAll Systems: You must indicate "Yme" or"Np/'toeach nfthe following for all inspections: Yes No �� sewage�� clogged SAS orcesspool Discharge or ponding of effluent to the surface of the ground or surface waters due tnonoverloaded orclogged SAS orcesspool Static liquid level in the distribution box above outlet invert due to an overloaded orclogged SAS orcesspool �� Liquid depth incesspool isless than 8" below inva�oravailable vo|unDe |mless �� than Y2 day flow Commonwealth of Massachusetts q Title 5 official Inspection Form W s Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments ❑, 101 Granville Lane Property Address Larry Donovan _ Owner Owner's Name information is North Andover MA 01845 02/27/2018 required for every __. _ _... _.__.__. page City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zane 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply E-1 ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-- IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc rev.6(16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts °��N�� w��"�� ==�� 0�N�� Title �� *�� Inspection Form Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 1O1Granville Lane Property Address Larry Donovan Owner Owner's Name information is d MA 81845 O2 mguimd�rem� '""'`^' �---- -----�� 02/27/2018 page. City[T«w» State Zip Code Date ofInspection C. Checklist Check ifthe following have been done. You must indicate^ves" or"no^ es toeach ofthe following: | Yen No 0 n Pumping information was provided by the owner, occupant, or Board of Health Fl E Were any ofthe system components pumped out |nthe previous two weeks? R Has the system received normal flows inthe previous two week period? Fl �� Have large volumes of water been introduced to the system recently or as part of this inspection? Were umbuilt plans ofthe system obtained and examined? (If they were not available note osNA\) El Was the facility ordwelling inspected for signs ofsewage back up? Fl Was the site inspected for signs nfbreak out? • Fl Were all system components, excluding the SAS, located onsite? • El Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth nfliquid, depth ofsludge and depth ofscum? �l VVosthe facility nvvner(and occupants ifdifferent from nvvner) provided vvith �" �� information onthe proper maintenance ofsubsurface sewage disposal systems? The size and location ofthe Soil Absorption System (SAS) onthe site has been determined based on: H El Existing information. For example, e plan at the Board of Health. Determ|nodinthe field (ifany ofthe failure criteria related toPod(� iaatissue ` appnmximoUonofdistance imunacceptable) [31OCMR 1S.3O2(5)] D. System Information Residential Flow Conditions: ! 44 Number ofbedrooms (design): -------- Number of bedrooms (oobua)� ---------- | DESIGN flow based on31OCMR 16.2030orexample: 110gpdx#ofbedrooma): | ` t5ins.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts R ==r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 101 Granville Lane...._..__ _ Property Address Larry Donovan i Owner owner's Name information is North Andover MA 01845 02/27/2018 required for every —_. ...__ page. City/Town State Zip Code Date of Inspection D. System Information Description: item is made up of a Septic Tank, Distribution Box and S.A.S. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes M No Water meter readings, if available last 2 years usage d Well Water Detail Well is located over 100'from S.A.S. Sump pump? ❑ Yes ® No Last date of occu anc : Current p Y Date Commercial/Industrial Flow Conditions: Type of Establishment: __...._..................____ Design flow(based on 310 CMR 15.203): -- --.--_.._......_. Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): _._.._................. Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: —. ...- w......____.__ ___._........__.__._.....-._..___.__ 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System^Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 101 Granville Lane ---------- Property Address Larry_Donovan Owner Owner's Name information is required for every North Andover MA 01845 02/27/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 1. D ate Other(describe below): General Information Pumping Records: Source of information: Homeowner... Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? ---------—----- Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): ............. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts . q Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Granville Lane Property Address Larry Donavan Owner Owner's Name information is required for every North Andover MA 01$45 02/27/2018 page CitylTown State Zip Code Date of Inspection D. System Information (cont.) _ Approximate age of all components, date installed (if known)and source of information: 1990 per plan....._.. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 24'" Depth below grade: feet -_...___. _..__.._..........__.._..._ Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): _ Distance from private water supply well or suction line: NIA feet Comments (on condition of joints, venting, evidence of leakage, etc.): All ioints look to be solid with no signs of leakage Vented through building sewer. Septic Tank (locate on site plan): 16" Depth below grade: feet Material of construction: N concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yea .._....... _.w___.._......,_ rs Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 5' Sludge depth: 4.. —. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 101 Granville Lane Property Address Larry Donovan Owner Owner's Name information is required for every North Andover MA 01845 02/2712018 ...... page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 30" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 611 16-1 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape Measure and Sludge Judgee Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend yearly pumping. Inlet and outlet tees are solid. No signs of leakage. Liquid level is OK in relation to inverts. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: El concrete D metal El fiberglass polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle ------------ Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15!ns,doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 101 Granville Lane Property Address Larry Donovan Owner Owner's Name information is North Andover MA 01845 02/27/2018 required for every page. State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ........... ----------- ...... ----------- Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: ---------- Material of construction: El concrete El metal El fiberglass F-1 polyethylene El other(explain): Dimensions: Capacity: ._.__.gallons Design Flow: -1 gallons per I r da-y Alarm present: D Yes F1 No Alarm level: Alarm in working order: El Yes El No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ........... Attach copy of current pumping contract (required). Is copy attached? F-1 Yes 0 No 15ins,doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form = Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /a. 101 Granville Lane Property Address Larry Donovan Owner Owner's Name information is North Andover MA_ 01845 02/27/2018 ...- .....-. required for every ---___.._.... _.._ _.... .......... _._.. .. - page City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 01 __........ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution Box is solid with no signs of leakage. There is no carryover in or out of the box. The liquid level is ©K in relation to the inverts. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: F Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order„ system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l6ins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts ��"��N�� ^J��N 0�� &�� * �� m�� Nm ��m��N��m � N-�� mm Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 101Granville Lane Property Address Larry Donovan _ Owner Owner's Name information is North /\ndovorMA 01845 02/27/2018 required page Ci�o� — �� -' Code—�— Date ofInspection D. System Information (cont.) Type: El leaching pits number: n leaching chambers number El leaching galleries number �l leaching trenches number, length: leaching fields number, dimensions: 1 El overflow cesspool number: �] |nnovaUve/o|ternaiiveoymtem Type/name Vftechnology: Comments (note condition of soil, signs ofhydraulic failure, level of ponding, damp oni|' condition of vegetation, etc.): � Soil is dry with no signs of hydraulic failure and no pond.ing. Ve etation is normalhm the Cesspools (cesspool must bepumped anpart ofinspection)(locate unsite p|on): Number and configuration OepUh-hopof|iqukj to inlet invert � Oepth of solids layer � Depth ofscum layer ' Dimensions ofcesspool | Materials of construction Indication nfgroundwater inflow El Yee Fl No ,s^,.ou^'rev.m10 Title sOfficial Inspection Form:Subsurface Sewage Disposal System'Page 13m1r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 101 Granville Lane Property Address Larry Donovan Owner Owner's Name information is North Andover MA 01845 02/27/2018 required for every page. State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): -------..... Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insAoc•rev.6/16 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 101 Granville Lane Property Address Larry Donovan Owner Owner's Name information is required for every North Andover MA 01845 page. &ty&o_wn State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: F-1 hand-sketch in the area below Z drawing attached separately t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form Not for Voluntary Assessments $ ❑❑ 101 Granville Lane .......... Property Address Larry Donovan Owner Owner's Name information is North Andover MA 01845 02/27/2018 required for every .................. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Z Check Slope Z Surface water Z Check cellar Z Shallow wells Estimated depth to high ground water: 106.2' feet Please indicate all methods used to determine the high ground water elevation: z Obtained from system design plans on record If checked, date of design plan reviewed: 1990 Date El Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: -------------- El Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: ----------- You must describe how you established the high ground water elevation: Used ground water information from as built plans. ------------ ...........- ........... ------ ------------------------- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 <L� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 'M_ 0' 101 Granville Lane__—__ ............. Property Address Larry Donavan Owner Owner's Name information isj North Andover MA 01846 02/27/2018 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist • Inspection Summary: A, B, C, D, or E checked • Inspection Summary D (System Failure Criteria Applicable to All Systems) completed • System Information— Estimated depth to high groundwater • Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doo-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 u i i i r I � � t of ar a rad r Yk 1 ORIONr mid 1y � r � '; Ulf,' a y ill��"WF d �i d= 1p � �I �V - M �R� ,drp � l t r" a 3 ✓l�� Y�r d r � er ^�dri� �"rf� 9 � � , ' I rl � ➢r� rr fka 11/i� �4 r� l m rc'Gwk �W it w k 4 awN4 a�, l fi {,� ri � �� 7!r wif4 rW ✓a t„ �W �m 1 + e �1 Ell MEMO uR� „ n Ell G �� y c ,,:tia r �� 8 � i� �+^I� /'rj1,��i r. �' ; k9,»?U✓��.,b'i aW�t>8�� 'P a'�::�� '�'Ylu Q�1 ps 14Y ,?y ,1 ;.Ffi is fh a, �✓ 45i%jr,,) dN ., � r� y�.sp( d'�¢;�M "u{,bP�'"r ,r /aP P k r„” si ! w,��,N�G r U', e ✓,,-">;< �i 9✓n�dlrfi �fld�fiFla ,� � � m ud��a�r��ltird�r} �;. 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"a„,A iy�b a O H b • � a a Town of North Andover :; LI �'AL,TH DEPARTMENT CHECK ## DATE 3 ,, .w : LOCATION: "'� �Z un 1-1/0 NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service Type:_._ $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ — ❑ Offal(Septic)Hauler $ ❑ Recreational Cama $ ❑ Sun tanning ❑ Swimnning Pool $ _ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC stems: Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Titre 5 Report ' $ P ❑ Other: (Indicate) $ Hei"ith'Agent Initials White-Applicant Fellow-Ilealth Pink-- Treasurer