HomeMy WebLinkAboutMiscellaneous - 100 GLENNCREST DRIVE 4/30/2018 (2)I
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BOARD OF HEALTH
146 MAIN STREET
TELEPHONE# (508) 688-9540
APPLIC.4 TION FOR ABANDOiV IE, NT
OF SUBS(-,RFACE DISPOSAL SYSTE, V
(SEPTIC SYSTEM)
Pursuant to Section 310 CMR 15.354
of the State Environmental Code, Title V
Name �Nl
Address d
Contractor (tiredfor work;
T-2 Phone
Name i &,/(ylPhone
Address i - W1 n --,n 1 ).a. 4,tm "'V
Date for scheduled abandonment (- —9 �>
N1 EA LYN
'h
The septic system at the above address has been abandoned according to
Title V specifications.
Signature of Con actor
Me hod of septic tank abandonment (check one). (} removal () sandfill
(;Cl
crush ( ) other
Name of Offal Hauler t"7 Gmm e,
This form must be returned to the North Andover Board of Health
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
REPRESENTATIVE'S USE ONLY.
�ffi I -110
Inspecting Agent Date
e5��,/Pq F;rl . --
SEPTIC SYSTEM INSPECTION FORM
ADDRESS
DATE INSPECTED '?F
PROPERLY FliNCTIONING? (�) N
WEATHER CONDITIONS
COMMENTS:
WA i E: P, aZALiTy 1 ES ► C- '2' ?eSUL i S?
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name �c'1-VL'1_o'lt c�
2. Street Address t (- r&
3. How many members are in your household?
4. What type of sewage disposal system do you have?
❑ cesspool
K septic tank and leaching area
❑ connection to municipal sewer
❑ other (describe)
❑ do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health?
❑ yes ❑ no X do not know
6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years
;, over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes N no . ❑ do not know
If yes, approximately how long ago?
years. What was done?
8. How frequently is your sewage disposal system pumped out? ❑ annually
❑ every 2-4 years 91 every 5-10 years ❑ over 10 years ❑ never
9. Have you had any problems with your sewage disposal system? ❑ yes �, no
If yes, what problems?
❑ repeated pump -outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. How many of each appliance are connected to your sewage disposal system?
washing machine dishwasher ? garbage disposal
dehumidifier drain sump pump toilet ��--
roof/pavement drains shower/bathtub
11. Please state the brand and_ type (liquid or powder) of detergent you use for:
dishwasher
clotheswasher
12. Does your property have a lawn? R' yes ❑ no
If yes, approximately what size? �/
El less than 1/4 acre ❑ 1/4 acre L/ % acre ❑ 3/4 acre ❑ 1 acre
❑ more than 1 acre (Specify) acres
13. How often do you fertilize your lawn?
No. of applications per year
Season(s) of the year Sryv,,,
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
Check here if your lawn is maintained by a professional landscape contractor.
2. Street Address (�.,> r:T, t ..1` rte- �/r t
3. Fiew many members are in your household?
4. Wjhat type of sewage disposal system do you have?
rs cesspool
septic tank and leaching area
❑ connection to municipal sewer
❑ other (describe)
❑ do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health?
Lyes El no do not know
6. l &vk- old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years
L' over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes A no ❑ do not know
If yes, approximately how long ago? years. What was done?
8. Rew frequently is your sewage disposal system pumped out? ❑ annually
El every 2-4 years every 5-10 years ❑ over 10 years ❑ never
9. Have you had any problems with your sewage disposal system? ❑ yes ;�Z no
L_- yes, what problems?
❑ repeated pump -outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. 14f ow many of each appliance are connected to your sewage disposal system?
ash ing machine —L dishwasher -:garbage disposal
c _'-,,r rnidifier drain sump pump ;Filet .2—
r -f/pavement drains showerfbathtub _
11. Please state the brand and type (liquid or powder) of detergent" you use for:
d .si-washer
6otheswasher ecz� S
12. Floes you, property have a lawn? ❑ no
If yes, approximately what size?
❑ less than 1/4 acre ❑ 1/4 acre Z/% acre ❑ 3/4 acre ❑ 1 acre
❑ more than 1 acre (Specify) acres
13. l r.ow often do you fertilize your lawn?
Pk o. of applications per year f
S :afon(s) of the year Spy -t. --f, -, .2 T -L
14. F ea. se sta.:e the brand and type (liquid or granular) of lawn fertilizer you use:
j
-'� Cl : eck Dere if your lawn is maintained by a professional landscape contractor.