HomeMy WebLinkAboutMiscellaneous - 116 MARBLERIDGE ROAD 4/30/2018 (2) 116 MARBLERIDGE ROAD Od
210/037.B-0011-0000.0 1
,gyp RTS.,
o� ` °� BOARD OF HEALTH
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120 MAIN STREET TEL. 682-6483
SACHUS �y NORTH ANDOVER, MASS. 01845 Exc23
9SE�
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
PURSUANT TO SECTION 310 CMR 15 . 354
OF THE STATE ENVIRONMENTAL CODE, TITLE V
This form must be submitted to the Board of Health no less than
five (5) days prior to date of abandonment and be accompanied with
a cony of the sewer connection permit.
Name Ve-14 .012 ;�-kjt
Phone
Address r-- 'I`�,
Contractor hired for work:
Name 4p— JP�-- Phone
Address Lu L<—/ ',vim 1�C
Date for scheduled abandonment
Method of septic tank abandonment (check one) .
( ) removal ( ) sandfill crush ( ) other (describe
below)
Other
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH AGENT ' S USE ONLY
Inspecting Agent Date
Comments
J0- 1149
APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass. /a, 19
Application by the undersigned is hereby made to connect with the town sewer main in .i/ Street-
subject to the rules,and regulations of the Division of Public Works.
The premises are known as No. yC ci! l / ��G
- Street
or s-ubdi�vision lot no. j
Owner Address
C,
Contractor Address
Applicant's Signature
PERMIT TO CONNECT WITH SEWER MAIN
The Division of Public Works hereby grants permission to
to make a connection with the sewer main at Street
subject to the rules and regulations of the Division of Public Works..
Division of Public Works
By
Inspected by
Date
See back for rules and regulations
k
SEPTIC SYSTEM INSPECTION FORM
ADDRESS
DATE INSPECTED "
.PROPERLY FUNCTIONING? N
. WEATHER CONDITIONS
COMMENTS: '
7
DYE TEST PERFORMED? Y N
DATE?
SKETCH
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s.
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Please forward us as much of the following information that is possible,
1. Type of system C e- S S ro 4-
a
2. Age -5J 7ehw
L f �, ,ems" , l' d�cz,v�.•
3. ocat io�a,ny
4. Maintenance records and date of last pumping out ��/ 7r
'�'
5- Documentation of repairs and reconstruction
6® Site conditions
7. Builder of system
8. Engineer who approved;
— S ite' M""�
-- System °�
9 . Installation Procedure
10, Problems
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name
u,r --ci_
° 2. Street Address � ��' �M �.0 - /�� 3) '
3. How many members are in your household? Z `
4. What type of sewage disposal system do you have?
[A 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?
❑ yes ❑ no LR do not know -
6.
now ,-6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years
P over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes 11 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 ❑ every 5-10 years1 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
Q 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 A _
roof/pavement drains shower/bathtub —A--
11. Please state the bred and type (liquid or powder) of detergent you use for:
dishwasher �� -
clotheswasher
12. Does your property have a lawn? yes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre ❑ 1/4 acre ❑ % acre ldl % 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
14. Please state the brand and a (liquid or anular) of lawn fertilizer you use:
tYP q �' Y -�
0 Check here if your lawn is maintained by a professional landscaMcontractor.
BOARD 01 HEALTH �66a 4. '
146 MAIN STREET
TELEPHONE# (508) 688-9540 �bQe,D .
APPLICATIONFOR ABAhDOAMEA71 pC>�
OF SUBSURFACE DISPOSAL SYSTEM`�j
(SEPTIC SYS T& )
Pursuant to Section 310 COIR 13.334 i
of the State Environmental Code, Title V
Name 1 el Phone
Address r^ ' ; ��
Contractor hired for work:
Name ge-)dle� C-'V4. Phone
Address 'f e&J
Date for scheduled abandonment /0 0
The septic system at the above address has been abandoned according to
Title V specifications.
Signature of ntractor
Method of wp. c &k abandonment (check one). ( ) removal ( ) sandfill
X crush ( ) other
Name of Offal Hauler lt�l� �er vt`Ce
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.
— L)
Inspecting Agent Date
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