HomeMy WebLinkAboutMiscellaneous - 134 SOUTH BRADFORD STREET 4/30/2018 (2) 134 SO BRADFORD STREET ;d Street
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BOARD OF HEALTH
146 MAIN STREET {
,TELEPHONE# (508) 688-9540
APPLICATIONFOR ABANDONMENT
OF SUBSURFACE DISPOSAL :SYSTEV1
(SEPTIC SYSTEM)
Pursuant to Section 310 CMR 13.33-4
of the State Environmental Code, Title V
Name eqZ , 0015C711 Phone
Address ji4 5004t, 54-re,d-
Contractor (tired for work:
Name CUrro �u-5 t('L t`ok Phone Cgq-��3Co
Address 54- 13 (z),PP- 3f . 1\16 . A i Joffe✓ MP
Date for scheduled abandonment 9 - 17- 9/6
The septic system at the above address has en ando 'accord' to j
Title V specifications.
S attire of Contractor
Method of septic tank abandonment (check one). O removal O sandfill
(X) crush ( ) other
Name of Offal Hauler
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.
07� 43
Inspecting Agent Date
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Town of North Andover, MA
Watershed Septic System 4
Servicing Report 9
Date
Homeowner: 04—lav 4Pumper :-DANIELA. GIARD
Street 13V Address: btFlIC SERVICE
AfllnMir ...
Phone Phone (688)686.7653
Nature of Service: Routiney
Emergency
Observations: Good Conditiony
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other (Explain)
Description of Work:
Comments:
WA ERSHED RESIDENTS QUESTIONNAIRE
1. Name
2. Street Address `
3. How many members are in your household?
4. What type of sewage disposal system do you have?
❑ cesspool
L'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?
L'f,"'yes ❑ no ❑ do not know
6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years
[T�over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes 1�Yno ❑ 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 years ❑ over 10 years ❑ never
9. Have you had any problems with your sewage disposal system? ❑ yes [9---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 applia� are connected to your sewage disposal system?
washing machine dishwasher garbage disposal
dehumidifier drain sump pump toilet Gl
roof/pavement drains shower/bathtub _L
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher
clotheswasher / a
12. Does your property have a lawn? P yes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre ❑ 1/4 acre I�; "/2 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
14. Please state the brand and type (li uid or ranular) of lawn fertilizer you use:
u,' /,4 /1—
El
' , r—❑ Check here if your lawn is maintained by a professional landscape contractor.
SEPTIC SYSTEM INSPECTION FORM
ADDRESS_
DATE INSPECTED
PROPERLY FUNCTIONING? N
WEATHER CONDITIONS
COMMENTS :
WATT ER aVALI T Y TESTFT hEsoL-i$?
DYE TEST PERFORMED? Y N
DATE?
SKETCii:
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