Loading...
HomeMy WebLinkAboutMiscellaneous - 170 GREAT POND ROAD 4/30/2018 170 GREAT POND ROAD 210L037.C-0008-0000.-0 1lLi`�.�J1-iiL, J j \LSI DIL A �VL,v 1. �`J1�l�AL1�E 2. Street Address c 3. I-Ir,w many members are in your household? 4. VVnai type of sewage disposal system do you have? ❑ 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? D- yes ❑ no ❑ do not know 6. flow old is your sewage disposal system? ❑ 0-5 years 6-10 years ❑ 11-20 years ❑ over 20 years ❑ do not know I 7. Has your sewa a disposal system been rebuilt or repaired? ❑ _vc no ❑ do not know . If yes, approximately how long ago? years. What was done? S. How frequently is your sewage disposal system pumped out? ❑ annually C1 every 2-4 years ❑ every 5-10 years ❑ over 10 years lb never 9. Have you had any problems with your sewage disposal system? [ yes ❑ no If yes, what problems? ❑ repeated pump-outs needed '' � ll {_ Ai system s, backs up, or drains slowly W 'Z.v..l ❑ odors ❑ sewage surfaces through ground 10.' How many of each appliance are connected to your sewage disposal system? ,washing machine _(— dishwasher 1 garbage disposal deliumidifir- drain sump pump toilet roof/pavement drains shower/bathtub 11. Please state the rand a d ty e (liquid or powder) of detergent you use for: eishwasher clotheswasher 12. Uoes your property have a lawn? ® yes ❑ no 1 yes, approximately what size? j ❑ less than 1/4 acre ❑ '/4 acre ❑ 1/2 acre ❑ 3/4 acre ❑ 1 acre �] more than 1 acre (Specify) izzn acres 13. l low often do you fertilize yotuP? 1`.o. of applications per year Season(s) of the year 14. Flerse 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. ---- ---- - -- SEPTIC SYSTEM INSPECTION FORM ADDRESS o DATE INSPECTED � �ROPERLY FUNCTIONING? N WEATHER CONDITIONS COMMENTS: WATER QUALITY TESTED? RESULTS? DYE TEST PERFORMED? Y .N DATE? SKETCH: WATERSHED RESIDENTS QUESTIONNAIRE 1. Name (Y�r' �S-tu`ca_ d 2. Street Address C _ O 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ 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 ❑ do not know 6. How old is your sewage disposal system? ❑ 0-5 years J1 6-10 years ❑ 11-20 years ❑ over 20 years ❑ do not know 7. Has your se wa a disposal system been rebuilt or repaired? El yes L 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 O ❑ every 2-4 years ❑ 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? El repeated pump-outs needed � system I 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 1 garbage disposal dehumidifier drain sump pump toilet roof/pavement drains shower/bathtub 11. Please state the rand aTd type (liquid or powder) of detergent you use for: dishwasher (��Cf�C>Ft� clotheswasher 12. Does your property have a lawn? Z yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/2 acre ❑ 3/4 acre ❑ 1 acre [] more than 1 acre (Specify) �,0 acres 13. How often do you fertilize youaw ? O No. of applications per year Season(s) of the year 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. .F. 710 ". Tk NAIRE Rd _32. S .€>et Address1^(!�; -,YES.-�`r j! -Rd - 3. . l,ow many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool ❑ septic tank and leaching area ct.nnection 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 ❑ 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 sews a disposal system been rebuilt or repaired? El yes no ❑ do not know If yes, approximately how long ago? years. What was done? S. How frequently is your sewage disposal system pumped out? ❑ annually ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years k never 9. b"Eave you had any problems with your sewage disposal system? M yes ❑ no If yes, what problems? [❑ repeated pump-outs needed system s, backs up, or drains slowly O s)ketc ' ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine dishwasher 1 garbage disposal dehumidific- drain sump pump toilet roof/pavement drains showerlbathtub 11. Please state the; rand a d e (liquid or powder) of detergent you use for: dishwasher clotheswasher �C 12. Does your property have a lawn? ® yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/2 acre ❑ 3/4 acre ❑ 1 acre more than 1 acre (Specify) —acres 13. How often do you fertilize yougaw,p? .,xo. of applications per year L 1 Season(s) of the year 14. r-lease state the brand and type (liquid or granular) of lawn fertilizer you use: j Check here if your lawn is maintained by a professional landscape contractor.