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Home My WebLink AboutMiscellaneous - 173 JOHNSON STREET 4/30/2018 (2)N b V f0 W u � � o g= Z 0 Z p m � � m rt l SEPTIC SYSTEM INSPECTION FORM ADDRESS l q `3 DATE INSPECTED PROPERLY FUNCTIONING? OY N WEATHER CONDITIONS COMMENTS: WA i E:R aV,ALrry TES 1En ? RES0L-TS� DYE TEST PERFORMED? Y N DATE? SKETCH: r� WATERSHED RESIDENTS QUESTIONNAIRE 1. Name RUTH 113 JOHNSON STREET 1 2. Street Address NORTH ANDOVER. MA 01845 3. How many members are in your household? c C 4. What type of sewage disposal system do you have? ❑ cesspool C6+L e s ® septic tank and leaching area (ods . Bch i '%e_ ® connection to municipal sewer ❑ other (describe) ❑ do not know MI 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 X do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes ❑ no )4 do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? ❑ ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years 9. Have you had any problems with your sewage disposal system? If yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground annually ❑ never t.ko ❑ yes 9 no 10. How many of each appliance are connected to your sewage disposal system? washing machine dishwasher of I garbage disposal X dehumidifier drain K sump pump toilet X 2- roof/pavement roof/pavement drains shower/bathtub V t 11. Please state the brand and type (li u Aid or powder) of detergent you use for: dishwasher All V ctd t' clotheswasher 7je k 12. Does your property have a lawn? )I 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 your lawn? n No. of applications per year JLttur� Season(s) of the year'CLz 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: CX Check here if your lawn is maintained by a professional landscape contractor. 71,1 }_' �t`a► � �}.� _�\..k_w.,I L.,. r rA ';ESse�.0i�NA1RE 1. Name Rfiru r. KiL;gi. 173 JO'H�SON STREET WORTH ANDOVER. MA 01845 2. Sheet Address _ 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool Cf O+l e s KI septic tank and leaching area., Gods.�h i ti,c connection to municipal sewer ❑ other (describe) ❑ do not know MI 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no 0< do not know 6. flow old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years ❑ over 20 years hC do not know 7. Has your sewage disposals stem been rebuilt or repaired? El yes El no do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? ❑ ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years 9. Have you had any problems with your sewage disposal system? If yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground annually /� ❑ never'Q ❑ yes no 10. How many of each appliance are connected to your sewage disposal system? washing machine dishwasher aC I garbage disposal X I dehumidifier drain K sump pump toilet � � • roof/pavement drains shower/bathtub V l 11. Please state the brand and type (li uid or powder) of detergent you use for: dishwasher All -- p r U1 e r -. clotheswasher Wick IIA% It � 12. Does your property have a lawn? If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre ❑ more than 1 acre (Specify) V yes ❑ no ❑ 1/z acre ❑ 3/4 acre 1 acre acres 13. How often do you fertilize your lawn? � /1 No. of applications per year t. J v'n' Season(s) of the yeaftc vrt h � sTriti,a 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. Insurance Adjustment Service, Inc. 435 King St. Littleton, MA 01460 (978) 952-6966 Fax (978) 952-2459 UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 3B Date: October 8, 2004 TO: Town of N. Andover Board of Health/Building Inspector N. Andover, MA 01845 F1141004,p RE: Insured: Ruth Nelson Property Address: cc 173 Johnson St. North Andover, MA 01845 PARTM��°, Date of Loss: Policy Number: Type of Loss: 5/15/2004 HP02736244H water File or Claim Number: 18047 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file number. Thank you for your cooperation. YVeryTyours, il Adjuster Ext. 129 nr# John Barrington 173.Johnson Street North Andover,p Massachusetts Dear 'sir# Barrington: The Department of Public Health hes recently completed a sanitary survey of the watershed of Lake Cochichewick, the source of water supply for the town of Forth Andover# This report states there exists on your premises 'fast ovorflow of septic tank# less than 250 feet from brook and pond tributary to Lake Cochickew1oko a violation of Rule 21# Enclosed is a copy of Rules and Regulations adopted by the State Department of Public Health in 19121 for the purpose of preventing the pollution of the crater of Lake Cochicherick# You are hereby notified to correct this violation. Should you caro to discuss the matter further or obtain any additional information heretofore, please consult the Borth Andover Board of Hoalth# Very truly yourst BOARD OF HEALTH By.111ary Sheridan, Agent ---------------- i e ! c. / � .._.Pry -�• r�- � j r . 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