HomeMy WebLinkAboutMiscellaneous - 177 WINTER STREET 4/30/2018 (2)AUG "711-1
Name
Address 17
5ns
BOARD OF HEALTH
27 CHARLES STREET
NORTH ANDOVER, MA 01845
TELEPHONE# (978) 688-9540
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEA4)
Pursuant to Section 310 CMR 15.354
of the State Environmental Code, Title V
Contractor hired for work:
Name ra / r'o 644-
Address
0
Date for scheduled abandonment
c a. Phone
Phone 6- tel- 22 �'c
The septic system at the above. address has been abandoned according to
Title V specifications.
Si tore of Contractor
MFfiiod of septic tank abandonment (check one). () removal () sandfill
crush ( ) other
Name of Offal Hauler ,e
A.
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.
04 -6;p
Inspecting Agent Date
s
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Y"
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1557
APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass.}9—
Application by the undersigned is hereby made to connect with the town sewer main inl _ Street,
subject to the rules and regulations of the Division of Public Worksm
The premises are known as No. �7 7 Street
or s;ubqivision lot no.
141 /'-`L &0 t'cr
Owner
r
Contractor
Address
Address
Applicants Signatur
PERMIT TO CONNECT WITH SEWER MAIN
The Division of Public Works hereby grants permission to
to make a connection with the sewer main at
subject to the rules and regulations of the Division of Public Works..
Inspected by
Date
By
See back for rules and regulations
Street
Division of Public Works
APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass.
c
Application by the undersigned is hereby made to connect with the town sewer main inStreet,
subject to the rules and regulations of the Division of Public l Works.
The premises are known as No. T? Z6 / �e� Street
or subdivision lot no.
A-1 e l0 t C Z,
Owner
C I �L)
Contractor
Address
Address
Applicant s Signatur
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.. a'
Divisiori=of Public Works
By
Inspected by
Date
See back for rules and regulations
r
.� qr
Y: Ba)e
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Customer Name.
Service Location: --%
Phone: A
Contact:
Billing Address:
PAY
City: I Zip:
x G'.� tla'QIia
r I
FROMTHIS'_BILLrk
*A
/ 4 ' P.O. Box 4173 'B Station
Andover,` MA 01810
t ^� : ,;, 8) 475 593
l S
Professional. epti& Drain
Locally Owned and Operated
Special Instructions I)6,
Completed
❑ incomplete Reason: _
Per:
AM/PM C ��
Services Rendered /
Emergency 24 Hr. Svrc,—
,7 Days
3jllq
Vacuum Pumping
Observations Drain Cleaning
kO Septic Tank ❑ Good Condition ❑ Main Line
✓❑ Drywell ❑ Leechfield Runback ❑ Toilet Bowl
❑ Leech Pit / Overflow 'IF Riding High ❑ Kitchen Sink
(liquid level) ❑ Bathtub / Shower
❑ D -Box ❑ Full to Cover ❑ Vanity
❑ Pump Chamber Excessive Solids ❑ Floor Drain
❑ Grease Trap Top l�Bottom ❑Yard Drain
❑ Catch Basin ❑ se No Powdered Soap ❑ Vent
❑ Portable Toilet ❑ Heavy Grease
C3 Other C3w r Jet:.. l /�
Oty. ❑Roots
Size: ❑Suggest EI _ nc ' Footage:
t Under 1000 gallons ❑ 1000 gallons ❑ 1500 gallons ❑ �a°n°t��led �� %' V / �� � % 6
2000 gallons ❑ 3000 gallons ❑ 4000 gallons
El Other J' r
❑ 5000 gallons ❑ other
Misc.
❑ Digging Charge An.
❑ Backhoe
Vs.
❑Inspection
❑Certification: P/F
El Location
❑ Consultation
Reason:
❑ Service Call
ElEstimate
[I Pump Repair
❑ Labor
[I Portable Toilet Rental
❑Repair
❑ Waiting Time
Digging Charge Is Per Driver
❑ Baffle
G
❑Chemical Treatment
Discretion
f/�y'
/ ,-.
[IOther __--
Description of .Work I C?
Recommendations
Vacuum Pumping Drain Cleaning
Terms & Conditions ❑ Cash ; ,. Check
1.foot responsible for damage beyond curb line.
2. 11 complaints shall be reported within 48 hours.
` 4 -ft undersigned agree to all terms and conditions.
Customer Signature
W
arms It PafilWht
❑ Credit
3� 1°6 per month will be charged to accounts past due.
4. a per
agrees to pay all cost of.collection..
Parts
Tax
Discount
Total
Serviceman
Please
tilease f o.rward us as much of the foil ow:T1f?
information that '. S possible;
1. `hype of system V4,_,Z1--e.j
a
2. Aq,e � G
.3. Location
4. Maintenance records and date of last pumping; out
K, Dlocumentation of repairs and reconstruction
6, Site conditionsi�V
7. B i.i i 1 d e r of system��t�t/1-u-1
8. Bn?ineer who approved% y "�
—Site
S -y s t e m G d �✓��: �Z / (l �� �/�
9, Installation Procedure
10. Problems
SEPTIC SYSTEM INSPECTION FORM
ADDRESS I -n U) � vv+�
DATE INSPECTED
PROPERLY FUNCTIONING? & N
WEATHER CONDITIONS
COMMENTS:
WATER QUALITY TES T Eb 2 ReSULTS?
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name Z 2,�/`_�,�
2. Street Address %
T w 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 R;/ do not know.
6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years"-
2"' over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes L no ❑ do not know
If yes, approximately how long ago? years. What was done?
i
8. How frequently is .your sewage disposal system pumped out? ❑ annually
❑ every 2-4 years - ❑ every 5-10 years ❑ over 10 years [never
`0
� 9. Have you had any Problems with your sewage disposal system? Yes h" no
_—_
- If yes, what problems?
❑ repeated pump -outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
j❑ 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 L-'
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher
clotheswasher
12. Does your property have a lawn? 93,11 -yes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre EJ 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?
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.