HomeMy WebLinkAboutMiscellaneous - 202 GREAT POND ROAD 4/30/2018 (2)I
SEPTIC SYSTEM INSPECTION FORM
ADDRESS i Q a, of' pr al
DATE INSPECTED -T 0
PROPERLY FUNCTIONING? (�) N
WEATHER CONDITIONS
COMMENTS:-
WATER QUALITY TESTED? RESULTS?
DYE TEST PERFORMED? Y ,N
DATE?
SKETCH:
WATERSHED
1. Name ),q elP
RESIDENTS
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QUESTIONNAIRE
2. Street Address 0 a 6we-e rAwe PY
3. How many members are in your household? G
4.
What type of sewage disposal system do you have?
❑ cesspool
❑ septic tank and leaching area
CK 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 V do not know
6. How old is your sewage disposal system? VO -5 years ❑ 6-10 years ❑ 11-20 years
❑ over 20 years ❑ do not know
7. Has your sewyno
disposal system been rebuilt or repaired?
El yes ❑ do not know
If yes, approximately how long ago?
years. What was done?
8. How frequently is your sewage disposal system pumped out? ❑ annually /J/A
❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never
9. Have you had any problems with your sewage disposal system? ❑ yes Vno
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 app
lian a are connected to your "age disposal system?
washing machine dishwasher V garbage disposal
dehumidifier drain sump pump toilet
roof/pavement drains ,,shower/bathtub
10-1
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher C f-) ScA&
clotheswasher 01\ ( -, � jZ f1
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)
13
How often do you fertilize your lawn?
No. of applications per year
Season(s) of the year
/yes ❑ no
/I/2acre ❑ 3/4 acre ❑ 1 acre
acres
14. Please state the brand and 7e (liquid or granular) of lawn fertilizer you use:
Check here if your lawn is maintained by a professional landscape contractor.
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North Andover Board of Health
Town Hall, 120 Main Street
North Andover, MA 01845
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