HomeMy WebLinkAboutMiscellaneous - 222 SALEM STREET 4/30/2018 222 SALEM STREET
210/037.D-0023-0000.0
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STATEMENT
DANIEL A. GIARD
130A Appleton Street _cl 3
NORTH ANDOVER, MA 01845 DATE
Phone 686-7653
TERMS:
PLEASE DETACH AND RETURN WITH YOUR REMITTANCE
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BALANCE FORWARD
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PAY LAST AMOUNT
DANIEL A. GIARD IN THIS COLUMN
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SEPTIC SYSTEM INSPECTION FORM
ADDRESS
DATE INSPECTED
PROPERLY FUNCTIONING? N
WEATHER CONDITIONS
COMMENTS :
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WATEP, OUALITY TES I Eb ? lZesuLT�'?
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
Please forward us as much of the following information that is possible;
1. Type of system
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. Agre
.3. Location, I ,
4 - Maintenance records and date of Ia t pumping out
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Documentation of repairs and reconstruction
6. Site conditions
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7. Builder of system
8. ;ineer who approved'.
Site
— System W
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9 A Installation Procedure
10, Problems
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WATERSHED RESIDENTS QUESTIONNAIRE
1. Nameae aK
t An!!4_
2. Street Address �_ Se, 1 C m-
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 our sewage disposal system on file with the Board of Health?
❑ yes ❑ no do not know
6. HH w old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years
Lv1 over 20 years ❑ do not know
7. Has your se wa disposal system been rebuilt or repaired?
❑ yes Ino ❑ do not know
If yes, approximately how long ago? years. What was done?
I I
8. How frequently is your sewage disposal system pumped out? LIQ' 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 U/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 appliance are connected to your sewage disposal system?
washing machine dishwasher" 4— garbage disposal
dehumidifier drain sump pump toilet
roof/pavement drains shower/bathtub _J_
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher
clotheswasher T
12. Does your property have a lawn? Y/yes ❑ no
If yes, approximately what size?
[Iless than 1/4 acre El1/4 acre F11/2 acre 3/4 acre ❑ 1 acre
❑ more than 1 acre (Specify) acres,�1/
13. How often do you fertilize your la n? lick-�--
O No. of applications per year
KIA-
Season(s) of the year
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
110 '
❑ Check here if your lawn is maintained by a professional landscape contractor.
i"' TLSTIONNAIRE
IF r
2. Street Address ` �Q r t-r, �Ce
3. How many members are in your household.
4. What type of sewage disposal system do you have?
❑ cesspool.
❑�' septic tank and leaching area
L) connection to municipal sewer
:ether (describe)
do not know
5. Are the plans (drawings) f7do
ur sewage disposal system on file with the Board of Health?
El yes El no not know
E. H w old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years
I over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ 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? 9/annually
O ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never
a
9. Have you had any problems with your sewage disposal system? ❑ yes IV/no
Lf yes, what problems?
❑ repeated pump-outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. How many of each appli nce are connected to your sewage disposal system?
washing-machine dishwasher garbage disposal .
dehumidifier drain _� sump pump toilet
roof/pavement drains --6— shower/bathtub^,_JL_
11. please state the brand and type (liquid or powder) of detergent you use for:
dishwasher,
clotheswasher _
12. Does your property have a lawn? yes ❑ no
If yes, approximately what size?
Elless than 1/4 acre El1/4 acre El1/z acre LTJ 3/4 acre ❑ 1 acre
❑ more than 1 acre (Specify) acres
13. How often do you fertilize your a n? ncvc�–
` No. of applications per year
KIA-
Season(s) of the year
14. Please state the brand and type (liquid or granular) of lawn fertilizer you.use:
i
❑ Check here if your lawn is maintained by a professional landscape contractor. !