HomeMy WebLinkAboutMiscellaneous - 28 SOUTH BRADFORD STREET 4/30/2018 (2)C-0
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BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM) -
PURSUANT TO SECTION 310 CMR 15.354
OF THE STATE ENVIRONMENTAL CODE, TITLE V
TEL. 682-6483
Ext23
This form must be submitted to the Board of Health no less than
five (5) days prior to date of abandonment and be accompanied with
a -copy of the sewer connection permit.
Name Lt-,) IA -L e -p-- Phone
Address r -A -P6 "j
Contractor hired for work:
Name— e� Phone
Address- '5�j a L.AJa.-�e- P�-
Date for scheduled abandonment
Method of septic tank abandonment (check one).
removal sandf ill S-.6 crush other (describe
/ below)
Other
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH AGENT'S USE ONLY
IR!9`pe(:�ting Agent Date
Comments
,`^.~^,+ ill_,,, ;r�T~!,v .'' .~ �,7 .~_��0~~_�,___,,~~'~^�t^ww~~~~`^`~
RepNature
of ServiceNICReg.
Maint.LOU
SEPTIC
;IPO
EmergenANUOVER
PUMPTER!'
of;r /'v
I
Day 0 NightPAY FROM THIS BILLCustomer
Name:Ire�oO.
BOX 4173 B StationService
MA 01810(508)475-259311
Lowtion:,�Andover,
Contact:Locally
Owned and Operatedcity:
Emergency 24 Hr. Svc. — 7 DaysSpecial
ZIP-,
InstructionsI�
'in plete, Reason:Services
Rendered.'.V
Pumping
I Drain CleaningulmMain Line1771
Toilet BowlC3
Leach Pit I overflow,
Kitchen Sink'to
Pumpc�ambe
Cover0
t] VanityIt13
brease, Trap
&eti;sive Solids0
Top BottomYard
Floor Draintch,sis'l�-
�ortable Toilet i;
Use: No Powdered Soat]
Drain0
Other lj� I'll
0 Grease
RootsSuigot
dQty:
Electric6000
50o'toIr
gallons
:,,I Ingil I k lit
I0
O'Other -It
Certification: P/F0,
Service Call
Estimate
Reason:Rental0'Portable
04181,
C3 Pump RepairDiscretion
i
I
C3, Other�lot-)Lr
---
Description of WorkRecommendatro"I
Terms of Paymentc
u Pu pt Drain Clea�lno
NJET
il DAvS
artsmonih
TaxMonthConditions
Yr,
Cashr
1. N esponsible for damage beyond curb line. per th W
shall be reported within 48:hours, 4. lxjrch=aw
C11'Plaints
Co I tion.
ustomer Signature
�
C2 9�
Please forward us as much of the following information that is possible;
1. Type of system
2. Age "'Y
3. L ocat i on(
4- Maintenance records and date of last pumping out
7Y
6
/V,
5. Documentation of repairs and reconstruction
6. Site conditions
7. Builder of system D.
7s/ -Z, -
'17 e "U4
8. Engineer who approved;
— Site
System
9, Installation Procedure
1.0. Problems
SEPTIC SYSTEM INSPECTION FORM
<
ADDRESS oLS6 r
LKTE INSPECTED
PROPERLY FUNCTIONING? N
WEAT14ER CONDITIONS'
COMMENTS:.
W A "TE R a Z; A L I T Y 7 E.S TIE j-ZG':,
DYE TEST PERFORMED? Y N
DATE?
SKETC11:
m
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name bL ; Tr 1'6�
2. Street Address �T s 0 u IR 5 77
3. How many members are in your household? '4911,
4.
What type of sewage disposal system do you have?
cesspool
septic tank and leaching area
El connection to municipal sewer
El other (describe)
El do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board. of Health?
0 yes El no 1% do not know ---
6. How old is your sewage disposal system? El 0-5 years El 6-10 years 11-20 years --
D over 20 years El do not know
7. Has your sewage disposal system been rebuilt or repaired?
F-1 yes _%' no 0 do not know
If yes, approximately how long ago? years. What was done?
8. How frequently is your sewage disposal system pumped out? F-1 annually
r56 every 2-4 years every 5-10 years over 10 years El never
9. Have you had any problems with your sewage disposal system? El yes no
If yes, what problems?
El repeated pump -outs needed
D system clogs, backs up, or drains slowly
El odors
El 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 showerlbathtub
R., -PMase state the brand and type (liquid or powder) of detergent you use for:
dishwasher CA's C h me-
clotheswasher TIL24
12. Does your property have a lawn?
If yes, approximately what size?
[I less than 1/4acre 0 'Aacre
0 more than 1 acre (Specify) -
yes El no
1/2acre El 3/4acre El 1 acre
acres
13., How often do you fertilize your lawn?
No. of applicationsper year /V0/V'9
Season(s) of the year
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
0 Check here if your lawn is maintained by a professional landscape contractor.