HomeMy WebLinkAboutMiscellaneous - 29 SOUTH BRADFORD STREET 4/30/2018C',
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SEPTIC SYSTEM INSPECTION FORM
ADDRESS 29
,�.
DATE INSPECTED
PROPERLY FUNCTIONI NG? N
WEATHER CONDITIONS
COMMENTS:
WATiER aVALITy 'rESTIF-
DYE TEST PERFORMED? Y N
DATE?
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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 C1KR 15.354
OF THE STATE ENVIRONMENTAL CODE, TITLE V
T'EL. 682-64,83
Exi23
This form must be submitted to the Board of Health no less than
five (5) days prior to date of abandonment and be accomQanied wit�i
a co3py of the sewer connection Permit.
Name " X, "'e Phone
U1, 2
Address ��'q (�(-d ST -
0 Contractor hired for work:
Name 0-) -cc) b Phone cr�
Address C 5- 6'(-� 3 IlUo - ____z C7/Lz-� �/ ----
Date for scheduled abandonment �z
Method of septic tank abandonment (�chec one)
removal sandfill crush other (describe
below)
Other
FOR HEALTH AGENT'S USE ONLY
I n,�,e c -t -d. n e
Comments
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JN . 0
1108
APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass. t') 7 19 2(Lp
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Application by the undersigned is hereby made to connect with the town sewer main in Street,
subject to the rules and regulations of the Division of Public Works.
The premises are known as No.
or subdivision lot no.
Owner
Contractor
14 EX L 77-�L/
e0-,V'5E-2VAT10 KI
Address
Street
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
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name
2. Street Address Z-9
3. How many members are in your household?'
4.
What type of sewage disposal system do you have?
El cesspool
septic tank and leaching area
connection to municipal sewer
[I other (describe)
El do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health?
El yes El no I/ do not know
6. How old is your sewage disposal system? El 0-5 years El 6-10 years 11-20 years
El over 20 years El do not know
7. Has your sewagg disposal system been rebuilt or repaired?
El yes V no - El do not know
If yes, approximately how long ago?
years. What was done?
8. How frequently is your sewpge disposal system pumped out? El annually
El every 2-4 years V every 5-10 years D 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
El system clogs, backs up, or drains slowly
El odors
El sewage surfaces through ground
1'0. How many of each appliai3ce are connected to your sewage disposal system? . I
washing machine dishwasher garbage disposal
dehumidifier drain sump pump toilet
roof/pavement drains shower/bathtub
h. Please state the by�nd and type iouid or owder) of detergent you use for:
PAS
dishwasher
clotheswasher
12. Does your property have a lawn? Nel*`yes El no
if yes, approximately what size?
Vless than 1/4 acre El 1/4 acre El 1/2 acre 1/4 acre acre
El 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:
0 Check here if your lawn is maintained by a professional landscape contractor.
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Xorth Andover Board of Health
-Town Hall, -120 Main Street
"North Andover, MA 01845
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