HomeMy WebLinkAboutMiscellaneous - 350 GREAT POND ROAD 4/30/2018w
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Name
Addre
BOARD 0, HEALTH
146 IIAIN STREET
TELEPHONE# (508) 688-9540
.4 PPLICA TION FOR ABA yV DO,`i.'V1EA- 7'
OF SUBSURFACE DISPOS IL SYSTEV
(SEPTIC SYS TEV)
Pursuant to Section 310 CIVR 13.354
of the State Environmental Code, Title V
Contractor hired for work:
Name Phone j _ Z�
Address r
J/
Date for scheduled abandonment D 7
The septic system at the above address has been abandoned according to
Title V specifications.
Signator of Contractor
Method of septic tank abandonment (check one).
( ) crush ( other
Name of Offal Hauler —La�i 1Z-'�
( ) removal O sandfill
This form must be returned to the North Andover Board of Heal I
t r.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
REPRESENTATIVE'S USE ONLY.
Inspecting Agent
/0 t6
Date
STEWART'S
s SEPTIC TANK SERVICE
47 RAILROAD STREET, BRADFORD, MASS. 01835
Telephone: 372-7471
! Date____--
Mr.
Street .
n t�.
i
City A�
f SERVICE CHARGE
DIGGING
PUMP TANK l
SNAKE UNE
SERVICE CHARGE
Not responsible for grass & driveways.
INVOICE DUE AND
PAYABLE UPON RECEIPT
TOTAL "-
Driver
Signature
work done in satisfactory manner.
SEPTIC SYSTEM INSPECTION FORM
ADDRESS zs-b G Wot"A- 4/vA e�
DATE INSPECTED `6
PROPERLY FUNCTIONING? (1� N
WEATHER CONDITIONS
COMMENTS:
WATER QUALITY TESTED? RESULTS?
DYE TEST PERFORMED? Y .N
DATE?
SKETCH:
Ci
C
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name
2. Street Address
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 a. do not know
6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years j 11-20 years
❑ over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes R no ❑ do not know
If yes, approximately how long ago?
years. What was done?
8. How frequently is your sewage disposal system pumped out? ❑ annually
5; every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never
9. Have you had any problems with your sewage disposal system? ❑ yes 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 garbage disposal
dehumidifier drain sump pump toilet
roof/pavement drains shower/bathtub_
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher
clotheswasher�-i--
12. Does your property have a lawn? CF\ yes ❑ no
If yes, approximately what size?
a less than 1/4 acre ❑ 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?
1
No. of applications per year
Season(s) of the year - r�
V
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.