HomeMy WebLinkAboutMiscellaneous - 402 JOHNSON STREET 4/30/2018 402 JOHNSON STREET
210/038.0-0090-0000.0
SEPTIC SYSTEM INSPECTION FORM
ADDRESS �� /Z v-,
DATE INSPECTED
PROPERLY FUNCTIONING? N
WEATHER CONDITIONS
COMMENTS :
WA Ti ER QUALITY TES!Eta n RES0L:TS?
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
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Please forward us as much of the following information that is possible;
1. Type of system
c � _
2. Age J
3,. Locationj L-0 z J 0t-t- SQr I
4- Maintenance recordt and date of last pumping out
5. Documentation of repairs and reconstruction
6. Site conditions
7. guilder of system
8. Engineer who approved%
— Site
Fstem W
9 . Installation Procedure
10. Prohlems
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WATERSHED RESIDENTS QUESTIONNAIRE
1. Name D-) f1 A S J O H V5l Q (`s% 0 rJ
2. Street Address O Q�, Q\-, N<'>O N ST
3. How many members are in your household?
4. What type of sewage disposal system do you have?
❑ cesspool
a 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 M do not know i
6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years -F
9 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?
8. How frequently is your sewage disposal system pumped out? ❑ annually
® 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?
El 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 x garbage disposal
dehumidifier drain sump pump toilet
roof/pavement drains shower/bathtub >_
11. Please state the brand and type (liquid or powder) ofd tergent ou use for:
dishwasher SCRDe ! LA& Cl -LT �S6t-� LI
clotheswasher 7-%c6- FS-,12>, t3 0`0 VO uo C� .q AIM LX.0012
12. Does your property have a lawn? ® yes ❑ no
If yes, approximately what size?
❑ 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?
No. of applications per year /
Season(s) of the year -2 P,,?
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
SCo7T.S — D /�Jep-
❑ Check here if your lawn is maintained by a professional landscape contractor.