HomeMy WebLinkAboutMiscellaneous - 44 LISA LANE 4/30/2018 44 LISA LANE
2101098-A-0037-0000.0
BOARD OF HEA1-TI-1
146 MAIN STREET
TELEPHONE# (508) 688-9540
.4 PPLICA TION FOR 4BAjVDOA'., /--,\V T
OF SUBSURFACE DISPOSAL SY.S'TLVf
(SEPTIC SYS T EMS
Pursuant to Section. 310 CMR 13.354
of the State Environmental Code, Title V �k�u
Name �eye
i Phone
Address 44�
Contractor (tired for work:
Name__ ��/� l Phone
Address
Date for scheduled abandonment
The septic system at the above address has been abandoned according to
Title V specifications.
Y-A=�-
Signature of Contractor
Method of septic tank abandonment (check one). O removal O landfill
crush O other
Name of Offal Haulert��
This form must be returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
/ REPRESENTATIVE'S USE ONLY.
Inspecting Agent Date
f'
to 1
1�Iqg
11--800-345-6677 36689
Lawrence 688-1181 Haverhill 373-7151
Salem,NH 603-898-1554 Methuen 686-2214
Andover 475-4711 Newburyport 462 681
OPHONE
ILL ^ ^
L/ - `•'�✓, DAY WORK
1 CONTRACT
EXTRA
B N M AN A ION
JOB PNON
Ago - ?DESCRIPTION OF
uU �
TOTAL AMOUNT
No one home E] Total amount due Total billing to
ture for above work:or be mailed after
Signa
I hereby acknowledge the satlafactory completion of completion
wor
or the above described work of work
TERMS;C.O.D.
Because of the nature of the work herin described and of Its emergency,we prefer
that all payments be made to mechanic on the Job after completion.
A FINANCE CHARGE computed at a periodic rate of 1 1/2% PER MONTH which Is
an ANNUAL PERCENTAGE RATE of 18%will be charged on all accounts remaining
unpaid by the 10th of the month following the purchase.
THANK YOU.
A service charge of$15.00 will apply on all returned checks.
SEPTIC SYSTEM INSPECTION FORM
ADDRESS
DATE INSPECTED
PROPERLY FUNCTIONING? Y� N
WEATHER CONDITIONS
COMMENTS :
WA`i ER QL'ALi T Y TES I ECJ 2 JZESULTS?
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name ?_OLo ! :t t4� A. (nAhnjC) AX .
1 2. Street Address ' 0 1S'S/ .S
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 do not know, - _-
6. How old is your sewage disposal system? ❑ 075 years ❑ 6-10 years ❑ 11-20 years --_
W 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
i
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 --77-- toilet 2
roof/pavement drains shower/bathtub
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher o,ntlgL4 - /.�-nr-crr;QnA
clotheswasher '' ' rl'&'dA
12. Does your property have a lawn? yes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre ❑ 1/4 acre CK 1/z 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 _ 21
Season(s) of the year
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
' 6OL106 I UIQ,4y 62 bwVI ffIL .
❑ Check here if your lawn is maintained by a professional landscape contractor.
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