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HomeMy WebLinkAboutTitle V Inspection Report - 545 JOHNSON STREET 5/24/2018 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 545 Johnson St Property Address Davis Owner's Name Ma 01845 State Zip Code 5/1/18 North Andover Date of Inspection City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. 5-:0 Important:When A. General Information filling out forms ? on the computer, use only the tab 1. Inspector: key to move your cursor-do not use the return ...... ------ key. Name of Inspector Richard Briscoe VQ I Company Name R A Briscoe Inc. Company Address 61 Garrison St. Groveland Ma 01834 City/Town State Zip Code 978-372-2200 S1029 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: M Passes EJ Conditionally Passes 171 Fails Needs Further Evaluation by the Local Approving Authority 5/6/18 --------------- —-------- Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins,doo•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 545 Johnson St Property Address Davis Owner's Name Ma 01845_.__._......,_-. State Zip Code 5/1/18 North AndoverDate of Inspection City/Town B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A.) System Passes. 0 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 545 Johnson St Property Address Davis Owner's Name Ma 01845 State Zip Code 5/1/18 North AndoverDate of Inspection City[Town B. Certification (cont.) El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): El Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health)- 171 broken pipe(s) are replaced 0 Y El N El ND (Explain below): El obstruction is removed El Y 171 N El ND (Explain below): El distribution box is leveled or replaced ❑ Y 0 N El ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): 171 broken pipe(s) are replaced El Y n N 1:1 ND (Explain below): ❑ obstruction is removed 0 Y El N El ND (Explain below): C) Further Evaluation is Required by the Board of Health: F-1 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Owner it 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 545 Johnson St Property Address Davis Owner's Name Ma 01845 State Zip Code 5/1/18 North Andover Date of Inspection Cityfrown 1. System will pass unless Board of Health determines in accordance with 310 CMR 171 Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: E-1 The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. 1:1 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. E-1 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. El The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ...... This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 545 Johnson St -—-——- Property Address Davis Owner's Name Ma 01845 State Zip Code 5/1/18 North Andover Date of Inspection City/Town El FX-1 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El FX-1 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool R RX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow B. Certification (cont.) Yes No [:j 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. El 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. F1 RX Any portion of a cesspool or privy is within a Zone I of a public well. El 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. R 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] El The system is a cesspool serving a facility with a design flow of 2000gpd- 0 10,000gpd. The system fails. I have determined that one or more of the above failure R 0 criteria exist as described in 310 CMR 15.303, therefore the system fails, The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No El 0 the system is within 400 feet of a surface drinking water supply t5ins.doc,•rev.6116 fitle 5 official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Owner Title Official Inspection r information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 545 Johnson St Property Address Davis Owner's Name Ma 01845 State Zip Code P^ 5/1/18 North Andover Date of Inspection City/Town [❑ 0 the system is within 200 feet of a tributary to a surface drinking water supply F-1 .nx. the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? ❑ n Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? 0 ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Q ❑ Existing information. For example, a plan at the Board of Health. ❑ 0 Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] t5ins.doc-rev.8118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Owner information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 545 Johnson St Property Address Owner's Name Ma 01845 State Zip Code 5/1 . ......... North Andover Date of Inspection Cityfrown D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 ----30-- gpd D. System Information Description: 2 Number of current residents: _..._--......— Does .........Does residence have a garbage grinder? 171 Yes 0 No Is laundry on a separate sewage system? (include laundry system inspection 171 Yes 0 No information in this report.) Laundry system inspected? F-1 Yes Mx No Seasonal use? El Yes M No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? R-1 Yes El No Last date of occupancy: Occupied - Date Commercial/industrial Flow Conditions: t5ins.doc rev.6116 Title 5 Official Inspection FOFITI:Subsurface Sewage Disposal System-Page 7 of 16 Commonwealth of Massachusetts ©caner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 545 Johnson St ...... _............_— _ Property Address Davis Owner's Name Ma 01$45 State Zip Code 51111$ �.._.. North Andover Date of Inspection Cityr own Type of Establisment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.) __- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: D. System Information (cont.) Last date of occupancy/use: oateY_ — __- Other(describe below): General Information Pumping Records: Source of information: Wane Was system pumped as part of the inspection? ❑ Yes 150 No If yes, volume pumped: __..— gallons Haw was quantity pumped determined? Reason for pumping Type of System: Septic tank, distribution box, soil absorption system E1 Single cesspool t5ins,doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 545 Johnson St ...... Property Address Davis —------ Owner's Name Ma 01845 State Zip Code 511118 North AndoverDate of Inspection City/Town El Overflow cesspool 1:1 Privy 1771 Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract El Tight tank. Attach a copy of the DEP approval. El Other(describe): D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2010 Were sewage odors detected when arriving at the site? 171 Yes Fx1 No Building Sewer(locate on site plan): 1.5 Depth below grade: feet Material of construction: 171 cast iron R-1 40 PVC El other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 545 Johnson St Property Address Davis Owner's Name Ma 01845 State Zip Code 5/1/18 North Andover Date of Inspection City/Town 1 Depth below grade: .fe I et ------- Material of construction: Fx-1 concrete El metal El fiberglass El polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No Dimensions: Sludge depth: D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 1.3 ....... Scum thickness .3 Distance from top of scum to top of outlet tee or baffle -1 Distance from bottom of scum to bottom of outlet tee or baffle Now were dimensions determined? Dip ube Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Baffles In Place t5ins.doe rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 10 of 16 Commonwealth of Massachusetts Owner Title 5 Official Inspection r information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 545 Johnson St Property Address Davis owner's Name Ma 01845 State Zip Code 5/1/18 North Andover Date of Inspection City/Town Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: --..- ..... Scum thickness Distance from top of scum to top of outlet tee or baffle --- - -— Distance from bottom of scum to bottom of outlet tee or baffle — - - - Date of last pumping: ©ate D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: - Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: k5ins.doo•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 11 of 18 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 545 Johnson St Property Address Davis ------ Owner's Name Ma 0,184.5 State Zip Code 5/1/18 North Andover Date of Inspection City/Town Capacity: gallons Design Flow: gallons per day Alarm present: El Yes 0 No Alarm level: Alarm in working order: El Yes ❑ No Date of last pumping: Date _m._.._—_._.—----------- Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? r-] Yes El No D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): no signs of failure Pump Chamber(locate on site plan):none 15ins,doo-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 545 Johnson St Property Address Davis Owner's Name Ma 01845 State Zip Code 5/1/18 North Andover Date of Inspection Cityrrown Pumps in working order: Yes F-1 No* Alarms in working order: FX1 Yes 171 No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: D. System Information (cont.) Type: ❑ leaching pits number: El leaching chambers number El leaching galleries number: ....... El leaching trenches number, length: leaching fields number, dimensions: 1 28x20 ❑ overflow cesspool number: 171 innovative/alternative system Type/name of technology: -------- t5ins.doc-rev.6116 Trite 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 545 Johnson St Property Address Davis ------------- Owneeg Name Ma 01845 State Zip Code 5/1/18 North Andover Date of Inspection CityrFown Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc. No signs of failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth -top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow 171 Yes El No D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: ...... Dimensions ----—------ t6ins.doe•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Owner it 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 545 Johnson St ...... Property Address Davis ....... Owner's Name Ma 01845 State Zip Code 5/1/18 -------......... North AndoverDate of Inspection City/Town Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): .......... D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet, Locate where public water supply enters the building. Check one of the boxes below: n hand-sketch in the area below 0 drawing attached separately t5ins.doc•rev.6116 Titto 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 16 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 545 Johnson St ------- Property Address Davis ......... Owner's Name Ma 01845 State Zip Code 5/1/18 . ....... North Andover Date of Inspection City/Town D. System Information (cont.) Site Exam: El Check Slope 1-1 Surface water El Check cellar El Shallow wells Estimated depth to high ground water: 30 inches in original feet 15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 Commonwealth of Massachusetts Owner Tile Off Inspection r information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 545 Johnson St Property Address _.. Davis Owner's Name Ma 01845 State Zip Code _North Andover Date of Inspection Cityfrown Please indicate all methods used to determine the high ground water elevation: d Obtained from system design plans on record If checked, date of design plan reviewed: 2010 ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Soil lop for design a Before filing this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist d Inspection Summary: A, B, C, D, or E checked 0 Inspection Summary D (System Failure Criteria Applicable to All Systems) completed O System Information—Estimated depth to high groundwater �IL-6 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Page 17 of 18 tbins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• Commonwealth of Massachusetts Owner Title 5 Official Inspection Farm information is Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments required for every page. 545 Johnson St _...----- .... _.._.._ Property Address Davis Owner's Name Ma01845 --___ ___.___.—_..._ State Zip Code North Andoverdate of inspection City/Town t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 DERBY 296 ,4 PROPOSED L OCA TION OF SEP Tl LINER REL OCA TED DUE TO ENCOUNTE s 2 t , ZFE F'-1 INSPECTION 20' PORT SEPTIC TANK,,, `� 1 #2 SOIL REPLACEMENT d AREA FM / } 10. 2 i� Coq ¢ FORCE MAIN CHAMBER DISTRIBUTION BOX D r A 303.93 RC,q STREET j {�I�RIZONTAL TIESA._ B,• C. D. SEPTIC TANK INLET COVER ------ 30.5 19.3 --- SEP TIC TANK CENTER COVER ---- 28. 0 24. 4 ---- SEPTIC TANK OUTLET COVER --- 272 26.8 --- PUMP CHAMBER INLET COVER --- 25.8 33, 4 --- PUMP CHAMBER OUTLET COVER ---- 26.3 39.5 --- BEND --- 30.2 50. 0 --- DIS TRIBU TION BOX 119.8 --- 109. 0 ---- CORNER FIELD 1 111.5 ---- 99.0 --- i #2 --- , 2 --- --- 100.5 119.9 #3 --- --- 120.5 136.0 , 4 128.8 --- 118.9 INSPECTION POR T --- ---- 108.5 121. 7 FENT --- --- 120.8 136. 0 STRUCTURES.' CLEANOUT @ BUILDING SEWER PIPE 1500 GALLON 2-COMPARTMENT MONOLITHIC SEPTIC TANK W/ EFFLUENT FIL TER AND GAS BAFFLES & MH 1000 GALLON MONOLITHIC PUMP CHAMBER W/ LIBERTY LE41A EFFLUENT PUMP & MH 2" 0 PVC FORCE MAIN 6-OUTLET H-20 DISTRIBUTION BOX W/EQUALIZERS & 2" TEE- 20' EE20' X 28' LEACH FIELD W/ 4 LINES ALL SCH-40 PVC PIPE INSPECTION PORT AS SHOWN VENT AS SHOWN PTIC, INC. y WGINEERING, LLC - //M SCANLAN, P.E. �4�2010 P1 DI PL Tf S E PL tot Town of North Andover HEALTH DEPARTMENT, CONTRACTOR NAME: Type of Permit or License: (Check box) • Animal -_______ � • Body Art Establishment $ • Body Art Practitioner $ • Funeral Directors $ • Massage Establishment $- • Massage Practice $ • Offal(Septic)Hauler $ • Recreational Camp 0 Sun tanning $ • Swimming Pool $ • Tobacco • TrashlSolid Waste Hauler 13 Well Construction $ | SEPTIC Systems: 11 Septic Disposal Works Construction(DW0 $ 0 Septic Disposal Works Installers(DWI) $ El Title 5 Inspector 0 Other. (Indicate) jMkjLe-Applicant Yellow.--Health Pink-Treasurer