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HomeMy WebLinkAboutTitle V Inspection Report - 1049 SALEM STREET 7/5/2018 Commonwealth of Massachusetts 47) Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1049 Salem Street -Property Address Sue Lee Owner Owners Name information is North Andover MA 01845 6-28-2018 required for every page. City/Town State Zip Code Date of Inspection 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. Important:When A. General Information RECEIVL=L) filling out forms on the computer, use only the tab 1 Inspector: JUL key to move your cursor-da not Neil James Bateson i A --------------- -use the return key. "A MENT Name of Inspector RT�vl`) Bateson Enterprises Inc. ----------- -dompany Name 111 Ar9#1a Road Company Address rehm Andover MA -4___-- 01810 Cityrrown State Zip Code 978-475-4786 SI-15 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 inspect on 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: Passes ❑ Conditionally Passes F1 Fails Need� Further Evaluation by the Local Approving Authority 6-28-2018 S Ins krr ignatu 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 DER 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 at that time.This inspection does not address how the system will perform in the future unt er the same or different conditions of use. t5ins.doo-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1049 Salem Street PropertyAddress Sue Lee Owner Owners Name information is North Andover MA 01845 6-28-2018 required for every — page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: 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: F-1 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 o Compliance indicating that the tank is less than 20 years old is available. El Y ❑ N El ND (Explain below): ---------- t5ins.doc-rev.6/16 "rifle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1049 Salem Street Property Address Sue Lee Owner Owner's Name information is North Andover MA 01845 6-28-2018 every required for eve page. Cit !Town - -§fa—te Zip Code Date of Inspection B. Certification (cont.) F-1 Pump Chamber pumps/alarms not operational. System will pass with Board of Health approv�l 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 e to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System, ill pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N F ND (Explain below): i ❑ obstruction is removed ❑ Y ❑ N 0 ND (Explain below): ❑ distribution box is leveled or replaced El Y F] N El ND (Explain below): I -------------------T [1 The system required pumping more than 4 times a year due to broken or obstructed pipe(s). �he system will pass inspection if(with approval of the Board of Health): El broken pipe(s)are replaced .0 Y E] N Fj ND (Explain below): ❑ obstruction is removed El Y [:1 N F] ND (Explain below): -_7 C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine i f the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public he Ith, safety and the environment: ❑ 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 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 8t 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments -------- 1049 Salem Street ------ Property Address Sue Lee Owner Owners Name information is MA 01845 6-28-2018 1 North Andover required for every State Zip Code Date of Inspection page. Cityrrown B. Certification (cont.) 2. System will fall 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: F] 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. F] The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ 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 e ual to or less than 5 ppm, provided that no other failure criteria are triggered, A copy of the analysis must be attached to this form. 3. Other: L D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters E] N due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloa ded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5in&doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 f 17 � Title 5 Ommmcmam Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments -0�r—operty Address— Sue Lee Owner Owners Name infonnmUonisr MA 01845 -28-2O18 noqui�dfor exo� '^=`^'^'~~`~ State Zip Code Date of Inspection page. City/Town. B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Any portion of the SAS, cesspool or privy is below high ground water elevati:)n. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. F1 Any portion of a cesspool or privy is within a Zone 1 of a public well. El ED Any portion of a cesspool or privy is within 50 feet of a private water supply 'well. El 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 f et from a private water supply well with no acceptable water quality analysis. �his system passes if the well water analysis, performed at a DEP certifipd laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppr ii, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- The system fails. I have determined that one or more of the above failure 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 thel questions in Section D. Yes No El the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply�1 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. min^uoc'rev.wm Title,Official Inspection Form:Subsurface Sewage Disposal System Page`T ^ � / Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1049 Salem Street Pro party Address Owner Ownees Name information is MA 1 45 G-2G-2U1D �quimd«orexery "°^°''^'~~`~' page. ~',-- m��uoc'rev.6/1m Title^Official^Inspection^Form:Subsurface Sewage Disposal System '~--r '' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1049 Salem Street Property Address Sue Lee Owner Owners Name information Is required for every North Andover-,--------- MA 01845 6-28-2018 page. CityfTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ o Is laundry on a separate sewage system? (include laundry system inspection El Yes El o information in this report.) Laundry system inspected? El Yes Ej \lo Seasonal use? n Yes (A No Water meter readings, if available(last 2 years usage(gpd)): Yes Detail: Sump pump? © Yes 0 NO Last date of occupancy: Current Date 7-_ Commercial/Industrial Flow Conditions: Type of Establishment: ---------- -------------- -------- Design flow(based on 310 CMR 15,203): Gallons per jiy(gpd)_____ Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? D Yes El No Industrial waste holding tank present? El Yes n o Non-sanitary waste discharged to the Title 5 system? F1 Yes El o Water meter readings, if available: t6ins.doo-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1049 Salem Street -Property—Address Sue Lee Owner Owners Name information Is North Andover MA 01845 6-28-2018 required for every State Zip Code Date o f Inspection s ipe c tho—n page. City/Town D. System Information (cont.) Last date of occupancy/use: ma-te Other(describe below): T-- --------—------------- General Information Pumping Records: Source of information: Never pumped Was system pumped as part of the inspection? E Yes Ej No 1500 If yes, volume pumped: gallons How was quantity pumped determined? Measured-- tank Inspect tank&tees Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool El Privy ❑ 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 IIA system by system operator under contract El Tight tank. Attach a copy of the DEP approval. El Other(describe): t5ins.doe•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 if 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments A 1049 Salem Street Property Address Sue Lee Owner Owner's Name information is MA 01845 6-28-2018 required for every North Andover State Zip Code Date of Inspection page. d7it—y/Town —- -—---------- D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 4 years old, 6-20-2014, as built plan Were sewage odors detected when arriving at the site? El Yes M No Building Sewer(locate on site plan): 5 Depth below grade: Material of construction: F1 cast iron E 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): Unable to see piping leaving foundation, finished cellar walls. 4" PVC in house, no leaks visible Septic Tank(locate on site plan): 4 Depth below grade: Material of construction: E concrete El metal El fiberglass El polyethylene ❑ other(explain) -—-- --- If tank is metal, list age: -years I Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes F] No 10'x 5' x 4' Dimensions: ........... 311 Sludge depth: .- -1--11 -,----—-- t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 1049 Salem Street Sue Lee Owner Name information isMA 01845 G-28-2O18 required for every ``"'°' ''^~``~' page. _^r'~~^ State Zip Code Date of InspectionD. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 811 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1311 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural n egr� liquid levels as related to outlet invert, evidence of leakage, etc.): Depth of liquid above outlet invert, found filter clogged, clean same. Inlet tee ok . Outlet tee ok. Tank in ground four feet, inlet cover has riser 2"deep, outlet cover has riser 8"deep. No evidence of tank leaking. Pumped septic tank. ----------------- Grease Trap (locate on site plan): Depth below grade:| Material of construction: El concrete n metal El fiberglass polyethylene El other(explain): Scum thickness Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: mm°don'rev.6110 Title"Official Inspection Form:Subsurface Sewage Disposal System,Page~ .. T ^ � Commonwealth of Massachusetts Title 5 Official ~~ --- m- - - -- - - - Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Sue Lee Owner Owners Name infonnaUonis MA 01845 0-28-2O18 required*mreve� "=°'''^~~`�' page. City/Town~ D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integnty, 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: F] concrete F] metal F] fiberglass polyethylene other(exp1q in): Design Flow: gallons per day Alarm present: El Yes E-1 No Alarm level: Alarm in working order: n Yes El N Date of last pumping: Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? Yes N� mm '~~`~^~~~~~�~~~~`----- —�'----' �-~' am,�^ ^wx ~� Sewage— 17 if | Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1049 Salem Street Property Address Sue Lee Owner Owner's Name information is North Andover MA 01845 6-28-2018 required for every State Zip Code Date of Inspection page. City[Town 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.): D-box level &distribution equal has flow levelers. Evidence of carryover, pumped d-box to clean. No evidence of leakage. Pump Chamber(locate on site plan): it Pumps in working order: F-1 Yes E] No Alarms in working order: F] Yes E] 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: 151ns.doo-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 If 17 Commonwealth of Massachusetts Title 5 Officinal Inspection Form ments Subsurface Sewage Disposal System Form - Not for Voluntary Assess 1049 Salem Street Property Address Sue Lee Owner Owner's Name information is MA 01845 6-28-2018 equ|edfornxo� '^~'^'''^'~~`~' page. ..'.~_ n State Zip Code Date of Inspection D. System Information (cont.) E-1 leaching pits number: El leaching chambers number: El leaching galleries number: El leaching trenches number, length: I field 15' x leaching fields number, dimensions: overflow cesspool number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition f vegetation, etc.): Soil ok. Vegetaion ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration ----- Depth of solids layer | Depth ofscum layer Dimensions ofcesspool Materials ofconstruction Indication Vfgroundwater inflow E1 Yes [] NV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1049 Salem Street Property Address Sue Lee Owner Owners Name information is North Andover MA 01845 6-28-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetatic n, etc.): Privy (locate on site plan): Materials of construction: Dimensions ----- _ - Depth ----- Depth of solids )F vegetation, Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition (f vegetati n, etc.): t5ins.doo-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 141f 17 | ' Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 1049 Salem Street Property Ad_d�e­ss information is MA 01845 1O mquimdfuravo� '""'"' '^'~~^~' state Zip Code Date of.In-spection pogo. ~'"''.~. 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: hand-sketch in the area below El drawing attached separately | 17/ wm".d" 'rev.6/16 Title~~~~~ ^~~~~^~~Subsurface� ~--,--,osal--'-'' '-~ - 117 T ' ' | � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1049 Salem Street Property Address Sue Lee ...... Owner Owner's Name information is North Andover MA 01845 6-28-2018 required for every page. dk�/—T—own ­ State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Z Check Slope Surface water Check cellar Z Shallow wells 3.8 Estimated depth to high ground water: feet ___.-__ _.__. Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 10-10-2013 If checked, date of design plan reviewed: Date 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: Test pit data on design plan shows water 46" Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15hs.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 116 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1049 Salem Street Property Address Sue Lee ---------- Owner Owner's Name information is North AndoverMA 01845 6-28-2018 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist [K Inspection Summary* A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file II i5ins.doo-rev,6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts s Citj/Town of . System Pumping.Record Form 4 DEP has provided this form`for use-by local Boards of`Health.other farms may'be'used,but the Information,must be substantially the game as that provided here. Before using.this form,check with y ur local Board of Health to determine the forrrt they use.The System Pumping Record must be submitte�c to the local Board of Health or other approving authority. A. Facility Informlatlon` 1. System Location: L6hl front of Hous Left/Right rear of house, Leff:/right side of house, Left Right side of building, Left/Right tront of building, left/Right rear of building, Under deck Address i city/rown State Zip code Z. system Owner. i Name' Address(if different from location) cityrrown Stat ` ,r+ Zip CI Grp f. '/ C7 ----fix Telephone Number .B. Pumping Record 1. Date of PumpingDate 2. Quantity Pumped; Gonane r 3. Type•of system: ❑ Cesspool(s) OLSeOcTank ❑ Tight Tank ❑ other(describe); 4. Effluent Tee Filter present? " No if yes,was it cleaned? 0-*virn No, 5. Condition of Sys# 6; 9 stm e { Y P y Nell.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Lo here contents were disposed; L S: Lowell Waste Water 1 SlqnAt4e 9t Hhul Date t5form4.dorr 06103 System Pumping Record•pags 1 of 1 Summary Record Card generated on 6/1312018 2:03:48 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-104.D-0070-0000.0 Parcel Id 16758 1049 SALEM STREET SUE LEE 1049 SALEM STREET NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Res dential Size Total 0.39 Acres FY 2018 UB Mailing Inde Name/Address Type Loan Number Active/Inact, From Until SUE LEE Owner 1049 SALEM STREET NORTH ANDOVER MA 01845 JULIE KELLY Previous Customer Inactive 7/15/2009 1053 SALEM STREET N.ANDOVER,MA 01845 JUSTIN PERKINS Previous Customer Inactive 10/11/2013 1049 SALEM STREET NORTH ANDOVER. MA 01845 HANNAFORD&RIELLY LLC Previous Customer Inactive 8/29/2014 PO BOX 802 ANDOVER MA 01810 JEFFCO Previous Customer Inactive 10/2/2014 PO BOX 802 ANDOVER wmmo110 � UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 78OO.0-1Oo9SALEM STREET Last Billing Date 4MO/2O18 316037/ O8Cycle 03 Active UB Services Maint. Account No.J1O0877 Service Code Rate Charge Multiplier/Users M|SCPEEADMIN FEE 0.636/8 7.82 1/ VVTRWATER O1ALL METER SIZE 41.V0 /1 UB Meter Maintenance Account No. 3180377 Serial No 8tmbm Location Brand Type Size ons *5320721 oAcVve o0ERT MM hBad�n wNbtor 0.630.83 � �- 484 Dein Reading Code Consumption Pno,od Date Variance �/2VlV 489 o8�ua| 15 6/6/2018 3/5/2018 484 oAutuo| 11 4/23/2018 12/5/2017 473 nActua| 17 1/25/2018 9/7/2017 456 eActoa| 33 10/102017 8/5/2017 423 aActua| 28 7/25/2017 3K6/2017 395 aAntoa| 17 4/12/2017 37%12/7/2016 � 2VYO 378 aAma| 28 1/23/2017�O17 90/2016 350 oActua| 102 1024/2016 6/3/2016 248 oActuo| 31 8/2/2010 3/3/2016 217 aActuo| 17 4/22/2016 120/2015 200 aAutua| 52 1/202016 9/2/2015 148 oActua| 71 10/16/2015 ^`" 1m 6/5/2015 77 aAotuo| 08 v24/2015 3/6/205 39 u8ctum 21 4/202015 6 L"i Town of North Andover HEALTH DEPA11TMENT CHECK#: DATE: LOCATION: A(I 1" .......... H/O NAME: CONTRACTOR NAME: 72 Type of Permit qa1cense: (Check box) 0 Animal • Body Art Establishment • Body Art Practitioner • Dunipster 0 Food Seivice-Type:--,--,,,---- 0 Funeral Directors • Massage Establishment • Massage Practice • offal(Septic)Hauler • Recreational Camp • Sun tanning • Swimming Pool El Tobacco 0 Trash/Solid Waste Haider 0 Well Construction SEPTIC btemp. 0 Septic-Soil Testing 0 Septic-Design Approval 0 Septic Disposal Works Constriction(DWC) 0 Septic Disposal Works Installers(DWI) 0 Title 5 Inspector e Title 5 Report $ El Other. (Indicate)----.,- $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer