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Home My WebLink About- Title V Inspection Report - 48 SUNSET ROCK ROAD 9/6/2018 :J�,, Commonwealth of Massachusetts Title icial Inspection I3i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t� !'Y 48 Sunset Rock Road Property Address Thomas Page Owner Owners Name information's required for every North Andover MA 01845 8/24/2018 page. Citytiown 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 filling out forms A. Inspector Information - _on the computer, ` use only the tab Benjamin C.Osgood,Jr. key to move your Name of Inspector _ cursor-do not NIA use the return Company Name key. 157 Bluff Street Company Address Salem NH 03079 City/Town state Zip Code 978435-1324 S1870 Telephone Number License Number B. Certification I certify that:I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true,accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails r {/moi 8/28/2018 Inspectors?ijnature j 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 form should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Please note: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. Mnsp d.-rev.7/2612616 Ti1!e 5 Official Inspection Form_Sebaurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 1 0Inspection l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 48 Sunset Rock Road Property Address Thomas Page Owner Owner's Name information'a01845 Andover MA 01845 8/2412018 required for every page. city/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary:Complete 1,2,3,or 5 and all of 4 and 6. 1) 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: 2) 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): t8insp.tlx•rev,]28t2t118 Tine 5 Official Inspectiee Fain'.Sutrsartace Sewage Dlacosa Sy-,•Page 2&18 Commonwealth of Massachusetts aTitle 5 Official Inspection Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 48 Sunset Rock Road Property Address Thomas Page Owner Owners Name information is North Andover MA 01845 8/2412018 required for every page. CitylTown State Zip Code Date of Inspection C. Inspection Summary(cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(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): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ 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. a. 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 health, safety and the environment: t5in,,. —712612018 Till.6 efiid.1 Mn p.cli-F—SO-1—Sewage System•P.q.3&18 Commonwealth of Massachusetts Title iil Inspection i=� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments li , 48 Sunset Rock Road Property Address Thomas Page Owner Owner's Name information is North Andover MA 01845 8/24/2018 required for every page. CitytTown State Zip Code Date of Inspection C. Inspection Summary(cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. 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: ❑ 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. ❑ 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 ❑ 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 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. a Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.Mc rev.MW2018 Till,5 ORrAaI Insp,ction Fm Subsurface Se-wage Disposal System•Page 4 of 18 commonwealth of Massachusetts Title Official Inspection ht Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t' 48 Sunset Rock Road Property Address Thomas Page Owner Owner's Name information isNorth Andover MA 01845 8/24/2018 required for every page_ Cityrrown state Zip Code Date of Inspection C. Inspection Summary(cant.) 4) System Failure Criteria Applicable to All Systems:(cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow El ® 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 elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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 5 ppm, 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 2000 gpd- 10,000 gpd. El ® 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. 5) targe 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 CA. Yes No ❑ ❑ 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 El El Area system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone ii of a public water supply well tse,V.d.•rev.7126/2018 T tft 5 oredoi h.pxaoa Form-sobure..S—g.oi$P—1 system•Paae 5 a 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sunset Rack Road Property Address Thomas Pam — Owner Owner's Name information is required for every North Andover MA 01845 8!24!2018 page CitylTown State Zip Cotle Data of Inspection C. Inspection Summary(cont.) If you have answered"yes'to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? El ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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? ® El information the facility owner(and occupants if different from owner)provided with 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: ❑ ® Existing information.For example,a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)] f5insp tl,v•rev.7126!2!118 Tnie 5 Orrdai inspection Fain-Sub..J—Sexege niep W Sys..•Page 6 0 18 Commonwealth of Massachusetts �aTitle 5 Official Inspection 1� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sunset Rock Road Property Address Thomas Page Owner Owners Name information is North Andover MA 01845 8/2412018 required for every page. Cityrrown state Zip Code Date of Inspection D.System Information 1. Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): 440 Description: 1 Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes,discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insp.,im—712612018 Till.5 OR'al Inspection Pwm:Sb-f..Sewage Disposzl System•P.,e 7 of 18 Commonwealth of Massachusetts Title iil Inspection ;ti� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sunset Rock Road Property Address Thomas Page Owner Owner's Name information is MA 01845 8/24/2018 required for every North Andover page. Citytrown state Zip Code Date of Inspection D.System Information(cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 GMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes,discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 5/22/18 per BON Records Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15i,w.M_c•rev.7t26W 8 Tille 5 Ofdal Inspedim Fw Subsw am Sr ge Disp sa.Sysiem-Page 6&18 Commonwealth of Massachusetts Title ici l Inspection Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ��;y48 Sunset Rock Road Property Address Thomas Page Owner Owner's Name information is North Andover MA 01845 812412018 required for every page. City/Town State Zip-Code Date of Inspection D.System Information(cant.) 4. Type of System: ® Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records,if any) ❑ 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 ItA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed in 1996 per assessor's record card Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 6 Depth below grade: feet Material of construction: ®cast iron ❑40 PVC ❑other(explain): NIA _ Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Pipe looks OK in basement i5 r.=p.tl�•rev.Tt2&+2018 Title 5 Otfitial Inspection F—Sobsu.-Sewage Dispose SYpt-m•Page 9 d 18 Commonwealth of Massachusetts Title icial Inspection Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 48 Sunset Rock Road Property Address Thomas Paqe Owner Owners Name information is North Andover MA 01845_ 812412018 required for every page. Cityri-own Stara Zip Code Date of Inspection D.System Information(cont.) 6. Septic Tank(locate on site plan): 5 Depth below grade: feet Material of construction: ®concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1500 gallon Dimensions: <1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 33" <1 Scum thickness Distance from top of scum to top of outlet tee or baffle 6" -- Distance from bottom of scum to bottom of outlet tee or baffle 15" Measure stick How were dimensions determined? Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank in good condition with riser to just below Grade i5insp.doc•rev.Tf26f1o18 Title 5 O1ficIal Inspection Form:SubsWs.Sewage Disposal System•Page 10.f18 Commonwealth of Massachusetts Title i iInspection y �1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments +i 48 Sunset Rock Road Property Address Thomas Page Owner Owner's Name information is required for every North Andover MA 01845 8(2412018 page. Cltyfrown State Zip Code Date of Inspection D.System Information(cont.) 7. 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: Date Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 8. 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: Capacity: gallons Design Flow: gallons per day t5insp.dx•ray.7t26f V18 Tiile 5 oTiciai Msi—ion Form:Subsixface Sewage 6isposai System•Paao 11-f48 Commonwealth of Massachusetts Title ffici l Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w f 48 Sunset Rock Road v Property Address Thomas Page Owner Owner's Name information is North Andover MA 01846 8(24/2418 required for every page. CityrTown State Zip Code Date of Inspection D.System Information(cont.) 8. Tight or Holding Tank(cont) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No 9, 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.): Box in good condition.No sollids carryover or leakage in or out.Box over 4'below grade so risers added as partof inspection (see photo attached) t5insp.dec rev.1t2612ni8 Title 5 Offldal Fo+m'.Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title i i Inspection i`s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 411 48 Sunset Rock Road Property Address Thomas Page Owner Owner's Name informaequine for is North Andover MA 01845 8124/2018 required for every page. Citytrown State Zip Code Date of Inspection D.System Information(cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ 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. 11. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: — ® leaching trenches number,length: 3-55'+1- ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5mp-�—.2126(2418 Title 5 Oifida:Inspection Forth:Subsurtace Sewage Disposcl System Page 13 of 18 ` Commonwealth of Massachusetts Title Official Inspection Form } Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sunset Rock Road Property Address Thomas Page Owner Owner's Name informa quire tifo isr every reequired foNorth Andover MA 01845 8/24/2018 page. Citytrown State ZIP—code Date of Inspection D.System Information(cont.) 11. Soil Absorption System(SAS)(cont.) Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): Area of leach trenches looks normal No pondingor r damp soil Vegetation under repair 12. 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 ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): t5mnd—r®v.1t2612t11e Title 5 Off-I imr-ticn Farm:Sllosurt2a8$—I.DIsposa!System•Page 14 of 18 Commonwealth of Massachusetts Title i i l Inspection Subsurface Sewage Disposal System Form-Not for Voluntary Assessments x,>x 48 Sunset Rock Road Property Address Thomas Page Owner Owner's Name information is g North Andover MA 01845 8/24/2018 page. for every pcitytrown State Zip Code Date of Inspection D.System Information(cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): 15insp.tloc•rev.Tt26=16 Title 5 Off—I inspectiaR F—Subssf.-Sewage Disposal System•Paga 15 of 18 Commonwealth of Massachusetts Title ici I Inspection tF Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /3'l 48 Sunset Rock Road Property Address Thomas Page - Owner Owner's Name information is North Andover MA 01845 8/24/2018 very required for e State Zip Code Date of Inspection page Cityrrown D. System Information(cont.) 14. 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 ❑ drawing attached separately F 3 r t � q°3 t5insp.Coc•rev.7126QD 8 The 5 Qtfidal inspeclia�Fain:Sv6avRace Sewage nisposel Sysiem•Pa&e 16 or iH Commonwealth of Massachusetts R I. Title Official i r ii Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 48 Sunset Rock Road Property Address Thomas Page Owner Owners Name information is required for every North Andover MA 01845 8/24/2018 page. CitylTown State Zip Gode Date of Inspection D.System Information(cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: feebelow system Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record 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: USGS indicates soils are Canton which usually have a seasonal high groundwater 4 to 5 feet below original ground based upon this inspectors experience.System located approximately 3 feet below old existing grade.Property dropps off in the back with no visible wetlands- Before etlandsBefore filing this Inspection Report,please see Report Completeness Checklist on next page. t5insg.d.c•rev.7Y28tro18 Till.5 0 .l Inspection Fain:Svbsudaca Savage Disposal System•Page 17.f 18 _. _ ril� g�Or�,rr^. � y,��' i '"�y� ° ,�. a�/"��, tia�°'dr r�l'miu�' r , � N�� 'r �" m �� r r �; ��,frr��" ,,r � 1 rw� gyp, r wi urvly^r ® f ,d �1 D�r. � �Y� r�/✓rll A err@ �� f�J� � ,/P, �� N �"1r r 9Pr�'0� " �' y � � r in r m�1� n��"a� � '!n ff � � � � no /v � �; f er, , ' " �� , � � , Nn , � ��, �� r ! �r j o � rr� ro", %� i� �r i; �� ' � �Vp � .IIF � 11 I HE�rv'd �� / r rr �hi i '�'r r'% Ol/////%/ y � Mrd� ,l � , r //i�� ; �� /r � �� /�/ r r�i r�i�', l cif //f�l�� r/�r%� / l �i �'�� r�� oM" �� r r 1r /�i i r c �' dr ifl o r nll �/ f/��/1� � f/i%� r psi �nl , /�rr� -r�r �/��rr��, '� ,� �F / ''r �h a /��J r I j l d° �r aq y m / �/� ! i ! `� „y uJ �V r r rs �i C�'° frr �� r � l� lei/w�� / '�/�p��r r rl ;, r � / /r r/%//ii r// •� r +x�i q / IN n,%' q'�d�� / �N1 �� / ��% f�, rf j�r l:%1� / r ��n q '4,,,. 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J".'� � f�//�l�'�!t�/ / rr�/�� ,,,1v��1�,�� 'J,. �' 1, ar,F,:^;? >!'i;�.., �;.,�,,,,,� � �� r, �� "'� %;1r' r , ,, ,/ � �p�� noli ! �/�//�� !`�riflir�///I�r J ;��„ r J ri/"�� 1,. y';� �l� »� ✓��,.,n a- r, �:,1 �l10'u✓/ i>�Ir 1 �./,�Dr 7r' //r/(IJo��i/�''�. /�/�, r �.., ��„, '„�r.0 r m y,; �� /� � r ,� ��', ��' � �� ;:, r�r!?.;1f ,r�,j J% �� ,i%J,/ ( r �/��%��j,,/>'// /,.i n; 4� rrc ." ! �r �F� l�,�: �. 4 �R � r.;N"`J ��r�,f��i , �!,, r ) �'��rJ�/��/ �� '�nni i fy y`��a,� .� r ,f;;Rr"yry'�f r/t�r;��,;'. ,” ,` ' " ��;;,y0;1 �,,.�,i..,4 ,o,. � '� rl/��/L� �� r I�� '� ��! ��r, , ,�znM1,,,r�,'�.',�,�,,: r�l/ ,.,�.H�;i�,r/Jlri�'"',m..n , nro�". s y V��",;.,:vel � ��„r�,r„Ir ,.� �i ..,.c, 'y�,�sfi a�/„r/ ��i�r,r�� 'f,,,,r�/�/ a Town of North Andover HEALTH DEPARTMENT CHECK 4: C-- DATE: Pz LOCATION: L H/O NAME: CONTRACTOR NAME: '_�Qnck Type of Permit or License:(Check box) • Animal $ • Body Art Establishment $ • Body Art Practitioner El Duntpster $ • Food Service-Type.-- • Funeral Directors $ • Massage Establishment 11 Massage Practice 0 Offal(Septic)Hauler El Recreational Catup • Sun tanning • Swimming Pool • Tobacco $ • Trash/Solid Waste Harder • Well Construction SEPTIC Systems • Septic-Soil Testing s— • Septic-Design Approval $ 0 Septic Disposal Works Construction(DWQ 0 Septic Disposal Works Installers(DWI) 0 Title 5 Inspector Title 5 Report A-1- 0 Other.(Indicate) HeWth-AgentInitials, White-Applicant Yellow®Health Pink®Treasurer