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Home My WebLink About- Title V Inspection Report - 10 HAWKINS LANE 10/24/2018 RECEIVED Commonwealth of Massachusetts Title 5 Official Inspection Form XT 2 ?018 Subsurface Sewage Disposal System Form Not for Voluntary Assessments TOWN OF NORTH ANDOVER 10 Hawkins Lane HEALTH DEPARTMENT ---------- Property Address Battersby. Owner 6w—r-e-r's—N-a rn e information is No. Andover MA 01845 09-28-2018 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 filling out forms tn. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not John DiVincenzo use the return key. Name of Inspector ............................... J and S,Development Stewarts Septic-S.ervice"..--............. VQ Company Name 58 South Kimball St .......... Company Address Bradford MA 01835 City/Town State Zip Code 978-372-7471 S113386 ... ........ ............. 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 F-1 Conditionally Passes ❑ Fails El Ned th valuationj Kythe Local Approving Authority ........ ........ ------------ ........... ,inspector's Signature Date' The system inspect,'r shall Submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) ' ,inr-3018ays 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.doc•rev.6/16 1itle 5 Official inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 <� Commonwealth of Massachusetts uTitle 5 Official Inspection == 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Hawkins Lane Property Address Battersby ___ ........_._.__ Owner Owner's Name _._____ ............._„ _ _ _,....... information is required for every No. Andover MA 01845 09-28-2018 _._._.__.. ...... _..._........_ ._...._ _._.. __._..._ . _.__.._-__ page, City/Town State Zip Code Date of Inspection B. Certification (cant.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: Z 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 17 Commonwealth of Massachusetts =�"��0 �� ~��|o ~ U Inspection �� Title N��U�� N�� 6�� O �� =�H � �� m@ @mw�� Form ' w w m �� u��m o ��m 1-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 18 Hawkins Lane Property Address Patter b Owner Owner's Name infonnmuionia Andover MA 01845 09-28-2018 mqwiedk`reve� ----- page. C�ynowm Steoa Zip Code Date ofInspection B. Certification (cont.) E] Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (oonL): El Observation of sewage backup or break out or high static water level in the distribution box due to broken mr obstructed pipe(a) or due toabroken settled. � pueo inspection if(with approval of Board of Health): F1 broken pipe(s) are replaced El Y [l N F ND (Explain below): 0 obstruction is removed F-1 Y F-1 N [l ND (Explain below): Fl distribution box is leveled or replaced F1 Y F-1 N F-1 ND (Explain below): | � � 0 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 ufthe Board ofHeelth): F1 broken pipe(a) are nyp|uoad [l Y El N Fl ND (Explain below): El obstruction is removed Fl Y [l N [l ND (Explain below): � Cl Further Evaluation km Required by the Board ofHealth: M Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public hee|th, safety or the environment. 1. System will pass unless Board mf Health determines in accordance with 310CY0R 15.303(1)(b)that the system |s not functioning inm manner which will protect public health, safety and the environment: F-1 Cesspool or privy is within 5O feet cfe surface water Fl Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh .mns."m"'rev.6/16 Title o Official Inspection Form:Subsurface Sewage Disposal System'Page o*/r / Commonwealth of Massachusetts =�'"4�N�� u��=��N Q�� M=��h � @�@�� m�� Inspection ��m � mu Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1O Hawkins Lane `~ Property Address B b Owner Owner's Name information is required for every No. Andover MA 01845 00-28-2018 page, CityfTuwn State Zip Code Date ofInspection 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: [l The system has a septic tank and soil absorption system (SAS) and the SAS is within | 10Q feet ofa surface water supply or tributary tuasurface water supply. i [] The system has septic tank and SAS and the SAS is within a Zone 1 of public water | supply. � Fl The system has a septic tank and SAS and the SAS io within 5O feet nfe private water � supply well. F� The aysbarn has o septic tank and SAS and the SAG is |eeo than 100 feet but 50 feet or � more from a private water supply we||°° | Method used to determine diatanoe' � � °*This system passes if the well water analysis, performed eda 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 bm attached ho 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 F� �� Backup of sewage into fa:|dvor system component due tuovedoadedor �� clogged SAS nrcesspool Discharge or ponding of effluent to the surface of the ground or surface waters due toan overloaded or clogged SAS orcesspool Fl �� Static liquid level |n the distribution box above outlet inveddue toenoverloaded �� or clogged SAS nrcesspool Liquid depth in cesspool is less than G^ below invert oravailable volume is |eam �� than }6 day flow o�^ C��[�O0��l1h Massachusetts�" Title �' ��% �� .�� " 0 Inspection �� H �� N��N�� R�� Official�� ow�� ' m �� m w �� m��o � ��ommu Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 1O Hawkins Lane Property Address Be�enab Owner Owner's Name infnrmationio �qui��ra�� N Andover MA U1 �5 09-28-2018 page. City/Town State Zip Code Date ofInspection B. Certification (cont.) Yea No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(e). Number nftimes pumped: Fl �� Any � ~~ ~~ � �l �� Any pu�innof cesspool mrph � v�vyi�w��hin1000aotof� su ��maternupp|yor �� tributary toe surface water supply. Fl z Any portion Vfe cesspool or privy is within a Zone of a public well. � � 1-71 M Any portion of a cesspool or privy is within 50 feet of a private water supply well. � � El Z 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 oo|iYormm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen |a equal tomr less than 5 ppmm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must ho attached tm this fornn.] [l �� The system iea cesspool serving ofaoiMty with a designf|ovvof2OOOgpd- �� 10.000Qpd. The system fails. | have determined that one or more of the above failure criteria exist aadescribed in 310 CK4R 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: Tohe considered m large system the system must serve m facility with a design flow of10'0O0gpd to18.0O0gpd. 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 El the system is within 400 feet ofm surface drinking water supply D E-1 the system is within 200 feet ofa tributary to o surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— |VVPA) ura mapped Zone || ofa public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yee" in Section D above the large system has failed. The owner n[operator nf any large system considered a significant threat under Section E or failed under Section D shall upgrade the � � system in accordance with 31OCN1R15.3O4. The system owner should contact the appropriate regional office ofthe Department. | Title o Official Inspection r Subsurface Sewage Disposal Syste Page 5 /,r -.:- Commonwealth of Massachusetts rTitle 5 Official Subsurface sewage Disposal System Form - Not for Voluntary Assessments 10 Hawkins lane Property Address Battersby... _.... ._.__........ .._. ....... ._. _.____ Owner Owner"s Name information is No Andover MA 01845 09-2$ 2018 required for every :._._.......— ._____....-- page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No M ❑ 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? ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ❑ ❑ Was the facility or dwelling inspected for signs of sewage back up? Ej ❑ 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? ® ❑ 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: ® ❑ 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) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions. Number of bedrooms (design): 4 Number of bedrooms (actual); 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600.. - -- t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts it 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Hawkins Lane Property Address Ba rs Owner Owner's Name information is required for every No required Andover MA 01845 09-28-2018 page. City/Town State Zip Code Date of Inspection 1. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? Z Yes El No Is laundry on a separate sewage system? (Include laundry system inspection D Yes M No information in this report.) Laundry system inspected? D Yes R No Seasonal use? El Yes Z No Water meter readings, if available (last 2 years usage (gpd)): Detail: ........... ........ --------____-- ---------- Sump pump? E-1 Yes 0 No Occupied Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: ........ Design flow(based on 310 CMR 15.203): ..........I.............. ............... ................ ..................... Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? 0 Yes R No Industrial waste holding tank present? El Yes n No Non-sanitary waste discharged to the Title 5 system? El Yes El No Water meter readings, if available: ........................11.......... ____.._. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts T"tie 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Hawkins Lane ---- Property Address Battersb Owner Owner's Name information is No. Andover MA 01845 09-28-2018 required for every ........... .........................- page. City/Town State Zip Code Date of Inspection D. System Information (cont) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: -....................................................................... ............... Was system pumped as part of the inspection? Z Yes ❑ No , If yes, volume pumped: 1 500 .............................................................................-.............................................. gallons How was quantity pumped determined? site gauge on truck Reason for pumping: inspect tank Type of System: M Septic tank, distribution box, soil absorption system F-1 Single cesspool E-1 Overflow cesspool E-1 Privy 0 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 ]/A system by system operator under contract El Tight tank. Attach a copy of the DEP approval. Other(describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 <rs Commonwealth of Massachusetts -------------------- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Hawkins Lane Property Address Owner Owner's Name information is No. Andover MA 01845 09-28-2018 required for every ___---- page, -- City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1992 Were sewage odors detected when arriving at the site? El Yes E No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: M cast iron [-] 40 PVC F-1 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): Depth below grade: ............. feet Material of construction: R1 concrete F-1 metal ❑ fiberglass ❑ polyethylene F1 other(explain) 1 O'X5'X4' -------------- ............... ............... ---------- If tank is metal, list age: years ................Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes E-1 No Dimensions: Sludge depth: t5ins.doe-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Hawkins Lane Property Address Battersby Owner Owner's Name information is required for every No. Andover MA 01845 09-28-2018 ---------- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 23" .................... Scum thickness 0 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle .1711 How were dimensions determined? Tape measure/sludge.jud e Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both baffles good, no leakage,'liquid levels are good. .............-- ..............I........... ---------- ------ ----------------------------- Grease Trap (locate on site plan): Depth below grade: feet Material of construction: F-1 concrete n metal El 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: -D ate t5ins.doc-rev,6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 ............ Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Hawkins Lane Property Address Battersby ......... Owner Owner's Name information is required for every No. Andover MA 01845 09-28-2018 page. City/Town State Zip Code Date of Inspection 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.): ..................11111111............ --------------------------- Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: R concrete F-1 metal [I fiberglass El Polyethylene El other(explain): Dimensions: Capacity: gallons- , ...... .......... Design Flow: gallons per day Alarm present: R Yes ❑ No Alarm level: Alarm in working order: El Yes E-1 No Date of last pumping: - - ..Date I-- ---------- Comments (condition of alarm and float switches, etc.): ------------- ....................... ................ ------------........ Attach copy of current pumping contract(required). Is copy attached? F-1 Yes F] No tSins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Hawkins Lane Property Address Battersby Owner Owner's Name information is No. Andover MA 01845 09-28-2018 required for every ............ ---- page, City/Town State Zip Code Date of Inspection 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.): Equal distribution, no leakage, no carryover solids. Pumped distribution box while there. ............... ------------------------------------- ......................... ................ — ----- Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: n Yes El 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: ---------------- ................................................... ............................................. t5ins.doe-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Officnal Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Hawkins Lane Property Address B.attersby ............ Owner Owner's Name information is No. Andover MA 01845 09-28-2018 required for every ....... page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: n leaching pits number: FI leaching chambers number: - El leaching galleries number: leaching trenches number, length: 3 - 90 ❑ leaching fields number, dimensions: F1 overflow cesspool number: ---........... El innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure, no ponding,_no.damp soils ------------------------ .................... --------------- - -------------- -------------- ................. 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 El Yes ❑ No t5ins.doc-rev.6/16 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Hawkins Lane .......... Property Address Batters�y_ Owner Owner's Name information is No. Andover MA 01845 09-28-2018 required for every .............I--...........-- 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 vegetation, etc.): ...................... ............. ....................................... ....... ................... 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.): ...................... ................................................. .......................................... ----------------- t5ins.doc-rev.6/16 Titie 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Off"Icial Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Hawkins Lane ------------------ Property Address Battensty Owner Owner's Name information is No. Andover MA 01845 09-28-2018 required for every -....................... ----11 page. City/Town State Zip Code Date of Inspection 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: F-1 hand-sketch in the area below Z drawing attached separately t5ins.doc-rev.6/16 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 g Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Hawkins Lane Property Address Battersby .......... Owner Owner's Name information is required for every No. Andover MA 845--. 09-28-2018 page. city/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: R Check Slope F-1 Surface water RI Check cellar F-1 Shallow wells Estimated depth to high ground water: 4t -ieW '''............ ...... ............... Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record If checked, date of design plan reviewed: -Datea--t e ------------- ----------..... El Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Pulled file ❑ Checked with local excavators, installers -(attach documentation) Accessed USGS database-explain: ............... ---------- --------------- —-------------You must describe how you established the high ground water elevation: Taken from design plan on record —---------- ------ ------------------- .............................. ............................. ........................... - Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Hawkins Lane Property Address Batte Owner Owner's Name information is required for every -No.A n,,d.ov,e,r-,-... MA .-0.1.8.4.5-.-- 09-28-2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Surnmary D (System Failure Criteria Applicable to All Systems) completed System information— Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6116 'Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Page 10 of l I OFFICIAL INSPECTION PO —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION Property Address: 10 Hawidus Lane �_1�la�rt6 Andover — Date _Agarw21� — TDate of Inspection.,_5/3Q/2OO8 SKETCH CDT+"srswAaz IDISPOSAIL SYSTpgm Provide a sketch 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 eaters the building llD� 1 Box Septic Tank House 2 'water Meter Driveway A to t=321511 N to t=3815" Bto2=3` 1911 Title 5 Inspection Form 6/15/2000 10 8 4 04 000 Town of North Andover HEALTH DEPARTMENT "SA U A CHECK#: DATE: A',�)/ok I H/O NAME: 2 CONTRACTOR NAME: ,,, Type of Permit or License: (Check box) 0 Animal $ • Body Art Establishment • Body Art Practitioner 0 Dumpster $ • Food Service-Type.--,,-,-.-- $ • Funeral Directors $— • Massage Establishment $ • Massage Practice $ • Offal(Septic)Hauler $ • Recreational Camp $ • Sun tanning $ • Swimming Pool $ 0 Tobacco • Trash/Solid Waste Hauler • Well Construction $ SEPTIC Systems: 0 Septic-Soil Testing $ 0 Septic-Design Approval $ [I Septic Disposal Works Construction(DWQ $ [3 Septic Disposal Works Installers(DWI) $ 0 Title 5 Inspector $ Title 5 Report $ 0 Other. (Indicate) we "Agent fnitials4 3ykiLLe-Applicant Yellow-Health Pink-Treasurer