HomeMy WebLinkAbout- Title V Inspection Report - 50 DEER MEADOW ROAD 5/28/2019 r
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Subsurface Sewage Disposal Syt Form,'""wNot,for Voluntary " 'r ts w ywru � r,» 4,,,J FAA
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Property df
Owner Ownier'
Information is
requir ed for every O�N
Ci��own State Zip Code Date,of Inspection
Inspection s ts must be submitted this form. Inspection s may not be,aftered in,any
Please see completeness checklist at the end 'the form.
Important-
fillingA Inspector Informat'
outforms .�
n the computer,
use only the tad
key to move your Name of Ins ector
cursor-do not
lu�)
use the return � ,
A,
key, Name
00-
;f, LP 14
Co n Address
own StateZip Co'a 444 2�
de
Telephone Number License Number
B. Cleftification
certify that. I am a DEP approved system 'Inspector in full compliance with Section 16.340 of Fiala 6
(310 C 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 bas on my training and experience in the proper t n ti n
and maintenanceof on-site sewage disposal systern ,After conducting this inspection I have determined
that the system
1 Passe
. Ell Conditionally Passes
3. Needs Further Evaluation by the o Approving authority
. Fails
Ispect4sC-;n 'Date
system inspector s 11 s t a copy ofthis inspection report to the Approving Authority(Board
f Health or within 30 days ofcompleting this inspection. Ifthel system has a design,flow o
109000 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 a seat to the system owner and copies seat to,
the buyer, if applicable, and the approving authority*
i
Please note:This report only describes one at the time of inspection and under the
,conditions of usethat,time.This Inspection does,not address how the systemwill
perform,
n the future under the same or different conditions of use.
t6lr,spk -rev,7/26/2018 rive 5 Omciaj insped�on Fora:Subsurface Sewage Disposal S,ystem-Page I of 1
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Commonwealth ssc 'se
TwItle 5 isial Inspection Form
01 SubsurfaceSewage W11sposall System Form a-Not for,Voluntary Assessments
»
joil
OwnerProperty Address
Owner's aM
information is
requite forever
page. 6 /Cwn .State Zip Code Date of Inspection
,tt
C. Inspec 'mon Summary
Inspection Summary.- Complete 1, 2, 3, or 5 and all of 4 and 61.
System
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CIMP, 15.304 exist-Any faillur criteria not evaluated are
indicated elow.
Comments:
A)6
oe CYMI AIC101 d"NoLd L OLIL
t kt,
\J
System Conditionally Passesp
One r more rrrrrert as diescrd t 'T, r��ditirl " s + ctirr to be
laced r repaired. The system, upon completion of the replacement r repair, s roved by
the Ir 1 Health,Will pass.
check the box "' s , it, r" t eterr in d" , , for the following statements. if"not
determined; please 'mn'
The septic wti tarry is metal and 2 years lid* r the septic tan (whether,metal r riot) is structurally
sound, exhibits substantial in iltr ` n or eAltr ton ortank failure is imminent. System will pass
inspection the exii,st,ing tank,is replace 't acomplyingc tam,as approved the Board of
Health.
metal yeti tare will, inspection i it Is start sound, not leaking i Certificate of
Compliance indicating that the tank �s less than years � available.
l plain below).
t ins .d .1 rear.742 =1, a 5 Offidal InspecUort F, Subsurface Sege Disposal System•Fags f 1
Commonwealth of Massachusetts
Itle 5 unicial Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
Owner Owner's Nam
0
informaillon is
required for every '04
page. ity/Tovm 81ate Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes
0 Pump Chamber pumps/alarms not operational. Systern 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,
inspection if(with approval of Board of Health):
El ken p'lpe,(s)are replaced Y F] N E] ND(Explain below):
key pipe"s'are rep"
pu Observation
10%
to
p 0
t d
0 obstrudi is removed El Y El N El ND(Explain below):
'n i'o ox v Ile
E] distnibution Xboxieveled or replaced El, Y El N 0 ND(Explain below).
El The system required pumping more than 4 times a year dt'i o brok�e�n or obstructed p�ipe(s). The
system wili pass inspection if(with approval of the Board f He,
broken pipe(s)are replaced Y Ej N D(Explain below)*
El obstruttion is removed Y N ND(Explain below):
3) Further Evaluation dis, uir the Board of Health,:
Ej Conditions exist which req, , urther evaluat�ion by the Board of Health in order,to determine if
the system is failing to pro ct p i health, safetyor the environment
a. System will pass unless Board of h,determines in accordance with 310 CMR
16.303(1)(b)th) t the system is not:functioni an a manner which will protect,public health,
safety and the environment:
t5insp.doc-rev.7/26120,18 Title 5 Offid a]Inspection Form Subsurface Seviage Disposal System, -Page 3 of 18
Commonwealth of Massachusetts
Tmit,le ci or
Subsurface Sewage Disposal System Form Not for,Voluntary Assessments
Property Address
7-D*
Owner Ome9
es Nam
i
nformation is
required for
aw amity/Town State Zip Code Date of Inspection
C, Inspection Summary (cont.)
-A---
rvi
11 1 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
1 9. Sy m will fail unless the Board of Health (and Public Water Supplier 1 i n
y)
determi s that the system is functioning in a manner that protects the public health,
d
safety an nvironmeft:
E] the systems as a septic tank and soil absorption system (SAS)and the SAS is,within
100 feet of a sub water supply or tributary to a surface water supply.
El the system has sepfic tank and SAS and the SAS is within a,Zone 1 of a public water
supply.
E:1 The system has a sep tank and SAS and the SAS is within 50 feet of a private water
supply well.
[:1 The system has a septic tan 'SAS and,the SAS is less than 100 feet but 50 feet or
more from a private water supply
Method used to determine distan
This system passes if the,well water analysis, pe ed at a DEP clertified laboratory, for fecal
collform bacteria indicates absent and the presence of monia nitrogen and nitrate nitrogen is equal
to or less than, 5 ppm, provided that no other fallu re criteri, re triggered,. A copy of the analysis must
be attached to this form.
c. 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
Backup f sewage into facility or system component,due to overloaded or
clogged SAS or cesspool
Discharge or ponding of e luent to the surface ofthe ground or surface waters
due to an overloadedor clogged SAS or cesspool
t5insp.doc-rev.7126/2018 Tide 5 Offidal Inspecton Form-Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
]�Fitle 5 aial Inspection Form
> Subsurface Sewage Disposal System Form Not for Voluntary Assessments
110
low .
Property,Address
Owner Owner's Nam
information is . b V
required forever - 7
page. City/Tom. State Zip Code Date of Inspection
G, Inspection Summary (cont.)
4) System Failure Criteria Applicableto, All Systems: (cont.)
Yes, No
Static liquid level in the distribution box above outlet, invert due to an overloaded
El or clogged SAS or cesspool
E] Liquid depth in cesspool is less than 6"below invert or available volume is less
than,Y2 day flow
Ej pq Required pumping more than 4 times in the last year NOT due to clogged or
obstructe ipe(s). Number of times pumped*. .,
Any portion of the SAS, cesspool or privy is below hig�h ground water elevation.
Any-portion of cesspool or privy is within feet of a surface water supply or
tributary to a surface water supply.
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.,
El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from as private water supply well with no acceptable,water quality analysis. [This
system passes if the well water analysis, performed at a DE,P 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,
p rov Ided that no other failure criteria are triggered.A copy of the analysis i
and chain of custody must,be attached to this form.]
E] The system is a cesspool serving a facility with a design flow of 20,010 gpd-
10gpd
The cyst e falls. 1. have determined'tha mo
t one or re:of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system falls. The
I
system hou owner sld contact the Board of He thto,determine what will be
necessary to correct the failure.
6) Large Systems: To be considered a large system the system must serve a facility with a
nr flow of 101000,gpdr to'16100(i gpd.
For la systems, you must indicate either"yes"or"no,"to each of the following, in addition to the
4
questions ect,i o n,,,
Yes No
El 0 the syste within 400 feet of a surface drinking water supply
the system is within eat of a tributary to a surface drinking water supply
nitro
the system is located in,a nitro sensitive,area(Interim Wellhead Protection
El El Area—IWPA) or a mapped Zone 11"'b� 4 public water supply well
,u
t5insp.doc-rev.7/26r2018 M Offi e 6� cial Inspection Form:--S%ubsu Sewage Disposal System-Page f 18
Commonwealth of Massachusetts
-�Tiotle 5 Offi'wci"ali Inspection Form
Subsurface,Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
j oil
Owner A owners yarn
information is ;L 6V 044*� A47
required for every
page. City/Town State Zip Code i Date 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,answerer"yes'to any question in Section C. 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. shall upgrade the system in accordance with 310!CMR 15.304. The systern owner
should contact the appropriate regional office of the Department.
6. You mush Indicate"'yes" or"no"'for each of the foillow ink for all inspectionis.s
Yes No
k 1:1 Pumping information was provided by the owner, occupant, or Board of Health
E] K Were any of the system components pumped out in the previous two weeks?
E] Has the system received normal flows in the previous two week period?
FO%30 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.7(If they were not
available note as N/A)
El Was the facility or dwelling inspected for signs of sewage bii up?
El Was the site inspected for signs of break out?
El Were all system cornponents, excluding the SAS, located on site?
El 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?
Ei Was the facility owner,�(an,d occlu pants if diffe rent from owner) provided with
information on the proper maintenance,of'subsurface sewage disposal systerns?
The size and location,of�the Sloill Absorption System (SAS) on the site has
been determined biased 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 G is at issue
I
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5 Insp.dioc rev.7/2612018 Title 5 Offidial Inspedain Form:$UbSUrface$ewage Disposal$ystsm-Pagle,6 of 18
Commonwealth ofMassachusetts,
It IN
U'lotl'e 5 official Inspectmion Form
Subsurface Sewage,Dispersal System Form Not for,Voluntary Assessments
Property Address
Owner Ownees N 00MM
4 9.417,e
infoffna,fion is yl
rp
required for every,
page. City[Tom State Z1'p Cody Date of Inspection
R, System Information.
1. Res1dential Flow Conditions:
Number of bedroorns(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms).-
Descripfion.-
Number of current residents:
A
Does residence have a garbage grinder? Yes AL No
Does,residenc have,a water treatment unit.? 0 Yes NNo
If yes, discharges to:
Is laundry on a separate sewage system? (include laundry system inspection 0, Yes K No
informabon in this report.)
Laundry,system Inspected? El Yes No
Seasonal used EI y s No
Water mleter,readings, llable(last 2 years usage(gpd),):
Detail:
Sump pump? Yes No
Last date of occupancy,.- Ct�K""eoZ
Date
t6insp.dor, rev.M6=1 8 Ti Ue 5 Offidat Inspeden Fom Subsurface Sewage Disposal System-P'age 7 of 18
A
Commonwealth of Massachusetts,
'tie 5 Off'
' i i ,
ciaI Inspect*ion Form
Subsurface Sewage Disposal System For Not for,Voluntary Assessments
OwnerProperty Address,
Owneet
informationis, �700/�
required for eves
)'o *Mj 61 . ........
page. �IOwn State Zip Cede Date of Inspection
D. System Information (coAA
2. Clommerciallindustrilal Flow Conditions:
pe of Establishment.:
Di, flow(based on 310 C 5.23 : Gallons per d,ay(gp,d),
Basis of ide, 1 s t ers s/sq ft., etc
Grease trap r rat. Yes El No
Water treatment unit present? El Yes _ N
l 'yes, discharges to:
Industrial waste holding tank resat,' Yes No
Non-sa,nitary`Fasts discharged to the itl 5 system? E Yes N
Water meter readings, if available:
Last,date of,occupancy/use: t
Other(describe w l w
3. Pumping sr,
Source of ion ati n:
Was system purnped as part f the inspection? Yes N
If yes, volume umped: gallons
How was quantity pumped stem
Reason for pumping:
t 5in .doc-rev„7/26/2018 Me 5 Official Inspedon Form,Subsurface Sewage Disposal System-Fags 8 of 1
Commonwealth of Massachusetts
T'altle 5 Off .1 Inspection
Form
Subsurface Sewage Disposal S s,tem,Form -Not for Voluntary Assessments
AA
17 c4i,
Property Address
6<�F61
Owner Owiefs Name
infonnation is
required for every esN.00
page. ityf Town, State, Zip Code Date of Inspection
D. System Information (cont.)
4. Type of'System:
Septic tank, distribution box, soil,absorption system
Single cesspool
Overflow cesspool
Privy
Shared system, (yes r if yes, attach previous,inspection records,, if any)
Innovative/Alternative tech nology. copy of the rrent operation and
maintenance contract(to be obtained from system,owner) and a copy of latest
iris of the I/A system by system operator under contract
Tight tank.Attach a copy of,the DEP approval.
E), Other(describe):
Approximate age of all components, date Installed(if known)and source of info it
Were sewage odors detected when arriving at the site? El Yes No
5. Building Sewer(locate,on site plan):
Depth bel,ow grade: feet
Material'of construction*,
cast iron 40 PVC other(explain)*.
/U
Distance from private water supply well or suction line'. feet
Comments (on condition of JoInts, venting, evidence of leakage, etc.):
I -
CA K
t5ins.p.doc-rev.7126/2018 Title 6 Oftal Inspedon Form Subsurface Sewage,Disposal System-Page,9 of 18
Commonwealth of Massachusetts
f u cia a "io orm
vm
Subsurface Sewage Disposal S ;earn Form, -Not for Voluntary Assessments
LI)
Property Address,
Owner 0mar's Na
4
informaflon
required for every
Page., cko�cw State Zip,Code Date of Inspection'
doft
M ;system Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade.- feet
Material of construction:
concrete F] metal El fiberglass polyethylene E]other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of'certificate) Yes N o,
Vto\
Dimensions:
Sludge depth.-
Distance from top of sludge to bottom of outlet tee or baffle
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
How were imr ensions determined.?
Comments(on pumping recommendations, inlet,and outlet to or baffle condition, structural integrity,,
liquid levels as,related to outlet,invert,, evidence of leakage., etc.):
CS
LLVXO I 4r
U, C)
t5tnsp.doc-rev.7/2612G18 Me 5 Offidal I'nspedon Fonn,Subsurface Sewage Disposal System-Page 10 of 18
R
pX
Commonwealth of Massachusetts
�Tmitle 5 Officimal Inspecti"on Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address,
Owner Ownefs,N
reqrui red for every M"
page. City/ State Zl Code Date of Inspection
D. System, Information (cont.)
cease T (locate on site plan):
Depth lore grade. feet
Material of corgi ction
concrete tal fiberglass polyethylene other(explain):
Scum thickness
Distance from top of scum to fop of outlet tee or baffie
Distance from bottom of scum to bottorri of outlet tee or baffle
Date of last i Date
Comments n pumping recommendations, Inlet and outlet tee or batecondition, : aural integrity,
liquid levels as related to outlet Invert, evidence of leakage, etc.)
. Tight + t i k(tank must t firrie of'irrs ect rr)((locate on site plan).-
Depth below grade.-
Material of,construction:
concrete met ,l er l Iss EI:polyethylene other(explain),-.
Dimensions:
C a1 � gallons,
Design, Flow: gallons per dad
t6ln pa. -rev.7/26=18 Me 5 OM d aI I on Form Sub u rface,Sege Disposal System,-Page 11 of 1
Commonwealth of Massachusetts
'Title cia ns io
I Ipecto Form
n
Subsurface Sewage,%sposal System Form, Not for Voluntary Assessments
Property Address
Owner rOwnees ANNa
information is 6 1 Soo** r ZS-MWj
required for every
page. Cityaovm '�—tate Zip Code Date of Inspection,
D. System Information (cont.)
Tight or Holding Tank(cont.)
Ala , resent: 0 Yes No
Alarm, level.: Alarm"in working order- Yes Nio
Date of,last pumping.- Date
Comments(condition of al'arm a dfloat,switches, etc.):
Attach copy of'current pumping contract(required). Is copy attached?, [:1 Yes 0 No
9. Distn"bution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert,
Comments,(noteif box is I evel and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out,of box, etc.).*
0 10
4 Uj
LA JQ,--t
t5insp.doc rev.U2612018 Title 5 Official Inspection,Fors:Subsurface Sewage Disposal System Pag 12,
Commonwealth of Massachusetts
Tintle o� 0'�i"Taicmial Ins ectaion, Form
P
4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
lII
o!tA, P� tA_1 d6j,
Property Address
Owner Ome-r s N Wa
infoffnat,ion is ylilk- ar(4 5 5"
required for every %n Zip Code In
City/To 7§tate Date of sp�ection
page.
D. System Information (cont.)
1.0. Pump Chamber(locate on site plan)-.
A
umps in working order: 0 Yes El No*
Alarm Working order: [_1 Yes 0 NO*
Comments(n condition of pump c beak condition of pumps,and appurtenances,, etc.):
If pumps or alarms are,not In working order, system is a condi' �al pass.
p
tio not
11. Soi'l Absorption System (SAS) (locate on site plan, ex�c>avatio�n not re quired).,
If SAS not located, explain why:
Type-.
11 leaching pits, number:
1:1 Ileaching chambers, number:
13 leaching galleries number:
1:1 leaching trenches number, length:
36
leaching fields number,, dimensions.,
overflow cesspool number:
innovativetalterriative system
Type/name of technology
t5insp.doe-rev.7M/2018 Tithe 5 Official Inspection Form.,-Subsurface Sewage Disposal System-Page 13 Of 18
Commonwealth of Massachuseft
TI Ufficial Inspection For
tle 5
Subsurface Sewage Disposal System Form Not for Voluntary Assessment$
Property Address
offlu. WWWRIMMMIft
Owner Owneijs, e
goo*)
information is
required forievery
page. cityrro" Itiatte — 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,);
12. Cesspools(cesspool mus, e 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 [:1 Yes Ej No
Comments(note condition lof Soil, signs of hydraulic failure, level of nding, condifion of vegetation,,
etc.).,
t6in p.doc rev.7/2612018 We 6 Official Inspedon Form:Subsufface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
AMM- at APE a
tie 5 Unicial, Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
.... ...........
Property Address
- -0—�
Owner Owners N
0
infonmati'art is,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Prlivy(locate on site plan).*
M: terfals of construction.-
Dim I sions
\teia's0'co r
me' sions
ids
apt r
Depth of lids
comments signs of'hydraulic failure, level of ponding, condition of vegetation,
(n condition of soil, 1
etc.),:
t5inwdoc rev.712MOl 8 TiU'o 6 Official Inspoefion Form,Subsurface-sewage Disposal System Page 15 of 18
Commonwealth of Massachusetts
T 0 Am 0 'Amh'ffocis* I Inspection For
itie 5 0 a
> Subsurface Sewage,Di ��osal System Form -Not for Voluntary Assessments
Property Address
Owner :0 w!;n,e rrj's N
information is 6
required for every
page. City/Town State Tip Code Date of I cti,on
D. System Information (cont.)
14. Sk age Disposal System:
Provide a,view of the sewage disposal system, including ties to at least two permanent re!ference
landmarks or benchmarks, Locate all w lls within 100 feet. L,oGate where public water supply enters
the building. Check one of the boxes below.
0 hand-sketchin the area,below
El drawing attached separately
A
C
7
A
t5insp.dac-rev.7/26/2018 title 5 Offi d al,In p dj n Form:Subsurface Sewage D is sale System-Page 16 of 18
U
Commonwealth of Massach setts
IN a
Ultle 5, Ufficial Inspect'ion Form
Subsurface Sewage Disposal System, Form Not for Voluntary Assessments
Property Address
Owner, Owners Na
4
information is
--% 2
required for every 0
page. city[TOYM State, Zip Code Date of Inspecti,on
D., System, Information (cont)
15. Site Exam.-
El Check Slope
,[I Surface water �U
Check cellar
El Shallow wells
Estimated depth to high ground water.,
Teet
Please indicate all methods used t eterm,Me the high ground water elevation:
Obtain 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)
El Checked with local Board of Health explain-
ej
El Checked with, local excavators, installers-(attach documentation)
01 Accessed USES database-explain:
You must describe how you established the high ground water elevafiorl:
A IL
Before filing this Inspection Report, please see Report,Completeness Checklist on next page.
Mnsp.doc-rev.,712642018
'1111e,6 Official Ire specdon Form Subsurface Sewage Difsposal System-Page 17 of 18
b
uommonwealth, of Massachusetts
IMML an ORO a Form
Tive,
5 Utticial Insop%ection
S � _Not for VoluntaryAssessments
µ
,
OwnerProperty Address
Owners
required for eves
page. Cityaown Zip Code Datef Inspection
E, Report; CompChecklist
Complete all applicable sections of thi'sform inclusive w
., Inspector Information.* complete all fields in this section.,
B. Certification: Signed& Dated and 1, 2, 3, or checked
C. Inspection r . r
(Failure Criteria) and 6 (Checklist)completed
D. System Inform, i .
ell
For : Tight/Holding Tank—Pumping contract attached
For Sketch of Sewage Disposal System drawn on pg. W r attached
' r 5: Explanation of e tir is e l depth to high,groundwater included
t5in p.d -rev.712642018Ue 5 Offidal Inspedon Form:Subsurface Sewage Disposal sal System-mega,18 of
01 41
Town of North Andover
HEALTH DEPARTME'NT
7
CHECK ff. DATE-
LOCATION J 12 Lc
H/0 N A M E
-_-
CONTRACTOR NAME.- (""41111L.".all
0 Animal
0 Food Service-Type-
0 Massage Establishment $
0 Massage Practice
13 Offal(Septic)Hauler $
El Recreational
'
0 Sun tanning $
0 Swimming Pool $
0' TraslVSolld Waste Hauler
11 Well Construction $
SEPTIC bs,tem .
'Title 5 Report
D Other:(Indicate) $
wo
th,,4gent Initials il
Mite-A nt Yellow-Health Pink-Treasurer
pplica
|
512 /2 1
2