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HomeMy WebLinkAboutPass - Title V Inspection Report - 73 RIVERVIEW STREET 6/17/2019 lal, m� CVIE Commonwealth of Massachusetts T, gp, tle 5 i r .,.;:. Subsurface Sewage Disposal System Form Not for Voluntary Assessments a kf 73 Riverview street Property Address OwnerOwner's information is No, Andover � 5 5-29-2 1 9 required for even �mm... ��. ��.,�...,��. page. City/Town, State Zip Code Date f Inspection �.,. Inspection results must be submitted on this form. Inspection forms may not be alt,eredin any way. Please see completeness checklist at the end of the fora. Important:When ,filling out forms A. Inspector Information on the computer, use only the tab, John Di ince z key to move your Name of Inspector cursor no t 1 slat Ste its Septic Service use the return company Name key.. So 'Kimball street rCompany Address Bradford MA 01835, .. .. State Zip Code Telephone,Num r License um r 131. Certification I certify that: I m approved system inspector inn full compliance with ,Section 5.3 Title (3,110, C R 5. 1j: I have personally inspected the sewage disposal syst m at the property address listed above, the information reported below is true„ accurate and complete as of the time of m inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of ors-site sewage disposal systems. Attar conducting this inspection I have determined that the system,,, w Lasses 2 Conditionally Passes asses 3. D bleeds Further Evaluation by the Local Approving Authority 4. Pail 1 r Ins e ori ignature" Date he system inspector's all slul it a copy,of'this is inspection report to theApproving Authority(Board of Health or E with in a s of completing this inspection. If the system has a design flow o 101000 gpd or greater, the Inspector,and the system owner shall submit the report to the appropriate regiona,l office of the DER The original form should be sent to the system owner and copies seat t the buyer, 'if applicable, and the appiroving authority, Please note: This repot only descri'bles conditions at the time of 'inspection and under the conditions 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, t5insp.d +rear. /61'2018 Title Official Inspection Fora;Subsurface Sewage Disposal Systern-Page 1 of 1 Commonwealth ris s ' "'tle 'ff" "i I 1ns,mpA0&ect'i"on orm� cia Subsurface Sewage Disposal System Form Notfor'Voluntary Assessments 73 Riverview street. Property Address 2 North Reallytrust Owner Owner's Name information is required forevery, N . A over ,1 5 5-2 2 9 page City/Town State ,Zips Code Date f 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 ire 310 CMR 15.303 or in 310 CI CIVIR 15.304exist. Any failure criteria not evaluated are indicatede1 below. Comments: 2 Sysem Conditionally sus: 0, one or more system components as des,cribeild in the "Conditional $$ section reed to be replaced r 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" r p`n t determined" N, ND) for the following statements. If''not determined,"d," please explain. 'The septic tank is metal and over,20 years, old* or the septic tank (wheth r metal or riot) is structurally unsound, exhibits substantial infiltration or exfIltration or tank failure is imminent. System will palsy inspection if the existing tank is replaced with complying septic tank s approved by the Board of Health. * metal septic tank will pass inspection if it,is,structurally ull sound, not leaking ing and if a Certificate of Complianceindicating that the tank is less than 2 years old is available. D Y Ej N Ej ND (Explain below): Title Official Inspection Fosse;Subsurface,Se igleDisposal System*Page 2 of 1 i Commonwealth of Msacss Tive I Inswpftect"ion utticia Form Subsurface Sewage Disposal System Fora Not for Voluntary Assessments mm 73 Riverview street t Property address 12, North ealt�...................... trust Owner is Dame information is No. Andover Ma 45 05-29-2019 required for every , Cityfrrown State Zip Code Date of'Inspection page C. Inspection Summary (cent.) ,2) Systems Conditionally Passes (cont.),-, Pump,Chamber pu,;m ps larr rs not operational, System will pass with Board of health approval if' pur rps/alarms are repaired.. E] Observation of sewage backup or break out or'high static water level in the distribution box due to broken or obstructed pipe( ) or due to a broken„ settled or uneven distribution box. System will pass inspection it with approval of Board f'l l lth),* E:1 broken pipe(s) are replaced E:1 IUD (Explain, below): E] obstruction is rear N El ND (Explain below): Ej distribution is leveled r replacedND (Explain below): The system required pumpin�g more than 4 times a year due to broken or obstructed pipes . The system will pass inspection i with approval of the Board of Health). [:1 broken pi p ,. E] obstruction is removed Y Ej N N (Explain below)* 3 Further Evaluation is Required by the Board Health: El u Conditions exist w ich require further evaluation by the Board of'Health in order t et rr 'ne it the system is failing to protect public health! safety or the environment. a. System will pass unless Board of with �1 Cl" Health determines a accordance 15.303(l)( i that the system is not un l lr� In a manner hillch will protect public health,, safety n the environment: tiro . o .rev,7126120,18 Title Official Inspection orr Subsurface urf Sewage 011 s l System-Pugs 3 of 1 Commonwealth, of'Massachusett,s ion q Title 5 Official Inspect" Form Subsurface Sewage Disposal System Form Not for Voluntary,Assessments, 73 Riverview street Property Address 12 North Reatty I tr u,sl Owner Owner's Name information is No. Andover Ma 011845 05-29-2019 required for every City/Townmmmm. .1111,statie 'zi-p"............C---o-de Date of Inspection page., C. Inspection Summary (coat..) El Cesspool or privy is within 510 feet of a surface water F1, 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 env1ironment: El, The system has a septic tank and soil absorption system, (SAS) and the SAS is within 1:00 feet of a surface water saupply or tributary to a surface water supply. E:1 The system, has a septic tank and SAS and the SAS is,within a Zone I of as public water supply. F] 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 'i1s 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 ofthe analysis must be attached to this form. c,. Other: 14) System Failure Criteria Ap,plicable to All lSystems:, You must indicate "Yes" or"No"'to each of the following for all inspections. Yes No El E Back up of sewa ue ge into,facility or system component d to overloaded or I clogged SAS or cesspool Disch'arge or ponding of effluent to the suir,face of the ground or surface waters due to an overloaded or cliogged SAS or sspool t5insp.doc rev,712.612018 Title 5 Official Inspection Forn Siubsurf Sewage Disposal System-Rage 4 of 18 I Commonwealth of Massachusetts, T'iltle 5 u4w""ffilcial Inspection Subsurface Sewage Disposal System Form Not for Vlunt r Assessments i 73 Riverview street Property Address 12 North Realtytrust Owner Owner's Name information is No. Andover lea 0,1845 05-29-2019 required for every or . Mate Z,ip Code Cate of:Inspection C. Inspection Summaryc i 4) System Enure Criteria Applicable to All Systems- (cunt.) Yes No Static liquid level in the distribution box abovie outlet invert dine to an overloaded r clogged SAS r cesspool Liquid e th in clesspool is less than 6"' below,invert or available volume is less than " flow E] E u ired pumping more than 4 times in the last year NOT dues to clogged r obstructedi s , Number of tines pumped: Any portion of the SAS, cesspool or privy is below high ground water elevation" El E Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply,, Ell Any portion of'a cesspool or privy is within a Zone 1, of a publicwater supply well. El E 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 1010 feet hint greater than 50 feet from, a pirivate water supply well with no,acceptable water quality analysis. [This system passes if the well water analysis, rformed at a D P certified laboratory, + r fecal c lit rrn 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,.] 0 The system is a cesspool serving a facility with a design flow of 2 ' g - 1 . the system s. I have determined, t'h at one or more of the above failure criteria exist as described in 3 10 CM R 1 a 5,3 3 therefore the system falls. The system owner should contact the Board f Health to determine what will h . necessary to correct the failure. 5 Large Systems: To be considered a large system the system must serve a facility with design flow of 10,000 gpd to 15,0010 g . For large systems, you must indicate either"Yes" r"no" to each of the following, in addition n to the questions in Section C" Yes No El 1:1 the system is within 400 feet of a surface drinking water suppily El E] the system is within 200,feet of a tributary to a surface drinking water supplEl El y the system is located in a nitrogen sensitive area (interim Wellhead Protection Area,- IWR it a mapped Zone 11 of'a pubilic water supply well t5lns :d *rev. / /0 8 Title Official Inspection Forte:Subsurface Sewage Disposal System-Page 5 of 1 Commonwealth of Massachusefts Tit"'-Ie 5 u'ff"i'c'ial Ins ect"ion Form J' Subsurface isposal System Form Not for Voluntary Assessments 73, Riverview street Property Address 12 North Re It trust Owner owni Na—me information l` . Andover lea 5 5 -29-2 required for r _m .m.. . _ ...� Ci mown State Zip Coide Date of Inspection C., Inspection Summary . If you have answered "yes" to,anyquestion in Section G,5 the system is,considered a significant threati or answered sa es" to any question in Section C.4 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 CA shall upgrade the system in accordance with 310 CM,R 15.E . The system owner should contact the appropriate regional office of the Department. You, must indicate "yes" our"no" for each of the f" llowli g for all Inspections: 'Yes No 0 1:1 Pumping information was provided the owner, occupant, r Board f Health 1:1 0 Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two weak period? Have large volumes of water been introduced to the system recently or as part,of this inspection? H El Were as 'built plans of the system obtained and examined'? if they were not available note as A El Was the facility or dwelling inspected for signs of sewage back up El Was the site inspected for signs of'break out? E El Were all system components, excluding the SAS, located on situ E El Were the septic tank nh l s uncovered, opened, and the interior of the tank inspected for the condition of the baffles air teas, material of construction, dimensions,, depth of liquid, depth of sludge and depth of stun? Was the facility owner(and occupants if different from owner) provided with H El information on the proper maintenance f subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been datermiin d based on: 0 Ell Existing information. For example, plan at the Board of Health. Determined in the field if any of the failure criteria related to Fort C is at issue approximation atior of'di tance is una oo to ilo [3110, CUR15.302(6,)] `5 in s p.doc-rev.'7 26/2018 Till ffi i l Inspection Forn Subsurface Sewage,Disposal System-Page 6 of 1 UTtic' I Insw%ection Form� Tittle 5 ia ... Subsurface Sewage Disposal System rm� Not four Voluntary,Assessments 3 Riverview street Property Ire ,Owner Owner"s Name Information i No. Andover Ma 011846 05-29-210,19 required for every City/Town, State Zip bode Date of Inspection U, System Information l 1. Residential Flow Conditions.- Number of bedrooms (design): Number of bedrooms (actuall).: 440 DESIGN flow based on 310 CIVIR 15.203 (for example: 11 x#of bedrooms): ...�. Description: Number of current residents- 3 Does residence have,a gar�ba,ge grindier ' El Yes 0 No Does residence have a water treatment unit" El Yes If s, d"scharges t m. ... .. .. Is laundry on a.separate sew l system? (Include laundry system inspection El Yes 0 N o information in this r port. Laundry system iins l cte Yes 0 No Seaso n l use es N Water meter readings, if available (last 2 yearn usage g * Detail- . SUMP Pump? Yes Z No Last date of arrowDOccupLied ate t5insp,doc rev.7/26/2018 Title,5 Official,Inspection Form:Subsurface Sewage Disposal System.'Page 7 of 1 Commonwealth of Massachusefts ion itle 5 Official Inspectm Form Not for Voluntary Assessments p m Subsurface Sewage, Disposal System Form ..� 3 Riy r Iew street Property rt Address 2 North Realt tr �s Owner information is Ma 01845 05-29-2019 required for even „ Andover page, Clit /Town State Zip Codle Date of Inspection D. System Information (cont.) Type of Establishment: ry wm.... .... Design flow (based ion, 310 CMR 15.2 3): . ,.�-ons per dayf lip l sis f'design flow(sleats/persons/sq.ft., etc.); .. .. ..m.. rv..„ Grease tray" pr s,ent? Yes Ej N lo Water,treatment unit resent Yes E] N to,- Industrial waste holding tank present? Yes El No Non-sanitary waste discharged to the Title 5 system? El Yes [:1 N o Water raster readings, if avallable# Last date of occupancy u see- bate Other (describe, bel m' ; 3. Pumping Records: Source of information. Stewart t. ._,.- Was system pumped as part of the inspection? Yes No If yes, volume pumped: 1500 .. �m.. mm.. gallons How was 'quantity pumped determined,.? Site ! � n tu�r�l.mm ..,. c. ... ... t5insp,do -rev.7/26/2018 Title 5 Official inspection Fora:Subsurface urf Sewage Disposal System-Page 8 of 18 ww Commonwealth of' Massachusetts T otle 5 0""F'po 0 1 Inspection 'I UTTICia �. A Subsurface Sewage Disposal System Form Not for Voluntary Assessments . a 73, Riverview street Property Address 12 North ea,ytrust Own r Owner's Name information is . An l r mm mm _ 9-2 19 required for even page. City/Town State Zip Code Date of Inspection D. System Information 4, Type ,Systems: Septic tank, distribution box, soil absorption system Single cesspool E] Overflow cesspool El Privy El Shared system (yes or,n if yes, attach, previous inspection records„ if'a,n 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 l system by system, operator under contract Tight tank, Attach a copy of the DEP approval. Other(describe),,. Approximiate age of all components„ date installed (if known) and source of information* 1 Were sewage odors detected when arriving at the situ` Yes No 5. BuIlding Sewer(locate on site plan); Depth below grade3 to 6 feet u..�. feet Material of construction, past iron PVC other(explain): m Distance from private water supply"well or suction line, feed . a� Co ments n condition of joints, venting, evidence f lea a „ etc.): t In;. o -rev. / / 0i 'Title 6 Official Inspection Fore:Subsurface Sewage Disposal System-Page 9,of 18 oft, Ith of uommonwea Massachusetts, orm, Not for Voluntary Assessments Subsurface Sewage Disposal System F mm Twt,le 5 ff'io c mi a I I n s ect�'ion Form �. ..... >� ' 3 Riverview street Property ! re 12 North Realt tr rst Owner Owner's�Name information is No. Andover lea 5 5-2 -2 9 r luir for every . m t � .� a, y, ��if �"ow� Cate of Inspection D., System Information (cont) 6* Septic Tarok(locate on site plan)# Depth below grade: �... ..... feet Material, of nstructi n: EJ concrete Emetal fiberglass El polyethylene El other(explain) If tank is metal, list age: years ...... Is age confirmed a Certificate of Compliance? (attach a copy of certificate) El Yes N 1411 Sludge depth* 20111 Distance i udge to 'bottom ofoutlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 611 Distance from bottom of scum to bottom of outlet tee or baffle 161111 . ..mm... . mm.. �.. . ud *u �� tape measure How were dimensions,determined? ..... ...,,,,,.�. Comments urn ing recommendations, inlet and outlet tee or baffle condition, structural integrity,, liquid levels as related to outlet in ° rt, evidence of leakage,, etc.). Both baffles good no, leakage, liquid legal good, t i p, -rev.712612018, Title 5 Official Inspection FFran Subsurface Sewage Dispo ail System*Page 10f 18 Commonwealth of Massachusetts � ion u icia Title 5 oq'kff Inspect" Form F6 " 6? �._... Subsurface Slew ge Disposal System Form Not for Voluntary Assessments t 3 Riverview street Property Address I 12 North Realtytrust Owner Owners Name information is1 , Andover a, 5 15-29-21 9 required for even .,,.. . , ._ Mate i Code Date f Inspection �it �"r tin 1 D., System Information (cont.) Gases "rap (locate onit plea): Depth below grade: .. a .., feet Material of construction: El concrete El melt l fiberglass D polyethylene other(explain): 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 . n Comments plumping recommendations'I inlet and outlet tee or baffle condition, structural integrity, liquid levels as related ted to outlet invert evidence of leafage, etc.): 8. Tight r Holding Tank (tank must be pumped at time of inspection) (locate, on site plan): Depth 'below grade: �. mm Material of construction, 0 concrete El metal E] fiberglass polyethylene E] other(explain), Dimensi ns- gallons Design Flow: gallons per day t5insp.doc*rev.7,12612018 Title Official Inspection Form.Subsurface Sewage Disposiat'System-Page 11 of„N � p... Commonwealth of Massachusetts MEMO Am am a in ,o y Title 5 Utticial Inspection Form _.. Subsurface Sewage DisposallSysteirn Form - Not for Voluntary Assessments �kf 0 73 Riverview er° iew street Property Address 12 North Realty ,j,rust Owner r Owner's Naas information,is required for every page. City/Town State Zip God Gode Date of Inspection i D. System Information (cost.) 8. Tight orH l n ant* Alarm present: El Yes N e Alarm leellw Alarm in working order: El Yes No Date, last ruing:I ,,, ..,m. ... Date Comments (condition ofalarm and float switches, etc.), Attach copy of current pimping contract(required). Is copy attached'.? Yes, El No 9. Distribution x (if present must be opened) (locate on site plan): Depth f liquid level above, outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leafage into or out of box, etc.):, equl dirt no solids carryover, no leakage t5jnsp.doc rev.7/26/,2018 Title 5 Official,Inspedion Form Subsurface Sewage Disposat System Page 12 of 1 Commonwealth assess 61 T10 t I e 5 uo""Td"t'p mi c'i"a mi mi n s p e c ion Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 3 Riverview street Property Address, 12 North irsm .mmm. ,. . Owner Owner's Name irr orr i ti n is . Andover , u1 5-2 -2 19, required or ever' � m. mm page. Cit [Town, State Zip Code Date ofInspection D. SystemInformation (co ) . Pump chamber(locate on site plan')* Pumps in wring order: 0 Yes El N o* Alarms in wring order, El Yes *. Comments (mote 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. Sol! Absorption System If SAS not located, explain why: Type: leaching pity EJ leaching chambers number. leaching galleries number" i leaching trenches number, length:; El leaching fielids number, dimensions" overflow cesspool near ..m. . El innovative/alternative system Tena,rne oftechnology: a ins,p. -rev.7/26/2018 Titlefair Inspection Form:Subsurface Sewage Disposal System-Paige 13 of 1 I I Commonwealth of: Massachusetts �. ._ t,le, UTT Inspection ...... .: .- Subsurface Sewage Disposal System Form Not for Voluntary ssess nts Riverview street Property Address 2 North Realtytrust owner Owner's Name information is 1 . Andover lea 5 5-29-2 required for eves _. m State. � i Code,m mm t+ �Inspection , page. Cit ow D, System Information (cont,.), 11. Soil Absorption Systems (SAS) (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of plonding, damp soil, condition of vegetation, etc.). No hydraulic failure, no ponding, no damp soils 2, Cesspools (cesspool must be pumped as part of inspection) (locate on site plan). Number and configuration Depth top of liquid to inlet invert Depth f solids Dyer �. . Depth of scum layer .m Dimensions ofcesspool Materials of construction .m . Indication f groundwater t r inflowEl Yes E] No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetationt it I I taro sp.d o rev,71261'20 18 Title 5 Official Inspedon Form'.Subsurface Sewage i al System-Page 14 of 1 I Cloommonwealth of Massachusetts am Title 5 UTTIcial r unnuuwx nmm�r».r- �-- ', xrn xr�r r+wrr Ins'w%ecItion, , mm Subsurface Sewage Disposal System Form Not for Voluntary Assessments mmmn 73, r Riverview street Property Address. 12 North elttrust Owner Owner's Name information is No., Andover 5 5-29-2 required for even .m�mm m. „ �m , m.mm , Ott i Code Date 10n tion . page. City/Town Town D, System !I c . 3. Privy (locate on site, plea): Materials ill of construction: Dimensions Depth of soliids Comments (note condition of soil, signs of hydraulic failure, level of ponding, conditilon of vegetation, etc. : i Title ffidi ar linspection Form,Subsurface g i p System-Page 16 018 I iumi" mmrmmrmummmmnmw�enem�n� ` I Commonwealth of Massachusetts mmme mar otle 5 �IF �� uvumr ,'y�r�imvm_ a� I i1 InsapAftection, 67 UTTIca _... Subsu'rface Sewage Disposal System Form Not for Voluntary Assessments ei is 3 Riverview street Property Address 2 North R It tr st �m.w n�mm.mmmmmmrrrm�� ��n mrmmmm�nrr m m n. �mmmr ���mmmmmrnr, nmm Owner Owner's Name information is No. Andover Ma 01845 05-29-201j 9 required for every �b7 paigeM ItFIT, ow State Zip Cody D t '"Inspection D. System Information (cont) 14. Sketch Of Sewage 1sp s 1 System: Provide 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, f the boxes below- hand-sketch etcl in the area below drawing attached separately t insp, rev.7/26/2018 Titleffi i l Inspection Form-,Subsurface e'Sewage Disposal System.Pugs 16 of"1 Commonwealth, of Massachusetts Title 5 Off ic"ial 1�nsr%ection Farm Not for Voluntary Assessments Subsurface Sewage Disposal System Form 73 Riverview street Pro pert 'dress 12 North Realtytrust Owner Owner's Name information is No. Andover Ma 01845 05-29-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont,.) 15. Site Exam, Z Check Slope, 0 Surface water Z Check cellar 01 Shallow wells 71, Estimated depth to high ground water: ..................feet Please indicate all methods used' to determine the high ground water elevation: z Obtained from system design plans on record If checkled, date of design plan, reviewed: 3/10/87 Date .............. 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 documentlati n) Accessed USGS database -explain: You must describe how you established the high ground water elevation: Taken from design plans,on record,, Before filing this Inspection Report, please see Report Completeness, Checkliis n next page. t6insp.doc-rev.7/26/2018 Till Official Inspection Form:Subsurface Sewage Disposal System-Page 17of 18 i i u Commonwealth s c e s ITTIC Toltle 5� 06� 1""m ial 1nspect"ion Form Subsurface Sewage, Disposal System Form - Not for Voluntary Assessments , 73 Riverview street Property rt Address 12 Forth Real r . Own r Owner's Name ............ information is required for eveMa 01845 05-29-2019 n .mm m page.. City/Town Mate Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections f this form inclusive f 0 .,. Inspector I f rr a. l n: Complete all fields in this section. . Certification: Signed 1& Dated and 1, 21 3p r 4 checked C. Inspection Summary* 11 2,1 3, or 5 completed as appropriate (Failure Criteria) and 6 (Checklist) completed D. System Information,-. 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" w p w w AOL P r " Y t w m , w * w „ « CA 10 k Town of North Andover, 00,AV#p 011+ HEALTH DEPART MENT "1 5 CHECK # DAT E LOCATION: 11"'W 00P1100 0, jI 1..........NAME, 6 G jral CONTRACTOR NAME, Type of Permit or License: (Check box) 0 Aninial $ EJ Body Art Establishinent $ 0 Body Art Practitioner $ D Dumpster 0 Food Service-Type.- $ El Funeral Directors D Massage Establishinent $ 0 Massage Practice $ 0 Offal(Septic),Hauler $ El' Recreational Camp $ 0 Sun tanning D Swlig Pool $ 0 Tobacco * Tias]VSofid Waste,Hauler $ * 'Well Clonstniction $ SEPTIC,,Systems: 0 Septic-Soll Testi'ng $ 0 Septic-Design A I $ El Septic Disposal Works Construction(DWQ $ Septic,Disposal'Works Installers,0M) $ 0 Witte 5 Inspector Title 5 Report 13 Other:(Indicate) H Aigent'Initials, ate-Applicant Ydlow-Health Plink-Treasurer .......... ...... ....../...........