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HomeMy WebLinkAboutPass - Title V Inspection Report - 30 SHERWOOD DRIVE 10/26/2023 Commonwealth of Massachusetts T i"Lle 5 Offic"al I spec l - Subsurface Form -Not for Voluntary Assessments .w � Property dress Owner ., information is required for every page. City/Town State Zip Code Cate of Inspection Inspection results must be submitted can this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the farm. Important:out t foams A. fttira� f . Inspector Information on the computer, use only the tab key to move your Name cursor-do not use the return key Com ny e 1 t r _ ..._. r . Nty State Zap Code T �ne Number License .. ,,. Number B. Certification I certify that: I am a DEP approved system inspector in hull compliance with Section 15.340 of Title 5 (31 tl C MR 16.000); I have personalty 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 to the proper function and maintenance of on-site sewage disposal systems.After conducting this:inspection I have determined that the system: 1. T4Passes . n Conditionally Passes 1 © Needs Further Evaluation by the Local Approving Authority 4. n Faits "r 1 � Sag tore_ Date The system inspector s tt submit a copy of this inspection report to the Approving Authority(Board of Health or D P)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 shell submit the report to the appropriate regional office of the DER 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 doves not address how the system will perform in the:future under the same or different conditions of use.. t5insp.doc•rev,7r4=1 8 1 We 5 Off mal 9nspecbon Fora;.Subsurface Sem9e Disposal System•Pap 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-blot for Voluntary Assessments e Property Address Owner Owner's Name information is required for every page. Ity fTown 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: n Ihave 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: L6- 2) System Conditionally Passes: El one or rri6'�system components as described in the"Conditional Pass"section need to be "s "replaced o rrepa'ired The system, upon completion of the replacement or repair, as approved by I the Board o eafth,will pass. Check the box for'e' -'-no'of"not determined"(Y, N, ND)for the following statements. If"not determined,"please e�04,in. The septic tank is metal ar"o r 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial in4h#j';n or extiftration or tank failure is imminent. System will pass inspection if the existing tank is repla6eqwith a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is st"rally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years olMd is available. n Y N [] ND (Explain below): 6nsp doc•rev.MAWDI 8 T Me 5 Offlual Inspechon Form Sub taw'- Dw4wwf System-Page 2 of 98 Commonwealth of Massachusetts . . a Title "wail Inspection Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments Property Address Owner _.. .._ ...._..._... w._._,_.._...._._.., ..._ is femme_._.,._..__ information is regtained for every . _.. __ page. t�.v.rit�a'6' vn State C. Inspection Summary (coat.) 2) Sys�emw Conditionalty Passes(cosut.): 1 ump Charmer pumps/alarms not operational. System will pass with Board of Health approval if pumpl„arms are repaired. µ [ Observation of'sea ckup or break out or high static water level in the distribution box due to broken or obstructed p' or due to a broken, settled or uneven distribution box. System will pass inspection if(withapprovih9ffloard of Health): E] broken pipe(s)are replaced F1 Y ® N n ND(Explain below) [� obstruction is removed [_J Y N Q NCB (Explain below): E] distribution box is leveled or replaced C] Y 0 N ND(Explain below): _...._..............._..___.,.,___,,..._ _......_.___ __ _.._____.__.._____.._._..__.._._.__..._,....._,__._._.._.._._ —_ ___ _ F1 The system required pumping more than 4 times a year due to broken or obstructed pip (s). The system will pass inspection if(with approval of the Board of Health): Q brokers (s) are replaced Q Y E] N C] ND(Explain below)- E] obstruction is removed ❑ Y N ND (Explain belowww)- M .M 3) Further Evaluation is Required by the Board of lth Gonditions exist which require further evaluation by th and of Health in order to determine if the system is failing to protect public health, safety or the vironment. aa. System will pass unless Board of Health determines in rd ' ace with 310 CaMR 15.3C13(1)(b)that the system is not functioning in a manner wawhit willproteetpubfic health, safety and the environment: tlxnrsp. .rd I8 'T Me 5 OffidW lrmpedm Form S wbsurface Sewap DmposW SeOm•Page 3 of 18 Commonwealth of Massachusetts Title 6 unicial Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Owner P e iFlicrl�rn�wteon e� .__ g� .,�e wwrw er s� recItired for every pii cityFfrovti 56te Zip ccfe Date of Inspection _ C. Inspection Summary (cont.) [ Cesspool or privy is within 50 feet of a surface water 0 Cesspool or privy is within 50 fleet of a bordering vegetated wwettand or a s,att marsh b, System will fail unless the Board of Health(and Public Water Supplier, if any) de ines that the system is functioning in a manner that protects the public health, safety°,end environment: [� The s has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a s ace water supply or tributary to a surface water.supply. F1 The system h a septic tank and SAS and the SAS is with in a Zone 1 of a public water supfgy. F1 The system has a se tank and SAS and the SAS is within 50 feet of a private water supply well. n The system has a septic tan nd SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply ww *" Method used to determine distance: **This system passes if the well water analysis, perfo at a DEEP certified laboratory, for fecal coliform bacteria indicates absent and a presence of am nia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria ar riggered.A copy of the analysis must be attached to this harm. c. Other 4) Systems Failure Criteria Applicable to All Systems: You Mgg indicate"Yes"or"Noll to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Ej Discharge or ponding of effluent to the surface of the ground or surface wwater's due to an overloaded or clogged SAS or cesspool t.5insp,doe•p'ev.7r2&2018 1`ifte 5 C.MFucW Inspecbon F--rxrre Sa bsui Sewage Drsmsal 14'rAern-Page 4 of 18 Commonwealth Massachuseft Title 5 Official Inspection For Subsurface Sewage Disposal System Form-plot for Voluntary Assessments ,. Vj ..... -.....w ... ... ... w_... �... _ .w ..___,.._. _... .__.. _..___._..._..._.. .w Owner ¢� p'�av�m ... � as ,w..- pnfbir mafi an is 561 page. Cityfrown _.. ,.... ... Stag dip +xl fete of Itpaarr C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems; (coat.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool E] Liquid depth in cesspool is less than 6"below invert or available volume is lass than V2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). plumber of times pumped. Any portion of the SAS, cesspool or privy is below high ground water elevation. E] Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply, E Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. El 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 duality 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 pprn, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) F, The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. E] 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) Large tems: To be considered a la system the system must serve a facility with a design fl 10,000 gpd to 16,000 gpd. For large systerft,,Vpu must indicate either"yes' or"no"to each of the following, in addition to the questions in Section Yes No Q © the system is within feet of a surface drinking water supply El © the system is within 200 feet o ributary to a surface drinking water supply the system is located in a nit en se ive area(interim Wellhead Protection El 11Area— A)or a Zone 11 of a is water supply well 1�d w o ,'� I8 Try a. ia&W � a F' :S.bwi&aw Dspowf, *P 5 of 18 _......_. ......w..... .---- u Commonwealth th of Massachusetts Title 5 Official Inspection Form Subsurface Sewage disposal System Form-Not for Voluntary Assessments ------ Property Address Owrw informationtAre is �._.. rga�red fray,every Pare. cwryrTown Sate a raf w C. Inspedion Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat„ or an "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 G,5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 5. You must indicate"yes"or"now"for each of the following for all inspections: Yes No 0 Pumping information was provided by the owner„ occupant, or Board of Health l 0, Were any of the system components pumped out in the previous two weeks? rl 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? E Were as built plans of the system obtained and examined? (If they were not available note as N/A) �] Was the facility or dwelfing inspected for suns 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 battles 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 Foil Absorption System(SASS 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),[31 g CMR 15.302(5)] t5twrsp,doe•rev.'i"l rP:M.'w18 TO*5(YfiaW nr'njxs clmn F''axm Subsurface& gee Dmp w 1 m*Page H<r 15 °. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Forma-Not for Voluntary Assessments Owner 0 Na reqtiredforevery WTS, rne t��1 µ _ _ _.._.__ _.___ .._._ __ ...m..�_.._.___.._...._ page, e tion D. System Information 1. Residential al Conditions: Number of bedrooms(design): Number of bedrooms (actual); DESIGN flow based on 310 C R 1 .203(for example- 110 gpd x#of bedrooms)- Description: Number of current residents: ..._. _._.... Cues residence have a garbage grinder?" El Yes E) No Does residence have a water treatment unit? E] Yes No Ifyes,discharges to: _._.u_.___._.___ ._.,_. . ._._.___.._....... _.__.w..._ _,_.......__......____.._.. _....._ .w_. Is laundry on a separate sewage system?(include laundry system inspection Yes No information in this report_) Laundry system inspected? El Yes No Seasonal use? 0 Ye Water meter readings, if available(last 2 years usage(gpd)); - " --.-N�4o0 Detail: Sump pimp?___--_____. ._._..___.____.___._........�___ .w.__......._...._...__..___ .. ..__._.�_..w_._.._.......__...._.__._ _____._.. ._ ._.... o. Yes Last date of occupancy: .., Date t5insp,dm-to MWO16 Tide 5(A aW armpectoa R='cxm;—Atb6urf*w Swaig1ez Drsposal*fit•Page"7 of 18 Commonwealth of Massachusetts . . Title 5 Official Inspection Form Subsurface Sewage Disposal t:system Forma-Not for Voluntary Assessments Owner infDrmation is reqLired for every w q rare page. Caste of Irspection D. ,System Information (cont.) Cornmercialfindustrial Flow Conditions: Ti*ofEstablishment: ......__....._........._........._ Design (based on 310 CMR 15. 03): Basis of design (se Jpersonsisq.ff., etc.). Grease trap present? El Yes E] No Water treatment unit present? E Yes E] No Ifyes,discharges to: _ ,�_ ____.... _.._._....__._.__... _. ............... . ....... Y___.......w .. .._... _....._._.. Industrial caste holding tank present? � El Yes C No Non-sanitary waste discharged to fhe Title 5 system�' 0 Yes E] No Water meter readings, i farlbbatalew _. _..... ... ....._._._._..._.._...__,____,_,....__._ .._...._..._w_. ... Last date of o nc�yduse: _.w..:._ ____ ....._..__�.._ ._..._.._ .__ .__... _ ....__... Cast Other(de§ii�*x below) . Pumping Records Source of information Was systern pumped as part of the inspection? Yes No If yes,volume pumpe& kzr How was quantity pumped determined? Reason for pumping: _.._ .._....,... .M._...w ... ___..... t`:inspn doc raw 7'/M2D 8 "Y' ;xd"kMficn�ad& mu rxorw 5.. art ram'". d` '� yr Page 8of 18 Commonwealth of Massachuseft *, Title 5 Official Inspection Form ... Subsurface Sewage Disposal System worm-blot for Voluntary Assessments r ✓ t y ----------- ress Owrer Owe Na infonnabon is �rirequ I red for every, u state_ Zip Code Date of I page, Cityrrawn nspechon D. system information (cont.) 4, Type of System: OkSeptic tank„distribution box,soil absorption systems El Single cesspool El Overflow cesspool 0 Privy Shared system(yes no), if yes„ attach previous inspection records, if any) [ Inno ati / Itemati e technology.attach a copy of the current operation and maintenance contract(to be obtained from systemowner)and a copy of latest. inspection of the VA systems by system operator under cordract El Tight tank.attach a copy of the DEP approval. Other(describe): Approximate age of all components,date installed f n)and source of information: Were sewage odors detected when arriving at the site' El Yes C] No . Building Sewer(locate on site plan): Depth below grade; feet Material of nstrectlon: EJ ast iron 0 40 PVC; El other(explain): Distance private grater supply well or sanction line; ._..._... � � ..Comments condition o ornts, venting,evidence of leakage, etc): ra gw.a e•ram. GER 'rft s OffiaW&nwecbw Fcam" ' 4 S 9 of 18 Commonwealth of Mai gauss Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Propetry Address I Owner r Lit i information is eqvd br every page, Qtyxo�wn /9�te' Zip Code Date of fropection D. SyStem Information (cont.) 6 Septic Tank(locate on site plan)- Depth be grade, feet Material of construction: �tprtncrete El metal nfiberglass 0 polyethylene other(explain) ........—------- If tank is metal,list age: -y I Mrs. ...... Is age confirmed by a Certificate of Compliance? (attach a copy of wofificate) n Yes n No 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 dimensions determined? Comments(on punVing recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.), ............. (IV 110 ------------ t5srosp dw-pay 7 r2W201 8 Tales 5(AhaaO 6 Fwns-Subwrt&*SevaW�DmpwW System-PaW 10 of 18 w Coffunonweal'th of Massachusetts Title 5 Officialr s ec or Form Subsurface Sewage Dis t System F -Not for Voluntary Assessments Property Address k.....c , Owner Owner's Ie informabon is reqtAred for �. page. ty r re _._ w _..__ State Zip Code Date of Inspedion D. System Information (cont.) 7. Gre $rapt(locate on site plan): �w Depthbe6* e: �....� _._....__... _..�.._.m....w_.____..__..w.._._..._..__....__..____. Material of con c tior - 0 concrete El metal µ fiberglass 0 polyethylene C] other(explain) Dimensions: ___.._ _._..___..___.__ __._.................__.w......._. .. Scum thickness Distance from top of s um to top of outlet tee or baffle a _........ __. �..ry . _.__.._...._..._.._._n......__..._ Distance from bottom of scum to bottom of outlet tee or baffle _._�..... __a Date of last pumping: ate 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. right or Holding Tank(tank must be pumped at time of inspection) (locate on site plan); Depth below grade— - Material of construction: 0 concrete E] metal fibe s E] polyethylene F1 other(explain): Dimensions. rapacity: ___.._..._..... _ ..._.__ g�elloras Design Flow: awurap doc-K ,.'MSM18 T 5(Aical.' Inspodw Form S ub smoface Sewage Dwposel mm•Page 19 0 18 Commonwealth Ma he ... Title 5 Official Inspection Form w Subsurface age Disposal System Form-Not for Volurltary Assessments ray OWW iftin'r. reqtired for every page. G4/Town state Zip Gode _ �a of Inspection D. system Information (count,) & right or Holding Tank(coat,.) Alarm pre,, El Yes n No Alarm level; µ _____ , ._..__.__. Alarm;In working order: ® Yes El No Date of last pumpingDate Comments(condition of alarm and float srr�rt a etc.): *Attach copy of current pumping contract(required). Is copy attached"? 0 Yes No , Distribution Box(if present must beopened) (locate on sfte plan): Depth of liquid level above outlet invert _,__... __......___._...... ..__.a.._--------- Comments (note if boar is level and distribution to outlets equal„ any evidence of solids carryover, any evidence of leakage into or out of box,etc.): !." a . fir "rz C cam„ t .a 1 I " I . t5ift i.dw•mw.'7MMIS 5"ge S CXSS meek kw4mdrai Fum"Subw fwn S&mge D' h g n.Nge 12 W 18 Commonwealth of Massachuseft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-riot for Voluntary Assessments or .. nrrrea iora � �'� � `. � page. CityfrovwMn Zip Code r r a rr D. System Information (cont.) 10. Pump Chamber(locate can site plan): .," Vwo rrtrirag order: Yes n No* Alarms in r rn o 0 Yes n No* Comments(note condition of pump„n-'amber,condition of pumps and appurtenances, etc.): w 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, T leaching pits number; n leaching chambers number.- El leaching galleries number: W � leaching trenches number, length- 0 teaching fieMs number,d" nsions: _ ,.__,._. ... .. ,�.... .M n overflown cesspool number _.__..____.._ . ....._... ....w El innovative/affernative system Type/name of technology, _.. . _..... __........_.w_._.__._,._. .....M. .. .__,_,_._.M,,._..__.._._ .._.. . .„ ...._,. Via,doc.near.MWDI 8 1 50(tvaW Inspedton 6'wm Sub rrf C S 13cf 1S Commonwealth of Massachusefts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a;'m✓ h ProAddress Owrier Owner's Name information is reqLinsd for every pang c y/T slate Zip a of Inspection C . System Information (cont.) � 11. Soil Absorption System (SAS) (coat,) Comments(note condition of soil„signs of hydraulic failure„ level of pending„ damp soil,condition of vegetation„ etc.). 1 . +Cesspools (cesspool must be pumped as pail of inspection)(locate on site plan): Mute r and c �nfiguration Depth to f liquid to inlet.invert Depth of solids la _....... _........_ . _.._..._. .... Depth of scum layer _.r_. .__..... ___ ___._.._..___._........__.....w._ Dimensions of cesspool -..._......._._w__.....0 .__.. w,_......._...._............ . m..._._. Materials of construction _._ . .... _.w._.._-_...w....w Indication of groundwater inft w E' Yes rl No Comments(note condition of soil,signs of h ullc failure, level of pond ng, condition of vegetation„ etc.): t5insp doc-rev '7r. . p 6 Tffle 5 OffkxW Pr4wbon Rom G * .P 4 of 18 „ ” Commonwealth mmonwealth Of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ownerNa inbrmation is �aurr page yftown State Zip Code Date of Impaction D. System Information (cont.) 13. Pri (i9cate can site plan)* n)* Materials of const ction. _..___...�_..w ......__ _____..w...._...._...__... ._ .._._ W...._ _. Dimensions _..__._._............. ._._._._____n_. .._..__._.___ _..._..._..___ _.._ Depth of scants _ _ ....__ _......_.... ._......._ _...... __. Comments(note condition of sell, sly of ftydrauW failure, level of pond ng, condition of vegetation, �N �t _..........�.__.__. ___.._ _ ._.._ ._._.____............_._... w� Vi me p doc-rev.MWM8 Tdfe5GWWW1nspeCbonFcrrwr S uNasutt'auLe w" e D ' d SrAe rw•Page 15 of 18 re Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments .....��. "" � . .__......__. .. . __.w.....w_ _,,..... Prrerty A�ddr� Owner Ow r' Na information i required for,every " .,,„,...w.._._.. page Cityfrown State 2jp Code Darek%pechon D. System Information (con.) _.._ 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two pertnanent reference landmarks or benchmarks. Locate all swells within 100 feet. Locate ere public water supply enters the building. Check one of the boxes below- head-sketch in the area below ® drawing attached separately t5ins p.rkx¢w ram.'712F8M 16 Tide 5 O f4aA krrspedion 9w`mm Smlasaedace;;age Dr na l SysWm-page f 6 d 18 Commomealth of Massachuseft Title 5 Official Inspection Form Substnface Sewage D. l System Foram-Not for Voluntary Assessments Owner Owner's mu _... .. inbrmation is' _... ' ....... m a page ityli" ii tale p Code e o tr�pe�t n D. System information (cont )--- . �.. 15. SiteExam: F1 Check Slope [ Surface water [ Check cellar [ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked„data of design plan reviewed: [ Observed site (abutting property/observation hole within 150 feat of SAS) El Checked with loc al Board of_,eaEth -explain;: Checked with local excavators, installers -(attach documentation) �] Accessed USGS database -explain: You must describe how you established the high ground water elevation: 4 LY Before filing this Inspection Report,please see Report Completeness Checklist on next pare:. tCximp doc-iev,7' , , I$ A ite 5 CAftoW k. Forma Ewboxtaw Swwago rs t Bunn-page'17 co 1 a Commonwealth of Massachusefts Title 5 Official Inspection Form '. Subsurface Sewage Disposal System F -Not for Volurtt wty Assessments ��rt~ Owror Na OW 2 reqUred for every page City/Town � � . .. ... ..µ,....4 ._._� _ _._ state Zip Code Date of inspection . R+ pot t Completeness Checklist Complete all applicable sections of this form inclusive of. A. Inspector Info len. Complete all fields In this section. [ B. Certification.- Signed&Dated and 1,2,3„ or 4 checked C. Inspection Summary: 1,2, 3,or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed D. System Information- For& Tight/Holding Tank-Pumping contract attached For 14. Sketch of Sewage Disposal System drawn on pg. 16 or attached For IS- Exptanation of estimated depot to high groundwater included insp,d ,r c IMMI8 T*15 OffmiaO kmpecton Form Subsudaw S e,OsposW System M P:*;e 18 d 18 V . - " 7 " C CIO* " AS ERALtw " ap r,✓ L r Wen OF r�SLWOMCE DI SSTEM �f LC"A"1ED HNAS . PREPAREDFOR rone, 9 41 0 :0 Town of North Andover HEALTH DEPARTMENT �2W "7 CHECK DATE. 1, e"') .3 1 LOCATION: 10 H/ONAME: CONTRACTOR NAME: .,. Type of Permit or License: (Check box) 0 Animal $ 0 Body Art Establishment $ 0 BodyArt Practitioner $ 0 Dumpster $ 0 Food Service-Type: ______ 0 Funeral Directors 0 Massage Establishment $ 0 Massage Practice $ 0 Offal(Septic)Hauler 0 Recreational Camp 0 Sun tanning 0 Swimming Pool 0 Tobacco $ 0 Trash/Solid Waste Hauler $- 0 Well Construction $ SEPTIC Sustems. 0 Septic-Soil Testing $ El Septic-Design Approval $ 0 Septic Disposal Works Construction(DWC) 0 Septic Disposal Works Installers(DWI) 0 Title 5 Inspector $ Title 5 Report $ 0 Other(Indicate) $ Hei"V�Agent Initials White-Applicant Yellow-Health Pink-Treasurer