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HomeMy WebLinkAboutPass - Title V Inspection Report - 1542 SALEM STREET 10/26/2023 Commonweafth of Massachuseft, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary AsAeissments .................. ress Owner Mormation is Owner's (6 z reqLdred for every I 7jp Code Dat e of Inspection page. &Iity�Ttm(own State 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 fornt. Importmt:Men A. Inspector Information filling ott 1bmm on the compder, use only the tab Name or lrqvdor key to move yow cursor-do not use ft, rebirn ...... key. COM me ......... Com Cityf!'own Code ----- ----- Nurribier Ucense Wimber J§:—Ce--r-fi—flc-at—ion I certify that., I am a DEP approved system inspector in full compliance with Section 15.340 of Title 6 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. 01 Passes 2 n Conditionally Passes 1 E] Needs Further Evaluation by the Local Approving Authority 4. n Fails nspector's Sig�L Date The system inspector shall s a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shaft 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 does not address how the system will perform in the future under t!he same or different conditions of use. ekmig�d0L Mv.M26=18 I'Me 5(X�impechan Form Subunface SewVe D�l Syg*mi-Page I of W Commonwealth of Massa+chulse N Tithe 5 Official Inspection Form i. Subsurface Sewage Disposal System Form .blot for Voluntary Assessments __......... Owner inn reqLgred for every cw C. Inspection Summary Inspection Summary:Complete 1,2, 3,or 5 and all of 4 and 6. 1) System Basses: l have not found any information which indicates,that any of the failure criteria described `n 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: m ) System Conditionally Passes: E] one or more system components as described in the"Conditional Paw section need to be repla or repaired.The system, up a of the replacement or repair, as a try the a of Health,will pass. Check the box for*y s"> "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please a In. The septic tank is metal and ov&2Q years *car the septic tank (whether metal or not) is structurally unsound„exhibits substantial infiltratibmpr exfiiltration or tank failure is imminent.System will pass inspection of the existing tank is replaced w tip complying septic trunk as approved by the Board of Health. *A metal septic tank will pass inspection if it Is structurali spund, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old l pliable. El Y [D' N ND(Explain below): k"swruV&PC•rev MWAY18 T'de 5 MaW InspecbDo R'coax Subwlacs" �4stsrm•Pa" 18 Commonwealth of Massachusetts T*tIe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner 6ddr"wer s iVam�informati __... r for eywy d . page- /Town State Zip Code Cie of Inspection C. Ins on Summary (cant.) 2) Sy Conditionally Passes (coat): © Puilr Chamber pumps/alarms not operational. System will pass with Board of Health approval if pump rms are repaired. E Observation of sewage bac or break out or high static water level in the distribution box due to broken or obstructed pipe(s) o e to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Bo of Health)- F1 broken pipe(s) are replaced Y n N C] ND(Explain below): Q obstruction is removed Q Y N C] NO(Explain below): (� distribution box is leveled or replaced ® Y F1 N ND (Explain below): [� The systcuWrequired pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass*,pection if(with approval of the Board of Health): w broken pipe(s)a placed ❑ Y [I N E] ND(Explain below): ® obstruction is removed F1 Y Q N E] ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in her to determine if the system is failing to protect public health, safety or the environment, a. System will pass unless Board of Health determines in accordance with 3 CMR 15.3t13(1)(b) that the system is not functioning in a manner which will protect p blc health, safety and the environment: t:"msp doe-rev.7rAM1t1 Table 5 Mug Irmpechon I=omi Ss bmirtaw:aesvage Uos l Systern-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form_Not for voluntary Assessments , ` � Cam, .......... ... _ .......... _.._ Property Address owrec I� a, y information is �1.�M�Ym required fear _ _ ._. .. __._,. 4 ..,,w,._.._.. _..___...... page- Crtyf rown Stag rp a tote of Inspection . Iwns Uon Summary (coat.) n Cesspool or privy is within 50 feet of a surface:water cesspool, is within 50 fret of a bordering vegetated wwettand or a salt marsh b. System will fail unless"ttte, rd of Health(and Public water Supplier, if any) determines that the system is fu ioning in a manner that protects the public heafth, safety and environment: a The system has a septic tang and soil abs ion system(SAS)and the SAS is within100 feet of a surface water supply or tributary to a ace water supply. ® The system has a septic tank and SAS and the SA ' within a Zone 1 of a public watersupply. ❑ The system has a septic tank and SAS and the SAS is wit 50 feet of a private water supply well. 11 The system has a.septic tank and SAS and the SAS is less than 0 fret 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 colif!orm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 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 of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool tInnsp.doc•tev,? . . I8 T"de 5 OffidW Insped3on F'om Subsudice 15em9e,Daposal SyAem W Page 4 d 18 Commonwealth Massachusefts. Title 6 04kfficial Inspection Form N Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P Address ropedy Owrw Ovr�nees infoffnation,is page. ,rrrro,�wn Stare Zip Code a awr�r woad for �___` .... ..m___.....n_w___.__ .__ _. on C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cwt.) Yes No E] Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 0 Liquid depth in cesspool is less than "below invert or available tuume is less than 11,E day flow Required pumping more than 4 times in the last year NO' duue to clogged or obstructed pi s). Nuumber,of tunes pumped: Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool!or privy is within 100 feet of a surface water supply or tributary to a surface water suupply, E Any Portion of a cesspool or privy is within a Zone 'I of a public water supply well. 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 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 caolifaorrn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrxigen is equal to or less than 6 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) The system is a cesspool serving a facility with a design flow of 2000 gpd- 10, gpd. -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 Sys To be considered a la system system must serve a facility with a design flow of , gpd to 16,CN00 gpd. For large systems, you t indicate either Oyes"or"no" to each of the following, in addition to the questions in lion CA, Yes No El E the system is within 40 let of a surface drinking water supply [� [� the system is wwithin 200 feet of burtary to a surface drinking water supply thEl 11e system is located in a nitrogen sen " 've area (Interim Wellhead Protection Area I A) or a ; one ll of a pu tic water supply well V' dw»save,.7rAM18 TOO 5 OffiaW Inspedxm wir m Subsurface DtspmW System•Pgge 5 of IS Commonwealth of Massachusetts " iNp Title ► Official Inspection Form Subsurface Sewage Disposal System Form-Not for" iglu Assessments information requned for every Z page. Cityffawn ,. state ....... zip cwe.._,_ _�.Date czf Nr .........._�__... C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C ,5 the system is considered a significant threat, or answered'yes"to any,question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat.under Section C..5 or failed under Section C A shaft upgrade the system in acwrdance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for aft inspections: Yes No 0 lumping information was provided by the owner, occupant, or Board of stealth Were any of the system components pumped out in the previous two weeks? E] Has the system received normal fkyws in the previous two week period? E] Have Marge 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 mate as N/A) Was the facifify or dwelling inspected for signs of sewage back up? C1 Was the site inspected for signs of break out? n were all system components, excluding the SAS, located on site? E Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions„depth of liquid„depth of sludge and depth of scum? El Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposat systems? The sire and location of the doll 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 fart C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)1 t"rmp. w rye.'8 18 I'"We 15 OffwaW Uw4wdim R m S uk suftw,`woAW"D bWy t SyUem•Page 0 d 18 u Commonwealth of Massachusetts -, Title 5 Officialns ecti n Form Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments w ._ ... . -_-.-_..._-.-___. .. .., .._... ...v_... r°s Nam k*rmafion is requrej for every page. Cityfrown _.._..:" '.. mw_ Cwe _ of Inswdion 1, Residential ntlal low Conditions: Number of bedrooms(design): _..__ Number of bedrooms(ae ua DESIGN flow based on 310 GMR 15.203 (fur example; 110 gpd x#of ms). __ . ...._ ._._...... Description; Number of current residents: _._..,..... Does residence have a garbage grinder? Yes No 6.P, Does residence have a water treatment unk? © Yes No If yes,discharges to: Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? n Yes 14No Seasonal use? Yes No Water meter readings, if available last 2 ears usage Detail, Sump pump? Yes E] No Last date of occupancy, V"a:' rmp. 't•my M26=8 7... 5 Mkml tnspedm F om bsw e DapowA m m•Pne 7 ot 18 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not c ,µ or Voluntary essrmerats Property Address owror n requred for every or" bmation is page, Zip Code _ m .w. car fra l r1 _... ... ..__.. _.. f Inspechon D. System Information(cunt.) 2. CornmercialAndustrial Flow Conditions: T ca ' .'bllsh ant: _.... _....._ _....................... ._. .._.. .. .._ .. _......._......_...._ _. Design (ta�aas 1 tl t�lw �t ' 1 Beds of design flow(seat tpe rrsJsq.ft., eta.); _._.__.__._. _.._._...._____....._._ Grease trap present? El Yes 0 No Water treatment unit present? n Yes El No If yes,discharges to; ._ .._... __ _ .. ......__ _.......... . .... Industrial waste holding tank present? F1 Yes E] No Nara-sawniteryr waste discharged to the Title 5 system? E Yes ® No Waiter meter readings, if available-le: _.w_.. Last date of occupancy/use: _Da. .__._... _. __......___. m Other(describe below), RA Records: . p ping r �.. Source of information: Was system pumped as part of the inspection? E' Yes No If yes,volume pum __.___ ..._w m..__.._._.. . ......_.._._.... _. _... ._.._....._. blow was quantity pumped determined' Reason for pumping: _._._....._ _ ....._ ... __. .__..._ 1'5%a ap ft, lees.'7 .. S' 1 8 T&5(M&W hw4mUm F-mm Subwrfac e S. s . i x n-Page 8 of 18 Commonwealth of Massachusetts =- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ess Owr*r i formatiion i reqL#red for every page. rafpB r own suft Zip Code Date of r D. System Infoffnation (cont.) 4. Type ofSystem: P� Septic tank„distribution box,soil absorption system Ingle cesspool Overflow cesspool CI Privy Shared system (yes o4oibf yes, attach previous Inspection records„ If any) El Innovative/A ternative technology.Attach a copy of the current operation and maintenance cont (to be obtained from systemowner)and a copy of latest inspection of the INA system by system operator under contract Q Tight tank..Attach a copy of the DEP approval.. n Other(describe).- Approximate age of all components,date Installed(if known)and source of Information: Were sewage odors detected when arriving at the site's Q Yes E] No . Building Sewer(locate on site plan): feet� ��._. Depth below grade: Material of con ction.- .cast Iron ❑40 PVC ❑ other(explain)- Distance from private water supply well or suction line: --- _. °-- ------- Comments(on condition of joints,venting, evidence of leakage„et' .): tm;agz,doc•read.7126W16 T Me 5 Inspeofian Fom Srirleoe Sevmge Dtsposal SYstern...Page 9 of 18 Commonweal of Massachwwft Title 5 Official Inspection Form Subsurface Sewage Disposal System I~carnn Not for Voluntary Assess ments Property Address Owner information is + required for ___ _... ... ,_.________ page. State pCode DateI ors D. System Information (cont.) 6. Septic Tarok (locate on site plan): Depth bekaw grade: ___m _.__..._.__ __..__..M........._.._..___...._._. .....,__..._._.._._,..... feet Material of construction:. O'Concrete ❑ metal F1 fiberglass polyethylene other(explain) If tank is metal, lust age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) [-1 'yes ® No Dimensions: it Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to tap of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? .._. Corn (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): t5vi sp.doc-rev R260018 TMe S A Inspection Form SubsudaceSpym9eDsposW System-Page 10 of 18 ConmameWdl of Massachuseft Title 5 Official Inspection Form Subsurface ge Disposal System Form-Not for Voluntary Assessments ` A Vn... _...__ �. Property Address .. .. , n Owner Owner's informationu i � "� ...,...... ._. .._......,,, . �'_.. ." requredW every frown state Zip page. D. System Information (cont.) 7. Gr ase Trap(locate on site plan): e. _._.__ _._ , ___._._._.....__. ..__ ...._.... Depth � 'al w feet Material of cianstrucl l n: ww. El concrete n metal inn ,G P fiberglass polyethylene n other(explain). Dimensions: � — ._.. .............__.._... .._._..._.. w.w__. .mm_...._ ...... �d acurrr thickness ...... ... Distance from top of scum to trap of Put tee or baffle Distance frorn bottom of scwr.rP,f8`� . , o b lao ttorn of outlet tee or baffle ...w.m.._ ,„�.� ._.._.... Date of last purnpt Date Comments(o wiping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid t s related to outlet invert, evidence of leakage,etc,). & Tlgtd or Holding Tank(tank must be pumped at time of inspection) (locate on site plan). Depth below grade. _..__._._.. .........__ _ __.,..._ ........„. � wwnn', r+^ Material of construction: El concrete 0 metal E]fiberglass 0 polyethylene other(exptacn), Dirrrensiorrs � __._ _........_ .__......_.___...__ _....... ... ... Ca Nt Design Flow �gallons per_day .�....._.... _.._.._. __�_.___._._..__..__..__........_. in 7126WI I'de50ftal kn%pecbwFwm Subsu r"wm ; d gym, 11 of i m Commonwealth of Massachusetts Title 5 Official Inspections Form Subsurface a Sewage ag Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Nam _.. .. .... ...... _.n.._..... _.. _ . _.___ry . .__ ._ 2 it , page. Cityffown state Zip Code Date of_ o rspecfion ► System Information (coat.) Tight or, rr+g Tank (cont.) l urrrr s rrt: l� @ No Alarm level, w ....._.. Alarm in rlwwnder `� No Date of last pumping: Comments (condition of alarm and float swifohes, etc.): Attsoh copy of cuffent pumping contract (required). Is copy attached? 0 Yes E] No Distribution Box(if present must be opener (kwate on site plan): Depth of liquid level,above outlet invert ______..._.._.....m_._.....mm_. _ ...w.._...___ __.__...._.. .__...___... w omments(note if box is level and dishibution to outlets sequel,any evidemce of solids carryover,any evidence of leakage into or out of box, etc.): -------------- taut doc.,cwN 762&2016 I" 5 CApw M k%;*w1m P=axwwt, 12018 Commonwealth of Massachusetts T'tie 5 Official Inspection Form Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments Property Address Ownerinform d for ..._.. _ .... .,_.._ ._...__.. _._ reci arnaraer s e information its � y _... __ . ` '... .._._. _._ ....._. __.__._ ...._.. page. Cityfrown ate Zip Code Date of k on D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: Yes [] No* Alarms in working carder. Yes C] No* Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.); tu If pumps or alarms are not in working order„system is a conditional pass. 11. Sail Absorption System (SAS)(locate can site plan, excavation not required): If SAS not located, explain why- Type: ® leaching pits number: EJ leaching chambers number: -.-...-.... .....__._.____.___ . ® leaching galleries number: leaching trenches number, length: - -- j leaching fields number,dimensions: _....n.._._.._._ n overflow cesspool number: - - 0 innovative/alternative system 'type/name of technology; t5irmp.doc w rev.7r2&2018 I Me 5 OffictW ffispection poser SutrwAoor $ b wPage 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form `m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Omer �.... informaWn is required far every page Cit lTc�wrn tafer .. _y p ode Date of I D. System Information (coot.) 11. Soil Absorption System (SAS) (cone.) Comments mote condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): u� l ____________........... 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): ,,5 tumoer and configuration _.............................. __.._.__..._.__....__ Depth—fa�of liquid to inlet invert _...._....__.__.._..._..._._..__._.__..____.._______.. Depth of solid "" yer Depth of scum layeX ........ Dimensions of cesspool Materials of construction Indication of groundwater inflow 0 Yes No Comments(note condition of soil, signs f hydraulic failure, bevel of ponding, condition of vegetation, etc.): ------------ t'.Sinsp.a •revs.7r" "2DI8 T Ore 5 OffK3W kwpectw FOM Subsufftee Sewage D n^Page 14&183 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G 2 VrOwrer arty F M ..y n1offnation is reqtsrW for _ _..__.. .___.___._.....__ _. .. Y Zip D. System Information (cone.) 13. Privy(locate on site plan): Materials f Dimensions _. .._... ....__µ._..w.... _........_ .w...._..w._.. _.. _.._�__�w..._...._.,.m._.__...._ .__....... Depths of selirt � Po _. ..._..m._ ._... ...... _...M_....�_._...__...__.._..._.. __..__m_...._ Comments (note condition of sail,signs 6 raulic failure, level of ponrting, condition of vegetation, etc.). w� k hw 15aC'arap.&w"RW p. fir"8 'rdjesmaw kr4mwn Foaft Stl',riba.x lDn4x,Y& 9ftM1'CG•Page 15oflo Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface� Disposal � Voluntary Assessments � +ate-1Vnt for Owrer r 1 ... arwrre�mPnrwaro as r6M 1 red f page, alyfTown Statep Code Date of tnspection D. System Inform 14. sketch Of SewageDisposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or bertchmarks.Locate all wells within 100 feet. Locate where pubfic water supply Minters the buiWing. Check one of the bares below- E) hand-sketch in the area below drawing attached separately t5irnp doc.my 70SM18 `P`we 511M OW Bfwqmdwn Form subsurfaw r�arwag e D mr j 9 yStma•Page;16 cr 18 Commonwealth of Massachusetts Witte 5 Official Inspection Form Disposal System f.M Voluntary ,ssessnnent;� R d. r�laa�� Sewaget'�is car�nn�Not for I�ra� rrtty l�rr� s '�11 VY Owner rr�rhirrrr�irrcirr requred for every page. Qtyffawn State Zip Coderein D. System info afi+ n fit:, 15. Site Exam* El Check Slope E] Surface water E] Check cellar Shallow wells Estimated depth to high ground water: .few Please indicate all methods used to determine the high ground water elevation, Obtained from system design plans on record If checked,date of design plan reviewed. �..._____ ..._.... _..._-___..v.... .._.... _....... ... ... .. .._......_ El Observed site(abutting property/observation hole within 150 fret of SAS) Checked with local Board of Health-explain:. [l Checked with local excavators, installers _ (attach documentation) El Accessed USGS database-explain.- You must describe how you established the high ground water elevation: Before filing this Inspection Report, ptease see Repoort Completeness Checklist on next page. 6insga¢arm w my 70=1 8 1'We 5 CAaW Inspecfion Ftx,m SubsudamSew4w DisposW Syaem w Page 17&18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forrn-Not for voluntary Assessments ` ..._.. ...... . ._ ... _ w.._ , ` ` Owner informetion is �,Cava r , d reqLired for every loe te of pages. 1Tn E. Report Completeness Checklist Complete all applicable sections of this farm inclusive of: A. Inspector information: Complete all fields in this section. ❑ B. Certification- Signed&Dated and 1, 2,3, or 4 checked C] C. Inspection Summary: 1,2, 3,or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14. Sketch of Sewage Disposal System drawn can pig. 16 or attached For 15: Explanation of estimaied depth to high groundwater included t5kvap.dw-rev.! IS Tide 50ftaW hr4w,1kmFwn�Wbaxiaw fkNmqr M SrAem-Page'18 of'18 Commonwealth of Massachu e t Title 5 Official Insl Subsurface Sewage Disposal System p Salem St _._.... . ._. ...._._.___.w Prep"Andress Alexander Grant Owner 6�� information is North Andover required for every _....w, ..._ __ ... _...... Page. D. SYStem Information (coat 14. Sketch of Sewage Disposal Syate Provide a view of the sewage dospo= landmarks or benchmarks. Locate a� the building. Check one of the boxes below. hand-sketch In the area below E] drawing attached separaWy r! OW ?� C 4-1& 7�l: r --, " 7 _ ,,,U f S o idw Ens o,RIM,:'Sur's-d s--9'D' "SYM" •P 1�ceaf i t%nsp.Goc•mv.70=1S r Yawn of North Andover RTMENT HEALTH DEPA H/O NAME: CONTRACTOR NAME: Typt..a?I "'erMLt air lc _use: wheck box) l Animal 0 Body Art Establishment 0 Body Art Practitioner -- 0 Dunipster 0 Food Service-Type:._......__w..,w_.w.. 0 Funeral Directors _ _._...__.... 0 Massage Establishment _u..__ _..... r l ,massage Practice �_._.__.u...w�.... C ()ffal(Septic)hauler l .Recreational Camp 0 Sun tanning ........ _... ._ 0 Swimming Pool ..._ _._ r� 0 Tobacco Cl Trash/Soled Waste Mauler Cl Well Construction $ ._�.._. ....._.. 1, SEI'�TC, S stt enjs: i 0 Septic-Soil Testing i 0 Septic-Design Approval l o Septic Disposal Works Construction(UWC) $__ Cl Septic Disposal Works installers(DWI) © Title 5 inspector Title 5 Report Cl Other: (Indicate) ---� F He4fthAgentInitials Applicant " �l t y- Health I�ln Treasurer rer �'a„a„ �� �m,r,yvYr'�"emaJlK�awi�fumuia�Grt�i��(Maomr�r,MlxGtaurmvrv9D�iNIr7r,�iID"xU1�hN`q�aM,"��"'r;;i nrm iirw�rcri�j P��1xA�m,+°�N��1r'rmarwc�Nt�P�✓�rm�wr9btic!vmr r�r� �.;,,,.,,_ ,�