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HomeMy WebLinkAboutTitle V Inspection Report - 115 VEST WAY 10/6/2012 Commonwealth of Massachusetts � Title 5 Official Inspection Form EW � p Y y _. Subsurface Sewage Disposal System Farm Not for Voluntary Assessmen ° Laura Chabot w Property Address T HEALTH D PARTMEN"T 115 Vest Way _._.-..._. —._.._ _ 19_ s Name Owner information is North}Andover.__.-...._.._ ___....._— _ MA 01845- 1.0/06120,12 4 required for every page. City own State Zip Code Date of Inspection i Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important;When A filling out forms , general Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not John SouC use the return —�._..____.._ key. Name of Inspector Soucy's Sewer Service, Inc. re6 Company Name- 78 N. Broadway Company Address t Salem NH 03079 CIty/Town State Zip Code 603-898-9339 13397 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: 15� Pass ❑ Conditionally Passes ❑ Fails EI/Need Further EvaluatiW by the Local Approving Authority C, 10/06/2012 ...,,,. ns p ors Signature - Date lie system inspector shall submi copy of this inspection report to the Approving Authority (Board �f Health or DEP)within 30 days f completing this inspection. If the system is a shared system or as a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins+11/10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System+Page 1 of 17 Commonwealth of Massachusetts Title 5 official inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Wa Owner Owner's Name information is required for every North Andover MA 01845 10/06/2012 _.__. page. Clty[Town State Zip Code Date of inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the "Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements, If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. -1Y ❑ N ❑ ND (Explain below): t t I t5ins•11116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 1: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments By+'t Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is Notch Andover MA 01845 10/08/2012 required for every _. _W. _m ..._ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(1)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh r l5ins•11/10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Iq Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Way _ Owner Owner's Name information is required for every North Andover _MA 01845 10/06/2012 _ page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ 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 is 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 of the analysis must be attached to this form. 0 y 3. Other; 9 _ d u D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool F1 ® Static liquid level in the distribution box above outlet invert due to an overloaded ? or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than �/2 day flow l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts - u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Wqy__ Owner owner's Name —u— information is required for every North Andover MA 01845 10/06/2012 - - -- m page. cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 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 well. ❑ ® 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 DEI' certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] El ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® 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 p necessary to correct the failure. u E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No El Elthe system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 otfciat Inspection Form;Subsurface Sewage Disposal System•rage 5 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments b '~ Laura Chabot Property Address 115 Vest WT ay Owner Owner's Name information is required for every North Andover MA 01845 10/06/2012 page. CltylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? i1 ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ElDetermined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] is D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 — Number of bedrooms(actual): 4 440 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): — — t5ins•11116 Title 5 Official Inspection Form:Subsvface Sewage Oisposal System•Page 6 of 17 Commonwealth of Massachusetts u Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Laura Chabot Property Address 115„Vest Way Owner Owner's Name - information is North Andover MA 01845 10/06/2012 required for every page. Citylrown State Zip Code Date of Inspection D. System Information Description: 3 Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): See Attached Detail: Garbage grinder should be removed. Sump pump? ❑ Yes ® No Current Last date of occupancy: ©ate Commerciallindustrial Flow Conditions: Type of Establishment: _. Design flow(based on 310 CMR 15.203): cations per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): W Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No 0 Water meter readings, if available: u 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 11 d 3G Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Waw Owner Owner's Name information is North Andover MA 01845 10/06/2092 required for eery —_ -. .... _-- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occu ane /use: Current p Y Date Other(describe below): General Information Pumping Records: Source of information: Owner, Pumped 2008 Was system pumped as part of the inspection? ® Yes ❑ No 1500 If yes, volume pumped: gallons How was quantity pumped determined? 3-�e o truck Reason for pumping: _ ....... Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy F1Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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 IIA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ElOther(describe): d t5lns•11110 Title 5 Official Inspection Form:Subsurface Sewage Ulsposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form rt Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ •''t Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is North Andover MA 01845 10/06/2012 required for every _ page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1983 D box replaced in 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 6' Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: - - feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 5' Depth below grade: feet­---" eet _. --. Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 6'x10' Dimensions: 3" Sludge depth: i l5ins•11110 Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 8 of 17 i I' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A Laura Chabot _ Property Address 115 Vest Way Owner Owner's Name information is required for every North Andover MA 01815 10/06/2012 ...._ — — ...._ _._ page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 38" Distance from top of sludge to bottom of outlet tee or baffle 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" 1411 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape and sludge tool _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Baffels in lace. Pump tank eyery year. Install low flow water fixtures to conserve water. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date i d Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t5ins•11/10 Tilla 5 O i 3 i Commonwealth of Massachusetts -- Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is North Andover MA 01845 10/05/2012 required for every - -.._ _. ._ . page. city/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade; Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: — Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 0 d. k5ins•11110 Title 5 Official Inspection Form',Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'' Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is required for every North Andover MA 01845 10/06/2012 � _ _.. ._. . � —.�..._— .. page. City/Town State Zip Code date of Inspection D. System Information (cant.) Distribution Box (if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert - — Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): "D" box flow checked good. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i. t5ins-11116 Title 6 Oficial Inspection Farm:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °4 Laura Chabot Property Address 115 Vest_ Way Owner Owner's Name information is North Andover MA 01845 10/06/2012 ' required for every .. - --- -- — — page. CltylTown State Zip Code Date of Inspection D. System Information (cant.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4 2'x1'x50' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No si nsof Hydraulic failure. i 9 d Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts R �u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is required for every North Andover MA 01845 10/06/2012 -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions ......_... _ Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts u u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Wa Owner owner's Name information is required for every North Andover MA 01845 10/06/2012 - - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached.separately c� Do 1 4 C� p J F 1 I 9 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 f5ins-11!10 8 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Way Owner owner's Name information is North Andover MA 01845 10/06/2012 required for every .. __. ._ ...._ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 41 feet 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: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Dug hole Wauger in low drop off area, compensated elevation difference. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins 11!10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i c Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot T Property Address 115 Vest WaY _......... Owner _.. _ Owner's Name information is required for every North Andover w.._ MA 01845 10/06/2012 ---�------ page. CityfTown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, 8, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 NEW OFFICE HOURS PAYMENT ON •' BEFORE Town of Forth Andover Monday 8-4:30 05/14/2012 $83.52 Tues 8-6:00 120 Main Street Wed 8-4:30 North Andover, MA 01845 Thurs 8-4:30 3170504 04/14/2012 � (978)688-9550 Fri 8-12:00 E111 _ ;7 71,7SERVICE DATES , Dkl DATE,; Billing Information: . .• MATTHEW& LAURA CHABOT (978)688-9550 1211212011-0311312012 __05/14/2012- 115 VEST WAY 8ERVj NORTH ANDOVER, MA 01845 Reading Information: _ _., CE AtC? ESS (978)68e-9570 115 VEST WAY TRA"1NSACTIONS 1 iIS PEF IQDµv�.,.. AM,OUIVT EVIOUS BALANCE $83.82 PAYMENTS THROUGH 04/05/2012 ($83.82) ADJUSTMENTS THROUGH 04/05/2012 $0.00 RETAIN THIS PORTION FOR YOUR RECORDS INTEREST AS OF 05/14/2012 $0.00 MOVING? PLEASE CALL(978)688-9570 IN ADVANCE BALANCE FORWARD $0.00 SERIAL# READINGS USAGE NB OF CURRENT BILL DETAIL USAGE/UNIT AMOUNT Current Type Date DAYS _..... _ 29821488 569 Actual 03/13!2012 20 92 WATER USAGE 20 $76.00 ADMINISTRATIVE FEE $7.82 ck-k q SERIAL# READINGS USAGE NB OF Previous Type Date DAYS Sub-Total $83.82 29821488 549 Actual 12/12/2011 20 90 29821488 529 Actual 09/13/2011 28 98 TOTAL : G MESSAGES * NOTE* PAYMENTS SHOULD BE MADE:TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O.BOX 184,MEDFORD,MA 02155 WATER RATE: FIRST 20 UNITS @$3.80 OVER 20 UNITS @ $5.55 Please note our office hours have SEWER RATE: FIRST 20 UNITS $5.83 OVER 20 UNITS $8.22 changed,effective Online at See above. @ @ Pay Online at BYPASS METER WATER RATE: ALL UNITS @$5.55 www.townofnorthandover.com Please return this portion with your payment by 05/14/2092 Any amount which is not paid by due date will be subject to interest charges of r Town of North Andover 14%Per Year 120 Main Street ` 47,6733,7,38 Billing Information: OFFICE HOURS North Andover, MA 01$45 I IIIIII II') im IReading Information:(97B)68$ -9550 on: Monday to Friday 1f 201397-000001 (978)888-9570 8:30am to 4:30pm ACCOUNT BILLING DATE 3170504 04/14/2012 SRUIC ADpRFS' .: 115 VESTWAY If your address has changed, correct it below, — ..— _.O _... PLEASE PAY N OR BEFORE MATTHEW & LAURA CHABOT 05/14/2012 1 $83.82 115 VEST WAY _ _... NORTH ANDOVER, MA 01845 AMOUNT PAID 04167311382012000000000DOOD31705040403170SO4000000008382000 Town of North Andover OFFICE HOURS - OR BEFORE 120 Main Street02/17/2012 $83.82 North Andover, MA 01845 Monday t© Friday - (978)688-9550 8:30am to 4:30pm A666-UNf,7" BILLING DATE, - 3170504 01/17/2012 Billing Information: SERVICE DATES DUE DATE MATTHEW& LAURA CHABOT (978)688-9550 0911312011-12/1212011 02/17/2012 _., _.. 115 VEST WAY Reading Information: SERVICE ADDRESS >; NORTH ANDOVER, MA 01845 (978)688-9570115 5 VEST WAY TRANSACTIONS THIS PERIOD, AMOUNT PREVIOUS BALANCE $125.53 PAYMENTS THROUGH 01/07/2012 ($125.53) ADJUSTMENTS THROUGH 01/07/2012 $0.00 RETAIN THIS PORTION FOR YOUR RECORDS INTEREST AS OF 02/17/2012 $0,00 MOVING? PLEASE CALL(978)688-9570 IN ADVANCE BALANCE FORWARD $0.00 SERIAL# READINGS USAGE NB OFCly NT BILL DETAIL USAGE/UNIT AMOUNT Current Type Date DAYS 29821488 649 Actual 12h212011 20 90 v�t7AT"` n 20 $7U © ADMINISTRATIVE FEE $7.82 SERIAL# READINGS USAGE NB OF Previous Type Date DAYS Sub-Total $83.82 29821488 529 Actual 09/13/2011 28 98 29821488 501 Actual 06/07/2011 21 92 TOTAL I � 0 1 (,4 ..... MESSAGES *NOTE* PAYMENTS SHOULD BE MADE:TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O.BOX 184,MEDFORD,MA 02155 WATER RATE: FIRST 20 UNITS @$3.80 OVER 20 UNITS @$5.55 SEWER RATE: FIRST 20 UNITS @$5.83 OVER 20 UNITS @$8,22 Pay Online at www.townofnorthandover.cam BYPASS METER WATER RATE: ALL UNITS @$5.55 Please return this portion with your payment by 02/97/2012 Any amount which is not paid by due date will be subject to interest charges of Town of North Andover 14%Per Year 120 Main Street 416731138 Billing Information: OFFICE HOURS North Andover, MA 01$45 Reading Information:t (978)688-9550 on: Monday to Friday A 1 6 1 l 201393-000001 (978)688-9570 8:30am to 4:30pm L ACCOUNT BIL ...m_ LING DATE 3170504 01/17/2012 SERVICE ADDRESS 115 VEST WAY If your address has changed, correct it below. PLEASE PAY ON OR BEFORE MATTHEW & LAURA CHABOT 02/17/201 $83.82 115 VEST WAY _._._...... _...... - _.._.....__ NORTH ANDOVER, MA 01845 AMOUNT 041,6731,1,38201,20000000000000317050404031,70504000000008380000 OFFICE HOURS Town of North Andover PAYMENT ON •• BEFORE ' 120 Main Street Monday to Frida11/12/2011 $125.53 North Andover, MA 01845 y (978)688-9550 8:30am to 4:30pm ACCgIN f.. BILI ING DATE 3170504 10/13/2011 Billing Information: SERVICfI]RTES DUE DATE (978)688-9550 0610712011-0911312011 11/12/2011 MATTHEW&LAURA CHABOT — - 115 VEST WAY Reading Information: SERVICE,AnC?RSS ,: ............ NORTH ANDOVER, MA 01845 (978)688-9570 _ 115 VEST WAY TRANSACTIONS THIS P)=RIOC3 AMOUNT PREVIOUS BALANCE $88.99 PAYMENTS THROUGH 10/13/2011 ($88.99) ADJUSTMENTS THROUGH 10113/2011 $0.00 RETAIN THIS PORTION FOR YOUR RECORDS INTEREST AS OF 11112/2011 $0.00 MOVING? PLEASE CALL(978)688.9570 IN ADVANCE BALANCE FORWARD $0.00 SERIAL# READINGS USAGE NB OF CURRENT BILL DETAIL USAGEWNIT AMOUNT Current Type Date DAYS w_ - --- — .__.....__: 29821488 529 Actual 09!1312011 28 98 WATER USAGE 28 $117.71 ADMINISTRATIVE FEE $7.82 SERIAL# READINGS USAGE NB OF j Previous Type Date DAYS Sub-Total $125.53 29821488 501 Actual 06/07/2011 21 92 OLl 29821488 480 Actual 03/07/2011 16 89 1�1v TOTAL , MESSAGES "NOTE* PAYMENTS SHOULD BE MADE:TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O.BOX 184,MEDFORD,MA 02155 WATER RATE: FIRST 20 UNITS @$3.80 OVER 20 UNITS @$5.55 Pay Online at SEWER RATE: FIRST 20 UNITS @$5.83 OVER 20 UMTS @$8.22 www.townafnarthandaver.com iBYPASS METER WATER RATE: ALL UNITS @ $5.55 Please return this portion with your payment by 1111212099 Any amount which is not paid by due date will be subject to interest charges of Town of North Andover 14%Per Year 120 Main Street 416731138 Billing Information: OFFICE HOURS North Andover, MA 01845 I��IIl� III � ��I�I )IIIIII ��IIII (978)688-9550 688-9550 ding Information: Monday to Friday 201390-x00001 (978)688-9570 8:30am to 4:30pm ACCOUNT BILLING BATE 3170504 10/13/2011 sERUICE f1DDRES$:' . .. 115 VEST WAY If your address has changed,correct It below. ON •. •. MATTHEW & LAURA CHABOT 11/12/2011 $125.53 115 VEST WAY NORTH ANDOVER, MA 01845 AMOUNT PAID i 04767317382010000000000000037,705040403770504000000072553007 i RE Town of North Andover OFFICE HOURS •- = • 120 Main street 08/19/2011 $88.99 North Andover, MA 01845 Monday to Friday (978)688-9550 8:30am to 4.30pm = .._ „ACCOt1 IT BII LING DACE.:...,.. 3170504 07/2012Q11 Billing Information $ERVIGE C3ATES - DtJ1]ATE (978)688-9554 0310712011-0610712011 08119/2011 MATTHEW&LAURA CHABOT - - 115 VEST WAY Reading Information F: 7:� SI=RVI E ADDREs NORTH ANDOVER, MA 01845 (978)688-9570 115 VEST WAY TRAtJS CTIt3Ns T}i1S PERIC)D AMOUNT JE� PREVIOUS BALANCE $68.62 PAYMENTS THROUGH 07/20/2011 ($68.62) ADJUSTMENTS THROUGH 07/20/2011 $0.00 RETAIN THIS PORTION FOR YOUR RECORDS INTEREST AS OF 08/19/2011 $0.00 MOVING? PLEASE CALL(978)688-9570 IN ADVANCEBj ALANCE FORWARD $0.00 I SERIAL# READINGS USAGE NB OF CURRENT BILL DETAIL USAGEIUNIT AMOUNT Current Type Date DAYS - 29621488 501 Actual 06/0712011 21 W 92 WATER USAGE 21 $81.17 ADMINISTRATIVE FEE $7.82 SERIAL# READINGS USAGE NB OF Previous Type Date DAYS Sub-Total $88.99 29821488 480 Actual 03/07/2011 16 89 f 29821488 464 Actual 12/08/2010 20 90 TOTAL :VWRJE • I I MESSAGES * NOTE* PAYMENTS SHOULD BE MADE:TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O.BOX 184,MEDFORD,MA 02155 WATER RATE: FIRST 20 UNITS @$3.80 OVER 20 UNITS @ $5.55 SEWER RATE: FIRST 20 UNITS @$5.83 OVER 20 UNITS @$8.22 BYPASS METER WATER RATE: ALL UNITS @$5.55 Please return this portion with your payment by 0811912019 Any amount which is not paid by due date will be subject to interest chargers of STM: Town of North Andover 14%Per Year 120 Main Street 416731138 Billing Information: OFFICE HOURS North Andover, MA 01845 �IIII[Itli IlIllll II ) I i Reading Information:t {978}688-9550 on: Monday to Friday I!111 1 201386.000001 (978)688-9570 8:30am to 4:30pm ACCOUNT _ ._ . . BILLf!*I�DA'J"E 3170504 07120/2011 $EftVICE ADIDI?R55........: 115 VEST WAY If your address has changed, correct it below. PLEASE PAY ON •- BEFORE MATTHEW •- MATTHEW & LAURA CHABOT 2 $88.99 115 VEST WAY NORTH ANDOVER, MA 01845 AMOUNT PAID 04167311382011000000000000031705D40403170504000000008899000 18899000 r Town of North Andove OFFICE HOURS • OR BEFORE 120 Main Street 05/13/2011 $68 62 North Andover, MA 01845 Monday to Friday — (978)688-9550 8:30am to 4:30pm ACCOUNT 131i( v�DACE 3170504 04/13/2011 Billing Information: S<=RVICE;DATE$,,: DUE DAT! MATTHEW&LAURA CHABOT (978)688-9550 1210812010-0310712011 05/13/2011 115 VEST WAY Reading Information: SERVICE At3aRESS NORTH ANDOVER, MA 01845 (978)688-9570 115 VEST WAY TRANSACTIONS THIS PERIOD AMOUNT PREVIOUS BALANCE $83.82 PAYMENTS THROUGH 04/13/2011 ($83.82) ADJUSTMENTS THROUGH 04/13/2011 $0.00 RETAIN THIS PORTION FOR YOUR RECORDS INTEREST AS OF 05/13/2011 $0.00 MOVING? PLEASE CALL(978)688-9570 IN ADVANCE BALANCE FORWARD $0.00 SERIAL# READINGS USAGE NB OF CURRENT BILL DETAIL USAGEWNIT AMOUNT Current Type Date DAYS 29821488 480 Actual 03/07/2011 16 89 WATER USAGE 16 $60.80 ADMINISTRATIVE FEE $7.82 SERIAL# READINGS USAGE NB OF _Previous Type Date DAYS Sub-Total $68.62 29821488 464 Actual 12/08/2010 20 90 29821488 444 Actual 09/09/2010 28 93 TOTAL , • : . MESSAGES * W_........... ......... ................ NOTE* PAYMENTS SHOULD BE MADE:TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O.BOX 184,MEDFORD,MA 02155 WATER RATE: FIRST 20 UNITS @$3.80 OVER 20 UNITS @$5.55 SEWER RATE: FIRST 20 UNITS @$5.83 OVER 20 UNITS @$8.22 BYPASS METER WATER RATE: ALL UNITS @$5.55 Please return this portion with your payment by 0517312099 Any amount which is not paid by due date will be " subject to interest charges of • , . Town of North Andover 14%Per Year , 120 Main Street 41031 138 Billing Information: OFFICE HOURS North Andover, MA 01845 VIII VIII VIII VIII VIII VIII VIII VIII VIII!III II Reaim (978)688-9550 ding Information: Monday to Friday > 201377-000001 (978)688-9570 8:30am to 4:30pm ACCOtJIJT BILLI.N.G DATE;; 3170504 04/13/2011 ;'5ERVICE,ADDFtESS, ;" 115 VEST WAY If your address has changed,correct it below. BEFOREPLEASE PAY ON OR MATTHEW & LAURA CHABOT0511312011 $68.62 115 VEST WAY _..__�............ ____................. NORTH ANDOVER, MA 01845 A • • 0416733,13820110000000000000317056404031705040000000068L2068 i V I Town of North Andover OFFICE HOURS •- BEFORE 03/07/2011 $83.82 120 Main Street Monday to Friday - North Andover, MA 01845 $:30arlt to 4:30 m ACCOIJ:NT Bll.t,lilG RATE (978)688-9550 p 3170504 01/12/2011 Billing Information: SE.RUICE DATES DtlnATE 0910912010-1 MATTHEW&LAURA CHABOT {978}668-9550 2J0$/2010 0310712011 115 VEST WAY Reading Information: `: SERVICE ADDRESS. . .. NORTH ANDOVER, MA 01845 (978)688-9570 115 VEST WAY TRANSACTIONS THIS PERInD AMO.IJNT PREVIOUS BALANCE. $127.45 The Town is still experiencing a Water Drought, PAYMENTS THROUGH 01/12/2011 ($127.45) Call the Water Treatment Plant at 978-688-9574 for conservation kits information. ADJUSTMENTS THROUGH 01/12/2011 $0.00 RETAIN THIS PORTION FOR YOUR RECORDS INTEREST AS OF 03/07/2011 $0.00 MOVING? PLEASE CALL(978)688-9570 IN ADVANCE BALANCE FORWARD $0.00 SERIAL# READINGS USAGE NB OF CURRENT BILL DETAIL USAGE/UNIT AMOUNT �. Current Type Date DAYS_ 29821488 464 Actual 12!0812010 20 90 WATER USAGE 20 $76.00 ADMINISTRATIVE FEE $7.82 SERIAL# READINGS USAGE NB OF Previous Type Date DAYS Sub-Total $83.82 29821488 444 Actual 09/09/2010 28 93 29821488 416 Actual 06/08/2010 21 90 TOTAL c MESSAGES *NOTE* PAYMENTS SHOULD BE MADE:TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O.BOX 184,MEDFORD,MA 02155 WATER RATE: FIRST 20 UNITS @$3.80 OVER 20 UNITS @$5.55 SEWER RATE: FIRST 20 UNITS @$5.83 OVER 20 UNITS @$8.22 BYPASS METER WATER RATE: ALL UNITS @$5.55 Please return this portion with your payment by 0310712011 Any amount which is not paid by due dale will be subject to interest charges of Town of North Andover 14%Per Year 120 Main Street 416731138 Billing Information: OFFICE HOURS North Andover, MA 01845 I I��III�I��IVIII 111 1111111111111111111111111 III III '9711,688.9560 ingInformation: Monday to Friday ) m (978)688-9550 Rea 200870-000001 (978)688-9570 8:30am to 4:30pm BiLLtNGL3ATE_ 3170504 01/12/2011 \ 1t sERvICEAODss 115 VEST WAY If your address has changed,correct it below. PLEASE PAY ON •' BEFORE MATTHEW & LAURA CHABOT 03/07/2011 $83.82 115 VEST WAY NORTH ANDOVER, MA 01845 ' PAID 04167311382011000000000000031705040403170504000000008382003