HomeMy WebLinkAboutMiscellaneous - 120 LACONIA CIRCLE 4/30/2018 (38) fi RECEIVED
Commonwealth of Massachusetts
• _ W Title 5 Official Inspection Form SEP 0 3 2013
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
120 Laconia Circle
Property Address
Karen Crawford
Owner Owner's Name
information is North Andover MA 01845 August 2 2013
required for every g ,
page. City/Town State Zip Code Date of Inspection
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
filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Scott P. Cameron, PE
use the return Name of Inspector
key.
Cameron Site Inspection, Inc.
r� Company Name
PO Box 262
Company Address
Middleton MA 01949
City/Town State Zip Code
(781) 520-9496 12345
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:
❑ Passe ® Conditionally Passes El Fails
❑ Nee s u her Ev tion by the Local Approving Authority
�'2 l
nspec is ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection.tion. If the system Is a shared system or
has 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.
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