HomeMy WebLinkAboutMiscellaneous - 1423 SALEM STREET 4/30/2018 (24) Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1423 Salem Street _
Property Address
Courtney Scruggs
Owner Owner's Name
information is North Andover MA 01845 May 1 2017
required for _ Y
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms mayBred in any
way. Please see completeness checklist at the end of the form. it,
Important:
When filling out A. General Information NOL�
Lois`P `�
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forms on theoF
computer,use1. Inspector:
only the tab key
to move your Dean G. Luscomb II _
cursor-do not Name of Inspector
use the return
key. Dean G. Luscomb II & Sons
Company Name
0Q. 288 Maple Street
Company Address
Middleton MA 01949
' City/Town State Zip Code
978-774-4065 S1848
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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
r lawMa 1, 2017
Y
In ector's Signature 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. 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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