HomeMy WebLinkAboutMiscellaneous - 176 FRENCH FARM ROAD 4/30/2018J ��
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WATERSHED RESIDENTS QUESTIONNAIRE
1. Name'
2. Street Address
3. How many members are in your household?
4.
What type of sewage disposal system do you have?
❑ cesspool
❑ septic tank and leaching area
a connection to municipal sewer
❑ other (describe)
❑ do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health?
yes ❑ no ❑ do not know
6. How old is your sewage disposal system?.N' 0-5 years ❑ 6-10 years ❑ 11-20 years
❑ over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes *S�5 no ❑ do not know
If yes, approximately how long ago?
years. What was done?
8. How frequently is your sewage disposal system pumped out? ❑ annually
❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never
9. Have you had any problems with your sewage disposal system? ❑ yes no
If yes, what problems?
❑ repeated pump -outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. How many of each appli ce are connected to your wage disposal system?
washing machine 1/ dishwasher garbage disposal
dehumidifier drain sump pump toilet
roof/pavement drains %X--- shower/bathtub
11. Please state the brand and type (liquid,or powder) of detergent you use for:
dishwasher 9-�-
clotheswasher \,&4--a1
12. Does your property have a lawn? 19� yes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre ❑ 1/4 acre ❑ % acre ❑ 3/4 acre ,�' 1 acre 1
❑ more than 1 acre (Specify) acres
13. How often do you fertilize your lawn?
No. of applications per year -3 \�
Season(s) of the year a
14. Please state the brand and type (liquid o ranular f lawn fertilizer you use:
❑ Check here if your lawn is maintained by a professional landscape contractor.
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws_ Ch_ 139 Ser 3R
i
To: Building Commissioner or
Inspector of Buildings
Board of Health or
Board of Selectmen
addresses
Re: Insured:—)—,, ej" c L k
Property address:_. 174 4 —11,iL1 �U/`�� /(
N Xyl Jo ac r lM O/� _5
Policy No.. aQ a 6 7 /L37
I
Loss of _ _1 - 19
File or Claim No.
Ira P a 7
Claim has been made involving loss, damage or destruction of the above captioned property, which
may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable.
If any notice under Mass Gen. Laws, Ch. 139 Sec. 313 is appropriate please direct it to the attention
of the writer and include a reference to the captioned insured, location, policy number, date of loss
and claim or file number.
Title:
91
On this date, I caused copies of this notice to be sent to the persons name above at the addresses
indicated above by first class mail.
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Signature and date , wm, Y
.�. E�'�}�jSSO
SUITE 1.5
Ta.AINTIENCE, MA 01843
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MASSACHUSETTS CONNECTICUT
NEW HAMPSHIRE VERMONT MAINE RHODE ISLAND
Boston Lawrence Bridgeport
Barnstable Pittsfield New London
Claremont Brattleboro Augusta Pawtucket NA AL
Gorham Burlington Lewiston
CLAIM tttvtt8 OfF—�3 Brockton Salem No. Haven
AS%KjAt10N
Laconia Montpelier Skowhegan NEW YORK M
wtrr_ t"GLAND. INC. Fall River Springfield Stamford
Manchester White River Jet. S. Portland Utica WAIRAWLE
Fitchburg Worcester Waterbury
Portsmouth I,
lr/��"—"'I']'<�l_ W. Hartford
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