HomeMy WebLinkAboutMiscellaneous - 59 ROCKY BROOK ROAD 4/30/2018 (2) Commonwealth of Massachusetts
. Title 5 Official Inspection Form RECEivEo
Subsurface Sewage Disposal System Form -Not for Voluntary Assess entsDEC 1 5 2009
M 59 Rocky Brook Road
Property Address
HEALTH DEPARTMENT
Russell Norris
Owner Owner's Name
information is
required for North Andover MA 01845 11/16/2009
every 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:
Whenfilling out A. General Information
When
forms on the
computer,use 1. Inspector:
only the tab key
to move your Neil J. Bateson
cursor-do not
use the return Name of Inspector
key. Bateson Enterprises Inc.
Company Name
t� 111 Argilla Road
Company Address
Andover Ma 01810
City/Town State
Zip Code
978-475-4786 S115
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. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ N d Further Evaluation by the Local Approving Authority
11/16/2009
Inspector's Signature Date
The s
inspector shall system ns p all submit a co
of this inspection copy report to the Approving Authority
of Health or DEP)within 30 days of completing this inspection. If the system is a hared system or
d
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.
t5ins•09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17