HomeMy WebLinkAboutMiscellaneous - 66 COLONIAL AVENUE 4/30/2018 (29) Commonwealth of Massachusetts P' 7
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
66 Colonial Avenueu,p
l
Property Address
Jeremy Segal
Owner Owner's Name
information is
required for every North Andover MA 01845 5/28/2013
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forffpwaaX not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When
filling out forms A. General Information
JVN r,
on the computer, r1 V 3 2013
use only the tab 1. Inspector: TOWN OFN
currsokey ormdo nove oour Neil J. Bateson HE��TMDEPgRTME SER
use the return
key. Name of Inspector
Bateson Enterprises Inc.
ry Company Name
111 Argilla Road
Company Address
Andover MA 01810
Cityrrown State Zip Code
9784754786 SI15
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
5/2x/2013
Inspector's tignaturV 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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