HomeMy WebLinkAboutPass - Title V Inspection Report - 110 CRICKET LANE 6/20/2019 P
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w
00ninionwealth Of Massachusetts
RECEIVED
qp I
T4tle 5 Off'aclal Ins ect
w
Sewage,1W Isposal 4yatem : orm Not for Voluntary
EpARTMENT
r
re OWner
Wonsalon is ' n is Name
required for eves
/Tows 0
ZIP Code Date of Inspection
way- Please see co 1 11 'a form.Insplectionforms
IMPOrWnt:When
0111ing out forms A. InspeCrtor on the ,r lo)�n,
use only the tab
ke!y to 11110ve Your
cursor-do not Nam Inspectors
Use the r 'um %
key. Com any Name,
,a
awy� Cm any r
ess
or
Qt "
C)
$tat
Telephone Number %T ZIP Code
License Number
Ce
6-000)l I have personally' 'It COMPliance
h SewsIsPos,al system at the property address
inspected listed above;the information relpoirted below'S true, accurate and Ion t
inspeo I and the Inspection was
1 0 r *
ience,'in the,pr p r un'tion
and maintenance biased ntraining w �of my
systems.,on-site sewage disposal
that the s tem
Passes
w13Conditionally
3.
4. 0, Needs Further Evaluation by the
Local Approving�Authority
C1 Falls
Inspect
�`re
Cate,
of I Health or DEP)within days of Completinginspection.� r
10
grit
,000 gad r� , t rIf the system has a design flow of
w a the stem owner shall ��t t
ors roil fora seal sent t o report ththe e rat
fir, � � �� � � � � � �t� owner w �
r i g authority.w p i s seat to
co
of Ins
POWPlease
In the 1
ftthe Same,Or diffiarentWill perform
Irls P,dq ;,w
I of 18
Commonweaith of Massachusetts,
Totil'
i e 5, Inspecto
30
#on Form
SubsurfaCOSSWage Disposal
SYstem'FOW--Not for Voluntary Assessments
Prope iddress
Owner
Owner's
Information is me .........
fjr0pe
requIred for ever� Owner's
page.
Ti ty'
S—t
,ate
zip C048 Date of Ins pection
ary
Inspeation SurrimarY. Complete, T, 2,3, or 5 and all of 4 and 6.
ye�
[Yel have not fotind any information,which, Indicates that any of the failure criteria described
in 310 CMR 15.303 orin 310 CMR 15.304 e)d t,.An,y failure criteri
I's
cated below. a not evaluated are
Comments,,,
,I) SY-stem Conditionally,passes,-
El Onle or more system components as desictibed in the,"Conditional Pass"slection need to be
replaced or,repaired. The system, upon completion of the!replacement or repair, as approved by
the Board of Health,will pass'.
Checll(the box for 4-yes", 4tno$1 or"not deterrinined"(Y, N, ND)for the folliow,
determined,,If p1lease explain. ing statements.If"'not
The septic tank is Metal'and'over 20
Un year�s old*or the septic tank(Whiether metal,or not)
sO,Lmd, exhibits
SUbstantial Infiltrat" is structurally
ion or extIltration or tank Millure 1 1
1 is "Mminent.systerniioAll pass
Inspection if the existing tan k Is replaced with
Health. 8 complying septic to as approved'by,the Board of
A metal septic tank will Pass inspection if I it is,
i struoturauy sound, not leaking and If a Certificate
of
COMpillance ndi cat ing t ha t the ta nk i's less than 20 years old,is available.
Cl Y ON ND(Explain below),
MrISPAOC•rev,71261201,8,
Thile,5 Officlatinspection Form:Subsurtacesego,Disposal ISYMOM 10 Page,2 of 18,
Commonwesith of Massschusetjr
..........
To e 6 Off'3c"al Inspect
#on
SubsMP
MP
urface a Form
SsWage Dfispo,saj System Forf n Not for'Voluntary As�se,ssments
Property), ddre
Owner
information is, Wner's Name
required for every ---------
page. CRY/Town ---------
QA ()t
litalte
ZIP Z50de Date o inspection
ary (cont.)
P
2) SYStOm Conditionally pass!&S (cont.).
11 PUMP Chamber PUMPS/alarms not operational. System will Pass with Board of Health approval If
PUMPs/alarms are repaired,
EJ Observation of sewage backup or break out or h4gh static water level in t e dis"r h
-1A Oil: ox due
to broken or obstructed p1pe(s) or due to a broken,settled or uneven distribution box. Systern will
I
Pass Inspection if(With, approval Of Board of Health),-
,0 broken, plpe(s)are replaced Y Ej N 0 ND(Explain below):
obstruction is removed
Y N 0, N'D (Explao
distribution box Is leveled or replaced in below):
Y N C1, ND(Explain below),-
0, The,system required Pumping more th,an 4 ti
system wil pass * Imes a inspe year due to broken or obstructed pipe(s).The
ction if(Wth aPPrOvai of the Board'of Health),:
broken Pipe(s)are replaced
U N ND(ExPlain below)-
EJ obstruction Is removed El Y N 0 ND(E)(Plain below)-0
3) Further Evaluation I's Required bYthe Board ot Heajth#
El Condifions exist which require,further evaluation by the' Board of Health in to dete ,If
the system,is failing to,protect public health, safety or the environment. order rmIne
a- System will,Pass unless Board Of Heafth determllneis In accordance wi
thO system Is not,ifulict,lon,ing th 310 CMR
80ftty and the enVironme lit:1 mannier vvivetI will,Project pblic
Mnsp.doco 7�2612018
ttt
offlcja 1'nsP e CtiOn'Form,Subs u rta Se W2,90 Dispo so I System.paq,e,3 0,11 a
COMMonwealth Of Massachusetts
Toutle,
.0
SubaurfaceI i, 1C al Inspect
Sewage j,
Systsm
FOrm Not for Voluntary Assessments
ProdAddr
Owner
Information is Owners Name
required forever f) .
page. V
`IQ $�P(�)c It�Io n�S�u m�m�cj r`IIIIyZip Code Date Inse -------
.),
Cesspool or priory Is within
Cesspool or,p 'vY I's within 50 feet of a, bordering veget
a � Salt Marsh
b- SY18tem M1111 fall unless the Board of Health(and Public Watep Suppile,r, it any)
determines thit the systGm Is fun t anise
t � e � t�
The system has a septic tank and 100 soil absorption system SAS is within
feet: a surface water supply r t'1 t r
y to a surface!water supply.
Thesystem has a septic tank and SAS and the SAS I's Within a Zone 1 of a
public water
El The system has a,septic tank and SUPPly well. ��� t � ��, ti � � g r
ri
13 The system has,a septic tank and SAS cind the SAS is less than 100 feeit'but 50 feet or
to water supply well".
Method used to determine distance
This system: passes if the well water analysis, performed at a DEP certified laboratory, for fecal
Coliform bacteria indicates absent and
t r r � t the presence of r n is nitrogen and orate i
be provided that other failure criteria are triggered. nitrogen � �
attached t thisform. � r PY Of the analysis rnusI�t
Other:
SystOm FailureCriteria etc t
YOU M.Iust indicate"Yes"or"No"to each of the following for M.11 Inepections.
yes, No
cloggedE3 Backup Of sewage into facility or system component due,to overloaded or
i-cesspool
Discharge,
due a rload �d r l �r� � �at
SAS r cesspool
llf rfMal rpecuon arm:
urtape sewage C Isposal system I PAge 4 Of 1
P Title 5 Official Inspectoo,on Form
SubsurfacO i
ftwago Disposal Syslem
j A.dPdm
Owner
Info l 1 niA0 rs N.,a.mm.,
required for evory
City/Tows
� + Zip Code Date of Inspection
C. lns�p
me�c,�,o�n
SUMMOry (cont.
Syst(g,mFallUreCrilterl'aAppillcLgbletc),All$ystem,s- (Cont.)
Yes No
C] EEr Static liquid level in the distribution box above outlet invert due to,an ded
r clogged r cesspool �rJcc
Liquid depth in cesspool is less than "'l to ►" N
lablevolurne Is less
than %day flow
ED,,-- Required ding'More than 4 times In the last year JVOT due to clogged or
obstructed pipe(s),. Number offirries N
Any portion of'the SAS, cessplool or privy
is below high grouted water elevation.
E] Any portion, ofcesspool r privy,is within feet surface water s l
tributary asurface water supply.
� � r
E] Any portion Of a cesspool l r privy is within, a Zone I of a public water supply
El 0010" Any portion Of a cesspool or privy is within 510 feet of a private water supply well,
Any Portion of a cesspool or privyls lessgreater t�
from a private water,supply well with 110 acceptable water quality analysis. [Thls
system passes If the well water anallyalso perfor,m,ed
laboratory, fOr fGcQ1 c i r e'f'a Indicate,s absent and'the Presence
of ammonia nitrogen and nitrate nitrogen is a jai to or less than 5 ppm,
provided thalt no other failure criteria are triggered.A cOlPY of the analysis
and ch,aln of custody must be attached
The system is cesspool serving facility i t a o,designflow
'1 , g2000 c1
Thesystem
i - J he've determinedthat n or more of criteria exists Sri rr 3 5 � � rJr�r
ore the system falls.,The
system owner should contact the Board of health etermline what will
considerednecessary to correct the fallure.
Large SYStems.', To be large
des' l
large
N systems, mustrrr. r rl�r "yes" �m sN
r
saute i Section CN to each of li �rr� ,r � r�arr to the
Yes No
0 N
the system is within feet of a surface drinking i
E3 0 the system
is vAt'hin, 200 feet of a,tributary to a surface drinking water SL
El the system
I Ns located r•N 'wuoL nitrogen sensitive,.area(Interim Wellhead Protection
Area—IWPA) or a "napped Zone 11 Ofe public water supply well
�f Title ,O,mclal inspection Fora:Subsuffact Seftge Disposal
i
i
I
COMMOnwealth Of Massachusetts
I? Tj"tle 5 OffR '2
n I
1c a,l Ins Di ''tion LFn
Subsuflace,89wage Disposal Sy,stem Form.
Not for Voluntary Assessments
Prope ddre
Owner
14brmation is Owne... -'e
required for every 'ITT
page. 5 n--L
City/Town
State, Tip Code
Date o tion
C. Onspectalon SUMMMY (cont.)
If You have answered"Yes"to any ques'fion in Section C.5 the system Is considered significant
.4 above the large,system has,failed.The
threrat, or answered"yes"to any question In Section C a
owner,or operator of'any far ge system considered a significant threat under Section C.5 or falled
under Section CA shaill upgrade the system in accordance with 310 CMR 16.304.The,system owner
should contact the appropriate regional'office, of the Department.
ye, It
6- st ndicate YOUlmulis' no"for each of thefoRow-ng for all inspections:
Yes No
Pumpin Information was providedby the owner, occupant, or Board of Health
Were any,of the system components Pumped our the previous two weeks?
Flas the systenn received normal flows in the previous two week period?
Ej Have large'volumen of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined.? (If they were not
available note as N/A)
'130'� El Was thefacility or dWelling inspected for signs of sewage baCk LIP?
E-T Was,the site,inspected for signs of break out?
Were all system compon nts,,excluding the SAS, located on site?,
Were the septic tan[(manh�oles uncovered,,opened,and the Interior of the tan k
inspected for the condition, of the,baffles or tees,, material,of construction,
dimensions, depth of lJqL11d,,depth of sludge and depth of scum' ?
E] Was the facility owner(and occupants if different from owner)provided with,
information on the proper maintenance of subsurface sewage disposal systems?
'The a1ze and'location O�f the Soll Absorption System(SAS)on the,site has
been determined based on:
El Existing information. For exa,rnple, a plan at the Board of Health.
Determined In'the field if any of the,fallure cri'teria related to Part C Is at issue
approximation of distancel"S Unacceptable)[3,10 CMR I 5-302(5)]
t5inS P.do c-rev,7/2 6120,18
Me 5 official inspection For Subsui-faca,Sewage Disposal System,.page 6 of 1,8
COMMon
Title 6 Offo I
c al Inspectloon Form
Ir,
SP0
8 1 SYStem Form Not forV
ddress
1
Owner f
i O tlo i Owner's Name
required forever 1411
page. Ll
ClItgrown APO
State Zip 6Node
DateResided
w it .. t :
NUmber of bedrooms(design).- N'uMber of bedrooms,(actuail),
DESIGN fl'ow based on 310 CMR 15.203(for exannple.- I 10 gpdx of bedrooms):
Description-
Dumber of current residents:
Does residence have a garbage grinder? 0 Yes L7�No
Does residence have a, water treatment unit?
Yes No
If `s,discharges
Pecti
lnforjnatlon in,this
Is laundry'on a separate sewagesystejn?(Include laundry system ins
) ion ED Yes N o
Laundry system inspected?
Water meter readings, If v ii ie last 2 years
Detail:
sump pumo
Last date Of Occupancy:
Date
t5i ap,doc rev,7f2&2016
TJV0 6Offici'm inspection Form:subsurrace sewage 019POsal SYSIOM«Page 7 of 18
Commonvveauh of ma.9,88chusetts
lon Form
s off'm
Ito TO'
lCulal Inspect
Voluntally i
Subsurface SOMEige Dispossl System Form,Not for A ges t
PrOPe, d'dre
Owner 0wrier's Ime
information is
re it for every
Page. �FtY/Town
Zip Code
Dos Date ofinspectlon
yetem
2.
CO3MMOMIRIA111dustrial Flow Conditions,,
Type of Establishment:
Diesign flow(based ors 310 CMR 15.203):
BEISIS of design flow(seats/persons/Sqft, etc.)- Gallons peIr day(gpd)
Grease trap Present?
Water treatment unit present? El Yes No
0 Yes El No
If yes, discharges to:
Industrial waste holding tank present?.
Non-sanitary waste discharged to the Title 5 system? Yes, No
Water melter readings,, if available-. El Yes No
Last date Of Occupancy lure;
Other,(describe below): Date
1
3. "t"Ping Records.- e Is
"C
Source of informati "C
IC
Was system Pumped as Part of the,Insp eCtion
[B"Yes El N o
If Yes, Volume Pumped:
all
How was quantity Pumped determined? e A-C t
Reason for,pump*
ing:
t5ftp.doc•rev.712af2ol'S
Title!5 officiat inspection Form,Subsurface SOM90 DlWsaf system-No 8 or is
'Otle 5
Off"
.6 To
#on
#coal InsIL
FOrni
Not for Voluntary AssessmentsPrope ddress
w
Informatlon i
required for every k8 C)
city/Town
Zip ode Date ofinspection
4. Type of b
Septic
distributilon box, si ll absorption system
Single, cesspool
Overflow cesspool
Privy
Shared system (yes or,no yes,attach prevlous inspection records, M
f any)
Innovative/Alternative 11Ir�ol
l ,mainten act e obtained from system owner and a
iIn o the l system system o �of ��
ract
Tight tank.Attach a GY of the DEP,approval.
Other
Appiroxi
lmateag,e Of all
rats, date ins ll (if known) and source ofilnfo mr ion:'
h n
p ,
Were sewage odors detected when arriving at the site? Yes M--,�N 0
Building SewGr
w
(10cafe on site plea);Depth
below grade;
material ofconstruction:
cast iron L-9,P'40 PVC. EJ other(explain).- ------------------
D'sta,11ce from private water supply well orsuction line:
feet
COMMents (on ors l l n of Joints,venting, evidence
of leafage, etc.):
MnSp. oc rev,7/2�2,0,'1
T11105 Offidal InsPeCtIon Form; ubsu wagec),isposal,System•page 9()1 1
I
I
IIWWiG'Ifl!@I4MHYlV,'NYUINtlMFG'@Ym^o..m ..... mm........ WIIIIIIIMImmamN�$,WIVIV ...,e.
Commonwealth Of Massachusetts
T"t'le 5 Off",
O'Clal Inspecto'3on Form
IN Subsurface v%. Wage Dispos,al Not for Voluntary Assessments
Prope ddress
Owner I C)
Infon-nation is OWner,$ ame
reqLj1'red for every, CL
page, City/T own
Inspection
State Zip Code Date of Inspecction
6. Septic T anl((,locate on site plan):
Depth below,grade:
Material of cons truction.-
31011 crete metal fiberglass
polyethylene E] other(explain)
If dank is rnetal,,list age:,
years
Is age confirmed by a Certificate Of Compliance?(attach a copy of certificate) Yes No
Dimensions-,
x
Sludge depth:
Distance from SOP of sludge to bottom Of Outlet fee or baffile 1
Scum th kness 14'
Distance from top of Scum to top of outlet tee or baffle
Distance from bottom, of scum to bottom Of outlet to or baffle
How were dimensions determined? 16%10 is
Comments (on puinn* I
I ing,recommendations,Inlet and outlet tee or baffle condition,,structural Integrity,
liquid levels as related to outlet inveill', evidence of leakage, eitc.):
t5insp.do c,rev.7/2,612018,
T111e6i Official Inspection Form;Sub suffaco$eytajge DISposa I Sy'starry.page I 00t I a
Commonwesith of massachusetts
Off T'I VC0 ntle 5
i oal Inslaection Form
Su,bsurface SewaGI(B Disposal
5 SYStem FOr'm-Not for Voluntary Assess,ments
Ik D
Owner Owner's Name
Information is
req,Uired for every
page, Qiturr Yfrowl
Zip Code at of Inspection
7. GrOase Tree P('locate on site plan),-,
Depth below grade-,
Material of con,struction: feet
0 concrete metal, 0 fiberul,ass polyethylene 0 other(explain),-
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom Of scum to bottom of'Outlet tee or baffle
Date of'last pumpin,g:
Comments pump*
ing
rel recommendations, Inlet and outlet baffl ndit
tee or e coion,StrUCtUral
liquid levels as ated to outlet 1:nveirt, evidence of leakage,etc.): integrity,
8. Tight or 1,ibldhig Ta,nit(tank must be pumped at the ofinspection)(locate on site p
Depth below grade:
Material of construction:
Elconcrete 0 metal fiberglass, 0 POIYethylene other(ex,plaln):
Dimensions.-,
capacity..
Design Flow,: gallons
t5i .do c (01V.U26r2018 gallons per day ------
TitiDSOff(Ciai'linsP,ecOon,F' rime Subsurtac&Bugs Dfsposal System*pa0e 11 ot,a
Commonwealth of massachusetts
T'Otle 5 Off"
Ct
1clal In
ion
Form
Stern FOrM Not,for Voluntary Assessments:
Pape Iddress
Owner
Informatton is ear's Name
required for every,
page.
at own
Ott Zip,Code Date of Inspection
S�Y�81(�)m III`OnI`for�ma�uo�n
Alarm: present: YerS No
Alarm level:
Alarm In workingorder: El Yes N
Date Of IaSt PLUMpin
go
Date
Oets (condition of lean and float switcheIs,
El Y es, 0 Attach COPY of currient pumping contract(requireld). Is COPY attached?
x(if preseInt must be opened) (locate on site :-y e S
Depth of liquid level above outlet invert YAOCMIeAl leve,
Comments (note if box, iIs level and distribution to outlets
evidence of leakage into, U of box, etc,.): s carryover, any
w
.TM
t5IMP.doc rev. rumj
TRID 6 OfWal inspection orm:Subsurface sewage DISPO f SY I r,-Page 12 of I
Commonwealth Of Massachusetts
R Title 5 Off3
1cialins ectlon Form
P
Subsurface Sewage DlIs
08all Svet em Form Not for Voluntary Assessments
LcA
PrOP8 ddress
Owner Owner's Me
Information is
reqUired for every
page.
zip Code Date of Inspection
10- PUMP Chamber(locate!on site plan):
Pumps In working order: Yes El No*
Alarms in working order: El Yes El N o"
Comments (note condition of Pump chamber, condition Of Pumps and appurtenances, etc.):
If PUMps; or,alarms are not in working order, system
conditional pass.
8011,Absorpt,lon, System (SAS) (locate on, site plan,excavation not required):
If SAS not located, explain why.
Type:
0 leaching pits number,*
0 leaching chambers nu rnber:
leaching galleries nUmber.-
leaching trenches
number,length.-
E] leaching fields number,dimensions,#
E3 Overflow cesspool, number.-
Inn ovat'j"Ve/afte rnatve system
Type/narne,of technology,&
t5inSp.doc rev.,U26/201,8
TIfle 5 01ficial Inspacuon Form,SubsutMce SeM90,1),1SP0931,SYStem Page 13 of 18
T1'4tl,e 5 Offo
#coal
lon Form
Inspect
Subsurfacew ,SYsteM F0VM Not
for Voluntary Assessments
"
rope dress Art
Owner
,informationI owner Name
required for ever'
pageZIP Code
Date of Inspectlon
SOH Absorption,Syste,m(SAS)
.
Comments (note condition of$0111,signs of hydraulic
failure
vegetation, etc.), r � l, in of
t4
12. Ce, 8$130018(cesspool must be pumped as part of Inspection)(locate on site plan):
Number and configuration
Depth —top of liqu 1 d to i nI et invert
Depth of solids layer
DepthSCUM layer
Dimensions cesspool
Materiels of construction
Indication of groundwater inflow Yes No
Comments(note
etc.): , level, , r i+ ,
tiro p.do -rev "12 f2o1
Tiftle 5 Onicial Inspection Form:SubsurfaceSeVeage01SpO l S M•P DO 14 or 1
irmmmu_.: n�romlDni"iryyjr uwIMuw .. — --
Commonweaith of massachus,etts '
Tl"tle 5 Off"
Is % Pcoal Inspecto"on Form
Subsurf6ce Sqwage,Disposal SyStGM F OWM Not,for Volunta As essmen
ry s, ts
1P ro P,e ddress,
Owner ........... f%CA
Inform,ation Is Owner s Name
required for every lr�
page. LAY/Town IS
State dip—Code Date of Inspection
Do, SYStem Information (cont.) .....
13. Pfiv'Y(locate On SitO plan):
Materials Of conStrtlCtlon:
DIMensions
Depth,of solids
Comments(note condition of so'l,signs of hydr,a u l'o fall r
etic.): U e, le l of ponding, condition of vegetation,
M I nsp,.doc-rev.7/26no,1 a,
Tftle 6 Officiat ire specuare Form:sub sutt4ce se%vage D,sposs,system paq 1 of I a
Commonweaith of Massachusett's
Titib 5 offg
ec ion, orm
Subsurface Sewage coal Insp t," F
IsPOW SYstem Form
Not for Voluntary Assessments,
2,111
PMpe, dress
ji ji ji ji
Owner
Owners ame,
Inf0fMation Is
required for every
page. QtY/Town
Zip Code flon
114- Sketch Of SeWSqe Dhsposal System.
Provide a view of the sewage disposal'sYstem, including ties,to at least two permanent reference
landmarl(s or benchmarl(s-Locate all wells win 100 feet. Locate where Pu wat supply enters
the building., Check one of the boxes below,,* blic er
hand-sketch in the area below
drawing attached separately
0 0
1A o u,
t5fnSP.doc rev.7t2&20j a
TWO 6 0111clail Imspectfon Form.,subsurtaze'Rewago j)jBP0SRj,5YqtDM page Is
COMMonwealth of m,n,ssac,husette
3 H
H T"mtle 6 O,ffo I
"C"al Inspection Form
Subsurface 89tvage DISPOSal SYStem Forin-Not for Voluntary Assessments
Pope r OPe dress
Ow,ner Ownerls me
information is
FeWired for every A"
page, C1tYfrbwn
ate Ylp—C�,ode D ...............O S, Date Inspection
Ystem information (cont.)
1 S. Site Exam:
M
Check Slope 1A
ED %9urface water IV(,,)
0 Gheol(cellar
EJ Shallow wells
Estimated depth to high ground water.
-
feet
Please Indicate all methods used to determine the high ground water elevation:
Obtained from system design Plans on record
If checked, date of design plan reviewed,- Date
Observed site, (abutting props s ervation hole within 150 feet of SAS)
Checked with, local Board of Health-explain,,,
Checked with loca I excavators,,installers-(attach documentation)
Accessed USG S database-explain:
YOU Must describe how YOLVestablished the high ground water elevat'
ion
----------------
f.111 n' OhIs InsPectI0111 Report, pjeEj,% gee fieport
t51rVSP.d0c*,rev,U2612018, e , COMPleteness Checklist on ne)(ti pags.
Title 5 Oflicial inspection r-ormsubsuHace semg,e Djqposal 6,y'stem,,Pa go 17 ot 18,
Commonwealth
T'Itle 5 Official Inspection Form
it Subsurface SMage
Wspo
sal SYstem FOVM Not for Voluntary Assessments
rOPOrty' dress
Owner
owner's Namle
t
Ifformation is
required for eves
j
Cl /Tows
state ZIP oV
Date of Inspection
SSG CheCklpst
..PIGRG all!aPPIlIcable se,eflo-ris of,this form M ,,ff
clusivs
(IT"A.
Inspector Information: Complete Il fields in this sect-ion.
ErB. Certification-w Signed& Dated and 1,21 31 or 4 checked
Inspection SUMM,ary-,
2; 3, or 5 completed as appropriate
llure Criteria) and ' cl lsCompleted
M'D..System lnrnnin
For :Tight/HoldingTank— LII n contract
attached
ForSketchSewage Disposal System drawn
For 1'5Explanation of estimated depth to high groundwater
T5 OfficigI I SP U010 n For(TI.Subsu r Sewage DispoS I Sys to •'Pao 0
1 0f
t
Billing,
Information
TOIWN OF NORTH ANDOVER IN
9 8 8- 570 IN
r
M vi 1 IN STREETReading Information I
11 R 5 BEFORE NORE 3.9 €
04/18/19
-9,570
P9781-688-9550
i (978)688
E R �� s
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Mon,Wed,Th8-4:,30
SERVICE,DATES DUE
HIS O ' N * R your''REf cORDS
MOVINGPLEASE CALL ADVANCE
SERVICE SIS
110 CRICKET LANE
BENJAMIN NASSA
TRANSAC fON"T III PERIOD ;
II CRICKETce-
ous M n
Adjustments,/Late Charges
Interest as of.-4/18/2019
Balance,Fomard
Nb
CutTentMI'Detail ge/Ulu."i Aiii,,ount
Deeding Ri , . Days
WATER USAGE WAT ER, 29 124.80
1,,: V4/19 ADMIN FEE 9.18
Sub-Total 133.9780
Total
MESSAGE
P AYMEN T S A HOUL E D T HMI'.,L 120 MAIN STREET R BY M 'r I LOCKBOX C P.O. BOA.
at e r rat e First 20 units Ca) . 0 Over 20 units @ $5 . 55
Selves rate : 141
"ir t 20, units @ $5 . 95 Over 20 units $9. 24
Bypass Meter Water rate: all unit @ $5 . 55
PLEAS] RETURN THIS PORTION WITH PAYMENTS
TOWN OF NORTH H NDOV Billing Rain
hif ion
*e*�tW*lam. * 7 - 8- 0
41671,0078
SERVICE, 'REESS, NUMBER
I 10 CRICKET LAB 21 - 1 1 " 10078
ON OR
10 QRICKET LAND
NORTH ANDOVER,MA 0 1845 AMOUNT PAID
t 668 670
0416710'0782019000�000000000000000000402100709000000013398009
06 A
Town of North Andover
*Alropdl HEALTH DEPARTMENT
CHU$
CHECK# DATE:
LOCATION: /Al
H/O NAME.
e"4 101
CONTRACTOR NAME:
0V
c., %04
Type of Permit or License:-(Checkbox),
D Aninial' $
01 Bod'y Art Est ablishmejit $
0; Body Art Practitiotter $
0 Dintipster $
El Food Service-Type:__-_ $
0 Funeral Directors $
0, Massage Establishment $
01 Massage Pivetice $
0, Offal(Septic)Hauler $
EJ Recreational Camp $
* Sun tanning
* Swimming Pool $
13 Toba�cco $ J
• TrashlSolid Waste Hauler $
• Well Constnictioll $
SEPTIC Systems:
Ej Septic-Soil Testin, $
0 Septic-Des' i Approval $
191
El Septic Disposal Works Construction(DWQ $
0 Septic Disposal Works Installers(DM) $
0 Title 5 Inspector $
Titl'e 5 Report
[I Othen-Undicate) $
k.........("foRM
HM-1 th-Agent Initials
White-Applicant Yellow Health Pink, Treasurer,
..........