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HomeMy WebLinkAboutPass - Title V Inspection Report - 67 TUCKER FARM ROAD 10/28/2021 cry Commonwealth of Massachusetts ip Title 5 Official Inspection Form in I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 1, P anrty Address � Owner 0 ner' me �j information is wn r 0 P p — -01 required for every - State Zip Code Date of Inspection page. City/To 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:When A. Inspector Information f t_ filling out forms `''` ZH ANQQV on the computer,use only the tab CHARLES J. ROUX �,�NOR *►EI�- key to move your Name of Inspector C+v= cursor-do not CHARLES J. ROUX, LLC use the return Company Name key. 213 PATTEN ROAD r� Company Address — TEWKSBURY MA 01876 City/Town State Zip Code 978-640-9984 S1891 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 16 Inspekefils S nature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.- :rUC ar0 _ Property Address Owner Owner's Name information is required for every _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: 5z I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, , ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years of or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or filtration or tank failure is imminent. System will pass inspection if the existing tank is replaced ith a complying septic tank as approved by the Board of Health. *A metal septic tank will pass ins ction if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the t k is less than 20 years old is available. ❑ Y ❑ N ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C-ke r- ra r vo u V Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water I el in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or u ven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y N ❑ ND (Explain below): ❑ obstruction is removed ❑ ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced Y ❑ N ❑ ND (Explain below): ❑ The system required pu ping more than 4 times a year due to broken or obstructed pipe(s). The system will pass insp tion if(with approval of the Board of Health): ❑ broken pi (s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obs ction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which requirXfctioning io y the Board of Health in order to determine if the system is failing to protecfety or the environment. a. System will pass unlessh determines in accordance with 310 CMR 15.303(1)(b) that the systeing in a manner which will protect public health, safety and the environmen t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v Property Address Owner Owner's Name information is required for every page. City[Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that pr cts the public health, safety and environment: ❑ The system has a septic tank and soil absorption syste SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface ater supply. ❑ The system has a septic tank and SAS and the SAS s within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the AS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and a SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water an ysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and t presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that n ther failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �r Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Ackley F�Trm M Property Address Owner Owner's Name information is required for every _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less �M than '/z day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ [� Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ [2� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ d Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ [?� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E� Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ 2f The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ d The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 fe of a surface drinking water supply ❑ ❑ the system is within 2 feet of a tributary to a surface drinking water supply ❑ ❑ the system is loc d in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts 9� p Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address — Owner Owner's Name -- information is required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No y ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Q' Were any of the system components pumped out in the previous two weeks? Q" ❑ Has the system received normal flows in the previous two week period? Q/ ❑ Have large volumes 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) J ❑ Was the facility or dwelling inspected for signs of sewage back up? Ltd ❑ Was the site inspected for signs of break out? Y1 ❑ Were all system components, excluding the SAS, located on site? Q7 ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: I� ❑ Existing information. For example, a plan at the Board of Health. �/ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts I3 Title 5 Official Inspection Form I} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Le r- ra V� Property Address — Owner Owner's Name — -- information is required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): — Number of bedrooms (actual): — f---- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedroo s):JJ PI) Description: x Number of current residents: 3 —_ Does residence have a garbage grinder? ❑ Yes © No Does residence have a water treatment unit? ❑ Yes [Z No If yes, discharges to: -- --_ Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes E?f No Laundry system inspected? N/� ❑ Yes ❑ No Seasonal use? ❑ Yes F� No Qom` I Oc,c�n/ Ib- er Water meter readings, if available (last 2 years usage (gpd)): -- Detail: Sump pump? ❑ Yes E( No Last date of occupancy: xj Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments rw� Property Address -- Owner Owner's Name information is required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: --- Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): - Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: -- Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 sys m? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes [?r No If yes, volume pumped: gallons How was quantity pumped determined? --- Reason for pumping: - t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address -- Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: [� Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes F,� No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): ---- Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �d 1p Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 u C Ir Property Address - Owner Owner's Name --- information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: feet -- Material of construction: [concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: _— years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: -J Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle l 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 l 1 / -- How were dimensions determined? `>t d e `� l e— Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Lj f lcg� t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�� �� I u cT��t r�✓1� }� — Property Address Owner Owner's Name -- information is required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene 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 baffle Date of last pumping: I --- Date Comments (on pumping recommendations, iWet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r� 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: - - Material of construction: ❑ concrete ❑ metal ❑/rglass ❑ polyethylene ❑ other(explain): Dimensions: —_ Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (f // b L r G rVYI/ -- u� Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: /witches, ❑ No Alarm level: — working order: ❑ Yes ❑ No Date of last pumping: -- Comments (condition of alarm and fl 3� r/a-ale_ *Attach copy of current pumping contract(required). Is copy tached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert —- Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): to v 4-6-t S =rn,eriL� oe t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61-6(-L-er Property Address -- Owner Owner's Name information is required for every _ page. City/To m State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: -- ❑ leaching chambers number: -- ❑ leaching galleries number: ��[ ---- leaching trenches number, length: V t ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: ---- t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c Lf Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): /pOtt-A (KJ p 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert _ Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of so', signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts �e Title 5 Official Inspection Form 1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions -- Depth of solids -- Comments (note condition of soil, signs of hydraulic failu , level of ponding, condition of vegetation, etc.): l/ t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments lG�---!� C �r Gy- Property Address -- Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters �7h wilding. Check one of the boxes below: and-sketch in the area below ❑ drawing attached separately —� BOX 5T l 10 `t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments __rU_C r u� Property Address Owner Owner's Name -- information is required for every St page. City/Town ate Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet S I> --- Please indicate all methods used to determine the high ground water elevation: EJ Obtained from system design plans on record If checked, date of design plan reviewed: Date ---- ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: LS LJ 7—C- S c� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form die Subsurface Sewage Disposal Syst Form - Not for Voluntary Assessments 67 Iuc bor j5 r Property Address Owner Owner's Name -- information is required for every page. City/To m State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: V A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or checked [� C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Z975 Billing TOWN OF NORTH ANDOVER Information +°t� •• ••°4 (978)688-9570 120 MAIN STREET • NORTH ANDOVER MA 01845 Reading Information(978)688-9570 BEFORE 10/21/21 ► $416.82 978-688-9550 OFFICE HOURS Mon,Wed,Th 8-4:30 The 8-6:00,Fri 8-12:00 rM100330-41670�7191 9/21/2021 M7 RETAIN THIS PORTION FOR YOUR RECORDS 6/1/2021 -8/31/2021 10/21/21 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE 67 TUCKER FARM ROAD CHAD&MAGGIE PAQUIN 67 TUCKER FARM ROAD Pmvious Balance NORTH ANDOVER MA 01845 Payments Through 09/21/2021 (68.62) Adjustments/Late Charges - Interest as of 10/21/2021 - Balance Forward itr entBi11 Detail - _�-usage/Unit _ Amousit WATER USAGE WATER 80 409.00 5i5ni s/4m ADMIN FEE 7.82 128 11360 80 Actual 91 Sub-Total 416.82 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL Q 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX ® P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units @ $3. 80 Over 20 units $5 .55 Sewer rate : First 20 units @ $5 .95 Over 20 units 3 $9.24 Bypass Meter Water rate : all units ® $5 . 55 PLEASE RETURN THIS PORTION WITH PAYMENTS TOWN OF NORTH ANDOVER Billing Reading 120 MAIN STREET Information Information NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 ` 978-688-9550 416707191 *416707191 * 67 TUCKER FARM ROAD 2100330-416707191 =BEFORE CHAD&MAGGIE PAQUIN 10/21/21 , $416.82 67 TUCKER FARM ROAD NORTH ANDOVER MA 01845 AMOUNT PAID 2,975 r 329 04167071912022000000000000000000000402100330000000041682006 2,943 Billing Information "4''` :•�t TOWN OF NORTH ANDOVER -9570 « ; 120 MAIN STREET s ; NORTH ANDOVER MA 01845 Reading Information BEFO 07/15/21 ► $68.62 (978)688-9570 - - 978-688-9550 OFFICE HOURS Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100330-416707191 6/15/2021 RETAIN THIS PORTION FOR YOUR RECORDS 3/1/2021 -5/31/2021 07/15/21 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE 67 TUCKER FARM ROAD CHAD&MAGGIE PAQUIN 67 TUCKER FARM ROAD Previous Balance 76.22 NORTH ANDOVER MA 01845 Payments Through 06/15/2021 (76.22) Adjustments/Late Charges Interest as of:7/15/2021 Balance Forward - WATER USAGE WATER 16 60.80 2/4l21 5i5n1 ADMIN FEE 7.82 1264 1280 16 Actual 90 Sub-Total 68.62 1. Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX Q P.O. BOX 184 , MEDFORD, MA 02155 Water rate : First 20 units $3 . 80 Over 20 units $5 . 55 Sewer rate : First 20 units 3 $5 . 95 Over 20 units 3 $9 .24 Bypass Meter Water rate : all units ® $5 . 55 Nomr. PLEASE RETURN THIS PORTION WITH PAYMENTS t TOWN OF NORTH ANDOVER Billing Reading 120 MAIN STREET Information Information + * NORTH ANDOVER MA 01945 (978)688-9550 (978)688-9570 +� 978-688-9550 416707191 *4167Q7191 67 TUCKER FARM ROAD 2100330-416707191 =BEFORE- CHAD&MAGGIE PAQUIN 07/15/21 ► $68.62 67 TUCKER FARM ROAD NORTH ANDOVER MA 01845 AMOUNT PAID 2,943 1 328 04167071912021000000000000000000000402100330000000006862004 2,975 Billing jtA Information TOWN OF NORTH ANDOVER (978)688-9570 120 MAIN STREET ON OR NORTH ANDOVER MA 01845 Reading Information BEFORE 10/21/21 ► $416.82 978-688-9550 (978)688-9570 OFFICE HOURS Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100330416707191 9/21/2021 RETAIN THIS PORTION FOR YOUR RECORDS 6/1/2021 -8/31/2021 10/21/21 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE "�W7TUMERMARMROAD CHAD&MAGGIE PAQUIN 67 TUCKER FARM ROAD Previous Balance 68.62 NORTH ANDOVER MA 01845 Payments Through 09/21/2021 (68.62) Adjustments/Late Charges Interest as of: 10/21/2021 - Balance Forward - WATER USAGE WATER 80 409.00 56i2l 814n1 ADMIN FEE 7.82 1280 1360 80 Actual 91 Sub-Total 416.82 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL Q 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units ® $3 . 80 Over 20 units Q $5 . 55 Sewer rate: First 20 units Q $5 .95 Over 20 units ® $9.24 Bypass Meter Water rate : all units ® $5 . 55 adR�h PLEASE RETURN THIS PORTION WITH PAYMENTS TOWN OF NORTH ANDOVER Billing Reading g 120 MAIN STREET Information Information 0 ; # NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 ' 978-688-9550 416707191 *416707191 * 67 TUCKER FARM ROAD 2100330-416707191 =BEFORE CHAD&MAGGIE PAQUIN 10/21/21 10- $416.82 67 TUCKER FARM ROAD NORTH ANDOVER MA 01845 AMOUNT PAD) 2,975 1 329 04167071912022000000000000000000000402100330000000041682006 2 874 Billing �0R1'r 4y Information �.;� ''•.q� TOWN OF NORTH ANDOVER (978�88-9570 { 120 MAIN STREET Reading information ON OR � � NORTH ANDOVER MA 01845 (ging Information BEFORE 01/15/21 ► $562.47 -9570 978-688-9550 OFFICE HOURS Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100330-416707191 12/16/2020 RETAIN THIS PORTIONFOR YOUR RECORDS 9/1/2020- 11/30/2020 01/15/21 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE 67 TUCKER FARM ROAD CHAD&MAGGIE PAQUIN 67 TUCKER FARM ROAR Previous Balance NORTH ANDOVER MA 01845 Payments Through 12/16/2020 (573.38) Adjustments/Late Charges 2.85 Interest as of: 1/15/2021 0.04 Balance Forward 1.35 WATER USAGE WATER 106 553.30 8i4r20 11i3/20 ADMIN FEE 7.82 1140 1246 106 Actual 91 Sub-Total 561.12 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX Q P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units $3, 80 Over 20 units ® $5 . 55 Sewer rate: First 20 units 3 $5.95 Over 20 units ® $9.24 Bypass Meter Water rate : all units Q $5 . 55 ,w PLEASE RETURN THIS PORTION WITH PAYMENTS °.'"":•+��� TOWN OF NORTH ANDOVER Billing Reading 120 MAIN STREET Information Information NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 978-688-9550 416707191 � sA *416707191 * "��67 TUCKER FARM ROAD 2100330416707191 =BEFORE CHAD&MAGGIE PAQUIN 01/15/21 ► $562.47 67 TUCKER FARM ROAD NORTH ANDOVER MA 01845 1 AMOUNT PAID 2,874 2 329 04167071912021000000000000000000000402100330000000056247004 2,841 Billing 0,, Information .•+:� TOWN OF NORTH ANDOVER (978)688-9570 * 120 MAIN STREET ON OR a NORTH ANDOVER MA OI 84S Reading Information BEFORE 10/09/20 ` $571.84 (978)688-9570 978-688-9550 i + OFFICE HOURS Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100330416707191 9/9/2020 RETAIN THIS PORTION FOR YOUR RECORDS 6/1/2020-8/31/2020 10/09/20 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE 67 TUCKER FARM ROAD CHAD 8t MAGGIE PAQUIN 67 TUCKER FARM ROAD Previous Balance NORTH ANDOVER MA 01845 Payments Through 09/09/2020 (89.37) Adjustments/Late Charges - Interest as of: 10/9/2020 Balance Forward WATER USAGE WATER 108 564.02 5/4i20 8i4no ADMIN FEE 7.82 1032 1140 108 Actual 92 Sub-Total 571.84 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL ® 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units $3 . 80 Over 20 units $5 . 55 Sewer rate : First 20 units @a $5 .95 Over 20 units 3 $9.24 Bypass Meter Water rate : all units Q $5 . 55 Mca PLEASE RETURN THIS PORTION WITH PAYMENTS w;} . .,'•�°k TOWN OF NORTH ANDOVER Billing Reading 120 MAIN STREET Information Information ' a NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 " �•.;°�",,,� } 978-688-9550 416707191 *416707191 * 67 TUCKER FARM ROAD 2100330-416707191 ON OR CHAD&MAGGIE PAQUIN BEFORE 10/09/20 ► $571.84 67 TUCKER FARM ROAD NORTH ANDOVER MA 01845 AMOUNT PAID 2,841 5 329 04167071912020000000000000000000000402100330000000057184006 2.747 Billing Information TOWN OF NORTH ANDOVER (978)688-9570 120 MAIN STREET ON OR NORTH A MA 01845 (97)6gg-9570 BEFORE 01/22/20 , $160.37 978-688-9550 Reading Information 550 +a�eNuss� OFFICE HOURS Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100330-416707191 12/23/2019 RETAIN THIS PORTION FOR YOUR RECORDS 9/1/2019- 11/30/2019 01/22/20 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE 67 TUCKER FARM ROAD CHAD&MAGGIE PAQUIN 67 TUCKER FARM ROAD Previous Balance NORTH ANDOVER MA 01845 Payments Through 12/23/2019 (155.59) Adjustments/Late Charges - Interest as of: 1/22/2020 Balance Forward rUSAGE WATER 34 152.55 2!19 11/4/19 ADMIN FEE 7.82 64 998 34 Actual 94 Sub-Total 160.37 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units $3 . 80 Over 20 units $5 . 55 Sewer rate : First 20 units § $5 . 95 Over 20 units 3 $9 .24 Bypass Meter Water rate : all units ® $5 . 55 00 PLEASE RETURN THIS PORTION WITH PAYMENTS .!:r ••°g TOWN OF NORTH ANDOVER Billing Reading ,► 120 MAIN STREET Information Information NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 " :�,.r i 978-688-9550 416707191 ;,"i1� *416707191 * 67 TUCKER FARM ROAD 2100330416707191 =BEFORE CHAD&MAGGIE PAQUIN 101/22/20 ` $160.37 67 TUCKER FARM ROAD NORTH ANDOVER MA 01845 AMOUNT PAID 2,747 1 328 04167071912020000000D000D0000000000402100330000000016037004 2,778 Billing .6 ''!" TOWN OF NORTH ANDOVER Information + + _` ° (978)688-9570 Aiggift a 120 MAIN STREET ON OR Reading Information 04/15/20 , $57.22 NORTH ANDOVER MA 01845 BEFORE �"►.����-- `'�' 978-688-9550 (978)688-9570 +•"`^' �`•' OFFICE HOURS a�a+u Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100330416707191 3/16/2020 RETAIN THIS PORTION FOR YOUR RECORDS 12/1/2019-2/29/2020 04/15/20 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE 67 TUCKER FARM ROAD CHAD&MAGGIE PAQUIN 67 TUCKER FARM ROAD Previous Balance 16037 NORTH ANDOVER MA 01845 Payments Through 03/16/2020 (160.37) Adjustments/Late Charges Interest as of.4/15/2020 - Balance Forward WATER USAGE WATER 13 49.40 1114i 19 2i4a0 ADMIN FEE 7.82 998 1011 13 Actual 92 Sub-Total 57.22 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL ® 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX ® P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units Q $3. 80 Over 20 units $5 . 55 Sewer rate : First 20 units @ $5. 95 Over 20 units 3 $9.24 Bypass Meter Water rate: all units © $5 . 55 *a PLEASE RETURN THIS PORTION WITH PAYMENTS TOWN OF NORTH ANDOVER Billing Reading s 120 MAIN STREET Information Information + + 978 688-9550 978 688-9570 NORTH ANDOVER MA 01845 ( ) ) 978-688-9550 416707191 *416707191 * 67 TUCKER FARM ROAD 2100330416707191 =BEFORE CHAD&MAGGIE PAQUIN 04/15/20 ► $57.22 67 TUCKER FARM ROAD NORTH ANDOVER MA 01845 AMOUNT PAID 001, 2,778 4 329 04167071412020000000000000000000000402100330000000005722009 2,904 Billing Information ` TOWN OF NORTH ANDOVER (978)688-9570 120 MAIN STREET ra!ONOR NORTH ANDOVER MA 01845 Reading Information ORE 04/15/21 ► $76.22 978-688-9550 (978)688-9570 OFFICE HOURS is:A� ti Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100330416707191 3/16/2021 RETAIN THIS PORTION FOR YOUR RECORDS 12/1/2020-2/28/2021 04/15/21 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE 67 TUCKER FARM ROAD CHAD&MAGGIE PAQUIN 67 TUCKER FARM ROAD Previous Balance 562.43 NORTH ANDOVER MA 01845 Payments Through 03/16/2021 (562.47) Adjustments/Late Charges 0.04 Interest as of 4/15/2021 Balance Forward oil 71246 R USAGE WATER 18 68.40 1113120 2/4n1 ADMIN FEE 7.82 1264 18 Actual 93 Sub-Total 76.22 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX Q P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units @ $3 . 80 Over 20 units $5 . 55 Sewer rate : First 20 units @ S5 . 95 Over 20 units 3 $9.24 Bypass Meter Water rate : all units ® $5 . 55 Mona, PLEASE RETURN THIS PORTION WITH PAYMENTS TOWN OF NORTH ANDOVER Billing Reading s 120 MAIN STREET Information Information e : NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 978-688-9550 416707191 t=NtIMf *416707191 * 67 TUCKER FARM ROAD 2100330-416707191 =BEFORE CHAD&MAGGIE PAQUIN 04/15/21 ► $76.22 67 TUCKER FARM ROAD NORTH ANDOVER MA 01845 AMOUNT PAID 2,904 3 329 04167071912021000000000000000000000402100330000000007622001 2,809 Billing ""`°:•+ TOWN OF NORTH ANDOVER Information 120 MAIN STREET (978)688-9570 Reading Information =BEFORE NORTH ANDOVER MA01845 (978)688-9570 07/10/20 ` $89.37 978-688-9550 OFFICE HOURS Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100330-416707191 6/10IZ02O RETAIN THIS POR77ONFOR YOUR RECORDS 3/1/2020-5/31/2020 07/10/20 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE 67 TUCKER FARM ROAD CHAD&MAGGIE PAQUIN 67 TUCKER FARM ROAD Previous Balance NORTH ANDOVER MA 01845 Payments Through 06/10/2020 (57.22) Adjustments/Late Charges Interest as of 7/10/2020 Balance Forward - WATER USAGE WATER 21 81.55 2/4/20 5i4n0 ADMIN FEE 7.82 1011 1032 21 Actual 90 Sub-Total 89.37 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX Q P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units $3 . 80 Over 20 units $5 .55 Sewer rate : First 20 units @ $5 . 95 Over 20 units 3 $9.24 Bypass Meter Water rate : all units @ $5 . 55 PLEASE RETURN THIS PORTION WITH PAYMENTS .•",r x: °a� TOWN OF NORTH ANDOVER Billing Reading 120 MAIN STREET Information Information NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 ' 978-688-9550 416707191 *416707191 * 67 TUCKER FARM ROAD 2100330-416707191 =BEFORE CHAD&MAGGIE PAQUIN 07/10/20 ► $89.37 67 TUCKER FARM ROAD NORTH ANDOVER MA 01845 AMOUNT PAID 2,809 2 328 04167071912020000000000000000000000402100330000000008937006 9`f 6 E,l O`NORT.,y �' Town of North Andover `�°•-o;-;;:; ,' HEALTH DEPARTMENT ,SSACNU°+t4 CHECK#: T C3�'�--- --DATE: $_ OZ/ LOCATION: A -7 H/O NAME: f CONTRACTOR NAME:,()X Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems.- ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector 55 $ .)EJ Title 5 Report a $50 ❑ Other. (Indicate) $ 1 Health`Agent Initials i White-Applicant Yellow-Health Pink-Treasurer