HomeMy WebLinkAboutTitle V Inspection Report - 136 SALEM STREET 9/29/2015 Commonwealth of Massachusetts
Title ff' ' I Inspection Form
Subsurface Sewage DisposaLSystem Form-Not for Voluntary Assessments
Property Address
Owner �G
information is �—ame
required for v`e Y`
every page. ity/To stated 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. RECEIVED
Important;
When filling out
A. General Information
forms on the OCT 2
computer,use 1 Inspector.
only the tab key TOWN OF NORTH AN
to move your ,r �'
m
HEALTH DEPARTMENT
ENT
use the retut Name of Inspector
k 1J ey. I e 15 ��.-: ` U
Company Name - "� —
Af
Company Address r-•--, /� ,[�
`aua C /Ton 1'P W U� /l' I /7j
� w ®�,,, state _
G f (� � 4 � Lip Code
Teleph ng Number ` I 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 an� 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:
Ef Passes ❑ Conditionally Passes Cj Fails
0 Needs Further Evaluation by the Local Approving Authority
Ins r' g ature 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 alt the time of inspection and unE,der the conditions of use
at that time.This inspection does not address how the system will pertorm In the future under
the same or different conditions of use.
t5ins.U3/13 Title 5 Of el ImPet*on Foart Subsuft�O Sewage big
Pogei System•Pege 1 or 17
i
Commonwealth of Massachusetts
9 Title 5 Official Inspection (Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l3665,q/ed
Property Address
Owner
Information is Owner's Name
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
[fI 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:
Nhn�a vm
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" ection need to be
replaced or repaired. The system, upon completion of the replacemen r repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"ar"not determined"(Y, N, ND)fo a following statyements. If"not
determined, " please explain.
The septic tank is metal and over 20 years old*or th eptic tank(whether metal or not)is
structurally unsound, exhibits substantial inflitratio r extiltration or tank failure is imminent. System
will pass inspection if the existing tank is repla with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspecti rt if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank ' less than 20 years old is available.
Y ® N ND (Explain below):
[Sins•03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection (Form
A Subsurface Sewage Disposal System Form Not for Voluntary Assessments
/ 0
" Property Address
Owner
Information is Owner's Name
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.);
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven 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 ❑ Y ❑ N ❑ (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ND (Explain below):
❑ The System required pumping more than imes a year due to broken or obstructed pipe(s). The
system will pass inspection if(with appr al of the Board of Health):
❑ broken pipe(s)are replace ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety r the environment.
1. System will pass unless Board of Health termines in accordance with 310 CMR
15.303(1)(b)that the system is not functio ng in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 et of a surface water
❑ Cesspool or privy is within feet of a bordering vegetated wetland or a salt march
t5ins•03113 Title 5 official Inspection Form Subsurface sewage Disposal Svstem.Pam 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner
Information is Owner's Name
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
deterimes that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water s Vpply.
❑ The system has a septic tank and SAS and the SAS is within a one 1 of a public water
supply.
® The system has a septic tank and SAS and the SAS is wit n 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS i ess 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 analysis, pe ormed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of am onia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure Iteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ 2 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ 2' Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SA;i or cesspool
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑0A ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less
than M day flow
t51ns•03/13
Title 5 Official Inspection Form Subsurface sa—rn...... i
Commonwealth of Massachusetts
Title 5 Official Inspection f=orm
f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner
Information is Owner's Name
required for
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ R Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 2' Any portion of the SAS, Cesspool or privy is below high ground water elevation.
❑ FL,,r Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ 2" Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 2 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.]
❑ This system is a cesspool serving a facility with a design flow of 2000gpd-
�/ 10,000gpd.
El LvJ 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.
E) 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 D.
Yes No
❑ ❑ the system is within 400 feet a surface drinkiing water supply
❑ ❑ the system is within 200 et of a tributary to a surface drinking water supply
❑ ❑ the system is locate n a nitrogen sensitive area (Interim Wellhead Protection
Area- IWPA or a pped Zone II of a public water supply well
If you have answered "yes"to any pa estion in Section E the system is condidered a significant threat,
or answered"yes" in Section WDD ,tfov e the large system has failed. The owner or operator of any large
system considered a signific reat under Section E or failed under Section D shall upgrade the
system in accordance with 10 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
(Sins-03113
Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner
Information is owner's Name
required for
every page. '61 ,crown State
ZIp Code Date of Inspection
C Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ 0 Has the system received normal flows in the previous two week period?
❑ 12 Have large volumes of water been introduced to the system recently or as part of
this inspection?
2" ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
12' ❑ Was the facility or dwelling inspected for signs of sewage back up?
2' ❑ Was the site inspected for signs of break out?
2 ❑ Were all system components, excluding the SAS, located on site?
13� ❑ 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?
2 ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
This size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design):
Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
t5ins•03/13 Title 6 Omclal Inspection Form Subsurface sewage Disposal System•Pape 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewa a Disposal System Form- Not for Voluntary Assessments
Property Address
Owner
Information is Owner's Name
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes Er No
Laundry system inspected? /V 1 ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gPd)): t U w
Detail:
Sump pump?
❑ Yes 11� No
Last date of occupancy: L�
Commercial/Industrial Flow Conditions:. Dat
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sq.ft.,etc.) Gallons per day(gpd)
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present
❑ Yes ❑ No
Non-sanitary waste discharged the Title 5 system?
❑ Yes ❑ No
Water meter readings, if av 'able:
15ins•03/13
Tide 5 Official Inspection Form Subsudsoe sewage Disposal system•Paae 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6b '5qzo yyl
Property Address �
Owner
Information is Owner's Name
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below): Date
=7Z
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes Q No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
ff 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):
ISins•03/13
Title 5 Official Inspection Forth Subsurface Sewage Disposal System•Page 8 of 17
\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
a t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner
Information is Owner's Name
required for
every page, Clry/Town State zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)Ind source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade;
Material of construction: feet
ff cast iron ❑ 40 PVC ❑ other(explain)
Distance from private water supply well or suction line: - �A feet Comments (on condition of joints, venting, evidence of leakage, etc.): --
a llea,k�l i
Septic Tank(locate on site plan):
Depth below grade: i
Material of construction: feet
C�concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: �b
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: u 1 ''
Sludge depth
t5ins•03113 Title 5 Official Inspection Forth Subsurface Sewage Disposal System•Pape 9 of W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a ' Subsurface Sewage Disposal System Form_ Not for Voluntary Assessments
x
Pro���-{�cL�
p rty Address
Owner
Information is Owner's Name
required for
every page. Citylrown State Zi Code
P Date'of
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness t
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle D
How were dimensions determined? U d 2 U 2
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I I r I—e Al i r r ra v ---
�.
° rA r'11
i 11 1114,7
Grease Trap(locate on site plan):
Depth below grade.
Material of construction: /etaibe feet
❑ concrete ❑ ss
13 Polyethylene ❑ other(explain)
Dimensions:
Scum thickness
Distance from top of scum ffle Distance from bottom of s ee or baffle
Date of last pumping:
t5ins•03/13
Date
TWO 6 Omcial Inaper.Uon Fort Subsurface Sewage Dlabosal S"tam•pAmA 1A M 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sew ge Disposal System Form - Not for Voluntary Assessments
Property Address
Owner
Information is Owner's Name
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumpeq-at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ olyethylene ❑ other(explain)
Dimensions: 1
Capacity:
�
4
Design Flow:
gallon, per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and fl t switches, etc.):
-7---
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-03113
Title 5 Official Inspection Form Subsurface$swage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
m
Subsurface Sewage Disposal System Form - Not for Voluntary Assessm nts
Property Address
Owner
Information is Owner's Name
required for
every page. C1tyRown State Tip Code Date of Inspection
D. System Information (cost.)
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.):
L 2v 2 °� - rovl �5 �'VP✓1 - V1)tM `1 I
E� {� L
i
Pump Chamber(locate on site plan):
Pumps in working order: . 7Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, co /ffion/o f pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavatio of required):
If SAS not located, explain why:
z 7�
t5ins•03/13 Title 5 Offidal Inspection Form Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
goTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary AssesSrne nts
Property Address
Owner
Information is Owner's Name
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑
leaching renches
g number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type%ame of;technology:
Comments (note condition of soil, signs of hydraulic failure, level of pond ng, damp soil, condition of
vegetation, etc.):
Su a t 5 V 2
p (' ✓1 D4
V)A rA S l 5 aT
"t etc—Plurt - � e
-Cyo,--o I A-I L_ej c(,�� ---------7T7--'Cesspools(cesspool must be pumped as part of inspectio�t)(locate on sil a 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 i ow ❑ es ❑ No
!Stns-03/13 Title 5 official Inspection Form Subsurface Sewage Disposal System•page 13 of 17
Commonwealth of Massachusetts
lug° Title 5 Official Inspection p tion Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
% 6
Property Address
Owner
Information is Owner's Name
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of pon ing, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydr ulic failur:1evel :poncling, condition of ve etation etc.): vegetation,
t5ins-03/13 Title 5 Official Inspection Form Subsu I face Sewage Disposal 9 po System•Pepa 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
roperty Address
Owner
Information is Owner's Name
required for
every page: Cityli•own State Zi Code
P Date of Inspection
D. System Information (cont.)
i
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 al wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
4y
i
I
t5ins•03/73
Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
lug Subsurface Sewage Disposal System Form -Not for Voluntary Assess m nts
Property Address
Owner
Information is Owner's Name
.required for
every page. City/Town
State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water:
i
feet �
Please indicate all methods used to determine the high ground water el�vation:
u Obtained from system design plans on record
f
If checked, date of design plan reviewed:
ae
❑ Observed site(abutting property/observation hole within 15(?feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers -(attach document tion)
❑ Accessed USG$database-explain;
i
I
You must describe how you established the high ground water elevation;
Soti
�
Before filling this Inspection Report, please see Report Completene s Checklist on next page.
t5fns•03113
Tille 5 Official Inspection Porte Subsu ace Sewage Disposal System•Pape to of t�
Commonwealth of Massachusetts
Title 5 Official '
Inspection i-orm
��.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen s
y
Property Address
Owner Owner's Name
Information is
required for
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
2' Inspection Summary:A, B, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Sy�tems)completed
System Information - Estimated depth to high groundwater
i
Sketch of Sewage Disposal System either drawn on page 15 or atta hed in separate file
i
I�I
Title 5 Official Inspection Form Subfa a Sewage Disposal System•Page 17 of 17
t5ins•03113
TOWN OF NORTH ANDOVER
(978)688-9570
120 AMAIN S T RI lE T
Reading Informati on
O'N OR
11/1411
NOXFI I ANDOVER MA 0 1845 3f�ORE
y 4
(979)688-9570
978-688-9550
OFFICE HOURS
Mon,Wed.Th 8-4:30
Tue 8-6:00,Fri 8-12:00 3170085-4 t 6729700 10/15/2014
tE7A TN Y'HIS POR TION FOR Y0 UR RECORDS 7/1/2014-9J30rZ014 11,114/14
40VING?PLEASE, CALL 978-698-9570 INT ADVANCE
1360 SALEM STREET
GAN,JOHN, PIN PIN Previous Balan,ce — ,�jj 72A2
1360 SALEM STREET Pa)Tnents Through 10/03/2014 (72.42)
N.ANDOVEIZ,MA Adjustments I Late Charges
01845 Interest as of 11/14/2014
Balance Forward
-_ --- -V -------T 77
C
0
-M
W
na ON iy'
®R
I 031�'
WATER USAGE WATER 18 68,40
11();t.; 9/10114 ADWN FEE 7.82
926 944 18 Actual 92
k Sub-Total 76.22
'total
MESSAGE
PAYMENTS SHOULD BE MADE : TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P .O. BOX
184, N4FDFORD, NfA 02155 Over 20 units
e (
Water rate = First 20 units (-
'0 $3 . 80 idf 55 . _55
Sewer rate. : First 20 units q; $5 . 95 Over 20 units qji S9 . 24
Bypass meter Water rate : all units @ $5 . 55
PLEASE RE
�TIJRIN THIS PORTION WITH PAYMENTS
'%,"'T
%,"'Tif TOWN OF NORTH ANDOVER Billing Reading
Information 120NIAIN STREET Inforn Information
NORM ANDOVER MA 01845 (978)688-9550 (978)688-9570
416729700
978-688-9550
M
_570_9
R . ........
-"'5� '35 T'�*'�
ME _0 0_1
�!M
12MIN11-1 01 Of M 7"No R A-0
S"M Ne 3170085416729700
1360 SALEM STREET
ON(DR
BFFORE 11/14/1.4 0111- S76.22
GAIN,JOHN PIN 13IN
1360 SALEM STRLET EAMOUNTI PAID
N.ANDOVER,NfA
01945
1944 1 1,040
nLil,k7i:19700201500000110000000000000004031700850000000076220119
TOWN OF NOWFR ANDOVER (978)688-9570
ON OR
migmaMR 120 MAN STREET $49.62
Reading information 02/16/15 00*
NORTH ANDOVER N4-A 01845 (979)688-9570 BEFORE,
978-681-9550
OFTICEHOUR,
Mon,Wed,Th 8-4:30 3170085416729700 1/15/2015
Tuc 8-6:00,Fri 8-12:00
EMLIV THIS PORTION FOR YOUR RECORDS 10/1/2014 - 12/3112014 02/16/15
LOVING? PLEASE CALL 978•688-9570 IN ADVANCE -
1360 SALEM STREET
GAN,JOHN PIN PIN -7 6.22
1360 SALEM 51-REET Previous a ante
N.ANDOVE12,MA Payments Through 01/07/2015
Adjustments/Late Charges
0845 interest as of-.2/16/2015
Balance Forward
vwftm—9-10W
WATER USAGE WATER 11 41.80
9A0114 ADMIN FFE 7.82
944 955 H -Actual 90 Sub-Total 49.62
Total
MESSAGE
PAYNfENTS SHOULD BE MADE : TOWN HALL @ 120 NIAIN STREET OR BY T,,4AIL '1'0 OUR LOCKBOX @ P.O. BOX
184, NdT--DFOB.D, NIA 02155
Water rate : First 20 units (R $3 . 80 Over 20 units a $5 . 55
Sewer rate : First 20 u a i tS (d' $5 -95 over 20 units g $9 . 24
Bypass tvicter water rate : a) I uni is 55 - 55
PLEASE RETURN THIS PORTION WITH PAYMENTS
axrfr Billing R(-Aing
TOWN OF NORTH ANDOVER information
120 MAIN SIREL'I• Information
NORTH (9-18)688-9550 (979)688-9570
,,\N1)GvER MA 01845
416729700
978-688-9550
F lI VIII 11 �I 11111I��1�Iilly11 11111
I
WIN.-
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N.ANDOVER, MA
01845
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120 MAIN STREET ON OR
Reading Information 05/?8/15 $94.92
NORTH ANDOVFR MA 01845 (978)698-9570 BEFORE
978-688-9550
OFFICE HOLIRS gju'
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688-9570 IN ADVANCE
............
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1360 SALEM STREET
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GAN,JOHN PIN PIN
1360 SAIX-M STREET Previous Balance 49,62---
N.ANDONFER.,MA Payments Through 04/16/2015 (49.62)
01845 Adjustments/Late Charges
hiterest as of- 5/28/2015
Balance Forward
WATER USAGE WATER 22 87.10
I2 IM4 19115 ADMN FEE 7.82
955 977 22 Actual 90 Sub-Total "112
94.92
Total ME
4ESSAGE
PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MiAIN STREET OR BY MAIL TO OUR LOCKBOX (q) P.O. BOX
184 , NE-DFORD, MA 02155
Water rate : First 20 units C4� $3 . 80 Over 20 units 0) $5 . 55
Sewer rate : First 20 units d) $5 . 95 Over 20 units 5, S9 . 24
Bypass Meter Water rate : all units Ca. $5 , 55
PLEASE RETURN THIS PORTION WITH PAYMENTS
TOWN OF NORTH ANDOVK Billing Reading
120 NUMN STREET Information Information
NOM ANDOVER MA 01345 (978)688-9550 (978)688-9570
416729700
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1360 SALEM STREET 3170085-416729700
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01845
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TOWN OF NOW-rH ANDOVER
120 INCUNI STREET Readinc, Information ON OR
NORTH ANDOVER MA 01845 BEFORE 08/24/15 76.22
978-688-9550 ---
OFFICE HOURS
Mon,Akled,Th 8-4:30
Tue 8-6:00,rri 8-12:00 7/24L>O 15
t -
THIS PORTION FOR YOUR RECORDS
ET41A'TI m—Iffil
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1360 SALEM STREET
GAN7 JOEIN PIN PIN
1360 SALEM S'IW.L.T PIrevious Balance 94.92
W,IX
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N.ANDOVER,MA Payments Througli 07/14/2015 (94.921)
01845 Adjustments/Late Charges
Interest as of 8/24/2015
Balance Forward
Px IN -
R
WATER USAGE WATER is 68.40
64115 M)MIN FEE 7.82
9-1'7 995 18 Actual
sub-Total 76.22
Towl
4ESSAGE
PAYMENTS SHOULD BE MADE: TOWN HALL 120 MAIN STREET OR BY NMAJI. TO OUR LOCKBOX @ P -O. BOX
194 , MEDFORD, MA 02155
Water rate : First 20 units 11-11 S3 . 80 Over 20 units $5 . 54;
Sewer rate : First 20 units @ $5 . 95 Over 20 units - . $9 . 24
Bypass Meter Water rate : all units rd $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 x'978}689-9570
978-688-9550 416729700
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1360 SALEM STREET 3170085-416729700
ON OR
GAN,JOHN PIN PIN BEFORE 08/24/15 $76.22
1360 SALEM STREET
N.ANDOVER,MA AN40UNT PAID
01845
0416729700201500000000000000I)BOU000403170085000000007622009