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HomeMy WebLinkAboutTitle V Inspection Report - 72 WINDSOR LANE 3/18/2014 e /5 o n Professional Stormwater Management System and Septic System Inspectors OFFICIAL TITLE V INSPECTION REP for the property located at 72 WINDSOR LAN NORTH ANDOVER, MASSACHUSETTS Prepared for: Matthew Carpenter 72 Windsor Lane North Andover, MA 01845 Prepared by: Scott P. Cameron, P.E. Mass Certified Title V System Inspector# 12345 Cameron Site Inspection, Inc. P.O. Box 262 Middleton, MA 01949 P: (781) 520-9496 MARCH 18, 2014 CSI Job No,2014-001 t Commonwealth of Massachusetts Title 5 Official i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 72 Windsor Lane Property Address Matthew Carpenter Owner Owners Name information is North Andover required for every MA 01845 March 17, 2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. general Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Scott P. Cameron, PE key the return Name of Inspector Y• Cameron Site Inspection Inc r� Company Name PO Box 262 Company Address Middleton MA 01949 City/Town State Zip Code (781) 520-9496 S112345 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CM 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Need urther Evalua ' n by the Local Approving Authority Inspec or' Si nature ��p�1�i- 9 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. Cityfrown 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: ® 1 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: System in good functioning condition, current owner has re ularly maintained. New Distribution Box. System Conditionally Passes: ❑ e or more system components as described in the "Conditional Pass" section need to be repl d or repaired. The system, upon completion of the replacement or repair, as approved by the Boa f Health, will pass. Check the box for' ", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please ex in. The septic tank is metal and o 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltr . n or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replace ith a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is stru ally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 year Id is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if umps/alarms are repaired. B) S tern Conditionally Passes(cont.): ❑ Obse tion of sewage backup or break out or high static water level in the distribution box due to broke r obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspe ion if(with approval of Board of Health): ❑ broken ' e(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction I removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box i leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 tim a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of th Board of Health): ❑ broken pipe(s)are replaced ❑ 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 Healt\31CMR rmine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordMR 15.303(1)(b)that the system is not functioning in a manner which lic health,safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wersh l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Official Title 5 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 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) determines that the system is functioning in a manner that protects the public health, s ety and environment: ❑ Th system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet surface water supply or tributary to a surface water supply. ❑ The Sys t has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has septic tank and SAS and the SAS is within 50 feet of a private water supply well, ❑ The system has a septic to and SAS and the SAS is less than 100 feet but 50 feet or more from a private water sup well**. Method used to determine distan **This system passes if the well water analysis, rformed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presenc f ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure crl is 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 ❑ ® 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 ❑ ® 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 than %day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter _ Owner Owners Name information is required for every North Andover MA 01845 March 17, 2014 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well ❑ ® 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.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. Large Systems: To be considered a large system the system must serve a facility with a n flow of 10,000 gpd to 15,000 gpd. For large sys you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section Yes No ❑ ❑ the system is within feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a ' tary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive a (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public wa upply well If you have answered"yes"to any question in Section E the system is considere i nificant threat, or answered"yes" in Section D above the large system has failed. The owner or opera any large system considered a significant threat under Section E or failed under Section D shall upgra system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Official Title 5 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. City/Town 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? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ 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: ® ❑ 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Offiaal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Official Title 5 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? �� Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (9p d))� 49 GPD Detail Based on actual water readings 2/3/14 to 5/2/12 Sump pump? ❑ Yes ❑ No Last date of occupancy: Date mercial/Industrial Flow Conditions: Type of Establish Design flow(based on 310 CM 03): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc. . Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Seviage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 72 Windsor Lane _ Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health- Last Pump 11/6/12- 1,500 Gal Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: not pumped gallons How was quantity pumped determined? not pumped Reason for pumping: not pumped 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 28 y/o-8/2/86 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18 p g feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): cast iron in dwelling, PVC at tank Distance from private water supply well or suction line: +30' to Water Service feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer in good condition no evidence of cracks leaks within the dwelling. Septic Tank(locate on site plan): 6"-8" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: not metal years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 10'-6"x 5'-2"x 5'-0" Sludge depth: t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Official i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter _ Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 15.. Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 20.. How were dimensions determined? slude judge, ruler and measuring stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition, baffle secure and typical for a 28 y/o tank, inlet secure. Greas rap (locate on site plan): Depth below gra 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 or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �., 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) C ments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liqui evels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(t k must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: g Ions Design Flow: gallons er day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worki order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ N t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts 1 1 Inspection Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ti 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is North Andover MA 01845 March 17, 2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0.. 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.): D-box replaced as part of inspection. Approximately 42"deep. Concrete risers added to within 6"of finished grade Flow equalizers added. Plenty of slope on d-box outlets to field. Chamber(locate on site plan): Pumps in working o ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, co n of pumps and appurtenances, etc.): _77777� * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 @ 53' Long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Field located at top of small hill. No evidence of breakout or hydraulic failure on the ground surface (snow cover during inspection, no melted snow or irregularities observed). Excavated test hole at d- box. No standing/weeping water encountered at field. Trench dimensions obtained from system plan of record indicate at least 4'wide x 30" deep trenches. Soil is moderately well drained, 20 minute per inch rate according to design plan of record. ools (cesspool must be pumped as part of inspection) (locate on site plan): Number and config on Depth—top of liquid to inlet inve Depth of solids layer Depth of scum layer - Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts H F Title 5 Official Inspection Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) mments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc. . Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failur level of ponding, condition of vegetation, etc.): 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Inspection Tit-le 5 Official C Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A 3 C TAmv cN 47.G' TANK auT 52.4' D_ soy, Coo.5 r 49.:-i ^ t)-6oK o '15A-Ay�OUT o ` ANC t ty C $ A. #?2 �. w } � r t r Noy- 'ro S�q�.E t5ins-3113 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 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: At least 6' 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: 5/14/86 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: Observed leaching field at top of small hill. Nearest estimated groundwater observation in detention pond in rear of parcel, at least 10' below bottom of system. Also checked system design plan which indicates a seasonal groundwater elevation of 140.00. System As-Built (8/2186)assuming 30" of stone per design plan, bottom of lowest trench elevation 146.00. Also excavated near d-box. No water observed. No evidence of water in basement, it was observed to be dry and homeowner reports no history of water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Official Title 5 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °4 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Water Usage Calculation ,,(t6on Address: 72 Windsor Lane North Andover, MA 01845 Proj. No.: 2014-001 Date: March 18, 2014 aj E CS I ra rofessional Stormwater � Management System and Septic System Inspectors Meter Days Between Average Date Reading Readings Usage per Day(GPD) 2/3/2014 648 94 51.6 11/1/2013 632 87 54.3 8/6/2013 611 97 47.1 5/1/2013 591 86 51.4 2/4/2013 572 97 44.1 10/30/2012 549 90 45.6 8/1/2012 528 91 43.4 5/2/2012 501 Average 49.0 Summary Record Card generated on 2/14/2014 9:54:20 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-106.0-0070-0000.0 Parcel Id 17827 72 WINDSOR LANE MATTHEW& MONICA CARPENTER 72 WINDSOR LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1,01 Acres FY 2014 UB Mailing Index Name/Address Type Loan Number Activellnact. From Until MATTHEW&MONICA CARPENTER Owner 72 WINDSOR LANE NORTH ANDOVER,MA 01845 POLIZZOTTI,LOUIS Previous Customer Inactive 2/15/2008 72 WINDSOR LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant_Narne Active/inactive Bldg Id. 13417.0-72 WINDSOR LANE Last Billing Date 12/16/2013 2100062 02 Cycle 02 Active UB Services Maint. Account No.2100062 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0,635/8 7,82 1/ WTR WATER 01 ALL METER SIZE 81.55 /1 UB Meter Maintenance Account No.2100062 Serial No Status Location Brand Type Size YTD Cons 32707583 a Active ERT HH b Badger w Water 0.63 0,63 508 Date Reading Code Consumption Posted Date Variance 2/3/2014 648 a Actual 16 -29% 11/1/2013 632 a Actual 21 12/20/2013 17% 8/6/2013 611 a Actual 20 9/18/2013 -7% 5/1/2013 591 a Actual 19 6/18/2013 -7% 2/4/2013 572 a Actual 23 3/13/2013 2% 10/30/2012 549 aActual 21 12/13/2012 -21% 8/1/2012 528 a Actual 27 9/26/2012 -10% 5/2/2012 501 a Actual 30 6/20/2012 12% 2/1/2012 471 a Actual 27 3/14/2012 9% 11/1/2011 444 aActual 24 12/15/2011 4% 8/4/2011 420 a Actual 24 9/1412011 0% 5/3/2011 396 a Actual 22 6/13/2011 48% 2/7/2011 374 a Actual 17 3/15/2011 -19% 11/2/2010 357 aActual 20 12/13/2010 -31% 8/2/2010 337 a Actual 28 9/13/2010 16% 5/5/2010 309 a Actual 25 6/9/2010 8% 2/2/2010 284 a Actual 23 3/11/2010 -27% 11/3/2009 261 aActual 31 12/11/2009 69% 8/6/2009 230 a Actual 20 9/11/2009 -21% 5/1/2009 210 a Actual 23 6/16/2009 6% 2/2/2009 187 a Actual 22 3/16/2009 26% 11/512008 165 a Actual 18 12/10/2008 -18% 8/5/2008 147 a Actual 23 9/1212008 -21% 5/1/2008 124 a Actual 23 6/18/2008 282% 2/15/2008 101 f Final Bill 8 2/15/2008 -36% 11/6/2007 93 aActual 12 1/15/2008 -41% Commonwealth of Massachusetts City/Town of h��V C 6 2012 System Pumping Record N V NOFNORTHANDOVER Form 4 HEALTH DEPARTMENT DEP has provided this form fqr use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location.- forms on the computer,use _ _ �-n_.`� only the tab key Address to move your cursor-do not Cily/Town J T e✓`' State Zip Code use the return key. 2. System Owner: Name _ ... _ ... Address((f different frorh location} CilytTown - -- — Slate Zip Code Telephone Number B. Pumping Record - �- L(3. _` —. 2. Quantity Pumped-. � '©o- 1. Date of Pumping Date p Gallons 3. Type of system: ❑ Cesspool(s) obeptic.Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - - 4. Effluent Tee Fifter present? Yes ❑ No If yes, was it cleaned? es ❑ NO 5. Condition of System: 6. System Pumped By: Name vehr'Efetcensetumber Company 7. Location where contents were disposed Sign Ha ule Date S! ature of Receiving Facility 15form4.doc-03106 System Purnping,Recom•Page t of t COMMONWEALTH OF MASSACHUSETTS MASS.DEP APPROVED TITLE 5 SYSTEM INSPECTOR rti C Scott Cameron °) 14 Kimberly Lane Middleton,MA 07949 PURSUANT THE gl30/2074 T GENERAL LAWS N ti