HomeMy WebLinkAboutTitle V Inspection Report - 835 CHESTNUT STREET 3/11/2016 (2) Commonwealth of Massachusetts
E I VE E"
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form m Not for Voluntary Assessments
TOWN OF ia ii NDOVL Z
835 CHESTNUT STREET
Property Address r t
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is
required for every N ANDOVER MA 01845 03/11/16
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 General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not John J Soucy
use the return Name of Inspector
key.
Soucy's Sewer Service Inc
rab Company Name
78 North Broadway
Company Address
Salem NH 03079
City/Town State Zip Code
603-898-9339 13397
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
/nsp)ectSignature 03/11/16
Date
m inspector shall subm' 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is MA 01845 03/11/16
required for every N. ANDOVER
Citylrown State Zip Code Date of Inspection
page.
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:
B) 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, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
t5ins•3/13
Commonwealth of Massachusetts
F
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is
required for eve ry N. ANDOVER MA 01845 03/11/16
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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 ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ 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 or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public 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 wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title i i Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
;M 835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is MA 01845 03/11/16
required for every N. ANDOVER
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,
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 supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the 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 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 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
11 ® 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
11 ® Static liquid level in the distribution box above outlet invert due to an over
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 17
t5ins-3/13
Commonwealth of Massachusetts
W Title 5 Official Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is MA 01845 03/11/16
required for every N. ANDOVER
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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.
❑ ® 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.
El 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 of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
t5ins•3/13
Commonwealth of Massachusetts
Title I Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is N. ANDOVER MA 01845 03/11/16
required for every
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.
® ❑ 9
® ❑ 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): 3 Number of bedrooms (actual):
3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title i i Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is MA 01845 03/11/16
required for every N. ANDOVER
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
2
Number of current residents:
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 (gpd)):
Detail:
SEE ATTACHED
Sump pump? ® Yes ❑ No
CURRENT
Last date of occupancy: Date
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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
t5ins-3/13
Commonwealth of Massachusetts
Title Official Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/11/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: CURRENT
Date
Other(describe below):
General Information
Pumping Records:
Source of information: Soucy's Sewer Service Inc
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 150
0
9 s
How was quantity pumped determined? Gauge on truck
Reason for pumping: Maintenance and Inspection
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
Title i Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/11/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2003
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"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.):
APPEARS TO BE WATERTIGHT.
Septic Tank(locate on site plan):
"
Depth below grade: 10
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: 6'X 10.5'
Sludge depth:
3"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title i i l Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/11/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
38"
5"
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
14"
How were dimensions determined? TAPE & SLUDGE TOOL
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
PUMP TANK ANNUALY. ALL TEES ARE IN PLACE, TANK APPEARS TO BE WATERTIGHT.
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 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
F Title 5 Official l i
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/11/16
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 pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working 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 ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title i al Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
„^A 835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is N. ANDOVER MA 01845 03/11/16
required for every State Zip Code Date of Inspection
page City/Town
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.):
Flow checked good
i
i
i
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 of pumps and appurtenances, etc.):
EVERYTHING LOOKS NORMAL
* 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:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
t5ins•3/13
Commonwealth of Massachusetts
F Title 5 Official
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/11/16
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 30' X 44'
❑ 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.):
NO SIGNS OF HYDRAULIC FAILURE
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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title Official
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/11/16
page. City/rown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (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 failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title i i Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is N. ANDOVER MA 01845 03/11/16
required for every State Zip Code Date of Inspection
page. City/Town
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
36' SYSTEM TIES
TP I
r 1 3 TO TANK 13.5'
4 TO TANK 13.61
t 1 3 TO PUMP 19.8'
DISTRIBUTION BOX— 1 '° 9 1 TO PUMP 68.1'
TO 0 Box 85.4'
2 TO 0 BOX 97.1'
PT 1 I TO A 74.1' 1 TO G 72.9'
2 TO A 86.1' 2 TO G 74.1'
1 TO F 97.S. TO L 96.9'
2 TO F 107.9' 2 TO L 99.1'
J BENCHMARK 2: SPIKE
�U IN PINE TREE.
I--+ ELEV 105.25
C
d
j..� 4'CAST IRON SLEEVE EXISTING THREE
BEDROOM HODS
� SILL ELEV 104.!
BENCHMARK 1:TOP OF
'ONE BOUND. ELEV 100.00(assumed) CA
m
`0 2'SCH 40 PVC o
FORCE MAIN j
Ci 1}
.- 1000 GALLON ) 3
PUMP CHAMBER ��
1500 GALLON
PUMP CHAMBER
PRESSURE
WATER SERVICE
120.5,9' 3
S09°30'30"17
CHESTNUT STREI
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
t5ins•3113
Commonwealth of Massachusetts
Title Official i
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is MA 01845 03/11/16
required for every N. ANDOVER
page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
5'
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 2/6/03 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:
107-101.95 = 5.05' FROM TOP OF S.A.S. LOCATION. ALSO DUG TEST HOLE WITH AUGER,
APPROXIMATELY 30' FROM REAR OF S.A.S. AT DOWN SLOPE. WATER AT 3' EXISTING
GRADE.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
t5ins•3/13
Commonwealth of Massachusetts
Title Official Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
835 CHESTNUT STREET
Property Address
DIANNA DEOSSIE GAUDET
Owner Owner's Name
information is N. ANDOVER MA 01845 03/11/16
required for every
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
I
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Summary Record Card generated on 311/2016 io 39:15 AM by Karen Hanion Page 1
Town of North Andover
Tax Map # 210®107.0.0026-0000.0
Parcel id 18308
835 CHESTNUT STREET -
DEOSSIE, DIANNA C
835 CHESTNUT STREET
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.04 Acres
FY 2016
UB Mailing-index
Name/Address Type Loan Number Activetinact. From Until
DEOSSIE,DIANNA C Payor
835 CHESTNUT STREET
N.ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg id.13624.0-835 CHESTNUT STREET Last Billing Date 2/812016
1090301 01 Cycle 01 Active
UB Services Maint.
Account No. 1090301
Service Code Rate Charge {VlultipllerNsers
MISCFEE ADMIN FEE 0,635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 41.80 /1
UB Meter Maintenange
Account No. 1090301
Serial No Status Location Brand Type Size YTD Cons
w Water 0.63 0.63 638
16802324 aActive 00 METE METE
Date Reading Code Consumption Posted Date Variance
1/21/2016 1506 a Actual 11 2/19/2016 -23%
10/2112015 1495 a Actual 14 1112012015 -6%
7/23/2015 1481 a Actual 15 8/14/2015 36%
4/23/2015 1466 a Actual 11 5/19/2015 -8%
1/22/2015 1455 aActual 12 2/20/2015 1%
10/23/2014 1443 aActual 12 11/14/2014 8%
7/23/2014 1431 a Actual 11 8113f2014 8%
4/23/2014 1420 a Actual 10 5/15/2014 -14%
1/24/2014 1410 aActual 12 2/1412014 -7%
10/24/2013 1398 aActual 13 11/18/2013 -35%
7/23/2013 1385 a Actual 19 8/15/2013 30%
4/25/2013 1366 a Actual 15 5/20/2013 18%
1/24/2013 1351 a Actual 13 2/13/2013 -8%
10123!2012 1338 aActual 14 11/9/2012 -37%
7/23/2012 1324 a Actual 22 8/14/2012 5%
4/23/2012 1302 aActual 21 5/9/2012 22%
1/23/2012 1281 aActual 18 2/13/2012 -30%
10/20/2011 1263 a Actual 25 11/14/2011 -46%
7/20/2011 1238 a Actual 45 8/15/2011 112%
4/22/2011 1193 a Actual 21 5/16/2011 8%
1/24/2011 1172 aActual 21 2/11/2011 -16%
10/21/2010 1151 aActual 24 11/12/2010 -14%
7/2212010 1127 a Actual 28 8/16/2010 -1%
4/22/2010 1099 a Actual 28 5/12/2010 13%
1122/2010 1071 a Actual 25 2/12/2010 -7%
10/23/2009 1046 aActual 27 11/11/2009 -3%
7/24/2009 1019 a Actual 27 8/12/2009 20%
4/27/2009 992 a Actual 24 5113t2009 24%
1/23/2009 968 aActual 19 2/10/2009 39%