HomeMy WebLinkAboutTitle V Inspection Report - 100 RALEIGH TAVERN LANE 3/30/2016 Commonwealth of Massachusetts
Title 5 Official Inspection
Subsurface Sewage Disposal System Form ® Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/30/16
---------
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.
filling out forms General Information RECEIVE E)
���°
filling out forms
on the computer,
use only the tab 1. I APR 1 � 2015
key to move your Inspector:
Or cursor-do not John J. Soucy TOM Or q( r i I C��DOVER
I°��
J
use the return Name of Inspector H A-I H —
key.
Saucy's Sewer Service Inc.
rea Company Name
78 North Broadway
Company Address
$ran 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
❑ Ne d`s Further Evaluation by the Local Approving Authority
3/30/16
Inspec r's` i ur Date
T 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 flaw 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 I I Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/30/16
page. Citylrown 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:
® 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:
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):
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title i i Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is N. ANDOVER MA 01845 03/30/16
required for every
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
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title i i Inspection
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/30/16
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
❑ ® 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
F Title 5 Official Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/30/16
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.
❑ ® 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title I I I Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is N. ANDOVER MA 01845 03/30/16
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.
® ❑ 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 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/30/16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
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
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:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Inspection AAMW Title 5 Official
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/30/15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (coot.)
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: 1500
gallons
How was quantity pumped determined? PLANS
Reason for pumping:
Type of System:
® Septic tank, ; 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
F Title 5 Official
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/30/16
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:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 30" OR 2.5'
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 18" OR 1.5'
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:
2"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form o Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/30/16
page. CityFrown 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
39"
Scum thickness
0°
Distance from top of scum to top of outlet tee or baffle
7"
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.):
TANK IS STRUCTURALLY SOUND, NO APPARENT LEAKS, TIES IN PLACE.
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
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/30/16
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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
' M 100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/30/16
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
N/A
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.):
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.):
ALL TESTED GOOD
* 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title ii Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is N. ANDOVER MA 01845 03/30/16
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number.
® leaching chambers number:
77 QUICK 4S
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
® innovative/alternative system
Type/name of technology: BIO MICROBES ��
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
NO SIGNS OF ANY HYDRAULIC FAILURE. PRESSURE DISTRIBUTION SYSTEM MEETS
PRESSURE TEST.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
f Title 5 Official Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is N. ANDOVER MA 01845 03/30/16
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 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 I Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 03/30/16
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
i
2GrHIIAf STEP.R LMT fi)F(1 P F- rtje
� �I1 11 L'R1.91i
COIITROL \ nA
fC11014 — r------ \
>olRl ` —------- —
\ ' 151111c'TOUR
EL
_.-— — -- ___`._\_ ,�.� — RILL I OUSE )
-__J '
_ FI'fR�"Ir UiE CnlC.ili-
_ __T t Y -� EX'S 'G CEr'(I. .....
0
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--------------
X00 °
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leEx------ /
ulw._ I
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°�...�-..�... ... .......> /' 155'.rift,i�xl1t
f
Pz N 1.7319 I
RaESSURE_/ =
40 MIT.114PEROO S ivAiER SERVIf,E /
f!NtaIER.lOP EI:EV.99.67
APFRO%INATE LDr,ArIUll IJF / — • _
,.,
EMS OM lEA!'N MEA
t�
R.ALIJIGII I1� VFR 1 L�11�lEi;
— — SYSTEM TIES
3 To TANK 27.7' 3 TO PUMP 41.8'
2 TO TANK 47.9' 2 TO PUMP 40.7'
1 To A 60.4' 1 TO H 113.8'
2 TO A 47.0' 2 To H 107.8'
1 TO G 44.6' ? TO 1 106.0'
2 TO G 35.8' 2 TO I 103.3'
INSPECTION PORTS
1 TO T 105.1' 1 To U 104.6' 1 TO V 102,1' 1 TO W 10o.8'
2 TO T 98.5' 2 TO U 98.5' 2 TO V 96.5' 2 TO W 95.E'
1 TO X 100.5' 1 TO Y 99.2' ` TO Z 98.0'
2 TO X 96.0' 2 TO Y 95.3' 2 TO Z 95.o'
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title i i Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is N. ANDOVER MA 01845 03/30/16
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 round water: 34" OR 2.83'
p g g 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: 8/03/04
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:
DUG HOLE WITH AUGER IN LOW DROP OFF AREA, WATER AT 20" (2' ELEVATION
DIFFERENCE ).
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
Title iil Inspection
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 RALEIGH TAVERN LANE
Property Address
LESLIE WONDOLOWSKI
Owner Owner's Name
information is N. ANDOVER MA 01845 03/30/16
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
44 Commercial Street
Raynham,MA
02767
Toi: (508)880-0233
Pax: (508)880.7232
June 18,2015
North Andover Board of Health
1600 Osgood Street
North Andover,MA 01845
Attention: Health Agent
Reference: PAST®Wastewater Treatment System-Serial Number: 24277
Attached please find the Field Inspection& Service Report with field test results for
services performed on 4/25/15 at the property of David Wondolowski located at 100
Raleigh Tavern Lane,North Andover,MA.
Please call if you have any questions or require additional infornnation.
Sincerely,
Wastewater Treatment Services,Inc.
Service Department
Enclosures
Copy to: David Wondolowski
Massachusetts DRIP
t M—N � � I-�'All ,
1 IIC 9 D Y O It 11 T [D
8460 Cale Parkway, Shawnee, KS 66227, Phone 913-422-0707, Fax 913-422-0808
e-mall'onsite(tz blomicrobics,com,www.biomicrobics, oc.�1r ,800-763-FAST(3278)
FIE.LU INSPECTION & SERVICE REPORT
For Bio-Microbics Single Horace FAST'System
23617
AU rHOR1 SERV! ��raE�
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Installation Address; 100 Raleigh Tavona Lanc Name:NVastewatorTreatment Services,Inc.
North Andover,MA 01845
OwnerNamc:David wondoloivski
Mail Address: 100 Ralcig Cravem Lane Mail Address: 44 Commercial Streel
North Andover,MA 01845 Raynham,MA 02767
Phone:617.821-1617 Fax: a-moil: phone:(508)8800233 Pax:(508)880.7232 c-mail:
Model No. Serial No. Date of installation Date oflastpump out
MieroFAST.5 24277 11/11/2004 9/23/2013
.-QY11pMT? T, f hf�t YES r t o NO ilC13 PTtCrUItQA 9 CO l z
MATNTL' . ,_...
Electrlcnl Pa11eT(9)
Visual Alann Operating x _
Audio Alarm Operating x
(ifprosent) -
Blower(s)
Air Inlet Filter Clean x
Blower Hood Vents Clear x
Bxcessive Noise x _---
Excessive Vibmtlon x
UcAlment unll(s)
Unusual Odor _ x -
Pumpont Required x
Priniory Settling Zone 12"
Aerobie`llrestmentZone
;�1?n�2�F:`�T(Qptton»�)_ ° --..__—..
Estimated Daily Flow 440gpd
pH(Standard Units) 6.84
Color Clear
Temperaturo
Odor Earthy
Commends _
SERVt�'CsI?Ai
N' T .¢
-Y` — Michael Folsy — 4/25115 __—
sUrnmary Record Card generated onm22/emvu29:54mwby Karen Hanlon Page 1
Town of North J\Ddo\/e[
Tax Map # 210-107.A-0109-0000.0
Parcel |d17934 �
100 RALEIGH TAVERN LANE
DAVID & LESLIE VVEND0LOWSN[|
100 RALEIGH TAVERN LANE
NORTH ANDOVER, K8A-01845
c|aom 101 Single Family Property Type 1 Residential
Zoning2 1 Reo|danbo| ZpninQ3 1 Residential |
Size Total 1.03 Acres |
FY 2016
UB Mailing Index
mammxwumes Type Loan Number AoUve8nau, From Until
DAVID&LESLIE VVENDOLDVVSK| Owner
1OU RALEIGH TAVERN LANE
NORTH ANDOVER,MAV184o
ARSNOVV8RYAN Previous Customer Inactive 11/17/2004
1VO RALEIGH TAVERN LANE
N.ANDOVER, MA
01845
Account No Cycle Occupant Name Active/Inactive �
Bldg |d. 13n47.0' 100 RALEIGH TAVERN LANE Last Billing Date 3/14/2016 �
2100200 O2 Cycle 02 Active |
Account No.21OO2UO �
Service Code Rate Charge Multiplier/Users
m|8CFEEADM|NFEE 0.6350 7.82 1/
VVTnVV8TER O1 ALL METER SIZE 64.60 /1
UB Meter Maintenance
Account No. 2100200
Serial No Status Location Brand Type Size YToCnno
16336835 aActi,e eRT METE METE wVVater 0.83Oa3 773
oaho Reading coda Consumption Posted Date Variance
2/2/2018 1352 a8mua| 17 3/289016 '40%
11/2/2015 1335 aAutuo| 31 12/30/2015 -14%
8w/2015 1304 axdua| 37 9/14/2015 113%
5/4/2015 1267 oActuo| 17 6/22/2015 9%
213/2015 1250 aActua| 10 3/202015 -42% �
11/3/2014 1234 uAmua| 28 12/15/2014 '51% �
01/2014 1206 aActva| 54 9/11C014 207%
5mo014 1152 aAmua| 18 012/2814 7%
2/4/2014 1134 aActue| 18 3/17/2014 -38m
10a1/2013 1116 axmua| 28 12/202013 '696
8/1/2015 1088 oAomo| 30 9/18/2013 80%
5/1C2013 1058 aActuu| 15 6/18/2013 0%
2/7/2018 1043 aActua| 18 3/13/2013 '30%
10D0/2012 1025 aActuo| 25 12Y13/2012 '28%
8/2/2012 1008 aActuo| 36 9/26/2012 *1Y6
5/2/2012 984 aActuu| 25 0/20/2012 38%
2/2/2012 839 e8dum| 19 3/14/2012 '31%
11/1/u011 920 e8mum| 27 12/15/2011 '43Y6
8/2/2011 893 oActua| 48 9/14/2011 167%
5/2/2011 845 aActua| 17 013/2011 '12%
2/4/2011 VxO aActuo| 21 3/15/2011 -23%
11/1/2010 807 aActua| uO 12/13/2010 ~54Y4
8/3/2010 781 aAotua| 58 9/13/2010 310%
5/3/2010 723 aActva| 14 8/9/2010 O%
2/1/2010 709 a8ctua| 13 3/11/2010 '19%
11/2/2089 898 oAotua| 16 12Y11/2009 -26%
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