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HomeMy WebLinkAboutTitle V Inspection Report - 201 RALEIGH TAVERN LANE 9/1/2016 �C_\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 201 Raleigh Tavern Lane _P_r�oeiiy­Address __ Thomas O'Donohue Owner Owner's Name information is North Andover MA 01845 9/1/2016 required for every 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. EEIVED Important: A. General Information When filling out forms on the computer,use I. Inspector: R, only the tab key �,ICAR' to move your -Neil J. ateson cursor-do not Name affil nspector use the return key. Bateson Enterprises Inc. Company Name 111 Arqilla Road Company Address Andover MA 01810 run city/Town State Zip Code 9784754786 S115 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 6(310 CMR 15.000).The system: n Passes E Conditionally Passes ❑ Fails r_1 eAs FurtheA Evaluation by the Local Approving Authority 9/11/2016 lnip4/for`_.sT4Signatuk/ 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 j 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owner's Name information is required for North Andover MA 01845 9/1/2016 every page. CityTrown State Zip Code date of Inspection B. Certification (cons.) Inspection Summary: Check A,B,C,D or E 1 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 basses; ® 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. o Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not a determined," please explain. a 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. El Y ® N ❑ ND (Explain below): 151ns-3/13 Title 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 201 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owner's Name information is required for North Andover MA 01845 9/1/2016 every page. CityfTown 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(coat.): ❑ 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 pipes) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): l 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 Sewaga Disposal System•Page 3 of 17 <�N, Commonwealth of Massachusetts Title 5 official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y 201 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owners Name information is required for North Andover MA 01$45 9/1/2016 -- every page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fair 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: Outlet tee in septic tank&d-box needs to be replaced. Riser on d-box needs to be installed. Repair cement around outlet pipe leaving foundation. 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 cutlet invert due to an overloaded or clogged SAS or cesspool 11 ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 �I s: s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owner's Name information is North Andover MA 01845 9/1/2016 required for every page. Cityfrown 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, prodded 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. 3 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 El 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 El the system is located in a nitrogen sensitive area (interim Wellhead Protection ❑ Area—IWPA)or a mapped Zone 11 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:Subsurfoce Sewage Dispose#System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owner's Name information is required for North Andover MA 01845 9/1/2016 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 NIA) ® ❑ 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? ® 0 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) 1310 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): 600 t5ins 3113 Title 5 Official inspection Form:Subsurface Sawage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owner's Name information is requir ed for North Andover MA 01845 9/1/2016 required every page. Cilyrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions. Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatstpersons/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•3113 Title 5 Official Inspedian Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 261 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owner's Name information is required for North Andover MA 01845 9/1/2016 every page. Cityrrown 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: Pumped three years ago, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: gallons 1500 How was quantity pumped determined? Measured tank. Reason for pumping: Inspect tank&tees 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•3113 Title 5 official inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owner's Name information is required for North Andover MA 01845 9/1/2016 every page. city/Town State Zip Code Date of Inspection D. System Information (cunt) Approximate age of all components, date installed (if known)and source of information: 35 years old, 4/14/1981, as built plan. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): DeDepth below grade. 2 p 9 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.): 4" Cast iron through wall, 3" PVC in house. Cement around pipe pulled away from founadtion, needs to be repaired. Septic Tank(locate on site plan): Depth below grade: 1 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: 10' x 5'x 4' 3" Sludge depth: t5ins 3113 Titte,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-Not for Voluntary Assessments i" k 209 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owners Name information is required for North Andover MA 01845 9/1/2096 every page. Cityrrown State Zip Code Date of Inspection D. System Information (coat.) Septic Tank(coat.) Distance from top of sludge to bottom of outlet tee or baffle N/A 211 Scum thickness L Distance from top of scum to top of outlet tee or baffle N/A= Outlet tee corroded off. Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee corroded off, needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. Pumped septic tank. 0 i1 a u Grease Trap(locate on site plan): Depth below grade: feat 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 Sawage Disposal System•Page tU of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Farm Not for Voluntary Assessments 201 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owner's Nance information is required for North Andover MA 01845 9/1/2018 every page. Cityrrown 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 s t5ins•3M Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Raleigh Tavem Lane Property Address Thomas O'Donohue Owner Owner's Name information is repaired for North Andover MA 01845 911/2016 every page. Cityfrown 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 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.): D-box cover broke, replaced it. D-box has corrosion, needs to be replaced. D-box has carryover, pumped d-box to clean. No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* l Alarms in working order: ❑ Yes ❑ No* 0 Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): B * 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•3133 Title 5 Offdal inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y 201 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owner's Name - requir information is North Andover MA 01845 9/1/2016 required for every page. City/rown state Zip Code Date of Inspection D. System Information (cons.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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.): Soil ok. Vegetaion ok. No sign of ponding to surface. Camera inside of pits though outlets in d- box, no liquid to inverts. p0p V pY ipt i 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 Una•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Raleigh Tavem lane Property Address Thomas O'Donohue Owner Owner's Name information is North Andover MA 01845 9/1/2016 required for every page. Cityfrown 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.): V I] 9 r t5ins•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fora}-Not for Voluntary Assessments Y 201 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owners Name information is North Andover MA 01845 911/2016 required far every page. City1T'own State Zip Code Date of Inspection D. System Information (coat.) 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 IN QC�1 U� WCuJ 90? : L4 D u 3 = 11W 1( k - !L4t Q t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Raleigh Tavern lane Property Address Thomas O'Donohue Owner Owners Name information is North Andover MA 01845 9/1/2016 required for every page. Cityfrown state Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 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: 5/23/1980 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan show no water 8' deep. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 i i I Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 201 Raleigh Tavern Lane Property Address Thomas O'Donohue Owner Owner's Name information is required for North Andover MA 01846 9!112016 every page. CitylTown 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 16 or attached in separate file t5ins•3113 Title 5 Ofticial Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 B I : Com'm'onwealth of Massachusetts y City/Town of . w° System Pumping-Record Form 4 DEP has.provided this form for use-by local Boards of Health. Other forms maybe'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 forth they use.The System Pumping Record must be submitted,to the local Board of Health or other approving authority. A. Facility Inform'a'tion ] 1. System Location: heft 1 Right front of douse, Left 1 Right rear of house, Left I right 1 d e of house Left I Right side of building, Left 1 Right front of building, Left I Right rear of building, Unde Address caylrown State Zip Code 2. System Owner. l C�J. 'Dono y -e-, Name' Address('IF different from location) Citylrown ' state- ip e Telephone Number +" 3 .B. Pumping record 1. Date of Pumping pate 2• Quantity Pumped: Gallons 3. Type-of system: ❑ Cesspool(s) ©--6,ptic Tank ❑ Tight Tank ; ❑ Other(describe): 4. Effluent Tee f=ilter present? ❑ Yap ©-,No- if yes, was it cleaned? ❑ Yes ❑ Na 5. Condition of System: 6: System Pumped By: Nell Bateson Fa821 Name Vehicle License Number Bateson Enterprises Ina Company 7. Location where contents-were disposed: G S: Lowell Waste Water siongWe I Hikui WU Date tftrmCdov 08103 System Pumping Record•Page 1 of 1 i u Summary Record Card generated on 812912016 12:13:32 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-106.C-0117-0000.0 Parcel Id 17750 281 RALEIGH TAVERN LANE O'DONOHUE, THOMAS 201 RALEIGH TAVERN LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.07 Acres FY 2017 UB Mailing Index Name/Address Type Loan Number Activellnact, From Until O'DONOHUE,THOMAS Payor 201.RALEIGH TAVERN LANE N.ANDOVER, MA 01845 UB Account Malnt. Account No Cycle Occupant Name Activelinactive Bldg Id. 14143.0-201 RALEIGH TAVERN LANE Last Billing Date 6/14/2016 21 00127 02 Cycle 02 Active UB Services Maint. Account No.2100127 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 11 WTR WATER 01 ALL METER SIZE 64.60 11 UB Meter Maintenance Account No.2100127 Serial No Status Location Brand Type Size YTD Cons 36207138 a Active ERT HH b Badger w Water 0.63 0.63 634 Date Reading Code Consumption Posted Date Variance 8/2/2016 641 a Actual 26 53% 5/3/2016 615 a Actual 17 6/21/2016 -5% 2/2/2016 598 a Actual 18 3/28/2016 -12% 11/2/2015 580 a Actual 20 12/30/2015 -21% 8/4/2015 560 aActual 26 9/14/2015 6% 5/4/2015 534 aActual 24 6/22/2015 29% 2/3/2015 510 aActual 19 3/20/2015 -3% 11/3/2014 491 aActual 20 12/15/2014 .31% 8/1/2014 471 aActual 27 9/11/2014 0% 5/5/2014 444 a Actual 28 6/12/2014 -6% 2/3/2014 416 a Actual 31 3/17/2014 2% 10/31/2013 385 a Actual 29 12/20/2013 13% 8/1/2013 356 a Actual 26 9/18/2013 7% 5/1/2013 330 a Actual 22 6/18/2013 2% 2/7/2013 308 a Actual 26 3/13/2013 10% 10/30/2012 282 a Actual 21 12/13/2012 -17% 8/2/2012 261 a Actual 26 9/26/2012 21% 5/2/2012 235 a Actual 21 6/20/2012 -20% 2/2/2012 214 a Actual 27 3/14/2012 41% 11/1/2011 187 a Actual 1'9 12/15/2011 -15% 8/1/2011 168 a Actual 22 9/14/2011 5% 5/2/2011 146 a Actual 20 6/13/2011 -25% 2/4/2011 126 a Actual 29 3/15/2011 -5% 11/1/2010 97 a Actual 29 12/13/2010 24% 8/3/2010 68 a Actual 24 9/13/2010 13% 5/3/2010 44 a Actual 21 6/9/2010 -14% 2/1/2010 23 aActual 23 3/11/2010 -100% 11/7/2009 0 n New Meter 0 12/11/2009 -100% 11/7/2009 3277 r Replacement 19 12/11/2009 -24%