The URL can be used to link to this page

Home My WebLink AboutTitle V Inspection Report - 59 WINDKIST FARM ROAD 9/15/2014 Commonwealth of Massachusetts y Title 5 Official Inspection For y� Subsurface Sewage Disposal System Form Not for Voluntary Asses nts k 6 ° tJt� A59 ��C�I"�tv QNADKIST ddress FARM ROAD Property � KATHY CROSETT Owner Owner's Name information is N.ANDOVER MA 01845 _ 09/05/14 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 a y way. Please see completeness checklist at the end of the form. Important;When A filling out forms . General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not John J Soucy use the return _...... _.._ key. Name of Inspector Soucy's Sewer Service, Inc. ran 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 ..._� r 09/05/14 actor' Signature Date The ystem inspector shall submit 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 u Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 WINDKIST FARM ROAD Property Address KATHY CROSETT Owner Owner's Name information is required for every N ANDOVER MA 01845 09/05/14 - --- -- page. City/Town State Zip Cone Date of Inspection B. Certification (cont.) 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 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): u V (Sins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 P • I Commonwealth of Massachusetts Title 5 Official inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 WINDKIST FARM ROAD Property Address KATHY CROSETT Owner Owner's Name information is N.ANDOVER __....._ _ MA 01845 09/05/14 required for every _..... 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 (cant.): ❑ 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 G Title 5 Official inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments w„ a' 59 WINDKIST FARM ROAD Property Address KATHY CROSETT Owner Owner's Name _^ information is N ANDOVER MA 01845 09/05/14 required for every __...._ _ --- -.-. page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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 E] ® 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 1/2 day flow 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts _ s Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments •4''¢ 59 WINDKIST FARM ROAD Property Address KATHY CROSETT Owner Owner's Name information is required for every N ANDOVER MA 01845 09/05/14 - .. - --- -----...W page. City/Town State Zip Code Date of Inspection B. Certification (cant.) 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 falls. 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 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. l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 WINDKIST FARM ROAD Property Address KATHY CROSETT Owner Owner's Name information is required for every N. ANDOVER MA 01845 09/05/14 —.___ -_ ------_---.-- 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? ® ❑ 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 ® El 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ." 59 WINDKIST FARM ROAD Property Address KATHY CROSETT Owner Owner's Name information is N ANDOVER MA 01845 09/05/14 required far every ..---- . 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 Last date of occupancy: Daterent 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: - 15ins•3113 Tido 5 Official Inspection Form'Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts _ u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 WINDKIST FARM ROAD Property Address KATHY CROSETT Owner Owner's Name information is required for every N ANDOVER MA— 01845 09/05/14 _...� page. City[rown State Zip Code Cate of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Soucy`s Sewer Service _ Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 1500 gallons How was quantity pumped determined? Reason for pumping: Maintenance and Inspection m m 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): l5ins•313 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 AN, Commonwealth of Massachusetts : y Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 WINDKIST FARM ROAD Property Address KATHY CROSETT Owner _ Owner's Name information is N ANDOVERMA 01845 09/05/14 required for every - page. CltylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: est --- Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: na feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: tet 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: Sludge depth: €sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 59 WINDKIST FARM ROAD _ ........ Property Address KATHY CROSETT Owner Owner's Name information is N ANDOVER MA 01845 09/05/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) (� 4011 Distance from top of sludge to bottom of outlet tee or baffle 2" Scum thickness 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 and 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.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: El concrete ❑ metal [_1fiberglass Elpolyethylene ❑ 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 _... d t5ins-3113 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 10 of 17 I s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w, •' 59 WINDKIST FARM ROAD .__._................ .._._... Property Address KATHY CROSETT OwnerOwner's Name _...._ �.._... ..._.. ._ information equir do re N ANDOVER MA— 01845 09/05/14 required for every _.. � � __...._.._,._ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be 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 15ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments a4''+ 59 WINDKIST FARM ROAD Property Address KATHY CROSETT OwnerOwner's Name ... ... ._ ._.___ ._ __._....... information is N ANDOVER MA 01845 09/05/14 required for every —.- page. Cityrrown 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 0" 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. NOTE: "D" BOX REPLACED PRIOR TO INSPECTION. SEE PERMIT. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Sol] Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 6 Official 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 59 WIND_KIST FARM ROAD Property Address KATHY CROSETT Owner _. w.. Owner's Name information Is N ANDOVER MA 01845 09/05/14 required for every N. _.. ._.. _._....�....__ page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Type: ❑ leaching pits number: — ❑ leaching chambers number: — - ❑ leaching galleries number: ® leaching trenches number, length: (2) 3' X 70 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: --- ❑ innovative/alternative system Type/name of technology: W. 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 m Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•3113 Title 5 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 w„ 59 WINDKIST FARM ROAD Property Address KATHY CROSETT Owner Owner's Name information is N.ANDOVER MA 01845 — 09/05/14 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.): 15€ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts u Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 WINDKIST FARM ROAD Property Andress KATHY CROSETT Owner Owner's Name information is required for every N. ANDOVER MA 01845 09/05/14 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 - - 'Aal � g� I.rv,.,: zrr.ta3 I~� m v g.lhr 9r.1 '"V LIL-17 I �I1-IJ„ - ZL4Jii4 I MV..t:217.00 A� 18. �- ! TO r exra,rN< �1 15ins•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 59 WINDKIST FARM ROAD Property Address KATHY CROSETT Owner Owner's Name information is N ANDOVER MA 01845 09/05/14 required for every �_— _.. __.._ page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 4` 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: 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 APPROXIMATELY 50' FROM REAR OF S.A.S., NO WATER AT 4'. �. _ S.A.S. LOCATImm ON•) GRADE ELEVATION DIFFERENCE 5 HIGHER AT S.A.S Before filing this Inspection Report, please see Report Completeness Checklist on next page. l6ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 L Commonwealth of Massachusetts u Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments a' 59 WINDKIST FARM ROAD Property Address KATHY CROSETT Owner Owner's Name information is required for every N. ANDOVER MA 01845 09/05/14 _..._. _.._._.._....� — ...... 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 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card gsnaroled on 8!4612014 915:69 AM by Karon Hanlon Page t Town of North Andover Tax Map # 210-109.0-0050-0000.0 Parcel Id 18864 59 WINDKIST FARM ROAD CROSSETT, ALEX 59 WINDKIST FARM ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 2 Acres I FY 2015 UB Mailing index NamelAddress Type Loan Number Activelinact, From Until i CROSSETT,ALEX Payor 59 WINDKIST FARM ROAD NORTH ANDOVER,MA f 01845 UB Account Maint. Account No Cycle Occupant Name Activeltnactive Bldg Id. 13777.0-59 WINDKIST FARM ROAD Last Billing Date 8/4/2014 1090454 01 Cycle 01 Active UB Services Maint. Account No. 1090454 Service Code Rate Charge MultlplierlUsers MISCFEEADMIN FEE 1 1 9.18 11 WTR WATER 01 ALL METER SIZE 175.52 11 UB Meter Maintenance Account No.1090464 Serial No Status Location Brand Type Size YTD Cons 33406214 a Active 00 b Badger w Water 1 1 699 Date Reading Code Consumption Posted Date Variance 7/25/2014 970 a Actual 38 8/1312014 176% 4/2412014 932 aActual 13 5/15/2014 -10% 1/27/2014 919 a Actual 16 2/14/2014 -57% 10/23/2013 903 aActual 36 11/18/2013 14% 7/23/2013 867 a Actual 31 8/15/2013 80% 4/24/2013 836 a Actual 17 5/20/2013 20% 1/25/2013 819 aActual 15 2/13/2013 -18% 10/23/2012 804 aActual 18 11/912012 -49% 7/23/2012 786 a Actual 35 8114/2012 250% 4/23/2012 751 aActual 10 6/9/2012 -41% 1/2312012 741 a Actual 17 2/13/2012 -39% 10124/2011 724 a Actual 29 11/14/2011 -44% 712212015 895 a Actual 50 8/15/2011 268% 4/22/2011 645 aActual 13 5/16/2011 -4% 1/2512011 632 a Actual 15 2/11/2011 -77% 1012112010 617 a Actual 61 11/12/2010 9% 7/2212010 556 a Actual 56 8/16/2010 273% 4/22/2010 600 aActual 16 6112/2010 -21% 1/21/2010 485 a Actual 19 211212010 -22% 10/22/2009 466 a Actual 24 11/1112009 -10% 7/24/2009 442 a Actual 27 8/12/2009 2a% 4/24/2009 415 a Actual 22 5/13/2009 •2%a 1/2312009 393 a Actual 23 2/1012009 -40% 10/22/2008 370 a Actual 38 11112/2008 -39% 7122/2008 332 a Actual 61 8/15/2008 207% 4/2312008 271 a Actual 19 6/19/2008 33% 1/28/2008 252 a Actual 16 2/19/2008 -85% 10/24/2007 236 aAclual 106 11/16/2007 59% 7/20/2007 130 a Actual 63 8/15/2007 212% • Commonwealth of Massachusetts "' ►, sioe t. t 109.00050 BOARD OF HEALTH Permit No North Andover SHP-2014-0765 FEE $125.00 DISPOSAL, WORKS CONSTRUCTION PERMIT Permission is hereby granted John Soucy to(Repair)an.individual Sewage Disposal.System. at No 59 WINDKIST FARM R -- ---.........--- . .......... ROAD ..-. _ . ,. . as showm on the application for Disposal Works Conshttction Permit No. BHP-2014-076 D rnber 03,2014 Issued On: Sep-03-2014 BOARD OF HEALTH Commonwealth of Massachusetts City/Town of NORTH ANDOVER MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. I A. Facility Information Important: When filling out 1. System Location: forms on the 59 WINDKIST FARM ROAD computer,use only the tab key Address to move your N.ANDOVER MA 01845 cursor-do not Cityfrown State Zip Code use the return key. 2. System Owner: KATHY CROSETT Name 59 WINDKIST FARM ROAD two Address(if different from location) N.ANDOVER MA 01845 City/Town State Zip Code 978-549-3205 Telephone Number B. Pumping Record 1. Date of Pumping pate 09105114 2. Quantity 1 500 Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? 0 Yes ❑ No 5. Condition of System: GOOD 6. System Pumped By: ROGER ROBEY Name Vehicle License Number SOUCY SEPTIC Company 7. Location where contents were disposed: G.L.&D. Rn-XI _ 09/05/14 Signature of KAuler Date http:tlwww.mass.gov/dep/water/approvalslt5forms.htm#lnspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 �1It#bis I 1 i PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As ofd 9/9/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair o ox By: John Soucy At. 59 . st Farm Road Map 109.0 Lot 0050 North ver, MA 01845 The Issuance f this certificate shat at be construed as a guarantee that the system will function satisfactorily. ,5u do awyer Public Health Agent IN,,o1� 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.6889540 Fax 978.6 88,8476 Web www.townofnorthandover.com