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HomeMy WebLinkAboutSeptic Pumping Slip - 295 CANDLESTICK ROAD 5/25/2017 Commonwealth of Massachusetts r�LTitle Official Ins R�on Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` �,- 295 Candlestick Road -- 60 ®u Property Address 1 Kris & John Kosheff Owner Owner's Name information is North Andover MA 01845 05/25/2017 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. Important:When p� General Information filling out forms f" on the computer, use only the tab 1. Inspector: key to move your cursor-do not Robert Herrick ° use the return key. Name of Inspector Wind River Environmental ran Company Name 163 Western Avenue Company Address f Gloucester MA 01930 CityfTown State Zip Code (9782-7315 _. _ S113758 ........ 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 El Needs Further Evaluation by the local Approving Authority i 05/25/2017 _..._.. - - ...__ _ — -- _ _. ...... ... Jrrs-pector's Signature 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 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p 295 Candlestick Road Property Address Kris & John Kosheff _ Owner Owner's fume information is Nth Andover MA 01845 _ 05/25/2017 required for every or page. City/Town 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: 13) 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): t5ins_doc•rev,6116 Title 5 Official Inspection Form'.Subsurface Sewage❑isposal System•Page 2 of 17 Commonwealth of Massachusetts u _ Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 295 Candlestick Road Property Address Kris & John Kosheff Owner Owner's Name information is North Andover MA 01845 05/25/2017 required for every _......_ __....._._ .... page. CItyFrown 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 i 3� 6ns_doc rev,6716 Title 5 Oficial Inspection Form:Subsurface Sewage disposal System-Page 3 of 17 I Commonwealth of Massachusetts �� ���^�0�� �� �������~~��N 0��������°��0���� �~��N°N�� mm�m�� �� -�' w " �~~��~� �� ����,~~~~~~~~ ~ ~ ~~ - - - - Subswrface Sewage Disposal System Form Not for Voluntary Assessments 295Candlestick Road Property Address Kris & John_Knsheff Owner Owner's Name information is No�hAndnv�r MA 01845 05/252017 evvin,uorr"e* page. ~'"''~`~' State -` Code Date of Inspection B. Certification (cont] 2. System will fail unless the Board oYHealth (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 100feet ufasurface water supply nrtributary toasurface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet ofm private water supply well. F-1 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 vvo|l ^ Method used todetermine distance: °^ This system passes ifthe well water analysis, performed at DEP certified |obonsbnry, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal toorless than 5ppm, provided that noother failure criteria are triggered. Acopy nfthe analysis must boattached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: � You must indicate "Yss" or"Nq"bmeach ofthe following for all inspections: Yes No ! �� �� Backup nfsewage into facility orsystem component due hooverloaded nr � �� �~ clogged SAS urcesspool � �� �� Discharge orponding ofefOuenthuthe surface nfthe ground orsur�cevvatero ^� �~ due toonoverloaded orclogged SAS urcesspool Static liquid level in the distribution box above outlet invert due to an overloaded �� [� �~ �~ orclogged SAS orcesspool Liquid depth in cesspool is less than 6" below invert or available volume is less �� �~ than 1/2da flow Commonwealth of Massachusetts Title~�"���N�� �� ��^��������N N��������°������� ����U�N7K� �� ��/� � ����mmN Nmw�����~���B�.mm Form SubsurfacmSevvmgwDispoaa| SvmtemmFonm - NotforVo|unbaryAa000nmenta 28SCandlestick Road � Property Address Kris & John Koaheff Owner 0wnr/vNam� information is required for every North Andover MA 01845 05/25/2017 Code Date of Inspection page. ~'`r'~~^ State Zip B. Certification (cont.) Yes No Required pumping more than 4times inthe last year NOT due toclogged or � obstructed pipe(s). Number oftimes pumped: El Z Any portion of the SAS, cesspool or privy is below high ground water elevation. � � El �� Any po��nofoonnopn orpr�yinvv�hin1OOfeet ofoour�y:ewater suppK/or � `� �� tributary toasurface water supply. Any portion nfacesspool orprivy iswithin oZone 1 ofapublic well. � El 0 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 oprivate water supply well with noacceptable water quality analysis. [This system passes ifthe well water analysis, performed at DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to orless than 8 ppm, provided that no other failure criteria are triggered, A copy of the analysis and chain ofcustody must bwattached bxthis formo.] �l �� The system isacesspool nom|ngafeniUtyvvithadesign Onwuf2OOOgpd- �� ~~ 10.000gpd� � El �� The systmnnfmUs. | have determined that one ormore ufthe above failure �� �~ criteria exist aadescribed in 310 CMR 15.303` therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary hncorrect the failure. E) Large Systems: Tmbeconsidered alarge system the system must serve afacility with a design flow of1Q,00Dgpdtp1S'00Ogpd' For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions inSection O. Yee No El the system iswithin 4U0feet qfa surface drinking water supply D F the system is within 200 feet ofm tributary to a surface drinking water supply | �� �l the system ialocated |nanitrogen monaidvoarea (Interim VVe||headProtection �� �� Area— |VVPA)oramapped Zone || ofapublic water supply well |fyou have answered^yen^ hzany question inSection Ethe system |aconsidered asignificant 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 inaccordance with 310 CMR 15.804. The system owner should contact the appropriate regional office ofthe Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 295 Candlestick Road Property Address Kris & John Kosheff i �. _......_ m Owner Owner's Name information is required for every North Andover MA 01845 05/25/2017 page. CItyCTown 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ElWere 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 ® ❑ 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. El ® 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): 660_gpd lsins,doc-rev.6116 Title 5 Official Inspection Form,Subsurface Sewage nisposaT System•Page 6 of 17 Commonwealth of Massachusetts I r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 295 Candlestick Road Property Address Kris & John Kosheff Owner Owner's Name information is /25/2017r MA 01845 0 North Andover required for every N _... ._ ..._ _... _ page. City/Town State Zip Code Date of Inspection D. System Information Description: item is made up of a se tp is tank, distribution box and soil absorption system. 3 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)): 105.3 gpd Detail: The gallons per day is based off of the last 2ey ars ofthe customer's water records. Sump pump? ❑ Yes ® No Occur upied. Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: -... Design flow(based on 310 CMR 15.203): Gallons per day(g pd) Basis of design flow (seatslpersonslsq.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 0 i Water meter readings, if available: i I i t5Tns,doc•rev_6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 7 of 17 3 Commonwealth of Massachusetts { Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 295 Candlestick Road Property Address Kris & John Kosheff Owner Owner's Name information is North Andover MA 01845 05/25/2017 required for every _....... ___..._ _...... _.........___ ... _.. ___... ___...._ page, CltyTown State Zip Code Bate of Inspection D. System Information (cont.) I Last date of occupancy/use, Date - Other(describe below): General Information Pumping Records: Wind River Environmental and Home Owner Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: _._.. _.... 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 IIA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins_doc•rev,6116 Title S Official Inspection Form Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 295 Candlestick Road Property Address Kris & John Kosheff ...................... Owner Owner's Name information is required for every North Andover MA 01845 05/25/2017 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: 1992; Plans on File Were sewage odors detected when arriving at the site? El Yes No Building Sewer(locate on site plan): 20" Depth below grade: feet Material of construction: cast iron El 40 PVC F-1 other(explain): Town Water Distance from private water supply well or suction line: fee.t Comments (on condition of joints, venting, evidence of leakage, etc.): A!I joints are solid and there are no signs of leakage. The venting js_through the building sewer. ............ Septic Tank(locate on site plan): Depth below grade: feet Material of construction: E concrete El metal El fiberglass El polyethylene El other(explain) If tank is metal, list age: y ears Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No 1010... x 68" x 68" Dimensions: Sludge depth: t5ins.doc-rev.6116 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 - Not for Voluntary Assessments °v 295 Candlestick Road Property Address Kris & John Kosheff Owner Owner's Name information is MA 01845 05/25/2017ove North Andover required for every _..._.. —_.......-- --_.. ...... .. _.,. 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 29 2" Scum thickness _ 6 Distance from top of scum to top of outlet tee or baffle 14 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape measure; Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.)-. Recommendup mpingyearly. The inlet and outlet are solid. There are no s ng s of leakage and the liquid level is OK in relation to the inverts. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: El concrete El metal Elfiberglass ❑ polyethylene Elother (explain): d n 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 I Date of last pumping: Date is t5ins.doc•rev,elle Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 295 Candlestick Road Property Address Kris & John Kosheff Owner Owner's Name information is required for every North Andover MA 01845 05/25/2017 page. Clty/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: ©ate Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ElYes ❑ No 0 i l5ims,doc•rev.6116 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 11 of 17 I I Commonwealth of Massachusetts u Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments a 295 Candlestick Road Property Add€ess Kris & John Kosheff Owner Owner's Narr€e information is North Andover MA 01845 05/25/2017 required for every —.-- _- _... .. _- page. City/Town State Zip Code Date of Inspection D. System Information (cant.) i Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 i 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.): The distribution box is solid and has no si ng sof leakage or carryover. The liquid level is OK in relation of the inverts. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6118 Title 5 Official Inspection Form:Subsurface Sewage Usposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °o- 295 Candlestick Road Property Address p Kris & John Kosheff _..... Owner Owner's Name information is North Andover MA 01845 05/25/2017 required for every _— _.. ._..� _ _.. 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: ❑ 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.): The soil is dry and there are no signs of"hydraulic failure. There is no ponding and the vegetation is normal for the area. 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.doc•rev_6116 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 asya 295 Candlestick Road Property Address Kris & John Kosheff Owner Owner's Name information is required for every North Andover MA 01845 05/25/2017 Sit�_te Zip Code Date of Inspection page. CityfTown 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, t5ins.doc-rev 6146 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 Form Not for Voluntary Assessments "0 295 Candlestick Road ............. Property Address Kris & John Kosheff Owner Owner's Name information is North Andover MA 01845 05/25/2017­___.1_____.­1 required for every page. Cityfrown 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: El hand-sketch in the area below Z drawing attached separately 15ins dcc-rev 6116 Tilte 5 Official Inspection Form:Subsurface Sewage Uaposai System•Page 15 of 17 �. �p -. -F.•,' 5- l ..:E'=v. 4a -3 •e.� Y .�i r i ELx 1:- ll, -i i. .3�r'.31- -r.f y.A t F 2-, <� _"fi3= 4 4 _ _ :�4 r, :qlchii-'. -?.s`i= `�'L. Lha \ t to- ti -a � . -� .�-, hF:. - i P.G r .n_ { .tt. d < >JIY § ','4,I - $ : s _ £- �^ - ,:fir. :. :_ - P-_ �€ �.'t€�#"' �_ _ '� - - r -:'-fit -<h �,_ €:p )t�:T'iyt q4 �:S.Y 'g' iK - ': I t� 1, 4 P -v', �! F ..�T _ - - 4 Z. - R,: Wrs_ ,SLS icS 3 t i - c fid& §- -s� .i _ :- f J _t- ,r r'. ,,�',,4' c'1 :t`5� -� ly "- - ' 3, c. '- 1� !', `g. -'s - _�£'�Z,„ Yil' + 1 } s,,,-��r €"- n - '-v itis F ."'<_ �66 v S;�,1 «'s-- �' P i '�fi;" 1 ? ! -_t �:t .� �.0 3 -- Bey. 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Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 1001, Estimated depth to high ground water: teat 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: 1990 _...._ 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: The estimated high ground water elevation was determined usin the 1990 design plan on file with the Board of Health. F i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage disposal System Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments —syr r 295 Candlestick Road Property Address Kris & John Kosheff Owner Owner's Name information is North Andover MA 01845 05/25/2017 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 16ins doc-rev 6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I Summary Record Card generaled an 51912017 8:33:18 AM by Karen Hanlon P89F 1 Town of North Andover Tax Map # 210-106.A-02330000.0 Parcel Id 17378 295 CANDLESTICK ROAD KOSHEFF, JONATHAN 295 CANDLESTICK ROAD N.ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential s Size Total 1.8 Acres FY 2017 " US Mailing Index Name/Address Type Loan Number ActivellnacL From Until KOSHEFF,JONATHAN Payor 295 CANDIES-FICK ROAD N.ANDOVER,MA 01845 US Account Maint. Account No Cycle Occupant Name Activelinactive Bldg Id, 17655.0-295 CANDLESTICK ROAD Last Billing Date 4/6/2017 3170325 03 Cycle 03 Active UE3 Services Maint. Account No.3170325 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63518 7,82 it WTR WATER 01 ALL METER SIZE 114.85 /1 UB Meter Maintenance Account No.3170325 Serial No Status Location Brand Type Size YTD Cons 36348639 a Active ERT HH b Badger w Water 0.63 0.63 2149 Date Reading Code Consumption Posted Date Variance 31812017 2172 a Actual 27 4/12/2017 -62% 12/912016 2145 a Actual 73 1/23/2017 -66% 919/2016 2072 a Actual 205 10!2412016 166% 6113/20/6 18667 aActua] 84 612/20t6 203% 3/9/2016 1783 a Actual 26 4122/2016 -43% 12/1012015 1757 a Actua] 47 1/20/2016 -74% 9/9/2015 1710 a Actual 182 10/16/2015 84% 619/2015 1528 a Actual 97 7/24/2015 246% 311112015 1431 a Actual 28 4/28/2015 -48% 12/11/2014 1403 a Actual 54 1115/2015 -68% 911//2014 1349 a Actual 168 10/1512014 200% 6/1112014 1181 a Actual 56 7/16/2014 105% 311112014 1125 a Actual 27 4/11/2014 -58% 12/1012013 1098 aActual 63 1117/2014 -42% 9111/2013 1035 a Actual 109 10/15/2013 73% 61'02013 926 a Actual 63 7/24/2013 87% 311312013 863 a Actual 34 4/22/2013 -3% 12/1112012 829 aActual 34 1/912013 -71% 9113/2012 795 a Actual 121 10/15/2012 50% 6/1212012 674 a Actual 78 7/16/2012 188% 311412012 596 aActual 28 4/14/2012 -2% 12/12/2011 568 a Actual 28 1/17/2012 -72% 9/12/2011 540 aActual 108 10/1312411 141% 6/712011 432 a Actual 42 7120/2011 -7% 3812011 390 aActual 44 4/1312011 -41% 1219/2010 346 a Actual 76 1/12/2011 -50% 9/10/2010 270 a Actual 162 1011512010 174% 6/7/2010 108 a Actual 56 7115/2010 49% 3/9/2010 52 a Actual 38 4/14/2010 40f i r