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HomeMy WebLinkAboutTitle V Inspection Report - 115 VEST WAY 6/14/2017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 115 VEST WAY ----------- ---------- Property Address DEREK MOUSSEAU OwnerOwner's Name information is required for every N., ANDOVER ........ MA 01845 06/14/17 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be atteredi �Xway. Please see completeness checklist at the end of the form. Important:When �3 7 filling A. General Information g out forms on the computer, Nvol?v use only the tab I key to move your I. Inspector: 10 cursor-do not JOHN SOUCY ��kv use the return Name of Inspector ------------- key. VQ SOUCY SEWER SERVICE INC ............ ........... Company Name 78 N BROADWAY ------------ Company Address SALEM NH 0-3-0-79- 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 C M R 16.000).The system: 0 Passes E] Conditionally Passes ❑ Fails 0 geds F rther Evaluation by the Local Approving Authority 06/14/17 toc,Sig Ins tors Sign re" 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.doo-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 � Property Address DEREKUUQ Owner Owner's Name information isMA 01845 06/14/17 required for every N. ==-�-- Code Date of Inspection ouuo. ~''''^`~' State ' B. Certification (cont.) Inspection Summary: Check A.B.C.D or E/always complete all nfSection O A) System Passes: 1 have not found any information which indicates that any of the failure criteria described -- in 310 CMR 15.803orin 310 CMR 15.304 exist. Any failure orihnhm not evaluated are indicated below. Comments: 2Q System Conditionally Passes: F1one or more system componentsaodescribed inthe"Conditional Pass"section need habe -- 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 dmtennined.^ 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 inless than 2Oyears old ioavailable. F1 y E] N Fl ND (Explain below): mmado"'rev.mm Title uOfficial uowrti=Form:Subsurface Sewage Disposal System'Page 2*,' Commonwealth of Massachusetts y Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU m _ Owner Owners Name information is required for every N.ANDOVER MA 01845 06/14/17 page. CitylTown State Zip Code Data of Inspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms 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 15ins.dac•rev.6116 Title 5 Oficial Inspection Foran:Subsurface Sewage Disposal System•Page 3 of 17 3 3 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is required for every N. ANDOVER MA 01845 06/14/17 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 El ® 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 l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER MA 01845 06/14/17 required for every page CitylTown State Zip Code Clete 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 fleet 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 El E] Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone I I 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. {5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 5 of 11 !I I Commonwealth of Massachusetts Title 5 Official Inspection Form p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER MA 01845 06/14/17 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 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. ® 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 t5insAoc•rev.6116 Title 5 Official Inspection Farm: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 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is required for every N. ANDOVER MA 01845 06/14/17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 4 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: RECOMMEND REMOVAL OF GARBAGE GRINDER. SEE ATTACHED METER READINGS. 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(g pd) Basis of design flow(seats/persons/sell t., 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: t5lns.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5Official Inspection Form Subsurface Sewage D\mpomo| System Fmnn -NctforVo|untmryAnoosnm*nto 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name informationMA 01845 is required w � u ,rvo 17 page, ~r'``~' State Zip Code Date of Inspection D. System Information (cont.) Last date ofoucupenq/uue: Date Other(describe be|pw): General Information Pumping Records: � Source ofinformation: SOUCY SEWER SERVICE INC � VVussystem pumped aopa�of�einupeodFl Yes ENuon? �~ �� |fyes, volume pumped: uexono How was quantity pumped determined? Reason for pumping: ~ ' Type pfSystem: F] Septic tank, distribution box, soil absorption system Fl Single cesspool n Overflow cesspool EJ Privy E] Ghonod system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology. Attach acopy ofthe current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection ofthe |64system bysystem operator under contract El Tight tank. Attach acopy ofthe DEP approval. El Other(describe): Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Fora -Not for Voluntary Assessments 115 VEST"WAY Property Address DEREK MOUSSEAU Owner Owners Name information is requiredN ANDOVER MA 01845 06/14/17 page. for every pCiiylTown State Zip Code Date of inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 6'+ Depth below grade: 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.): Septic Tank(locate on site plan): 5' Depth below grade: 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 10.5'x 6' Dimensions: 2" Sludge depth: Mns,dcc-rev.6116 Title 5 Official Inspection Farm: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 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is required for every N. ANDOVER MA 01845 06/14/17 page. CityrFown State Zip Code Date of Inspection D. System Information (cant.) Septic Tank(cont.) 39" Distance from top of sludge to bottom of outlet tee or baffle 0" Scum thickness 7" Distance from top of scum to top of outlet tee or baffle 15" Distance from bottom of scum to bottom of outlet tee or baffle 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.): BOTH TEES IN PLACE, TANK IS STRCTURALLY SOUND, NO APPARENT LEAKS, REMOVE GARBAGE GRINDER, PUMP TANK ANNUALLY. 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.doc•rev.6/16 'rifle 5 official Inspection Form:Subsurface Sewage Disposal System•age 10 of 17 Commonwealth of Massachusetts x .. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER MA 01845 06/14/17 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 Mns.doc•rev.6146 Title 5 Official Inapeclion 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 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owners Name information is N ANDOVER MA 01845 06/14/17 required for every 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 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.): 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: 15ins doc-rev.6116 Title 5 Offidal inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name i information is N ANDOVER MA 01845 06/14/17 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: — -- ❑ leaching galleries number: ® leaching trenches number, length: (4)2'W X 1'D X 50'L ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelalternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth–top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins.doc-rev.6116 lisle 5 Official Inspection Formc 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 115 VEST WAY Property Address DEREK MOUSSEAU W- Owner Owner's Name information is required for eery N.ANDOVER MA 01845 06/14/17 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.): Mns.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 77 u i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 115 VEST WAY Properly Address DEREK MOUSSEAU Owner Owner's Name information is required for every N ANDOVER MA 01845 06/14/17 page. CitylTown State Zip Code Date of Inspection D. System Information (cant.) 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 LHO17aIJer-AN I L-)::ATI'.1Nf11.11n7L•N PLAN 6T R F 6R8%Kf AIIU.ASSOC g,INr�J 2.vftAT)E5l1 pIiE FIElL1 °• AUJUSTEO TO MATtrH TOP. 1 ANC1U£.4ION URITEn1A, Iii 5 I(1 CER T4FY THAI.tHS. llAi INSTALL€U AS SHIAHN k .IIJI;1'i1111 C'.111'.,1HU(.T I.}µ LIAT-RI ALS ASS P�_'Wi iO- j IN 1 HE RELATED UESIGN. i ELLS VATIONS TOr I'OI?rdp: vIs I�JT'LLLI FlO JUI'. 16 Z.90 I SEPT I[TANh INLET+ OUTLET, 161.53 D-EPYN INLET'. I1&91 OUTLET: 159.15 I .11 331 IJ ENI10f T'SI?'N.H: . i _ijr It ` JJJ 8LT$ •J= aa= I487 1137 I 4 0 I 1 3 I LEA•_HIITG AND I FUN OF AS BU I L 11L$E.W,E I TR£N4:NE5 cOWTIONs I I ,i 6 LOT 34A VEST WA Y OWNFR.-'io'LImE COMMON I __.�...- `RIVE UAIE76h1b3 SCALC:I�aO' a ( I'REFARED 8Y: 112JL / ri I / FLYNN Assoc. P,c. - \f ! / CIVIL.SAHJFAAY dM CANStgUC1i0lI ENGINEEAS ' � _ I Pfdlslvx,dle.I Hd+nlhSIa P1B6y IFF II/N:.y 17 %�x.:t;s4� IIP.O.Bo•559 y� l5ins.doc•rev-6I18 TIIIe 5 Official Inspection Form:Subsurface Sewage Bsposat System-Page 15 of 17 i I i Commonwealth of Massachusetts -- : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owners Name information is required for every N ANDOVER MA 01845 06/14/17 page. CityFrown 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: 8131/83 AS BUILT ELEVATIONS 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: EXISTING SYSTEM INSTALLED AT EXISTING ORIGINAL GRADE. 4'- 5'OF FILL HAS BEEN ADDED, SYSTEM IS 3'-4'ABOVE EXISTING WET AREA, OPPOSITE SIDE OF DRIVEWAY. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins doc-rev.6116 Title 5 Official Inspection Form:subsurface Sewage 6isposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 115 VEST WAY Property Address DEREK MOUSSEAU ..., ......... _ ....._ ....,_.. OwnerOwner's Name ._...._.__.__ _.......____ information is required for every N. ANDOVER MA 01845 66/14/17 page. Cityrrown 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.doc•rev.6116 Title 5 Official lnspecton Form;Subsurface Sewage Disposal System•Page 17 of 17 i 3 e , 7ewart's Se ft Service � Ancover Septic � S �llSeptic U Roto-Ram (978)372-7471 (978)475.2593 (603)71M$U (978)452.9022 58 South Kimball Shve4 firy orad, MA 01835 pt FA.. FR 9 M THI ML L C stomar Name., C"3 C7 Nlo .Msin1. Service Location a BTWY Phone: Septlo Tank Primping and Cleaning 0 OW 0 NVA "Done the Right Way" content: BlllinpAddress: Not Responsible for Covers or Irrigation Systems c€ty: d Spedai Instruotlons mptotod r r ❑ Incompletod f�eelrExt:- I "C Per AFrVPHt SaMeas Rendered ecu urnping O a tione Drain Clearft Tank Condition Q Main tine i3 DrywelJ 4 Leachtteld Runbsaok 0 Toilet ScM O Laech P1110wrflow a Riding High a Wtahen Sink O D-Box (liquid level) O Satt►#ub/Shower 43 Pump Chamber i7 Full to Cover Q Vanity Q Gram Trap Q Fxo"alve Solids a Floor Dtwn Q Catch Savin Top I bottom ❑ Veno O Portable Toilet Q Use No Powdered Soap 0 Sewer Jet O other ❑ Heavy Crease O MaraY r -"' 1 Fly Footage: sem: a sum"t.(tWolda Q under 1000 gollone 0 1000 gailons Q 1500 gailons Raote g Gl 280q gallons t^t 34106 galinne f] 4000 gaiinna V, aIle Cal 5908 gallons Q Outer 9r r� misc. G7 t q189in • IgA o Charge ❑ Ci t3 okhoe v ft �aodon Location a Coneultion "` ci CettIUmflon: PIF . ❑ Ssrvlce cal! © Estimate. Reason: O Labor Q PortaWa Toilet Rental Q PUMP Repair C] Y1lgiting Time Q Baffle U Repair ' > nf Charge is Per Driver 4 Chemical Treatment Discretion O Other Desortptlon pi work / � � � i Raegmmendslrvns Terms of Payment ipartn vacuum Ptmrplrrp grain Groaning PAYMENT, DUE IN FULL Yr. th Yr._______Month UPON COMPLETION Tax Terms 8 Cond*ns a Cash o Check Q Credit Dieoount fospano*for damepe*VW corpt.0%per month V40 0 GharW 40acpaxxa peat due. Tow � 2. AN C4rnplalrlts AW ba taptt►ted vvtthlr< hours 4. Thq purchaser ag"to pay gti 0(ooilactlon. 3CDO, - r- cwtctrr r 8lgnalurs Summary Record Card generated on 6/12/2017 3:20:00 PM by Tara Hurley Page 1 Town of North Andover Tax Map # 210-104.6-0159-0000.0 Parcel Id 16481 115 VEST WAY MOUSSEAU, DEREK Since Jan 2014 MOUSSEAU, ANGELA, M. 115 VEST WAY NORTH ANDOVER, MA 01845 _ Class 101 Single Family Property Type 7 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.53 Acres FY 2017 UB Mailing_In_dex Name/Address Type Loan Number Active/Inact. From Until DEREK&ANGELA MOUSSEAU Owner 115 VEST WAY NORTH ANDOVER MA 01845 GLIKLICH, SHAWN&TASHA Previous Customer Inactive 7/31/2006 115 VEST WAY NORTH ANDOVER, MA 01845 MATTHEW&LAURA CHABOT Previous Customer Inactive 1/11/2013 115 VEST WAY NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name ActivelInactive Bldg Id. 17839.0-115 VEST WAY Last Billing Date 4/6/2017 3170504 03 Cycle 03 Active UB Services Maint. Account No.3170504 Service Code Rate Charge Multi pi ler/Users MISCFEE ADMIN FEE 0,635/8 7.82 11 WTR WATER 01 ALL METER SIZE 53.20 11 UB Meter Maintenance Account No.3170504 Serial No Status Location Brand Type Size YTD Cons 29821488 a Active ERT HH 8 Badger w Water 0.63 0.63 770 Bate Reading Code Consumption Posted Date Variance 6/8/2017 1053 a Actual 17 20% 3/9/2017 1036 a Actual 14 4/12/2017 -24% 12/9/2016 1022 a Actual 19 1/23/2017 -84% 9/7/2016 1003 a Actual 107 10/24/2016 368% 6/13/2016 896 a Actual 25 8/2/2016 63% 3/11/2016 871 a Actual 15 4/22/2016 7% 12/10/2015 856 a Actual 14 1/20/2016 -64% 9/9/2015 842 a Actual 38 10/16/2015 63% 6/10/2015 804 a Actual 23 7/24/2015 28% 3/12/2015 781 a Actual 18 4/28/2015 33% 12/12/2014 763 a Actual 14 1/15/2015 .46% 9/10/2014 749 a Actual 26 10/15/2014 32% 6/9/2014 723 a Actual 19 7/16/2014 25% 3/11/2014 704 a Actual 15 4/11/2014 -10% 12/12/2013 689 a Actual 17 1/17/2014 -3% 9/12/2013 672 a Actual 18 10/15/2013 8% 6/11/2013 654 a Actual 16 7/24/2013 -4% 3/14/2013 638 a Actual 12 4/22/2013 -100% 1/9/2013 626 f Final Bill 0 1/9/2013 -100% 12/12/2012 626 a Actual 18 1/9/2013 -9%Q Summary Record Cart}generated on 6112!2017 3:20:00 PM by Tara Hurley Page 2 Town of North Andover Tax Map # 210-104.6-0159-0000.0 Parcel Id 16481 115 VEST WAY MOUSSEAU, DEREK Since .Ian 2014 MOUSSEAU, ANGELA, M. 115 VEST WAY NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.53 Acres FY 2017 9/12/2012 608 a Actual 20 10/15/2012 4% 6/12/2012 588 a Actual 19 7/16/2012 -4% 3/13/2012 569 a Actual 20 4/14/2012 -2% 12/12/2011 549 a Actual 20 1/17/2012 -22% 9/13/2011 529 a Actual 28 10/13/2011 25% 6/7/2011 501 a Actual 21 7/20/2011 27% 3/7/2011 480 a Actual 16 4/13/2011 -19% 12/8/2010 464 a Actual 20 1/12/2011 -26% 9/9/2010 444 a Actual 28 10/15/2010 29% 6/8/2010 416 aActual 21 7/15/2010 60% 3/10/2010 395 a Actual 13 4/14/2010 -24% 12/11/2009 382 a Actual 18 1/12/2010 16% 9/8/2009 364 a Actual 15 10/15/2009 0% 6/9/2009 349 a Actual 14 7/20/2009 -33% 3/16/2009 335 a Actual 24 4/29/2009 71% 12/8/2008 311 a Actual 13 1/20/2009 -25% 9/8/2008 298 a Actual 18 10/10/2008 20% 6/6/2008 280 a Actual 14 7/16/2008 1% 3/10/2008 266 a Actual 14 4/11/2008 -31% 12/12/2007 252 a Actual 22 1/22/2008 -20% 9/6/2007 230 a Actual 22 10/12/2007 26% 6/20/2007 208 a Actual 22 7/20/2007 46% 3/14/2007 186 a Actual 14 4/16/2007 -18% 12/13/2006 172 a Actual 17 1/19/2007 -30% 9/13/2006 155 a Actual 13 10/20/2006 -39% 7/26/2006 142 f Final Bill 16 7/26/2006 194% 6/19/2006 126 a Actual 15 7/10/2006 13% 3/9/2006 111 a Actual 10 4/17/2006 -42% 12/22/2005 101 a Actual 21 1/17/2006 -5% 9/20/2005 80 a Actual 20 10/14/2005 -3% 6/28/2005 60 a Actual 22 7/15/2005 30% 3/30/2005 38 m Manual estimate 20 4/5/2005 -44% 12/14/2004 18 a Actual 18 1/14/2005 0% 10/22/2004 0 n New Meter 0 1/14/2005 0% 9/27/2004 2166 m Manual estimate 50 10/8/2004 18% 6/23/2004 2116 m Manual estimate 30 7/30/2004 154% 4/16/2004 2086 a Actual 21 5/17/2004 0% 12/17/2003 2065 n New Meter 0 12/17/2003 0% AIR Inquiry Sub System Account No. 3170504 Utility Billing Install Billed Adjt Bill Int/Pen Fee(s) Refunded Adit. Abated Paid Balance 1 St $4,820.31 $5.15 ($97.46) $4,728.00 $0.00 Entry Date Install Trans Type Amount Balance Due Amount Billed Posted Flag 5/17/2004 Billed $55.30 $55.30 $55.30 Posted 5/26/2004 Payment ($55.30) $0.00 Posted 8/4/2004 Billed $89.72 $89.72 $89.72 Posted 8/17/2004 Payment ($89.72) $0.00 Posted 10/18/2004 Billed $194.93 $194.93 $194.93 Posted 11/312004 Adjustment ($97.46) $97.47 Posted 11/16/2004 Payment ($194.93) ($97.46) Posted 1/14/2005 Billed $58.22 ($39.24) $58.22 Posted 4/15/2005 Billed $63.82 $24.58 $63.82 Posted 4/27/2005 Payment ($24.58) $0.00 Posted Summary Record Card generated on 6/1212017 3:20:02 PM by Tara Hurley Page 3 Town of North Andover Tax Map # 210-1043-0159-0000.0 Parcel Id 16481 115 VEST WAY MOUSSEAU, DEREK Since Jan 2014 MOUSSEAU, ANGELA, M. 115 VEST WAY NORTH ANDOVER, MA _ 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.53 Acres FY 2017 7115/2005 Billed $72.68 $72.68 $72.68 Posted 7/2512005 Payment ($72.68) $0.00 Posted 10/14/2005 Billed $75.62 $75.62 $75.62 Posted 1012712005 Payment ($75.62) $0.00 Posted 1/17/2006 Billed $80.08 $80.08 $80.08 Posted 2/6/2006 Payment ($80.08) $0.00 Posted 4/17/2006 Billed $41.72 $41.72 $41.72 Posted 5/1/2006 Payment ($41.72) $0.00 Posted 7/10/2006 Billed $58.67 $58,67 $58.67 Posted 7/26/2006 Billed $97.06 $155.73 $97.06 Posted 8/4/2006 Payment ($156.09) ($0.36) Posted 10/20/2006 Billed $48.51 $48.15 $48.51 Posted 11/30/2006 Interest $0.03 $48.18 Posted 11/30/2006 Interest $0.16 $48.34 Posted 11/30/2006 Payment ($48.15) $0.19 Posted 1/19/2007 Billed $61.03 $61.22 $61.03 Posted 2/23/2007 Interest $0.09 $61.31 Posted 2/23/2007 Interest $0.01 $61.32 Posted 2/23/2007 Payment ($61.23) $0.09 Posted 4/16/2007 Billed $51.64 $51.73 $51.64 Posted 7/20/2007 Billed $77.47 $129.20 $77.47 Posted 8/28/2007 Interest $1.97 $131.17 Posted 8/28/2007 Interest $0.34 $131.51 Posted 8/28/2007 Payment ($131.11) $0.40 Posted 10/12/2007 Billed $90.68 $91.08 $90.68 Posted 10/25/2007 Interest $0.01 $91.09 Posted 10/2512007 Payment ($91.09) $0.00 Posted 1/2212008 Billed $88.12 $88.12 $88.12 Posted 2/26/2008 Interest $0,01 $88.13 Posted 2/26/2008 Interest $0.12 $88,25 Posted 2/2612008 Payment ($88.12) $0.13 Posted 4/11/2008 Billed $58.08 $58.21 $58.08 Posted 4/2412008 Payment ($58.21) $0.00 Posted 7/16/2008 Billed $58.08 $58.08 $58.08 Posted 8/7/2008 Payment ($58.08) $0.00 Posted 10/10/2008 Billed $68.84 $68.84 $68.84 Posted 10/31/2008 Payment ($68,84) $0.00 Posted 1/20/2009 Billed $51.89 $51.89 $51.89 Posted 1/30/2009 Payment ($51.89) $0.00 Posted 4/29/2009 Billed $93.04 $93.04 $93.04 Posted 6/1/2009 Payment ($93.04) $0.00 Posted 7/20/2009 Billed $55.28 $55.28 $55.28 Posted 9/2/2009 Payment ($55.28) $0.00 Posted 1011512009 Billed $64.82 $64.82 $64.82 Posted 12/2/2009 Payment ($64.82) $0.00 Posted 1/12/2010 Billed $76.22 $76.22 $76.22 Posted 4/14/2010 Billed $57.22 $133.44 $57.22 Posted 4/28/2010 Interest $0.23 $133.67 Posted 4/28/2010 Interest $1.99 $135.66 Posted 4/28/2010 Payment ($136.13) ($0.47) Posted 7/15/2010 Billed $89.37 $88.90 $89.37 Posted 7/28/2010 Payment ($88.90) $0.00 Posted 10/15/2010 Billed $127,45 $127.45 $127.45 Posted 10/28/2010 Payment ($127.45) $0.00 Posted 1/12/2011 Billed $83.82 $83.82 $83.82 Posted 3/3/2011 Payment ($83.82) $0.00 Posted 4/13/2011 Billed $68.62 $68.62 $68.62 Posted 4/26/2011 Payment ($68.62) $0.00 Posted 7/2012011 Billed $88.99 $88.99 $88.99 Posted 7/29/2011 Payment ($88.99) $0.00 Posted Summary Record Card generated on 611212017 120:02 PM by Tara Hurley page 4 Town of North Andover Tax Map # 210-104.B-0159-0000.0 Parcel Id 16481 115 VEST WAY MOUSSEAU, DEREK Since ,tan 2014 MOUSSEAU, ANGELA, M. 115 VEST WAY NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.53 Acres FY 2017 10/13/2011 Billed $125.53 $125.53 $125.53 Posted 11/1/2011 Payment ($125.53) $0.00 Pasted 1117/2012 Billed $83.82 $83.82 $83.82 Posted 1/30/2012 Payment ($83.82) $0.00 Posted 411412012 Billed $83.82 $83.82 $83.82 Posted 4/30/2012 Payment ($83.82) $0.00 Posted 711612012 Billed $80.02 $80.02 $80.02 Posted 7/25/2012 Payment ($80.02) $0.00 Posted 10/15/2012 Billed $83.82 $83.82 $83.82 Posted 30/23/2012 Payment ($83.82) $0.00 Posted 1/9/2013 Billed $119.04 $119.04 $42.82 Posted 1/15/2013 Payment ($119.04) $0.00 Posted 4/22/2013 Billed $53.42 $53.42 $53.42 Posted 5/9/2013 Payment ($53.42) $0.00 Posted 7/24/2013 Billed $68.62 $68.62 $68.62 Posted 7/29/2013 Payment ($68.62) $0.00 Posted 10/25/2013 Billed $76.22 $76.22 $76.22 Posted 11/14/2013 Payment ($76.22) $0.00 Posted 1/17/2014 Billed $72.42 $72.42 $72.42 Posted 2/24/2014 Interest $0.02 $72.44 Posted 2/24/2014 Interest $0.17 $72.61 Posted 2/24/2014 Payment ($72.42) $0.19 Posted 4/11/2014 Billed $64.82 $65.01 $64.82 Posted 412212014 Payment ($65.02) ($0.01) Posted 7/16/2014 Billed $80.02 $80.01 $80.02 Posted 7/27/2014 Payment ($80.01) $0.00 Posted 1 011 51201 4 Billed $116.35 $116.35 $116.35 Posted 10/2312014 Payment ($116.35) $0.00 hosted 1/15/2015 Billed $61.02 $61.02 $61.02 hosted 1/27/2015 Payment ($61.02) $0.00 Posted 4/28/2015 Billed $76.22 $76.22 $76.22 Posted 5119/2015 Payment ($76.22) $0.00 Posted 7/24/2015 Billed $100.47 $100.47 $100.47 Posted 8/21/2015 Payment ($100.47) $0.00 Posted 10/1612015 Billed $183.72 $183.72 $183.72 Posted 11115/2015 Payment ($183.72) $0.00 Posted 1/2012016 Billed $61.02 $61.02 $61.02 Posted 2/5/2016 Payment ($61.02) $0.00 Posted 4/22/2016 Billed $64.82 $64.82 $64.82 Posted 5/5/2016 Payment ($64.82) $0.00 Posted 8/2/2016 Billed $110.42 $110.42 $110.42 Posted 8/7/2016 Payment ($110.42) $0.00 Posted 10/24/2016 Billed $566.67 $566.67 $566.67 Posted 11/23/2016 Payment ($566.67) $0.00 Posted 1/23/2017 Billed $80.02 $80.02 $80.02 Posted 2/14/2017 Payment ($80.02) $0.00 Posted 4/12/2017 Billed $61.02 $61.02 $61.02 Posted 5/6/2017 Payment ($61.02) $0.00 Posted i Founded in 1986 SAUCY'S SEWER SERVICE, INC. 78 NORTH BROADWAY(Rt.28) SALEM,NH 03079 PHONE 603-898-9339 TITLE 5 DISCLOSURE .lune 16, 2017 Derek Mousseau Angela Mousseau 115 Vest Way N. Andover, MA 01845 On the above date and time, I made a visual inspection of the septic system at the above referenced property. Based upon my visual inspection, I certify that the septic is in proper working order as of the date and time of the inspection. This certification does not constitute a guarantee or warranty and because of the age and unpredictable characteristics of the septic system, it isnot to be interpreted as insuring that the system will continue to be in working order for any future period of time, no matter how brief. Owner further agrees to indemnify and hold harmless inspecting company from any liability costs incurred from the result of any third party reliance upon informati p vided. John oucy Derek-Mousseau Presi entllnspector 4Ane1a"Modi eau Note: Not valid without parties`signature. 4KI" w - V A j o i, COMPLETE SEWER-SEPTIC SERVICE ( TIME SER4VICE DATE OF SEIkVICE 78 N. Broadway, Salem, NH 03079 Z SE - � (603) 898-9339 (800)541-9379 www.soucysewer.com I "WORKING FOR YOU AND THE ENVIRONMENT" CUSTOMER NAME: e- V/e STREET ADDRESS:"' CITY- STATE- PHON SPECIAL BILLING INSTRUCTIONS0 ----------- DESCRIPTION OF WORK COST TOTAL )YI PUMPED ADDITIONAL GALLONS DIGGING BATE,IZIA ADDED Uj TANK LEVEL HIGH 0 VERY HEAVY SOLIDS PUMP MORE OFTEN CASH CHARGE RESIDENTIAL COMMERCIAL CHECK BILL COMMENTS 77, A'i This is to acknowledge completion of the above work which has been done to my satisfaction.The company assumes n9jospo sibilityforany damage made to sprinklers,lawn,bushes,driveway,curb or walkway.Any form of payment provided by the c:ustpm,di const es a binding ne signature of this invoice and assumes all responsibility for payment in full,along with any collection or rea§,or6`6'le attar sees on outstanding b lances. Cr ate 41 Customer Signature rviceman-Signature