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HomeMy WebLinkAboutTitle V Inspection Report - 252 RALEIGH TAVERN LANE 10/31/2017 Commonwealth of Massachusetts �.RECEIVED_ _ ....... Title 5 Offidal Inspection Form� - Subsurface Sewage Disposal System Forma Not for Voluntary Asses mentsC�JN 15 200 252 Raleigh Tavern Lane TOWN O NORTH ANDOVER __._. ..._.__._..... _ _ .,..._.....___— Property Address gyEAtTp~i li"tF>fTMAmtt' 6s. . .. Evan Lai Owner Owner's Name information is North Andover MA 01845 5/1/2009 required far ._.._..._.__._._ ____..._._.._....._ every page, Cityrrown 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: en�ralln �r Information When filling out A. farms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not use the return Namee of Inspector Key. Bateson Enterprises Inc. _._._.. _..___ _. .. Company Name 111 Argllla Road Company Address Andover _..._... _._.._ Ma _._ 01810 . n State Zip Code 978-475-4785SI15 ------. _._.....m __ ._... -- .......... 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. 1 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 6/1/2009 _ .. . ........ _. _..__-._ —.-._......_.._.. __.._ _.___...._.._..... Inspector's S gnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the 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•09108 Title 6 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 252 Raleigh TaYern-L-ane Property Address Evan Lai OwnerOwner's Name information is required for North Andover MA 01845 6/1/2009 every page. CityrrownState Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E always complete all of Section 0 A) System Passes: Z 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: After permit from Board of Health, pumped septic tank & install new d-box with risers, inspection from Board of Health, septic system now passes Title 5 Inspection. ........... 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 F1 ND (Explain below): ------------- Wins-09108 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commohwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 252 Raleigh Tavern Lane .... .............. Property Address Evan Lai OwnerOwners Name information is North Andover MA 01845 5/23/2009 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: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not use the return Name of Inspector key. Bateson EnteTIFIDrises s Inc. — . Company Name VQ -JJIArgllla Road Company Address Andover Ma 01810 renrn CityfTown State Zip Code 978-475-4786 S115 - ---------- Telephone 'Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: El Passes Z Conditionally Passes El Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/23/2009.1111-11---.- Inspe-or S gnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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-09108 Title 5 official Inspection Fenn:Subsurface Sewage Disposal System-Page 1 of 17 CommohWealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forma Not for Voluntary Assessments 252 Rale!g.h Tavern Lane Property Address Evan Lai Owner Owners Name information is required for -North Andover MA 01845 5/23/2009 every 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: .......... ------------- ............ 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): —----------- t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commotiwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 252 Raleiqh Tavern Lane .............. Property Address Evan Lai Owner Owners Name information is required for North Andover MA- I.—I 01845 5/23/29-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 13) System Conditionally Passes(cont.): F] 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 F1 Y 0 N F-1 ND (Explain below): ❑ obstruction is removed [:1 Y Z N E] ND(Explain below): F-1 distribution box is leveled or replaced n Y Z 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): 0 broken pipe(s) are replaced Fj Y El N 0 ND(Explain below): El obstruction is removed F-1 Y Z N F1 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-09/08 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commohwealth of Massachusetts T"Itle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments . _. .M...... 252 Raleigh Tavern Lane Property Address Evan Lai OwnerOwner's Name information is North Andover MA 01845 5123/2009 required for every 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: F-1 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. El 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 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-Box repla�cemqnt-- 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 0 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 F] 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-09100 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commofiwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 252 Raleigh Tavern Lane Property Address Evan Lai ............... Owner Owner's Name information is North Andover MA 01845 5/23/2009 required for -m,..------- every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El Z 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. El 0 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. El E 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 6 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] El N The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El Z 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 El 1-1 the system is within 200 feet of a tributary to a surface drinking water supply El E] the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09/08 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 5 of 17 Commohmalth of Massachusetts Title 5 Offidal Inspection Form 6 Subsurface Sewage Disposal System Form m Not for Voluntary Assessments .252 Raleigh Tavern Lane _a_ _ , _ _ _ _.- —---—----------- ------------------- -——------------------------....................... Property Address Evan Lai Owner Owners Name information is required for North Andover MA 01845 5/23/2009 every page, Cityfrown 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 E Have large volumes of water been introduced to the system recently or as part of this inspection? E EJ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Z 1:1 Was the facility or dwelling inspected for signs of sewage back up? M n Was the site inspected for signs of break out? Z 0 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): 600 15ins-09108 Tilde 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commohwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 252—Raleigh Tavern Lane Property Address Evan Lai ----------- Owner Owner's Name information is North Andover MA 01845 5/23/2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: -------_---- .......... Number of current residents: 0. Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] El Yes 0 No Laundry system inspected? 0 Yes El No Seasonaluse? El Yes Ej No Water meter readings, if available (last 2 years usage(gpd)): Yes Detail: --- ----------- Sump pump? ❑ Yes H No Last date of occupancy: March 3,2009 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd)—.1-1— Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes F No Industrial waste holding tank present? F Yes Fj No Non-sanitary waste discharged to the Title 5 system? El Yes F No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commohwealth of Massachusefts A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments .2.5.2 Raleigh Tayern-Lane Property Address Evan Lai Owner Owner's,Name information is required for North Andover MA 01845 5/23/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): ------------------- General Information Pumping Records: Source of information: Pumped 2003, owner, Was system pumped as part of the inspection? EJ Yes E No If yes, volume pumped: .-....__-- gallons .......gallons Now was quantity pumped determined? ...... Reason for pumping: ------------- ........ Type of System: 0 Septic tank, distribution box, soil absorption system F-1 Single cesspool F-1 Overflow cesspool El Privy n Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09108 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commohwealth of Massachusetts Tmtle 5 Offucial Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 252Raleigh Tavern Lane ... .............. ----------- Property Address Evan Lai Owner ......_....._....— ....... ._._.__ _ ....—.......... ...._.. ._ ..-- _.._._._._. _....... Owner's Name information is North Andover MA 01845 5/23/2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 27 old, 9/3/1981, as built plan —--------- Were sewage odors detected when arriving at the site? El Yes 0 No Building Sewer(locate on site plan): 5 Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): unknown, finished cellar Distance from private water supply well or suction line: feet ..........I----------- Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 4 Depth below grade: feet Material of construction: concrete ❑ metal R fiberglass El polyethylene El other(explain) ----------- ----------- If tank is metal, list age: years- ............------- Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes E-1 No Dimensions: 10'x5' x 4' 31' Sludge depth: (5ing•09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 9 of 17 Comirno6wealth of Massachusetts 4. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form a Not for Voluntary Assessments 252 Raleigh Tavern Lane .... ........... Property Address Evan Lai Owner Owner's Name information is North Andover MA 01845 5/23/2009 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 24" 511 Scum thickness Distance from top of scum to top of outlet tee or baffle 811 1611 Distance from bottom of scum to bottom of outlet tee or baffle - How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet&center cover under deck. Outlet tee ok. Depth ofliquid qt invert, no evidence of leakq .......... Grease Trap(locate on site plan): Depth below grade: feet Material of construction: El concrete El metal F-1 fiberglass El polyethylene Ej other(explain): Dimensions: ...___- Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commohwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 252 Raleigh Lane Property Address Evan Lai Owner &,w l-er's--Name information is North Andover MA 01845 5/23/2009 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 R metal E] fiberglass El polyethylene F1 other(explain): Dimensions: Capacity: g.a-flo,n.s ...... Design Flow: g I allons per day Alarm present: 0 Yes ❑ No Alarm level: Alarm in working order El Yes El No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? F1 Yes Ej No (5inr•09/08 'title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 11 of 47 CommohWealth of Massachusetts m Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w. 252 Raleigh Tavern bane Property Address Evan Lai Owner Owner's Name information is North Andover MA 01845 5/23/2009 required for _.........._._,....._.._._..__.----.____._.._— ---......_._..._ -- every page. CityfTown 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.): D-box level &distribution equal. Evidence of leakage. D-box needs to be replaced. Evidence of carryover Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: © Yes Q No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc,): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Com mohwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 252 Raleigh Tavern Lane Property Address Evan Lai Owner 0-wrier's-Name information is North Andover MA 01845 5/23/2009 required for every page. State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: 2 leaching chambers number: n leaching galleries number: 11 leaching trenches number, length: EJ leaching fields number, dimensions: El overflow cesspool number: El innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface.Camera inside of pits thru outlets in d-box, no water to inverts ............ --- —-------- --—--------- ——------ -—--------- 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 n Yes n No t5ins 09106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commathwealth of Massachusetts Title 5 Official Inspection Form X Subsurface Sewage Disposal System Form m Not for Voluntary Assessments 252 Raleigh Tavern Lane ........... ........ ........ -.. ---------- Property Address Evan Lai Owner Owners Name information is North Andover MA 01845 5/23/2009 required for every page. Cityrrown 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 ......Dimensions ----------- Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5irls-09108 Title 5 Official inspection Foun;Subsurface Sewage Disposal system-Page 14 of 17 CommonWealth of Massachusefts Title 5 Offlocial Inspection Form Subsurface Sewage Disposal System Foy-Plot for Voluntary Assessments 252 Ralei hTavemLane Property Address Evan Lai Owner Owner's Name information is required for -North Andover MA 01846 5/23/2009 every 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 Av A,a,r \,c = 1`4 1 '_5 L41J'9 13 One-09105 Title 5 Official Inspection Form:Subsurface,Sewage Disposal System-Page 15 x117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 252 Raleiqh Tavern Lane .. ........................... Property Address Evan Lai Owner " r Owner's Name information is North Andover MA 01845 5/23/2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water Check cellar Shallow wells Estimated depth to high ground water: 4' below pits ......... feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 5/24/1980Date El Observed site (abutting property/observation hole within 150 feet of SAS) El Checked with local Board of Health -explain: ................ ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USES database-explain: You must describe how you established the high ground water elevation: -Asper design plan testpit data ---------- ------------ ................. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ms-09106 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Summary Record Card goneralad on 311312009 10:19:41 AM by Lisa Evans Page 1 Town ®f North Andover Tax Map # 210-106.C-0108-0000.0 Parcel Id 17741 252 RALEIGH TAVERN LANE LAI, XIONGWEN & XIE, DANBING 252 RALEIGH TAVERN LANE N. ANDOVER, MA 01845 Class 101 Single F am, Property Type I Residential Size Total 1.03 Acres FY 2009 QB Malligqjndex Name/Address Type Loan Number Active/Inact. From Until LAI,XIONGWEN&XIE,DANBING Payor 252 RALEIGH TAVERN LANE KANDOVER, MA 01845 UB Account Tint. Account No Cycle Occupant Name Activelinactive Bldg Id. 14147.0-252 RALEIGH TAVERN LANE Last Billing Date 3/512009 2100131 02 Cycle 02 Active UB Services Mdint. Account No.2100131 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0,636/8 7,82 1/ WTR WATER 01 ALL METER SIZE 215.91 /1 UB Meter Maintenance Account No.2100131 Serial No Status Location Brand Type Size YTD Cons 0002912854 a Active ENC RT w Water 0.63 0.63 161 Date Reading Code Consumption Posted Date Variance 214/2009 3707 m Manual estimate 50 3/16/2009 -8% MSG 11/3/2008 3657 a Actual 55 12110/2008 -4% 8/1/2008 3602 a Actual 56 9/12/2008 60% 5/1/2008 3546 a Actual 33 6/18/2008 -25% 2/4/2008 3513 a Actual 48 3/14/2008 -11% 11/1/2007 3465 a Actual 47 1/15/2008 -4% 8/11/2007 3418 a Actual 48 9/14/2007 14% 5/312007 3370 a Actual 30 6/2212007 54% 2/28/2007 3340 m Manual estimate 36 3/23/2007 -38% 11/212006 3304 a Actual 36 12/22/2006 -40% 8/21/2006 3268 a Actual 89 9/13/2006 101% 5/4/2006 3179 a Actual 37 6/2012006 39% 2/2/2006 3142 a Actual 27 3/13/2006 -36% 11/2/2005 3115 a Actual 38 12/14/2005 -10% 8/11/2005 3077 a Actual 48 9/12/2005 86% 6/9/2005 3029 a Actual 23 6/8/2005 7% 2/14/2005 3006 a Actual 23 3/15/2005 -19% 11/16/2004 2983 a Actual 31 12/17/2004 -19% 8/10/2004 2952 a Actual 33 9/2012004 29% 5/17/2004 2919 a Actual 27 6/14/2004 -25% 2/17/2004 2892 a Actual 41 4/16/2004 0% 11/6/2003 2851 n New Meter 0 11/6/2003 0%