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HomeMy WebLinkAboutTitle V Inspection Report - 75 WINDKIST FARM ROAD 1/30/2018 q'N Commonwealth of Massachusetts Title 5 Official Inspection Form 11174"',E C Ev N[1�1'1'�"!,1) Subsurface Sewage Disposal System Form Not for Voluntary Assessments 75 Windkist Farm Road /�NLXYVU�J Property Address �RA[1f1 DEPAR,f M 0`11 Steve Flora Owner i fo Owner's Name — n rmation is - required for every North Andover, MA 01845 2/11/2017 page. City/Town State Zip Code z--,,-Date-of,fns0b6tIon 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Neil James Bateson use the return Name of Inspector key. Bateson Enterprises Inc. Company Name 111 Argilla Road ---------- Company Address Andover MA 01810 Cityfrown State Zip Code 978-475-4786 SI-15 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: 0 Passes ❑ Conditionally Passes El Fails Needfurther Evaluation by the Local Approving Authority 2/11/2017 Inspector's lgnatu e 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 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. ""'1" 11 t5ins.doe•ray.6/16 r Title 5 official inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts .` Title 5 Official Inspection nspect°on F oNm Subsurface Sewage DispwsmlSvsh*mnFornn - NotforVo|untaryAooeonmentm 75VVindkistFarm Road Property Address Steve F|On3 Owner 0wnoreNamo information is require North MA 01845 2/11/2017 -- page. City/Town State Zip Code Date nfInspection B. Certification (cont.) Inspection Summary: Check A.B,C.O0rE/always complete all ufSection D � � A) System Passes: � I have not found any information which indicates that any of the failure criteria described in 310 CyNF< 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.().H., uut& remove trees & brush from leach area, locate &excavate buried manhole, check ten feet of pipe in last manhole, pump septic tank, septic system now passes Title 5 ins ection. B\ System CmmdbiommU|v Passes: F-1 one ormore system components mSdescribed inthe"Conditional Pass"section need tobe replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board ofHealth, 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|smetal and over 2Oyears old* or the septic tank (whether metal ornot) imstructurally unsound' exhibits substantial infiltration ormxfi|tnmtiVn ortank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. El Y 0 N Fl ND (Explain be|ow): �mn mm^o�'vmonv ��aomuyw°�"�"p�" a��u�=ow�n o�°�lo��m',�° Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 75 Windkist Farm Road Property Address Steve Flora Owner Owner's Name information is required for every North Andover MA 01845 2/11/2017 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: D hand-sketch in the area below M drawing attached separately Ll A, 01 C k_OVJ\aN,�Nok 41 14 ' lr(A�Ad\e_ 3 t5ins.doo-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage MPOSal SYst8m•Page 15 of 17 Commonwealth of Massachusetts QY/Town of , System Pumping.Record Form 4 DEP has provided this farm for use-by local Boards of Health. other forms may be'used, but the 1 information,must be substantially the same as that provided here. Before using.this form, ' heck with your local Board of Health to determine the forrh they use. The System Pumping Record must be submitted,to the local Board of Health or other approving authority, 9 A. Facility Information 1. System Location: Left/Right front pf House, Left 1ig ear of h zuser Left 1 right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address W IS city/Town state Zip Code 2. System Owner Name' Address(if different from location) Citylrown State- � Zip;Gay� , Telephone Number .B. Pumping Record 1. Date of Pumpingo�te 2. Quantity Pumped. cellons • 3. Type-of system: [] Cesspool(s) ®-SIc Tank ❑ Tight Tank ® Other(describe): 4. Effluent Tee Filter present? ❑ Yes 3_,4 if yes, was it cleaned? ❑ Yes ❑ No " S. Condition of System: j � • � � ..�..'`- V` 6. System Pumped By: Nell Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company I 7. Locati em)contents-were disposed: GLS: Lowell Waste Water Sign a htbule Date t5form4.doc*08/03 System Pumping Record+Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 75 Windkist Farm Road —-------- Property Address Steven Flora Owner Owner's Name information is North Andover MA 01845 1/11/2017 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 A. General Information filling out forms o�A on the computer, use only the tab 1. Inspector: & key to move your cursor-do not Neil James Bateson use the return (Jame ame of Inspector Bateson Enterprises Inc. -Company Name VQ 111 Argilla Road .......... Company Address Andover MA 01810 (Yit—yfTown State Zip Code 978-475-4786SI-15 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: F] Passes 0 Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority — 1/11/2017 In pe or Signat 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 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.doc-rev,6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form =w _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t .` 75 Windkist Farm Road ------------- - Property Address Steven Flora Owner Owner's Name information is North Andover MA 01845 1/11/2017 required for every .�.. page. Citylrown State Zip Code Date of Inspection B. Certifi Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 75 Windkist Farm Road Property Address Steven Flora Owner Owners Name information is North Andover MA 01845 1/11/2017 required for every -------- ...............- page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) E] 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): El broken pipe(s) are replaced El Y [Z N F ND (Explain below): FND (Explain below): obstruction is removed ❑ Y M N F❑-1 ❑ distribution box is leveled or replaced El Y 0 N F1 ND (Explain below): ----------Th❑ e 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): El broken pipe(s) are replaced n Y M N F-1 ND (Explain below): F-1 obstruction is removed El Y 0 N El 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: El Cesspool or privy is within 50 feet of a surface water F-1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins,doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 75 Windkist Farm Road ._._._ ___. --------- _. __ _ Property Address Steven Flora Owner Owner's Name information is required for every North Andover MA 01845 1/11/2017 page, Cltyfrown 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: Remove section of pipe coming out of last manhole with roots in it. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above 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 '/day flow t5ins.doc•rev.6116 Title 5 Official Mspeclion Form:Subsurface Sewage Disposal System•Page 4 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 75 Windkist Farm Road Property Address Steven Flora Owner Owners Name information is required for every North Andover MA 01845 1/11/2017 page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) Yes No El 0 Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: —. El 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. E-1 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. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El 0 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 EJ M 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. 15ins.doc-rev.6116 Title 5 Official fnspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 75 Windkist Farm Road Property Address Steven Flora OwnerOwner's Name information is North Andover MA 01845 1111/2017 required for every page. Cityrrown 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? E El 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? Were as built plans of the system obtained and examined? (if they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? • El Was the site inspected for signs of break out? • El Were all system components, excluding the SAS, located on site? • El 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? E El 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: • El 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 15M2(5)] D. System Information Residential Flow Conditions: 4 Number of bedrooms (design): Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 15ins.doe-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form K Subsurface Sewage Disposal System Form Not for Voluntary Assessments 75 Windkist Farm Road __- Property Steven Flora Owner Owner's Name information is North Andover MA 01845 1/1.1/2017 required for every State Zip Code Date of Inspection page. CitylTown D. System Information Description: ------------ Number of current residents: Does residence have a garbage grinder? 0 Yes El No Is laundry on a separate sewage system? (Include laundry system inspection F] Yes 0 No information in this report.) Laundry system inspected? F] Yes F1 No Seasonal use? El Yes 2 No Yes Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Cur Last date of occupancy: DatBrent Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): —-------- Gallons per day(Bpd) Basis of design flow (seats/persons/sq.ft., etc.): -——------------- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: _.------- l5ins.doc ------- t5ins.doc-rev,6116 Title 5 official inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts x : _n Y Title 5 Official Inspection Form -' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 75 Windkist Farm Road Property Address Steven Flora Owner Owner's Name information is North Andover MA 01845 1/11/2017 required for 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 three years ago, owner 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 <f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 75 Windkist Farm Road -Property--Address Steven Flora Owner Owner's Name information is North Andover MA 01845 1/11/2017 required for every 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: 20 years old, 11/20/1997, 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: R cast iron H 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): A7_PUC_through wall, :r PVC in house, no leaks. Septic Tank (locate on site plan): 4 Depth below grade: Material of construction: concrete El metal F] fiberglass R polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes R No Dimensions: 10'x 5'x 4' —_.________.._.._.-_- 3 Sludge --------------- 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 75 Windkist Farm Road ------------------- 'Property Address Steven Flora Owner Owners Name information is MA 01845 1/1112017 required for every North Andover---,—.---------..— 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 3011 411 Scum thickness 810 Distance from top of scum to top of outlet tee or baffle Ib Distance from bottom of scum to bottom of outlet tee or baffle Now were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage.-Center cover has riser 18"deep. ---------- ----------- Grease Trap (locate on site plan): Depth below grade: feet Material of construction: El concrete ❑ metal ❑ fiberglass ❑ polyethylene E] 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.doe-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts x Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Y 75 Windkist Farm Road Property Address ...-.- Steven Flora .-._... Owner Owner's Name information is North Andover MA 01845 1/11/2017 required for every 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 F1 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? Q Yes ❑ No t5ins.doc-rev.6/16 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Windkist Farm Road Property Address Steven Flora Owner Owner's Name information is North Andover MA 01845 1/11/2017 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level &distribution equal. No evidence of leakage. Evidence of carryover. Pump Chamber(locate on site plan): Pumps in working order: R Yes F] No* Alarms in working order: El Yes El 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: —----------- ------- ---------- —------- 16ins.doc•rev.6f16 Title 5 Official Inspection Form:SubsuriaGe Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 75 Windkist Farm Road Property Address Steven Flora Owner Owners Name information is North Andover MA 01845 1/11/2017 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: E-1 leaching pits number: E-1 leaching chambers number: EJ leaching galleries number: leaching trenches number, length: 2 trenches 46' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: E-1 innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetaion should be cleared over trenches, has a couple of small trees growing over& near leach trenches. No sign of ponding to surface. -–—----------- -------------- .....------ 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 El Yes n No t5ins.doc rev,6116 Titfe 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 19 of 17 Commonwealth of Massachusetts ry Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r - 75 Windkist Farm Road Property Address Steven Flora Owner Owners Mame information is North Andover MA. 01845 1/11/2017 ' required for every _ ------ --- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): .____.._-...__� privy (locate on site plan): Materials of construction: ___.________ __.__. _._____ Dimensions Depth of solids __-----------_ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): --------------- t5ins.doc•rev.6N6 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 "• 75 Windkist Farm Road Property Address Steven Flora Owner Owner's Name information Is North Andover MA 01845 1/11/2017 required for every -. page. Cityfrown State Zip Code Date of Inspection i D. System Information (cont.) 1 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 /A Doo< A 3 t5ins.doc•rev.6/16 Title 5 Official Inspection Forms Svbsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Windkist Farm Road Property Address Steven Flora Owner Owner's Name information is North Andover MA 01845 1/11/2017 required for every __.. __.-.-- page, CityTTown 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 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: 4/26/1997 ._..._..........__.— Date F1 Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: L As per test ip t data on design plan. ------------- I I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insAoc•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 75 Windkist Farm Road Property Address Steven Flora Owner Owner's Name information is North Andover MA 01845 1/11/2017 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist El Inspection Summary: A, B, C, D, or E checked F] inspection Summary D (System Failure Criteria Applicable to All Systems) completed Q System Information—Estimated depth to high groundwater El Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.dGc-rev,6116 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 1212012016 12:49:44 PM by Tara Hurley rage i Town of North Andover Tax Map # 210-109.0-0051-0000.0 Parcel Id 18865 75 WINDKIST FARM ROAD FLORA, STEVEN K Since Jan 2014 LORRAINE I. FLORA 75 WINDKIST FARMS ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.62 Acres i FY 2017 UB Mailina Index Name/Address Type Loan Number Active/Inact. From Until FLORA,STEVE&LORI Payor 75 WINDKIST FARM ROAD NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13776.0-75 WINDKIST FARM ROAD Last Billing Date 11/7/2016 1090453 01 Cycle 01 Active UB Services Maint. Account No. 1090453 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 464.50 /1 UB Meter Maintenance Account No. 1090453 Serial No Status Location Brand Type Size YTD Cons 33050854 a Active 00 b Badger w Water 1 1 1703 Date Reading Code Consumption Posted Date Variance 10/19/2016 2074 aActual 90 11/16/2016 -16% 7/22/2016 1984 a Actual 109 8/16/2016 679% 4/22/2016 1875 a Actual 14 5/25/2016 -6% 1/22/2016 1861 aActual 15 2/19/2016 -87% 10/22/2015 1846 a Actual 112 11/20/2015 86% 7/24/2015 1734 a Actual 59 8/14/2015 243% 4/27/2015 1675 a Actual 17 5/19/2015 -9% 1/30/2015 1658 a Actual 21 2/2012015 -71% 10/24/2014 1637 a Actual 68 11/14/2014 9% 7/25/2014 1569 a Actual 63 8/13/2014 297% 4/24/2014 1506 a Actual 15 5/15/2014 -47% 1/27/2014 1491 aActual 31 2/14/2014 -50% 10/23/2013 1460 aActual 60 11/18/2013 -4% 7/23/2013 1400 a Actual 61 8/15/2013 187% 4/24/2013 1339 a Actual 21 5/20/2013 -8% 1/25/2013 1318 a Actual 24 2/13/2013 -44% 10/23/2012 1294 aActual 42 11/9/2012 -41% 7/23/2012 1252 a Actual 70 8/14/2012 106% 4/23/2012 1182 a Actual 34 5/9/2012 112% 1/23/2012 1148 aActual 16 2/13/2012 -77% 10/24/2011 1132 a Actual 72 11/14/2011 -30% 7/22/2011 1060 a Actual 100 8/15/2011 462% 4/22/2011 960 a.Actual 17 5/16/2011 -18% 1/25/2011 943 aActual 23 2/11/2011 -68% 10/21/2010 920 aActual 69 11/12/2010 -33% 7/22/2010 851 a Actual 103 8/16/2010 506% 4/22/2010 748 a Actual 17 5/12/2010 -29% 1/21/2010 731 aActual 24 2/12/2010 -42%