HomeMy WebLinkAboutTitle V Inspection Report - 3 BRECKENRIDGE ROAD 3/26/2018 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
f
3 Breckenridge Rd
---------------------
Property Address
Antonio Rico
Owner Owner's Name
information is
required for North Andover MA 01845 3/16/2018
..........
every page. -61"t"y"r"r-ow "'n- 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 I Inspector:
only the tab key
to move your Warren Pearce Jr \A
cursor-do not
use the return Name of Inspector
4
key. Pearce Construction
domp-i`n,y"-"Name- ,-,
VQ 196 Park Street
Company Address
North Reading_._..__._.._.. MA 01864
City[Town State Zip Code
.978-664-5264 ................... S11959
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:
Z Passes E] Conditionally Passes F1 Fails
❑ Needs Further Evaluation by the Local Approving Authority
.................
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or j,
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.
16ins-3113 Title 5 Official Inspection Form:Subsufface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3 -ecke i
Bi
Property Address
Antonio Rico
Owner wrier's Name
information is
required for North Andover -MA 01845 3/16/2018
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 1)
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 CIVIR 15.304 exist, Any failure criteria not evaluated are
indicated below.
Comments:
........... ............
—------------- ......
B System Conditionally Passes:
Ej- 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, riot leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available,
El Y N El ND (Explain below):
..............
........ ........... ...... —-----
............ —--------
t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
P. 3 BreckenridgeRd
_
Property Address
Antonio Rico
Owner __._..__.._.....__-. w__..__...._ _........_---..__.-- ......_ ..__.......ma___.._.__.__�_w_......__ .__....__..._..-__.-___ .____
Owner's Name
information is North Andover MA 01845 3/16/2018
required for
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
13) System Conditionally Passes (cont.):
F1 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):
n broken pipe(s) are replaced El Y Ej N F1 ND (Explain below):
El obstruction is removed n Y El N El ND (Explain below):
❑ distribution box is leveled or replaced El Y El N El ND (Explain below):
.....................
.............
-------
---
F] 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):
El broken pipe(s)are replaced F] Y 0 N El ND (Explain below):
E-1 obstruction is removed Ej Y F N El ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
0 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:
F] Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
One 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
tion Form
Title 5 Official Inspec I
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3 Breckenridge Rd
Property Address ------------
Antonio Rico
Owner __ -_._.. _. �._...._._.a.-_ _ _.._�. ..._....._.
C7wnar's Name
information is
required for North Andover MA 01845 3/16/2018
every page. di-yao-wn, State Zip Code Date of Inspection ........
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public' ater°Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
El 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 stir-face water supply.
Fj The system has a septic tank and SAS and the SAS is within a Zone I of a public water
supply,
0 The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
Fj 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
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 'fa day flaw
t5ins•3113 Title 5 Official inspection Fonn:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form m Not for Voluntary Assessments
3 Breckenridge Rd ............
Property Address
Antonio Rico
Owner bvu-ner's Name
information is
required for North Andover ...... MA 01845 3/16/2018
every page, City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
E] z Required pumping more than 4 times in the last year NOT due 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.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
F] 0 Any portion of a cesspool or privy is within a Zone 1 of a public well.
El Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El 0 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.]
❑ E 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 16,000 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
El El the system is within 400 feet of a surface drinking water supply
1:1 1:1 the system is within 200 feet of a tributary to a surface drinking water supply
El n 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusefts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3 Breckenridge Rd
Property Address
Antonio Rico
Owner Owner's Name
information is
required for North Andover w MA 01845
3/16/2018
every page. 61tyrrown 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
0 El Pumping information was provided by the owner, occupant, or Board of Health
11 0 Were any of the system components pumped out in the previous two weeks?
0 11 Has the system received normal flows in the previous two week period?
11 9 Have large volumes of water been introduced to the system recently or as part of
this inspection?
0 El Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
M- Ej Was the facility or dwelling inspected for signs of sewage back Lip?
M El Was the site inspected for signs of break out?
1Z El Were all systern components, excluding the SAS, located on site?
M 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?
Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of Subsurface sewage disposal systems?
'T"he 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.
IN El Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
4 4
Number of bedrooms (design): ------- Number of bedrooms (actual): —
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Mile 5 Off"coal Inspection Form
$3.)
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3 Breckenridge Rd
Property Address
Antonio Rico
Owner Owner's Name
information is North Andover MA 01845 3/16/2018
required for ....... -----------
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
........... ----------------- -----------
.......... .. ...... —-----
4
Number of current residents:
Does residence have a garbage grinder? F1 Yes [D No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? El Yes F] No
Seasonal use? El Yes E No
Water meter readings, if available(last 2 years usage(gpd)): 202 GPD
Detail:
1-22-2016 to 1-18-2018 147,356 Gallons
-------
---------- -----------
Sump pump? F1 Yes Z No
Last date of occupancy: Current
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallo........
ns per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.): _a_--....____ __.
Grease
--------
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? EJ Yes n No
Non-sanitary waste discharged to the Title 5 system? n Yes El No
Water meter readings, if available:
t5ins-3113 Tire 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3-Breckenrio ged......
'Property Address
Antonio Rico
Owner Owner's Name
information is
required for North-Andover ....... MA 01845 3/16/2018
every page. City/Town State Zip Code Gate of inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
...........
................ .......... ........... ..........
General Information
Pumping Records:
r
Purp d 1 owner Source of information: _pp _Mg .. ...... ..........
Was system pumped as part of the inspection? E] Yes N No
If yes, volume pumped: ...................
gallons
I-low was quantity pumped determined?
Reason for pumping: .......
Type of System:
Septic tank, distribution box, soil absorption systern
Single cesspool
Overflow cesspool
El Privy
El C) 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 [/A system by system operator under contract
El "right tank, Attach a copy of the DEP approval.
Other(describe):
t5Jns-3/13 Title 5 Official Inspection Form Subsurfaces Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3 Breckenridg Rd
Property Address
AntonioRico
Owner Owner's Name
information is North Andover MA 01845 3/16/2018
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:
system approximately.3.0 years old based on the 1987design._&an.
Were sewage odors detected when arriving at the site? El Yes M No
Building Sewer(locate on site plan):
Depth below grade: 1t611
fee
Material of construction:
El cast iron Z 40 PVC ❑ other(explain): -------------- -_... ___.__
Distance
------------------
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
All appears in good shape inside the house.
........... ...........................
Septic Tank(locate on site plan):
Depth below grade: I 01i
feet
Material of construction:
concrete FI metal El fiberglass El polyethylene El other(explain)
------
If tank is metal, list age: -1 year.s
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No
Dimensions: 10'6"X5' 8"X5' deep 1500 Gal
Sludge depth: 5"5___...._—._.____.._--
15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachuseft
"T"Itle 5 Offlocial Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3 Breckenridge
F'roperty Address
Antonio Rico
Owner Owner's Name
information is
required for North Andover MA 01845 3/16/2018
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 31 ..........
Scum thickness < lit ------
Distance from top of scum to top of outlet tee or baffle 61/2
Distance from bottom of scum to bottom of outlet tee or baffle 121"
Flow were dimensions determined? TaMmeasure ............
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 is in place, outlet tee is PVC. Liquid is at the proper level. No evidence of leakage. Tank
.appears in_good shape,. —----------- ---------
......... -------
. -----
............... ............
—---------- ...............--....... ...............
Grease Trap (locate on site plan):
Depth below grade: —-----
feet
Material of construction:
0 concrete F (explain):
metal fiberglass polyethylene other'
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-3113 Title 5 Official Inspection Form:SUbSUrface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
'
Subsurface Sewage Disposal System Form ®Not for Voluntary Assessments
3 Breckenridge Rd __.-----
Praperty Address
Antonio Rico
Owner Owner's Name
information is North Andover MA 01845 3/16/2018
required for _
every page. City/Town State Zip Code nate of Inspection
D. System Infor ti n (cant.)
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 Molding 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: _. .___m.__.._---------------......__.....--------___---
gallons
Design Flow: - — ----
gallons perday
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
t5ins•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
_._- Title 5 Offidal Inspection Form
Subsurface Sewage Disposal System Form - {dot for Voluntary Assessments
3 Breckenridge Rd .................—-------
Property Address
Antonio Rico
Owner Owner's Name
information is
required for North Andover MA 01845 3/16/2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Oe
Depth of liquid level above outlet invert .........-—------------
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 APPEARS LEVEL. DISTRIBUTION IS EQUAI SPEED LEVELERS ARE IN PLACE AND
PROPPROPERLY ADJUSTED. MINIMAL SOLIDS IN THE D-BOX D-BOX APPEARS IN GOOD SHAPE.
............ ........—-—--------
............. .................
Plump Chamber(locate on site plan):
Pumps in working order: 0 Yes El 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:
............
--—--------- -----------
-
t5ins 3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal Systema Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection orm
8 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3 Breckenridge Rd
--------------
Property Address
Antonio Rico
Owner Owner's Name
information is
required for North Andover MA 01845 3116/2018
---------- ......--------
every page. C-ItyfTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
El leaching pits number:
El leaching chambers number:
leaching galleries number:
leaching trenches number, length: 3 X 54' ...............
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.):
NO SURFACE SIGN OF PLOBLEMS. NO SIGN IN D-BOX OF BACK UP.
..................................................... ------ ......
.............. .............
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 [:1 No
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
TwItle 5 Official Inspection Form
Subsurface Sewage Disposal Systom Form Not for Voluntary Assessments
3 Breckenridae Rd
Property Address
Antonio Rico
Owner Owner's Name
information is
required for North Andover MA 01845 3/16/2018
bi -............
every page. ityfTown 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-3113 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
3 Brecke9#qgq_Rd
............................
Property Address
Antonio Rico
Owner Owner's Name
information is
required for .,North Andover ------------ MA 01845 3/16/2018
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
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3 Breckenridge Rd
Property Address
AntonioRico
Owner Owners Name
information is
required for North Andover MA 01845 3/16/?918
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
Site Exam:
Z Check Slope
Surface water
Check cellar
Shallow wells
Estimated depth to high ground water: 6 1/2'
feet
Please indicate all methods used to determine the high ground water elevation:
0 Obtained from system design plans on record
If checked, date of design plan reviewed- 8/17/1987
Date --------
0 Observed site (abutting property/observation hole within 150 feet of SAS)
0 Checked with local Board of Health -explain:
Reviewed files
11 Checked with local excavators, installers- (attach documentation)
EJ Accessed USGS database -explain:
........... ---------- ........
You must describe how you established the high ground water elevation:
TEST HOLE DA-I-A FROM DESIGN PLAN Dated 8/17/1987 by Kaminski and Associates. Dry
basement with no SUMP PUMP,
............. -----------
............ -----------
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 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
3 Breckenridge Rd
Property Address
Antonio Rico
Owner Owner's Name
information is
required for North Andover MA 01845 3/16/2018
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Z Inspection Summary: A, B, C, D, or E checked
Z 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-3113 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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Summary Record Card gartaraled on 302010 3:36:47 PM tV Karen Hanlon Paltry I
Tumn of North Andover
Tax Map # 210-107.D-0053-0000.0
Parcel Id 18590
3 BRECKENRIDGE ROAD
JOSE ANTONIO RICO
3 BRECKENRIDGE ROAD
NORTH ANDOVER MA 01845
Class 101 Single Family Property-type I Residential
ZonIng2 I Residential ZonIng3 I Residential
Size Total 1.19 Acres
FY 2018
UB Mallingjndex
Name/Address Type Loan Number Active/Inact, From Until
JOSE ANTONIO RICO Owner
3 BRECKENRIDGE ROAD
NORTH ANDOVER MA 01845
DI RAFFAEL,KENNETH Previous Customer Inactive 8J27/2012
3013 SANTEE PLACE
SAINT JOHNS,FL
32269
UB Account Maint.
Account No Cyclo Occupant Name Active/Inactive
Bldg Id. 13707,0-3 BRECKENRIDGE ROAD Last Billing Date 2/912018
1090305 01 Cycle 01 Active
UB SepLices MaInt..
Account No.1090385
Service Code Rate Charge Multiplier/Users
MISCFEEADMIN FEE 1 1 9.18
WTR WATER 01 ALL METER SIZE 68.40
UB Meter Maintenance
/Account No. 1090385
Serial No Status Location Brand Type Size YTD Cons
33244874 a Active 00 b Badger w Water 1 1 859
Date Reading Code Consumption Posted Date Variance
111812018 939 a Actual 18 2/20/2010 -51%
10Y18/2017 921 a Actual 36 111/13/2017 16%
7119/2017 885 a Actual 31 8/1612017 92%
4/1912017 864 a Actual 16 5/17/2017 94/a
1/1912017 838 aActual 16 211612017 -53%
10/19/2016 823 aActual 31 11/16/2016 -7%
7/2212016 792 a Actual 34 8/16/2016 112%
412212016 758 a Actual 16 6/25/2016 8%
1/22/2016 742 aActual 15 2/1912016 -69%
10/22/2015 727 aActual 48 11120/2019 12%
1124/2016 679 aActual 42 8/14/2015 144%
4/2712015 637 a Actual 17 5/19/2016 1%
1130120115 620 aActual 19 2120/2015 -20%
10124/2014 601 aActual 22 11114/2014 1%
7125/2014 579 a Actual 22 8/13/2014 22%
4/24/2014 567 a Actual 17 5/15/2014 -6%
1127*014 540 a Acluall 20 211412014 -17%
10123/2013 520 a Actual 23 11/18/2013 -27%
7/2312013 497 a Actual 31 8/15/2013 70%
4/24/2013 466 a Actual
18 6120/2013 -27%
1/2612013 448 eActual 26 2/13/2013 -16%
10/23/2012 422 a Actual 20 111912012 103%
8/2312012 402 f Final Bill 5 8123/2012 -48%
7/2312012 397 a Actual 28 8/14/2012 -100%
4/2312012 369 a Actual 0 5/912012 -,t00% fi
1/2312012 369 a Actual 6 2/1312012 -70%
04
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Town of North Andover
HEALTH DEPARTMENT
�SSACHUS�'{
CHECK#, d,. e DATE.
LOCvATION: �,� �,„w � � e
i
H/O NAME:
CONTRACTOR NAME:/”
Twe of Permit or License: (Check box)
® Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $�
❑ Dumpster $ _
❑ Food Service._Type._—_ _ _ $
❑ Funeral Directors $ __
❑ Massage Establishment $
❑ Massage Practice
❑ Offal(Septic)hauler $_ _
❑ Recreational Camp $
❑ Sun tanning
❑ Swimming Pool $ _�
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC S stems:
❑ Septic-Sail Testing $
❑ Septic-Design ApprovaI $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Warks Installers(DWI) $
❑ Title 5 Inspector $ _
Title 5 Report
❑ Other.(Indicate) $
H alt Agent Initials
White-.Applicant Yellow- health Pink-Treasurer