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HomeMy WebLinkAboutTitle V Inspection Report - 345 RALEIGH TAVERN LANE 5/4/2018 Commonwealth of Massachusetts Itie 5 OfficialInspection w Subsurface Sewage Disposal System Form Not for Voluntary Assessments � � � ��345 RALEIGH TAVERN LAN � rarr�perty Adiiress t t1 t T t Pl �1HLLt� DEI MARCIA LANG L�4LItl�.a , Owner C w,ner's Norm Information Is NORTH ANDOVER MA 01845 515118 required far every ,...,. _. _ __ _ page, Cttyirown Ste to Zip Cade 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 enol of the form. Important:When A. General information filling out farms on the Computer, use only the tat, 1, Inspector; key to move your cursor-do not JAMES H, CURRIER II use the return key. Name of Inspector _ .. . J'S SEPTIC & DRAIN r s Company Name 131 FOREST STREET anip<rny Addros's _ MIDDLETON MA 011949 City/lawrr State Zip Code 978-774-6685512327 Telephone Number _ l 1cerrso Nurrrkrer 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 tirne 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 DRP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ( Passes E] Conditionally Pusses Il Fails Ej Needs Further Evaluation by the Local Approving Authority 5/5/18 Inspedtor"s Sirgnalura Data The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP, The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. **"*This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address Crow the system will perform In the future under the same or different conditions of use. tSr ns doc-rev.W16 r xea 5 0(rcirat Inspoction rurm Sutaseerlraco Sawa5o aisposntl Systorn•Page I or 17 .' Commonwealth of Massachusetts 11, kti rm it "ll Inspection r Nr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments n 345 RALEIGH TAVERN LANE Property Address _ . MARCIA LANE Owner owner's Marne information is NORTH ANDOVER MA 01845 515118 required far every ; page. t„fT°wn State Zip Code Elate of Inspection a o CI�... . Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D 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 15.354 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM WORKING PROPERLY. B) System Conditionally Passes: F] 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 j determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or riot) 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, N 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 (_I N Ej ND (Explain below): l5ins.doc•iov,6116 Tille 5 official Inspoction Firms Subsurface Sowago Disposal Syslom-r'ago 2 or 17 Commonwealth of Massachusetts �e4Title 5 Official b n Form iS y 7'iia''r Subsurface Sewage [Disposal System Form - Not for Voluntary Assessments i 345 RALEIGH TAVERN LANE Property Address MARCIA LANE _ Owner CDwner s tJarno information Is NORTH I ANDOVER MA 01545 5/5/15 required for every _...._. page, Cytyl Iowa State Zip Cade [Date of Inspection B,nNCertification .._(cant.) ..��_.._..___....._._____._._____._._...._..._._.._, . II E) Purnp Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): El 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 0 Y 0 N El ND (Explain below): obstruction is removed El Y n N 1-1 ND (Explain below): El distribution box is leveled or replaced ( Y I N ND (Explain below): Cl The system required pumping more than 4 tunes a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced El Y 0 N El ND (Explain below): [ obstruction is removed [� Y (_] N ND (Explain below). C) Further Evaluation Is Required by the Board of Health: ] Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment, 1. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(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 Cesspool or privy is within 50 feet of a bordering vegetated wetiand or a salt marsh fa"ins.dac•rev.6116 Tddee 5 Official hstw<dicn Fail"fiub'urfacea 5avrages Disposal SyMwn-Peago 3 of 47 Commonwealth of Massachusetts gN Title l Inspection ip Subsurface Sewage Disposal System Form Not for Voluntary Assessments 345 RALEIGH TAVERN LANE Property Address MARCIA LANE _. Owner Owners Narne Information is NORTH ANDOVER MA 01845 515115 � required for every _ ... pale cityowl) � ..._ State lip Code Date of Inspection _...__ _ ........... .. .._ .__ ._.._.._.... B. Certification (cant.) 2. System will fail unless the Hoard 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: 0 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. El The system has a septic tank and SAS and the SAS is within a Zone '1 of a public water supply. n The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well E] 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 El EXI clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters El 0 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 0 1 Liquid depth in cesspool is less than 5" below invert or available volume is less ` _ ___.___.._.... .. __..... ..�. than 'f day flow 15ins doc.rav,WIG Tido$Official Inspection Fofrn Subsuitoco Smvarlo Disposal Sysioni�r ago 4 of 17 { Commonwealth of Massachuset " N r 'yTitle 5 Official Inspection Form 111, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rL 345 RALEIGH TAVERN LANA Property Address MARCIA LANE Owner __... _ Owner's Naiiia information is NORTH ANDOVER MA 011345 5/5/15 required for every _ page, Cityrrown state Zip Coda Date of inspection B. Certification (cant.) Yes No n O Required pumping snore than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: [ Any portion of the SAS, cesspool or privy is below high ground water elevation, n Any portion of cesspool or privy is within 100 feet of a surface water supply or' tributary to a surface water supply. Q [:]\)V 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. [l ❑ 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 DFP 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.] El X The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd, Ej ;; 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. P) Large Systems: To be considered a large system the systern 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 t ❑ El the system is within 400 feet of a surface drinking water supply El ❑ the system is within 200 feet of a tributary to a surface drinking water supply 0- El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Pone II 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 F 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. t0ins.doc-rev,W6 Tiflo 5 omcim Inspection rourn Subsufftreo sowngfo Disposal sy,w(r)-Pogo 5 of 17 Commonwealth of Massachusetts on Form IV, . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 345 RALEIGH TAVERN LANE Property Address MARCIA LANE Owner NORTH ANDOVER MIA-1-11 9.181© 5118 pPretr age. information rlevery City/Town Stat_ p r.. .....__.CodeDateaate 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 El Pumping information was provided by the owner, occupant, or Board of Health (9 Were any of the system components pumped out in the previous two weeks? 121 0 Has the system received normal flows in the previous two week period? E—f EX-] Have large volumes of water been introduced to the system recently or as part of this inspection? ED Ej Were as built plans of the system obtained and examined? (If they were not available note as N/A) El Was the facility or dwelling inspected for signs of sewage back Lip? 191 El Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? EX) n 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? X - 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: [`�l El Existing information. For example, a pian 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)1 D. System Information Residential Flow Conditions: Number of bedrooms (design). NA Number of bedrooms (actual): 3NA ._ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins doe-rev.6116 Title 5 Offidof Inspection Form Subsurface Sewage oisrosal Systore,Pm.)e 6 of 17 Commonwealth of Massachusetts T"Itle 5 Offidal Inspection Form ' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 345 RALEIGH TAVERN LANE Property Address MARCIA LANE _ Owner Uwner`s Nara _ information Is Stafa .._..7fCode r r Date a required for every NORTH I ANDOVER MA 01,845 ala!18 page Cilyllawn _. p f Inspection ___......__........� __ __. __, .__..._..�_..w .,....0 ..._..._.._...._._ ......_ __.__. D. System Information Description: 4 Number of current residents: Does residence have a garbage grinder? Yes No Is laundry on a separate sewage system? (include laundry system inspection F] Yes No information in this report.) Laundry system inspected? El Yes ❑ No Seasonal use? 0 Yes No Water meter readings, if available (last 2 years usage (gpd)): 106 GILD Detail: Sump pump? El Yes F,�] No CURRENT Last date of occupancy. [lata Commercial/industrial Flow Conditions: Type of Establishment: _ Design flow based on 310 CMR 15.203 : g Gallaris for day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ( Yes (_�) No Industrial waste holding tank present? C_1 Yes F1 No Non-sanitary waste discharged to the Title 5 system? F) Yes G_ No Water meter readings, if available: 15ins.doe•re yv 6116 itw 5 oiro l Irrspotikon ronn Sulnuflace Savwngo Nli posal SyMom-Pap 7 of 17 Commonwealth of Massachusetts l Title 5 Official Inspection Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments 34 Aad TAVERN LANE ., Propertycaress i MARCIA LANE _ Owner Cbwnei's Narrae information is MA 01845 5/5/18 required for every NORTH I ANDOVEf _.. page, CityrrownState Lip Code W.DateInspection...._.w . ._._..w._ ,....___ D. Systemm Information (cant.) Last date of occupancy/use: c1ate Cather(describe below): General Information Pumping Records; Source of information; 8117 PER H.O, 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 l V " Septic tank, distribution box, sail absorption system Single cesspool f 0 Overflow cesspool El Privy E1 Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and f maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract i I `fight tank, Attach a copy of the DEP approval. Other(describe): lrrins.cloc•mv.6116 1'ltiq 5 offiml Inspeclion Foim Subsurface Sewage Disposal Syslnn Page 8 of 17 w Commonwealth of Massachusetts 1, l� iii j' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .ream. 345 RALEIGH TAVERN LANG i�raperty Address MARCIA LANE Owner 0wnor's'Nar11e � information is, MA 01545 5/5/18 required for every NORTH ANDOVER _ _. .. Pagr�, City/TavernState 26 Cade Gate of In%pectiaa _.._.. ._.. ._�.�..___.,_._..___..�__....�_..._.__ _..._.. .,._w....�. _._.. .......�_ .. ..._.,._w.�..... D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: LEACH FIELD AND TANK APPROX 45 YEARS, DBOX REPLACED 15 YEARS AGO _. Were sewage odors detected when arriving at the site? El Yes E!, No Building Sewer(locate on site plan): 11" Depth below grade: re-e-{ .__ ......_. Material of construction: ❑ cast iron O 40 PVC F-1 other(explain): Distance from private water supply well or suction line: NA PUBLIC H2O Comments (on condition of joints, venting, evidence of leakage, etc ): PLUMBING APPEARS IN GOOD CONDITION, NO EVIDENCE OF LEAKAGE. Septic Tank(locate on site plan): 31! Depth below grade: feel _ Material of constrUctlon: concrete metal fiberglass polyethylene ❑ other(explain) If tank is metal, list age: yor+rs _ Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 GALLONS - 7'X5'X4' Dimensions: 2"'-3" Sludge depth: _ lSrils doc-lay.1 1'100 5 Official trispediarr r01111 Subsurface,Saraue Disposal System-Page 9 of 17 Commonwealth of Massachusetts T"Itle 5 Official Inspection Form Subsurface Sewage Disposal System► Form -Not for Voluntary Assessments 7 345 RALEIGH TAVERN LANE Property Address MARCIA LANE Crwner c7wner's Name Wormation is NOR I I I ANDOVER MA 01845 5/5/18 required for every w... ._.__.._._.. ._ . _., page. Cftyfrown State Zip Cade Date of Inspection _. .___._..__...... ......ww. _....., ..___._._.____ _. .--____�._.__ ...._ _..___.__...____ D. System Information (cont.) Septic Tank (cont.) Distance from tap of sludge to bottom of outlet tea or baffle 25" Scum thickness g_111 ^]I I Distance from top of scum to top of outlet tee or baffle 1 _ Distance from bottom of scum to bottom of outlet tee or baffle I-low were dimensions determined? SLUDGE JUDGE & 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.): TANK DOES NOT NEED PUMPING AT THIS TIME, INLET AND OUTLET BAFFLES IN PLACE. OUTLET ALSO HAS PVC TEE IN PLACE BEHIND BAFFLE, LIQUID LEVEL CORRECT. Grease Trap (locate on site plan): Depth below grade: feet I Material of construction: i El concrete 0 metal [_] fiberglass polyethylene E:) other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottorn of scum to bottom of outlet tee or baffle Date of last pumping: Date Mns.doc-rev.(3116 T'Wo 5 plfidal Inspodinra Form Sutrrurfaaco Sowago Dispcnnl SYS1 rn)•Pap 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'� 345 RALEIGH TAVERN LANE Property Address MARCIA LANE Owner C7wner's Nanre tion required is State 0 Code fiat required for every NORTH _ 118 y f NC1RT1°I ANDf�VI f�t MA 018 ,� pays, Crt /"town . p of Inspection a D. System Information (cant,) i 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 Alar)); Depth below grade: Material of construction: concrete („ rmetal ) fiberglass El polyethylene L other(explain): Dimensions: _... Capacity: gallons Design Flow: � yalions Alarm present: El Yes [I No Alarm level: Alarm in working order. Yes No Date of last pumping: mate Comrments (condition of alarrn and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? El Yes El No I"rin�.d�ra w rrxv.G,J1C3 7itra 6 offcaol Inspac#ion C"ornv,Swbsurlaco Sewego piSpaBal System r nito 71 of 17 Commonwealth of Massachusetts u"A � TitleiInspection Form � �� .��'1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 345 RALEIGH TAVERN LANE Property dress MARCIA LANG. Owner .._.. .. __......_... _ Owner's Nemo Inforn ation is NORTH ANDOVER MA 01845 5/5/1 ...for _ to __...._..._p Code Dale of 1nspeafion page, Y Zip Code Cil !Yawn .� Stmt _._._ _..._... .�.._.....___�. D. System Information (cont.) Distribution Box (if present must be opened) (locate on site pian): 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.): BOX IS LEVEL AND WORKING PROPERLY, LIQUID LEVEL CORRECT. NO EVIDENE OF SOLIDS CARRYOVER. BOX IS 13" BELOW GRADE, WITH A SPRINKLER LINE OVER BOX, Pump Chamber(locate on site plan): Pumps in working order: 0 Yes El No" Alarms in working order: ❑ Yes No" Comments (note condition of pump charnber, 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: I 1.5ins,doc•roy CV10 I`411,a 5 01fcxal Iraarwrtion Form Subsurfsce Sevrrng®Disposal Systom•Page 12 of 17 Commonwealth of Massachusetts Title Official n r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 345 RALEIGH TAVERN LANE Property Address MARCIA Lank* Ownor bwnor's tJame information Isx required for every NORTH ANDOVER MA 0184a 5/511 f3 page C;ily/T own StateLip coda Date of Inspection U. System Information (cant.) n.... Type: ( leaching pits number: (� leaching charnbers number: [� leaching galleries number: ❑ leaching trenches number, length: X leaching fields number, dlmensions: (1) 20'X40' - [ overflow cesspool number: innovative/alternative system 'T'ype/narne of technology; Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOILS DRY, NO SIGNS OF HYDRAULIC FAILURE, VEGETATION NORMAL. 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, i Dimensions of cesspool Materials of construction Indication of groundwater inflow El Yes El Na 115inmsJoe my,6116 Tdw 5 Olfic,W htVwith,rarrwe SUbsurrsce Sewage Disposal Systern Pap 13 of 17 Commonwealth of Massachusetts Title 5 OfficialInspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 345 RALEIGH TAVERN LANE Property Address MARCIA LANE Owneror"s tVruno ---- I information is MA 011345 5/5/113 N(�RTlµt ANDOVER required for every page. cilyffown Mate 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,): I tl!rirn.axoe rav,411E7 --- I 5 01flcial Insparcf w Poww Subsurface S+rvarge Oispos al SyMom r aqv 1-1 of 17 Commonwealth of Massachusetts Title 5 Offl"c"lal Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �Aq_[�@I#Aljjavern Lane Property Address ,Qq.nnIs Wade Owner Owners Name information Is required for North Andover MA 01846 12/16/2008 every page. City/Town State Zip Code Date of Inspec(lon 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. 9 hand-sketch In the area below El drawing attached separately L5 114 11 P) Z- rad t 0 to ?keth C' —D.ex-,� 45ln--09= TWO 5 0016*1 lmgwAion rcmin:$09urfatAy SuwMfo Diq)osaj SyMimn Pop 15 of 17 SwMM RemdCBM COMMo l 0461 AOIB 272:x0 PM by KOM lbfdDA pAp 1 - Town of North Andover Tax Map # 210-107.A-0124-0000.0 Parcel Id 17951 345 RALEIGH 'TAVERN LANE SCOTT &MARCIA LANE 3"RALEIGH TAVERN LANE NORTH ANDOVER, MA 01845 _ Class 101 Single Family Property Type tat Zoning2 1 Residential Zoning3 ,Tat Size Total 1.01 Acres ' FY 2018 UB Mailinn !ride Name/Address Type Loan Number Activolls Atli SCOTT&MARCIA LANE owner 345 RALEIGH TAVERN LANE NORTH ANDOVER,MA 01845 WADE,NORMA 8,DENNIS Previous Customer Inactive l 345 RALEIGH TAVERN LANE NORTH ANDOVER,MA 01845 UB Account Malnt. ' Account No Cycle Occupant Name Bldg Id.14115.0.345 RALEIGH TAVERN LANE Last Billing Date 3120/2016 2100088 , 02 Cycle 02 UB Services MaInt. Account No.2100096 Service Code Rate Charge Multip ' MISCFEE ADMIN PEE 0.63518 7.82 1/ �,..�.----•---^"""' WTR WATER 01 ALL METER SIZE 76.00 11 UB Meter,f4alntenance Account No.2100096 Serial No Status Location Brand Type Size YTD Cone 36445477 a Active ERT HH b Badger w Water 0.63 0.63 1288 Date Reading Code Consumption Posted Date Variance 2/112018 1270 aActual 20 3/2812018 .13% 1111/2017 1250 aAclual 23 122912017 -41% 811/2017 1227 aActual 39 9/2012017 454/5 5/112017 1188 a Actual 26 6/28/2017 17% 2/112017 1162 a Actual 23 3/14/2017 -40°A 11/1/2016 1139 aActual 41 12/19/2016 -534/5 =12016 1098 aActual 86 0112016 138% 51312016 1010 aAclual 37 8/21/2016 43% MA 673 aAdual ZZ 0 -68% 10/30/2015 946 aActuel 77 12!3012015 8/412016 869 aActual 94 9/1412015 217% 514/2015 775 aActual 29 6122/2015 19% 2!312015 746 aActual 25 3/2012015 •68% 11/312014 721 aActual 79 12115/2014 -11% 611/2014 642 aActual 83 9111/2014 177% 615/2014 559 a Actual 31 6/1212014 Q -529 % 21312014 526 a Actual 25 3/17/2014 10/3112013 $03 aActual 48 12;2012013 -1% 81112013 465 aActual 49 9/1812013 5/1/2013 406 a Actual 21 6/1812013 t�1 d1 •6g6 2/712013 385 a Actual 27 3/1312013 V -31% 10/3012012 358 aActual 35 12113/2012 •29% 8/2/2012 323 aActual 51 9126120/2 85% 5/2/2012 272 eActual 27 6120/2012 7% 2!212012 245 a Actual 26 3/1412012 111112011 219 a Actuai 26 12/1612011 20% f Commonwealth of Massachusetts YTitle l Inspection Form � P p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 345 RALEIGH TAVERN LANE Oral)-arty Ad,dress MARCIA LANE Owner Owner"s Name required information is NORTH ANDOVER MA 01845 5/5/18 requ'rracf far every ....__ m...__.._ page. ,p JTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System; Provide a view of the sewage disposal systeal, 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: EJ hand-sketch in the area below j drawing attached separately i t5lns.c4au rnv,6116 rV1W 6 C71AIctui Inrspoc#fare Foarrr°;Srrbluxlnctit'"warga r'Iispoqul hyrolom•I'aEµr i';of 1"l Commonwealth of Massachusetts "c" Inspection Subsurface Sewage [disposal System Form Not for Voluntary Assessments 345 RALEIGH TAVERN LANE Property/address MARCIA LANE .. Owner Owner's Narne information edfo is NORTH ANDOVER MA 01845 5/5/18 raquiradforavary ... ....._._.____....._ ..... .._._...__.. _ __.._...._. _ ...,.M._.....,.. p Code Mita of Inspection pada, Cityl"rowr"w .....w. Stake Zr Cad.._........_ D. System Information (cont.) Site Exam: ® check Slope 0 Surface water 0 Check cellar 0 Shallow wells 6% Estimated depth to high ground water: foot Please indicate all methods used to determine the high ground water elevation: Obtained from system-design-plans on record If checked, date of design-plal'"I reviewed: 1216/08 -1"-�a,k "...V Gate [ ] Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Hoard of Health -explain: Checked with local excavators, installers-(attach documentation) 0 Accessed LISGS database -explain: i You must describe how you established the high ground water elevation: PREVIOUS TITLE-V , DATED '12/16/08. MAKES REFERENCE TO ESSEX COUNTY SOIL. MAPS SHEET#36, CHARLTON SOILS I-120 6 FEET DEEP Before filing this Inspection Report, please see Report Completeness Checklist on next page. rainn,aloa rr,Mv,6116 rico ofr6ol Inspoclion r onnr Surrastrarnr�r Sowawfpa nisposarl Systofir,Pago 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form E Subsurface Sewage Disposal System f=orm -Not for Voluntary Assessments sr„rr ///il 345 RALEIGH TAVERN LANA Property Address MARCIA LANE: Owner information is Owrrar'sNrna required for every ..__..__........__.__.__ page. t�F�TI"i ANDC?VCR .._.... A 0118,451. � Citytl"`ovwrr _. State ?Ip Cada Date o of Irrsryactorr_....._...� ._... ... ._. J E. Report Completeness Checklist f4- Inspection Summary: A, B, C, D, or f=' checkers 0 Inspection Summary D (Systern Failure Criteria Applicable to All Systems) completed System Information—Estimated depth to high groundwater x Sketch of Sewage Disposal System either drawn on page '115 or attached in separate file 151nm adQs rrav,l;6tiC3 rrN 5 Offioarl Inspichon Form Subsudaace Sowage Disvnal SysWin-114n10 17 of 17 I ORTH „' d 3•�`4t `M" �c w p � Torun of North Andover � tIEALTH DEPARTMENT T `f"Y"O�•`� p Sacmuse� s CHECK #; DATE ', LOCATION: _ » " Rr H/O NAME; _ � _- CONTRACTOR NAME Type 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 Systems: ❑ Septic-Soil Testing $ ❑ Septic a Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5Inspector $ �0 Titre 5 Report �� $ • �� ��. ❑ Other.(Indicate) aXth,Agent Initials, White-Applicant Yellow-Ifealth mink- Treasurer � k