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HomeMy WebLinkAboutTitle V Inspection Report - 15 WINDKIST FARM ROAD 5/16/2018 Commonwealth of Massachusetts Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments MAY '16 0 18 15 WIANDsKIST FARM ROAD _ ....._ - _-r C I`� 9��ryp^�::R.F VE[ Property 5" fl ROBERT MAUTHE Owner Owner's Name information is NORTH ANDOVER, MA. 01845 4/19/18 required for every page. Clty/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 tilling out forms A General Information on the computer„ use only the tab 1 Inspector: key to move your cursor-do not BRIAN S MURPHY use the return _.....__.___ —..... ..... Name of Inspector � - key. B & D SEPTIC INSPECTIONS �y Company game P.O.BOX 47 Company Address -- <asn HULL, MA 02045 Cityfrown State Zip Code (781) 290-9942 513675 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: FRI Passes ❑ Conditionally Passes Q Fails Needs Further Evaluation by the Local Approving Authority I J, __ 4/20/18 Inspector's Signature V Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts _ Title 5 OfficialInspection Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 WINDKIST FARM ROAD _.__.._..__..._.._...__... Property Address ROBERT MAUTHE OwnerOwner's Name .._..___-___..-- _._._.........__..� _...___ information is NORTH ANDOVER, MA. 01$45 4/19/1$ required for every NORTH -.... . .-----.__.._ _.. __._. .__....... page. Cityrrown State Zip Code Date of Inspection B. Certification (cant.) _ Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): 15ins.doc mv.6/16 Title 5 Official Inspection Pone:Subsurface Sewage Disposal System-Page 2 of 17 ^ , Commonwealth of Massachusetts ��^��D�� �� ����~�����0 N��������"��"���� ����0"��> � N�Q�� �� ��HDD��UwmN Inspection U—��muom Subsurface Sewage Disposal System Form'Not for Voluntary Assessments -.15 WINDKIST FARM ROAD Property Address R(}BERTMAUTHE Owner Owners Name information| is NORTH ANDOVER, ��/\ 01845 4/19/18 mno|mumrnve� ' page. otyrrnwn State-- Date mInspection B. Certification (cont.) Fl Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(conL): [] 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 |f(with approval ofBoard cfHeahh): Fl broken pipa(a)are replaced Fl Y [] N n ND(Explain be|ovv : F] obstruction isremoved El Y F] N El NU(Explain bm|ovv : [l distribution box imleveled orreplaced [| Y El N 0 ND(Explain be|ov ): [l The system required pumping more than 4times a year due bmbroken orobstructed pipe(e). The system will pass inspection if(with approval mfthe Board ofHea|th): Fl broken pipe(s) are replaced Fl Y n N Fl ND(Explain be|ow): obstruction ioremoved n Y 0 N El ND(ExV|ninbe|om): . . . C) Further Evaluation isRequired bythe Board mfHealth: [] Conditions exist which require further evaluation by the Board of Health in order to determine if the system isfailing 10protect public health, safety orthe environment. 1. System will pass unless Board mfHealth determines |maccordance with 31QCMR 15.3O3(1)(b)that the system isnot functioning inamanner which will protect public health, safety and the environment: [] Cesspool orprivy iswithin 5Ofeet ofasurface water [] Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh mm°.moc'rev.a,e Title nomualInspection Form:Subsurface Sewage Disposal System'Page 3",`7 , ' Commonwealth of Massachusetts �������� �� �������°��U H����������������� ����Q~��� BU�U"= �� �°�DNQ��N��N Inspection �—��mnmo Subsurface Sewage Disposa| SysbmnmPormm-NotforVo|untaryAemeammente 15 WIN[}KISTF/\RM ROAD pmpanvxuumeu ROBERT NY/\UTHE Owner 0wnmrowam° information i is NORTH /\NU(]\/ERK�/\ 01845 4/19/18 mquimomrow� �_ page. otxnn°n state Zip Code Date o,Inspection B. Certification (cont.) 2System will fall unless the Board mfHealth (and Public Water Supplier, If any) determines that the system isfunctioning inamanner that protects the public health, safety and environment: F] The system has a septic tank and soil absorption system (SAS)and the SAS is within 1QUfeet ofa surface water supply ortributary hnasurface water supply. ElThe system has aseptic tank and SAS and the SAS iewithin aZone 1nfopublic water supply. E] The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. El The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from aprivate water supply we||^^. Method used hodetermine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence nfammonia nitrogen and nitrate nitrogen iaequal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must beattached bzthis form. 3. Other: [q System Failure Criteria Applicable toAll Systems: You must indicate"Yem" or"0o"toeach ofthe following for all inspections: ! Yes No [l �� Backup ofsewage into facility orsystem component due tooverloaded or �~ �~ clogged SAS orcesspool | rl �� Dischargeor di ofeffluent tuthe au�aoeofthe gmundormu�acevvotorn �~ �~ due humnoverloaded orclogged SAS orcesspool | �l �� Stadoliquid level inthe dimdribuUonbox above ouUetimve�due toanoverloaded �~ �� orclogged SAS orcesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2d flow t5ms,^oc'rev.mm Title 5Official Inspection Form:Subsurface Sewage Disposal System'Page*m,/ Commonwealth of Massachusetts 0Inspectionorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments x` 15 WINDKIST FARM ROAD Property Address ROBERT MAUTHE Clwner's Name information is NORTH ANDOVER, MA. 01845 4119118 required for every —u__ ._....m... -.--_— page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ X1 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ X1 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Q ( 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. ❑ ZI 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. ® 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 ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 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 Titfe 5 Official Inspection Form:Subsurface Sewage Usposal Systern-Paye 5 of 17 , ' Commonwealth of Massachusetts =�'°����� �� �~����^��"��N N��������*��i���� ����W°8�� NH�Wn= �� ��N � U��H��W Inspection Q—��umwn Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15VVINDK|ST FARM ROAD Property Address R[>BERTMAUTHE nwmv/ Owner's Name information is NORTH ANDOVER, MA. 01845 4/19/18 required m � � ,pv= page. City/Town 7State — 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 [l Were any ofthe system components pumped out inthe previous two weeks? FX] [l Has the system received normal flows inthe previous two week period? F� �� Have large volumes ofwater been introduced hothe system nacenUyoroopa�of �� �� this inspection? �� Fl Were ambuilt plans ofthe system obtained and examined? (If they were not =~ ^~ available note asN/A) �� [] Was the facility ordwelling inspected for signs ofsewage back up? R-1 Fl Was the site inspected for signs ofbreak out? KI El Were all system components, excluding the SAS, located onsite? 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 ofliquid, depth ufsludge and depth ofscum? �� �l VVasthe fani|Uyowner(and oouupan�ifdifferent hnmowne�provided v�th �~ �~ information on the proper maintenance of subsurface sewage disposal systems? The size and location ofthe Soil Absorption System(SAS)onthe site has ^ been determined based on: ' 01 [] Existing information. For example, aplan mtthe Board ofHealth. Fl �� Determined inthe field(if any ofthe failure criteria related tuPa�Ciaotissue �~ �~ approximation ofdistance isunacceptable) [31OCMR 15.3D2(5)] D. System Information Residential Flow Conditions: Number ofbedrooms(d 4 4 (design): -------' Number ofbedrooms(aotua|): �����----- 440 DESIGN flow based on31OCMR 15.203 (for example: 118gpdx#ofbedrooms): --------- w*",clo"'rev.mm Title,mfiw /Inspection Form:Subsurface Sewage Disposal System'Page emn Commonwealth of Massachusetts Official Inspection Form it V Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15 WINDKIST FARM ROAD Property Address ROBERT MAUTHE ............... Owner Owner's Name Information is required for every NORTH ANDOVER MA. 01845 4119/18 page. Cltyrrown State Zip Code Date of Inspection D. System Information Description: -------------- -------------- ------------ ............... 3 Number of current residents: Does residence have a garbage grinder? F1 Yes M No Is laundry on a separate sewage system? (Include laundry system inspection El Yes nx No information in this report.) Laundry system inspected? El Yes R1 No Seasonaluse? El Yes rx-1 No Water meter readings, if available(last 2 years usage(gpd)): SEE ATTACHED Detail: ------------ Sump pump? El Yes 91 No Last date of occupancy: Present Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per aay(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes Ej No Industrial waste holding tank present? El Yes R No Non-sanitary waste discharged to the Title 5 system? F1 Yes E] No Water meter readings, if available: ---------------- -------------- t5ins.doc-rev.6/16 Title 5 Official Inspedion 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 WINDKIST FARM ROAD Property Address ROBERT MAUTHE ------------------ Owner owner's Name information is NORTH ANDOVER, MA. 01845 4/19/18 required for every page. City[Town tate Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: ---------------------—-----—--------- Date Other(describe below): ----—----- ----------- —-------- ----------- General Information Pumping Records: system lastpumped 2015 - owner Source of information: Was system pumped as part of the inspection? F-1 Yes N No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: FK Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy EJ Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract F-1 Tight tank.Attach a copy of the DEP approval. El Other(describe): -------------- —------- t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15 WINDKIST FARM ROAD -----------—---- ---- ----—------ Property Address -.ROBERT MAUTHE Owner Owner's Name information is NORTH ANDOVER, MA. 01845 4/19/18 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, system installed 10/97 - local BOH records .-............. Were sewage odors detected when arriving at the site? F1 Yes FX] No Building Sewer(locate on site plan): 2411 Depth below grade: feet Material of construction: F1 cast iron [XI 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): ---------- ------------- Septic Tank(locate on site plan): 2011 Depth below grade: feet Material of construction: Nfl concrete El metal El fiberglass [:1 polyethylene El other(explain) ------------ If tank is metal, list age: ---------- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 171 Yes F1 No Dimensions: 10' x5' x5' 1500gql. 1 Sludge depth: 15ins,doo-rev.6716 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts :mm ................. Title - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .m, 15 WINDKIST FARM ROAD Property Address ROBERT MAUTHE Owner Owner's Name information is NORTH ANDOVER MA. 01845„ 4/19/18 required for every ._. _ ._. . ..�........___.._ ------_.-- page, CftyfTown 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 -- 1-.-.-__._ outlet 50 Scum thickness - 1° 5'1 Distance from top of scum to top of outlet tee or baffle ...__..._.._............................_-...._,....___._....._.___.__.,_...._...._._........__. Distance from bottom of scum to bottom of outlet tee or baffle — 18" How were dimensions determined? Measured in field 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 and tee's in good condition, outlet tee has gas baffle in place liquid level with outlet, tank appears sound no signs of leakage, recommend installing risers on covers. Grease Trap(locate on site plan): Depth below grade: _ feet Material of construction: © concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness _.__._....__..a,_...._.............__...___..,_.__.____._._...-._.._-- 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 t5lns.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title iInspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 WINDKIST FARM ROAD Property Address ROBERT MAUTHE Owner Owner's Name information is NORTH ANDOVER, MA. 01845 4/19/1$ required for every _ _.. page City(fown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: ..............-- Material of construction; ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions; Capacity: - _......_ _...._ — .. gallons Design Flow: ------------ _ gallons per day Alarm present: ❑ Yes ❑ No Alarm level: -.-__._._ Alarm in working order: ❑ Yes ® No Date of last pumping: Date -_---.. Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6116 title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts - _ Title I Inspection Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f. 15 WINDKIST FARM ROAD Property Address ROBERT MAUTHE Owner owner's Name information is NORTH ANDOVER, MA. 01845 4/19_/18 page. City/Town State Z required for Query ......._ __. __._,__....._._._,..._.. .__. ._._____ ._ - _ .._._..... ........._. ip Code date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0" 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 in good condition, box starting to show slight signs of deterioration, liquid level distribution appears etual, no signs of carryover or Ieaka e. Box 10" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins.doc•rev.8118 Tille 5 Official Inspection Forn Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts it 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15 WINDKIST FARM ROAD Property Address ROBERT MAUTHE Owner Owner's Nam—e—' information is NORTH ANDOVER, MA. 01845 4/19/18 required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Type: El leaching pits number: El leaching chambers number: El leaching galleries number: RX leaching trenches number, length: 1' x 4' x 66' Fl leaching fields number, dimensions: El overflow cesspool number: El innovativelalternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil conditions appear normal, no siqns of hydraulic failure,�ve e 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 --------- Dimensions of cesspool Materials of construction Indication of groundwater inflow El Yes [-I No t6ins,doc,•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,r 15 WINDKIST FARM ROAD __�. Property Address ROBERT MAUTHE Owner Owner's Name information is NORTH ANDOVER, MA. 01845 4/19/18 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.): _.....__---------- _ _...,.,..-._.. ----------- i i I 15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts PFmq� Title 5 Official Inspection Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 WINDKIST FARM ROAD Property Address ROBERT MAUTHE Owner owner's Name information is NORTH ANDOVER, MA. 01845 4/19/18 requiredfor every ..._.._.-. __...,,__._ .._.._ �___..__ ___ _—--------- _._._ —_—....._ page. CityTrown 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 Q drawing attached separately I i 15ins.doc rev.6/16 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 "Y 15 WINDKIST FARM ROAD Property/Address ROBERT MAUTHE Owner owner's Flame information is FORTH ANDOVER, MA. 01$45 4/19118 required for every _......_. -. .-.. page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: El Check Slope El Surface water Q Check cellar E] Shallow wells 4' Estimated depth to high ground water: --...-._-... ___...._.......___..a.._...__..._-___..-- feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 2/3/97 If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: Checked with local excavators, installers- (attach documentation) © Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater determined from design plan on record at local BOH, eshgw determined to be @ 192.50 from perk test dated 5121196, .._...._- .....__...._......_-- bottom of system @ 196.52 per as-built on record. _..w__--- _-_.n._.-........._.._-__.._._.__.___._._-......_ Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 OfficialInspection Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 15 WINDKIST FARM ROAD Property Address ROBERT MAUTHE Owner Owner's Mame information is NORTH ANDOVER, MA. 01845 4/_19/18 required for every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked „x] 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 I t5ins.doc+rev.6116 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System•Page 17 of 17 I11 S.T• =l90 G7 S rrti.H (r TV.) '21,f3' 13.7' b-eox ass' �rq•s' WD-BOX =!40.0(0 �D-�'g( 77,3' S�1 ' Ov-r b-BaX =19"7.'70 Jsb T'2w2 IUl_TP-itj =197.08 rit•Tiz*Z I17.aq END 720-1 =197.52 F'ub TrzK-2 ;197.52 t i �x�57"ru� �N bT7,1. ms" U +x Ta lusin� FntE ~ s5m G r to o- M �1 f b 68, pS- 137.8, i r .._,. _ L.�S-'D AS BUILT PLAN! OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN AS PREPARED FOR GoLo l 1 I AL Ali LLAG E DEvE I)o PH 51-f1" C��f• . DATE: Nkj6uST' 5, M7 SCALE: Lt�T I W I bi n Kr ST" E_AR M MER.RrMACK FNGINERRING SERVICES 66 PARK STREf3T - { ,ANDOVER, MASSACHUSETTS 01810 Summary Record card generated on 1/23/2018 9:16:28 AM by Karen Harlon Page 1 Town of North Andover Tax Map # 210-109.0-0048-0000.0 Parcel Id 18862 15 WINDKIST FARM ROAD ROBERT & TERRI MAUTHE 15 WINDKIST FARM ROAD NORTH ANDOVER MA 41845 Class _ 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zonin93 i Residential Size Total 1 Acres FY 201$ UB Mailing Index Type Loan Number Active/Inact, From Until Name/Address Yp ROBERT&TERRI MAUTHE Owner 15 WINDKIST FARM ROAD NORTH ANDOVER MA 01845 DESIMONE,RALPH Previous Customer Inactive 7/14/2008 15 WINKIST FARM ROAD NORTH ANDOVER,MA 01845 IRA&MARIA HOUCHINS Previous Customer Inactive 6/26/2015 15 WINDKIST FARM ROAD NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Actkwellnactive Bldg ld.13779.0-15 WINDKIST FARM ROAD Last Billing Date 2/9/2018 1090456 01 Cycle 01 Active UB Services Maint. Account No. 1090456 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 1 1 9.18 11 WTR WATER 01 ALL METER SIZE 41,80 11 US Meter Maintenance Account No, 1090456 Serial No Status Location Brand Type Size YTD Cons 32948523 a Active 00 b Badger w Water 1 1 823 Date Reading Code Consumption Posted Date Variance 1 4118/2018 1133 a Actual 12% 1/18/2018 1121 a Actual 11 2/20/2018 -16% 1011812017 1110 a Actual 13 11/13/2017 -13% 7/19/2017 1097 aActual 15 8115/2017 -11% 4/19/2017 1082 a Actual 15 5/17/2017 •4% 1/19/2017 1067 a Actual 16 2/16/2017 -62% 10119/2016 1051 a Actual 41 11116/2016 -9% 7122/2016 1010 aActual 46 8/1612016 171% 16 7 4 0 4!2212016 964 a Actual 17 5/25/20 1122/2016 947 a Actual 16 2119/2016 -85% 10122/2015 931 a Actual 106 11120/2015 -28% 7/24/2015 825 a Actual 51 8/14/2015 118% 6123/2015 774 f Final Bill 43 612312015 629% 4/27/2015 731 2Actual 9 5/19/2015 -8% 1/30/2015 722 a Actual 11 2/20/2015 240% 10/24/2014 711 a Actual 3 11/14/2014 -88% 712512014 708 aActuap 25 8/1312014 294% 4/24/2014 683 a Actual 6 5115/2014 0% 1/27/2014 677 a Actual 5 2/14/2014 ?,20/o 10/23/2013 672 a Actual 6 11/1812013 % 1 7/23/2013 666 a Actual 6 8/15/2013 -1%-1% 6 5/20/2013 27u/4 4124/2013 660 a Actual I