HomeMy WebLinkAboutTitle V Inspection Report - 96 SUGARCANE LANE 5/22/2018 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
96 Sugarcane Lan
Property Address
Chris Madigan
OwnerOwner's Name
information is
required for every North Andover MA 01845 5-9-2018
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Neil J. Bateson
use the return Name of Inspector
key.
Bateson Enterprises Inc.
Company Name
111 Ar illa Road
Company Address
Andover MA 01810
City/Town 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:
Passes Fj Conditionally Passes F-1 Fails
❑ N e Further Evaluation by the Local Approving Authority
5-9-2018
sp cto s SignatDate
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.
15!ns.doc-rev.6116 TWo 5 Official inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
96 Sugarcane Lane
Property Ad—dress
Chris Madigan
Owner Owners Name
information is
required for every North Andover MA 01845 5-9-2018
page. CltyfTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist, Any failure criteria not evaluated are
indicated below,
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y n N ❑ ND (Explain below):
———----------------
l5ins.doc•rev.8118 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
96 Suqarcane Lane
Property Address
,Chris Madigan
Owner wner's Name
information is
required for every North Andover MA 01845 5-9-2018 ---------
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump 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):
F] broken pipe(s) are replaced F1 Y El N F-1 ND (Explain below):
M obstruction is removed 0 Y F-1 N R ND (Explain below):
F-1 distribution box is leveled or replaced R Y r-1 N El ND (Explain below):
-----------
❑
---------The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
F-1 broken pipe(s)are replaced 0 Y El N F-1 ND (Explain below):
El obstruction is removed F] Y Fj N F-1 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:
F Cesspool or privy is within 50 feet of a surface water
R 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
• 96 Sugarcane Lane
Property Address
Chris Madigan ------------- -—------
Owner Owners Name
information is
required for every North Andover MA 01845 5-9-2018
page. City/Town ........ State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
F] 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.
F The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
F 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 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 0 clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
EJ El due to an overloaded or clogged SAS or cesspool
El 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 Y2day flow
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
96 Sugarcane Lane ——-----
Property Address ----------
Chris Madigan
Ownerowner's Name
information is
required for every North Andover MA 01845 5-9-2018
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El 0 Required pumping more 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.
1:1 z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
R z Any portion of a cesspool or privy is within a Zone I of a public well.
R 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
E] 2 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
El 0 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
R R the system is within 400 feet of a surface drinking water supply
El EJ the system is within 200 feet of a tributary to a surface drinking water supply
El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
El ❑
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.
Mins,doc rev.6/16 Title 5 Official inspection 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
96 Sugarcane Lane
'F i r OP e rt-y Address
arcane
--------------------
Chris Madigan
Owner --- _----_.._
Owner's Name
information is
required for every North Andover MA 01845 5-9-2018
page. CityfTown 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
El E Were any of the system components pumped out in the previous two weeks?
0 El Has the system received normal flows in the previous two week period?
El H 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)
0 ❑ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
H 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:
Number of bedrooms (design): Number of bedrooms (actual):
600
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ----
t5ins,doo rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
E Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
96 Sugarcane Lane
Property Address
Chris Madigan -
Owner Owners Name
information is
required for every North Andover MA 01845 5-9-2018
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
----------------
Number of current residents: 3
Does residence have a garbage grinder? Yes No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes E No
information in this report.)
Laundry system inspected? R Yes El No
Seasonaluse? ❑ Yes No
Yes
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
------------
Sump pump? F1 Yes M No
Last date of occupancy: Current Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? R Yes E] No
Industrial waste holding tank present? El Yes [j No
Non-sanitary waste discharged to the Title 5 system? El Yes Fj No
Water meter readings, if available:
t5ins.doc rev.6/16 Title 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
96 Sugarcane Lane
Property— - -Address
Chris Madigan
Owner Owner's Name
information is
required for every North Andover MA 01845 5-9-2018
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 2017, owner
Was system pumped as part of the inspection? M Yes El No
If yes, volume pumped: 1500gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank&tees
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
E-1 Overflow cesspool
El Privy
E] Shared system (yes or no) (if yes, attach previous inspection records, if any)
F1 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
EJ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doe-rev.6116 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
96Sugarcane Lane ----------
Oroperty Address
Chris Madigan
Owner Owner's Name
information is
required for every North Andover MA 01845 5-9-2018 -------
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:
22 years old, 11-25-1996, as built plan -.- -------------- --——----------Were sewage odors detected when arriving at the site? FI Yes 0 No
Building Sewer(locate on site plan):
2
Depth below grade: feet
Material of construction:
El cast iron N 40 PVC F1 other(explain):
Distance from private water supply well or Suction line: fest e at
Comments (on condition of joints, venting, evidence of leakage, etc.):
Finished cellar, unable to see piping leaving foundation. 4" PVC out to septic tank.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
S concrete E] metal n fiberglass ❑ polyethylene n other(explain)
-----------
------------
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes ❑ No
10'x 5'x 4'
Dimensions:
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
96 Sugarcane Lane
Property Address
Chris Madigan
Owner Owner's Name
information Is
required for every North Andover MA 01845 5-9-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
3211
Distance from top of sludge to bottom of outlet tee or baffle . .........
311
Scum thickness
811
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 12" -----------
_j
How were dimensions determined? ape 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. Outlet cover broken, replaced same. Liquid level at outlet invert. No
evidence of leakage. Pumped septic tank.
----------
-----------
------------
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal n fiberglass n polyethylene ❑ 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:
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
96 Sugarcane Lane
Property Address
Chris Madigan
Owner Owner's Name
information is
required for every North Andover MA 01845 5-9-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete D metal F-1 fiberglass El polyethylene ❑ other(explain):
Dimensions: —------
Capacity: gallons
Design Flow: gallons per day
Alarm present: El Yes El No
Alarm level: ------ Alarm in working order: El Yes El No
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
——---------
----------
Attach copy of current pumping contract(required). Is copy attached? El Yes ❑ No
t6ins.doc•rov.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
96 Sugarcane Lane
RioperiiAddress' '--- --------
Chris Madigan ------- ------------
Owner Owners Name
information is
required for every North Andover MA 01845 5-9-2018
page. tatyfrown 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, pumped d-box to
clean.
Pump Chamber(locate on site plan):
Pumps in working order: El Yes El No*
Alarms in working order: F-1 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.doe-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
96 Sugarcane Lane
Property Address
Chris Madigan ---—T...._.--
Owner Owner's Name
information is
required for every North Andover MA 01845 5-9-2018
��7-
page. 0 State Zip Code Date of Inspection
D. System Information (cont.)
Type:
R leaching pits number:
R leaching chambers number:
R leaching galleries number:
0 leaching trenches number, length:
R leaching fields number, dimensions: I field 20'x 56'
R overflow cesspool number:
❑ inn ovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
—---------
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 R No
15ins.dor•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
96 Sugarcane Lane -------------
Property Address
Chris Madigan ------------------------
Owner Owners Name
information is
required for every North Andover MA 01845 5-9-2018
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
--------
Depth of solids ---—----------
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc,):
............
t5ins.doc•rev.6116 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
96 Sugarcane Lane
Property Address
Chris Madigan
Owner Owner's Name —-------
information is
required for every North Andover MA 01845 5-9-2018
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:
0 hand-sketch in the area below
El drawing attached separately
P` '--
I 11
4 S, `'14
0_d�zz 0(
151ns.cloc-rev.6116 Title 5 Off dal 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
96 Sugarcane Lane --------------------------
Property Address
Chris Madigan
OwnerOwners Name
information is
required for every North Andover —-------- MA 01845 5-9-2018
page. City[Town 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. 5-2-1995
Date
El Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain'.
Design plan
El Checked with local excavators, installers-(attach documentation)
El Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
As per test pit data on design plan
—--------- —--------- —-.�
i
Before
---------
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-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
96 Su arcane Lan
Property Address
Chris Madigan
Owner Owners Name
information is
required for every North Andover MA 01845 5-9-2018
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
[E Inspection Summary: A, B, C, D, or E checked
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
15ins.doe-rev,5116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
:. Commonwealth of Massachusetts
Citj/Town of .
i sys#ern Pumping.Record
Form 4
DEP hes provided this for rri for use-by local Boards 6f,Health. Other forms may'be'used,but the
Information`must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Informmtlon
1. System Location: Left/Right front of House, Leftl Right rear of house, Left/right side of house, Left t
Right side of building, Left/Right front of buildirig, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner: .6 6
Name'
Address of different from location)
city/Town State,r—, �-, � � �a ,
Telephone Number
k /
.B. Pumping Kecord
4. Date of PumpingDate 2. Quantity Pumped: Gaitans`��" —_s
1,
3. Type•of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): ,,-~
4. Effluent Tee Filter present? ❑ Yes 2-' o If yes, was it cleaned? ❑ Yes (1 NQ
' 6. Condition of System: r�� /�� � •
V0 G ..
6. System Pumped By:
Nell.Bateson (~5821
I
Name Vehicle License Number
Bateson Ehterprises Inc`
Company
7. Location where contentsrwere disposed:
OLLS-P Lowell Waste Water
SJgn aitHhulev Date
l5fbrm4.doc-06/03 System Pumping Record•Page 1 of 1
�
town
l�vmDnf |yOrfh Andover
��� N� f� 210-106.A-0265-0000.0
.== °°"��K� ,, "
^
Parcel |d1741B
96SUGARCANELANE
CHRISTOPHER K0A0GAN
MELANIE GARGER
96 SUGARCANE LANE
NORTH ANDOVER, MA 01845
Class 101Single Family Property Type 1 Residential
Zoning2 1Rooidmntia| Zooing3 1nnsidnnUo|
Size Total 1J3 Acres
Py 2018
UB Mailing Index
Name/Address Type Loan Number Aodvo/|naot From Until
CHR|ST0PHERMAD|GAN Owner
MELANIE GARGER
$6OUGARCANELANE
NORTH ANDOVER, M8 01845
CLARK,TODD&KAREN Previous Customer Inactive 12/1/2006
8VSUGARCANE LANE
NORTH ANDOVER, MA
01845
KURTKLE|NENDDRFT Previous Customer ' Inactive 6/23/2010
SOSUGARCANELxNE
NORTH ANDOVER, MA 01845
UB Account Maint.
Account No Cycle Occupant Name Aodvd|nnntive
Bldg |d. 17071.o-asSUGARCANE LANE Last Billing Date 4/10/2018
3170341 03 Cycle 03 Active
UB Services Maint.
Account No.3170341
Service Code Rate Charge Multi pl ier/Vse rs
M|GCFEEADMIN FEE 0,635@ 7.82 1/
VVTRVxATER 01 ALL METER SIZE 98,20 n
UB Meter Maintenance
Account No.3170341
Serial No Status Location Brand Typo Size YTD Cons
33605*81 m8ctkm ERT HH bBadger wVVuo/ 0.630�63 1825
Data Reading Code Consumption Posted Date Variance
3/9/2018 2019 mActuo| 24 4/23/2018 '44Y6
12/7/2017 1985 aActum| 41 1/2612818 'som
9/12/2017 1804 uActuu| 131 10/18/2017 259%
6/02017 1823 aAuua| uo 7/25/2817 35%
3/8/2017 1788 eActuo| zn 4/12/2017 -2594
12/9/2016 1763 aActua| nn 1/23o017 -/296
9/9/2010 1730 o**ua| 112 10124/2016 166%
6113/2016 1618 o*mum| 46 02o016 116Y4
�o 4/22/2016 -36%� 319/2016 1572 aA�ua|
| 12/10/2015 1552 u»m"m| 32 1/20/2016 '58%
/
919/2015 1520 aActua| 70 1016/2015 41%
6/102015 1444 uActua| 54 7/24/2015 98%
3/11/2015 1390 a*vma| 27 4/28/2015 -17%
12/11/2014 1363 aActum| 33 1/15/2015 '66Y4
9/11/2014 1330 aActua| no 10/15/2014238%
!
6/11/2014 1232 uActun| oe 7/16/201425%
|
3/11x3014 1203 aActuo| 23 4/11/2014 -54Y6
/ 12/10/2013 1180 eAotua| 48 1/17/2014 -6m
9M2/2013 1131 aAomal 54 10/15/2013 4m
54 7/24/2013 118%6/1212013 1077 aAcmo
i
rt d
x
Town of,North Andover
HEALTH DEPARTMENT
x. .6•,,,0
S�CHUS
CHECK#: :; DATE: Q�
LOCATION
H/O NAME: _ q
CONTRACTOR 'SAME: � w
Type of Permit or License:(Check box)
❑ Animal
❑ Body Art Establishment $
❑ Body Art Practitioner
❑ Dunipster
❑ Food Service_
❑ Funeral Directors $
❑ Massage Establishment
❑ Massage Practice $
❑ Offal(Septic)Hauler
❑ .recreational Camp
❑ Sun tanning
❑ Swimming Pool �
❑ Tobacco
❑ TraslVSolid Waste Hauler
❑ Well Construction s
SEPTIC em, ,
CJ Septic- Soil Testing
CJ Septic-Design Approval
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
13 Title 5 Inspector
4
Title 5 Report
❑ Other.(Indicate)__ _
t "'Ith�'AgentInitials
White Apixlicant Yellom-Health Pink- Treasurer �