HomeMy WebLinkAboutTitle V Inspection Report - 84 SUGARCANE LANE 6/4/2018 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 Sugarcane Lane
Property Address
Chris Hanson
Owner Owner's-Name
info nation is
req fired
for every North Andover MA 01845 5-24-2018
page, d FtyiT-o-w—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.
Im r ortant:When A. General Information ......
filling out forms
one computer, 4 7013
use only the tab 1. Inspector:
key� to move your jt4 OF t4c)RTH AK)0'v �
r-, �
cu I Tsor-do not Neil J. Bateson
use the return Name of Inspector
key Bateson Enterprises Inc.
Company Name
111 Argilla 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:
E Passes n Conditionally Passes El Fails
RMees Further Evaluation by the Local Approving Authority
5-24-2018
-i-nspect Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DER The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This Inspection does not address how the system will perform in the future under
the same or different conditions of use,
t6i sAoc w rev.6116 'ritio 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
A
Title 5 Official Inspection Form
rt Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 Sugarcane Lane
Property Add —ress
Chris Hanson
Owner Owner's Name
inft
rmation is North Andover MA 01845 5-24-2018
required for every
pa e. Cityfrown 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:
1 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,
El 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 R N El ND(Explain below):
---------------- ----------------------- ---------------------------------
t5l s.doc-rev,6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
_-_ -__-__ r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 Sugarcane-Lane
Property Address
Chris Hanson
0 DerOwner's Name
inf
re, enation is uired for every North Andover MA 01845 5-24-2018
pa I e. dityrrown 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.
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 R Y R N R ND (Explain below):
obstruction is removed R Y Ej N F1 ND (Explain below):
El distribution box is leveled or replaced F1 Y n N El ND (Explain below):
—------------
R 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):
❑ broken pipe(s)are replaced R Y R N R ND (Explain below):
❑ obstruction is removed El Y El N F1 ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
El 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:
F1 Cesspool or privy is within 50 feet of a surface water
Ej Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5i s.cloo-rev,6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
�L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 Sugarcane Lane
Property Address
0 ner Chris Hanson
Owner's_N__a—me—-------
10 rmation is No
required for every
North Andover MA 01845 5-24-2018
pa! e. 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:
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 surface water supply.
F1 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
F1 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 Na
El
0 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
El
E 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 Y2 day flow
t51r s.doc•rev,6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
-------------- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 Sugarcane Lane
Property Address
Chris Hanson
OwnerOwner's Name
inNtmation is
required for every North Andover MA 01845 5-24-2018
pa e. ditjifo-w—n 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:
F1 0 Any portion of the SAS, cesspool or privy is below high ground water elevation,
El E Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El E Any portion'of a cesspool or privy is within a Zone I of a public well.
El E 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.]
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
E] M 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 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.
t5f is.cloc-rev.W6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
<L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 Sugarcane Lane
Property Address
Chris Hanson
OwnerOwners Name
information is
required for every North AndMA 01845 5-24-2018
pae. City/Town 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
0 0 Were any of the system components pumped out in the previous two weeks?
0 0 Has the system received normal flows in the previous two week period?
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 0 Was the facility or dwelling inspected for signs of sewage back up?
0 El Was the site inspected for signs of break out?
Z ❑ Were all system components, excluding the SAS, located on site?
0 EJ 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?
0 EJ 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.
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): 4 Number of bedrooms (actual): 4---
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660
t5ir s.doc•rev.6/16 Title 5 official inspection Foam Subsurface sewage Disposal System-Page 6 of 17
1
Commonwealth of Massachusetts
u - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
-- 7
w
84 Sugarcane Lane
Property Address ---.---__
Ovu er Chris Hanson
- _------__ -
Owner's Name
inf ormation is North Andover MA 01845 5-242018
req fired for every __�....__
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
2
Number of current residents: --
Does residence have a garbage grinder? Yes® ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)); Yes ---
Detail:
Sump pump? ❑ Yes ® No
Current
Last date of occupancy: Date -
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 16.203): Gallons per day(gpd) -
Basis of design flow (seats/persons/sq.ft., etc.); — -
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5i`s.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 Sugarcane Lane
Property Address
Chris Hanson
Ow ier Owners Name
poormiois. -d for every North Andover MA 01845 5-24-2018
equire Cityrrown State Zip Code Date of Inspection
ge.
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below):
General Information
Pumping Records:
Source of information: fyTped_last year, owner
Was system pumped as part of the inspection? H Yes El No
If yes, volume pumped: 1500gallons
How was quantity pumped determined? Measured tank
Inspect tank&tees
Reason for pumping:
Type of System:
0 Septic tank, distribution box, soil absorption system
El Single cesspool
r-] Overflow cesspool
r-1 Privy
F1 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
El Tight tank. Attach a copy of the DEP approval.
D Other(describe):
lls.doq
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
I rev.6116
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
— a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
't 84 Sugarcane Lane
Property Address
OW ier Chris Hanson
ino
Owner's Name
matlon is North Andover MA 01845 5-24-2018
red fired for every ---------------------------__
. -
pa e City/Town State Zip Code Date of Inspection
i
D. System Information (cont,)
Approximate age of all components, date installed (if known) and source of information:
21 Years old, 2-26-1997, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: eet._------
Material of construction:
❑ cast iron ®40 PVC ❑other(explain): ------
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Finished cellar unable to see piping leaving foundation. 3" PVC in house, No leaks
visible. 4" PVC out to tank.
Septic Tank(locate on site plan):
Depth below grade; feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ 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: -
3"
Sludge depth;
t5Tdoc-rev.6116 Titte 6 offmial Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
<C\-- Commonwealth of Massachusetts
------------
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 Sugarcane Lane
Property Address
Chris Hanson
Ovi ner Owner's Name
infc rmation is
req jired for every North Andover MA 01845 5-24-2018
paC e. 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 30" _...e.__...__—
2"
Scum thickness
Distance from top of scum to top of outlet tee or baffle 811
Distance from bottom of scum to bottom of outlet tee or baffle 13"
How were dimensions determined? _Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade: -f6et
Material of construction:
concrete n metal E]fiberglass F] polyethylene E] other(explain):
—-----------
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
li
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
TRIe 6 Official Inspection Form:Subsurface sewage Disposal System Page 10 of 17
tsillmdor rev.6116
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 Sugarcane Lane
Property Address
Chris Hanson
Owner Owner's Name
rintc rmation is
eq ire for every North Andover MA 01845---,-- 5-24-2018
pa�a. 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] fiberglass E] polyethylene E] other(explain):
Dimensions:
Capacity: Talionis
Design Flow: -gallons
Alarm present: El Yes 0 No
Alarm level: Alarm in working order: El Yes El No
Date of last pumping: -bate
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? EYes No
t5is,doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 Sugarcane Lane
Property Address
Chris Hanson
0ner Owner's Name
ink rmation is
req u!red for every North Andover MA 01845 5-24-2018
page. City/Town 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 light carryover. Removed huge
rock on top of d-box cover.
——---—---------
Pump Chamber(locate on site plan):
Pumps in working order: F Yes E] No*
Alarms in working order: F] 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:
t5ls,doc-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
84 Sugarcane Lane
Property Address
Chris Hanson
Owner Owner's Name
information is
req jirecl for every North Andover MA 01845 5-24-2018
paa. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
E-1 leaching pits number:
0 leaching chambers number:
0 leaching galleries number:
leaching trenches number, length: 2 trenches 38'
E-1 leaching fields number, dimensions:
overflow cesspool number:
E innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. 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 F-1 Yes ❑ No
t�i s.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
84 Sugarcane Lane ------ ------
Property Address
Chris Hanson
Owner Owner's Name
information is
req jirec!for every North Andover MA 01845 5-24-2018
pa' e. 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.):
----------
t5lils.doe-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
84 Sugarcane Lane
Property Address
______.a_.____ __---_a_________._. -----
—
Chris Hanson
0 1 vrner Owner's Name
infli rmation is
rtic uired for every North Andover MA 01845 5-24-2018
p��Ie. 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:
M hand-sketch in the area below
El drawing attached separately
A,
10
L4 I
L-k a
ftl
Lf
H
l5ir s.doc-rev,6116 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
F v .. Title 5 Official Inspection Form
- o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
< 84 Sugarcane Lane _
Property Address
Chris Hanson
Owner's Mame
inf rmation is
re ulred for every North Andover MA 01845 5-24-2018
P8,e. 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: 8-17-1995 _
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
design plan
❑ Checked with local excavators, installers-(attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
As per test pit data on design plan.
-----
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5i s.doc•rev.6116 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
u ____v _ __ a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 Sugarcane Lane
Property Address
Chris Hanson
OvV er Owners Name
infc rmation is
req iced'for every North Andover MA 01845 5-24-2018
pac e- City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Z 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
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ir s.doc, rev.6116 Title 8 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
',. Commonwealth of Massachusetts
Clty/Town of .
System Pumping.Record
Farm 4
DEP has provided this form for use-by local Boards 6f Health. other form's may be•used,but the
Information,must be substantially the tame as that provided here. Before using.this form,check with your
focal 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. InforMation,
1. System Location; LeftILe
Eggiron
�obtufilldlrig,
Left l Right rear of house, Left I right side of house, Left
Right side of building, Left/Right rear of building, Under deck
Address
ClWTown State Zip Code
2: System Owner.
Name
Address(if different from location)
city/Town _ � State- ,�yCode
Telephone Number
1.
B. PuMping !Record
f
1. Date of Pumping C ate 2. Quantity.Pumped: Gallons
--�.
. r
3. Type-of system: ElCesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): •�''
4. Effluent Tee Filter present? El Yes M-tvo If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition c? St h �� �...
6: System Pumped By:
Nell.Bateson • F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatio where conterit;�were disposed:
L Lowell Waste Water
Slgnk4e qj HhulNU
Date
t5forrrmCq c•06103 System Pumping Record•Page 1 of 1
Town of North Andover
Tax Map # 210-106.A-0266-0000.0
Parcel Id 17411
84 SUGARCANE LANE
HANSON, CHRISTOPHER
84 SUGARCANE LANE
NORTH ANDOVER, MA
01845 _
Class 101 Single Family Property Type- 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Tort 1 0.97 Acres
FY 2018
UB ME ilinq Index
Namely`,,,dress Type Loan Number Active/Inact. From Until
HANSO CHRISTOPHER Payor
84 SUGARCANE LANE
NORTHNDOVER,MA
01845
UB Account Maint. .
Accour}k No Cycle Occupant Name Active/Inactive
Bldg Id.!' 7672.0-84 SUGARCANE LANE Last Billing Date 4/10/2018
3170342 03 Cycle 03 Active
UB Services Maint.
Account o. 3170342
Service Code Rate Charge Multiplier/Users
MISCFE-ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 81.55 /1
UB Meter Maintenance
Account o.3170342
Serial N Status Location Brand Type Size YTD Cons
3277298 a Active ERT F. RT, b Badger w Water 0.63 0.63 3235
pat Reading Code. Consumption Posted Date Variance
3/7/ 018 3568 a Actual 21 4/23/2018 53°!°
12/ 12017 3547 a Actual 43 1/25/2018 -84%
9/1i /2017 3504 a Actual 299 10/18/2017 888%
6/8/2017 3205 a Actual 29 7/25/2017 212%
3/81 017 3176 a Actual 9 4/1212017 -86%
12/ /2016 3167 aActual 64 1/2312017 -76%
9/9/016 3103 a Actual 253 10/24/2016 475%
6/1312016 2850 a Actual 48 8/2/2016 181%
3/9/ 016 2862 a Actual 16 4/22/2016 -81%
12%10/2015 2786 aActual 84 1/20/2016 -72%
9/9/2015 2702 a Actual 299 10/16/2015 321%
6/1(/2015 2403 a Actual 71 7/24/2015 485%
3/11/2015 2332 a Actual 12 4/28/2015 -82%
12/11/2014 2320 aActual 69 1/15/2015 -56%
9/11/2014 2251 a Actual 159 10/15/2014 695%
6/11/2014 2092 a Actual 20 7/16/2014 -1%
3111 2014 2072 a Actual 20 4/11/2014 -53%
12/10/2013 2052 a Actual 42 1/17/2014 -78%
9/121/2013 2010 a Actual 197 10/15/2013 261%
6/1?/2013 1813 a.Actual 54 7/24/2013. 88%
3/13/2013 1759 a Actual 29 4/22/2013 -3%
12/11/2012 1730 aActual 29 1/9/2013 -85%
9/13/2012 1701 a Actual 208 10/15/2012 549%
6/1/2012 1493 a Actual 31 7/16/2012 129°!°
3/1 /2012 1462 a Actual 14 4/14/2012 -19%
12/12/2011 1448 a Actual 17 1/17/2012 -91%
911 /2011 1431 a Actual 194 10/13/2011 333%
6lj/ 011 1237 a Actual 42 7/20/2011 96%
3/q/ 011 1195 a Actual 21 4/13/2011 46%
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Town of North Andover
t � HEALTH DEPARTMENT$ACNUS
CHECK #i. ° n DATE:
,ua
�, ��,,a° s 4� � eta,
LOCATION:.
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License: (Check box)
® Animal $ {
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $ __
❑ Food Service-
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic.)Hauler $_
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ TrashWSolid Waste Hauler $
❑ Well Construction $
SEPTIC Systems.-
*
ystems.❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWQ $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
Title 5 Report $
❑ Other:(Indicate), __...._._— $
Healtx agent Initials
White-Applicant Yellow-Health Pink- Treasurer �