Loading...
HomeMy WebLinkAboutTitle V Inspection Report - 20 NORTH CROSS ROAD 6/5/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 20 North Cross Property Address Marc Ouellette Own ar Owner's Name re information is red for every North Andover MA 01845 5-30-2018 pal City/Town State Zip Code Date of Inspectionmm j 10 Inspection results must be submitted on this form. Inspection forms may nsticriiin any way. Please see completeness checklist at the end of the form. Imprt nt:When A. General Information filiiq,oq't forms -foNNIA 01� ME'lo on the computer, �NI use. nly the tab 1. Inspector: key to move your curs�r-do not Neil J. Bateson use the return -------- key. Name of Inspector Bateson Enterprises 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 1 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 16.000).The system: El Passes El Conditionally Passes E] Fails ❑ NeedsfFurtheEvaluation by the Local Approving Authority 5-30-2018 I n s p ke_�' r-s"i c s ignature 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. i5insRdoq•rev.6/16 Title 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 --------- 20 North Cross -- _----------------------- ........ _---- Property Address Marc Ouellette Owner Owner's Name ........ infor-nation is requ red for every North Andover MA 01845 5-30-2018 page. City[Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E always complete all of Section 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 F1 N El ND (Explain below): ------ .......------ ------------- t5lriss dog•rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i Commonwealth of Massachusetts - - -W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments akt 20 North Cross Property Address _a.._._. Marc Ouellette owner _.-____..__.-_ _.._.... _. Owner's Name infdr nation is North Andover MA 01845 5-30-2018 requ red for every - € page. Cityfrown State Zip Code Date of Inspection — - 1 B. Certification (cont.) j ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cant.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ® Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ 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 `n in a manner which will protect public health tem is not functioning 1 3 1 b that the system p p 5.30 ( }( } y 9 safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water i ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh I 151ins dog«rev,6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System«Page 3 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Farm mm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 North Cross Property Address Marc Ouellette Ow er _ Owner's Name ..-----.-.___ infor anon is North AndMA 01$45 5-30-2018 .. evefed for every _ �_..._.._____ Page. CitylTown ._ - State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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; ❑ 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. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ 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: I **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ® Backup of sewage into facility or system component due to overloaded or { clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ ® than /day flow t5inIToo 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 20 North Cross Property Address Marc Ouellette Owner Owner's Name inf¢r-nation is required for every North Andover MA 01845 5-30-2018 paa Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El N Any portion of the SAS, cesspool or privy is below high ground water elevation. E] 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. El N Any portion of a cesspool or privy is within 50 feet of a private water supply well. EJ N 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.] El E The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. 0 Z The system falls. 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 El ❑ the system is within 200 feet of a tributary to a surface drinking water supply 0 E-1 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 Ifyou 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. t5m doe-rev.6116 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form _ p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments W.. < 20 North Cross Property Address _ .._ Marc Ouellette re er Owner's Name to -nation is qu-ired for every North Andover MA 01845 5-30-2018 pag CltylTown 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ❑ 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? 0 ❑ 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)] C. System Information Residential Flow Conditions: Number of bedrooms (design): 3— Number of bedrooms (actual): 4— DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 450 i r f5in..doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 20 North Cross Property Address Marc Ouellette Ow[npr Owner's Name regioinat* is red or every North Andover MA 01845 5-30-2018 pa ditytTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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? El Yes E-1 No Seasonal use? El Yes 0 No Yes Water meter II readings, if available(last 2 years usage(gpd)): Detail* ---------------------- ----------- Sump pump? Yes No Current Last date of occupancy: Date -------- — Commercial/industrial --------Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gal-lo ns per day(gpd.) Basis of design flow(seatslpersons/sq.ft., etc.): Grease trap present? El Yes [_1 No Industrial waste holding tank present? n Yes [-] No Non-sanitary waste discharged to the Title 5 system? El Yes El No Water meter readings, if available: t5in's doo-rev.6116 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 20 North Cross Property Address Marc Ouellette Ow ,r Owner's Name info r nation is reqb red for every North Andover MA 01845 5-30-2018 Pa6E Cityrrown State Zip Code Date of Inspection l D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): ---—-------- General Information Pumping Records: Source of information: Pumped 2014, owner Was system pumped as part of the inspection? Z Yes 0 No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Inspect tank tees ......... Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool El Overflow cesspool EJ Privy El Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology, Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract E-1 Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins doo-rev.6116 Titto 5 Official inspection Form:Subsurface Sewage Disposal SYSIAM-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 North Cross Property Address Marc Ouellette OW r Owner's Name info's anon is req red for every North Andover MA 01845 6-30-2018 City/Town State p d6dli pa Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank& leach area 30 years old, 9-1-1988, as built plan. D-box & Outlet tee in septic tank was replaced 2014, info at B.O.H. -----------------. Were sewage odors detected when arriving at the site? F] Yes Z No Building Sewer(locate on site plan): Depth below grade: ----------- Material of construction: 0 cast iron El 40 PVC R other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron through wall to septic tank. . 3" PVC in house. No leaks visible. ----------- Septic Tank(locate on site plan): Exposed Depth below grade: feef Material of construction: concrete F-1 metal El fiberglass ❑ polyethylene ❑ other(explain) ---------- ------- If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes E] No 10' x 5'x 4' Dimensions: 311 Sludge depth: s doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 &\ Commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 20 North Cross Property Address Marc Ouellette Own Bir Owner's Name information is reqred for everyNorth Andover MA 01845 5-30-2018 page.E. City1rown 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 3011 211 Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 13-1 Now 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: Material of construction: El concrete ❑ metal Fj fiberglass ❑ polyethylene El 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: Ir'Ins dog•rov.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts M LL Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .° 20 North Cross Property Address -Marc Ouellette Ouellette ___...._--- Ow r Owner's Name infon nation is req red for every North Andover MA 01$45_ 5-30-201$ __._.. pa Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 1 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I I ---------- ---- ------------ ___ _—------- .....—_.____...._...-- 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 El No Alarm level: —- Alarm in working order: ❑ Yes ❑ No i 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 15fa s dor,•rev.8118 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 11 of W \ Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 20 North Cross Property Address Marc Ouellette O� er Owner's Name info ationi's req red for every North Andover MA 01845 5-30-2018 pail City/Town State___ t-a-te Zip 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 level &distribution equal, has flow levelers. No evidence of leakage. Evidence of light 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 n 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: r5ii)sdoq-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Dlsposal Systern-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form mm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 20 North Cross Property Address Marc Ouellette Own Br Owner's Name information is reqU red for every North Andover MA 01845 5-30-2018 page,i E City/Town State —Code Date of inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: El leaching galleries number: 2 trenches 50' leaching trenches number, length: ------ El leaching fields number, dimensions: ❑ overflow cesspool number: E-1 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 —------- li Materials of construction Indication of groundwater inflow R Yes E❑-1 No t5i�'�'doq•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 20 North Cross Property Address Marc Ouellette Owner Owners Name inf6r,nation is reqs red for every North Andover MA 01845 5-30-2018 peg CityfTown State Zip Code Date of Inspection j 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.): t5lns 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 20 North Cross Property Address Marc Ouellette Own ar Owners Name infor nation is North Andover MA 01845 5-30-2018 requ red for every —----- pagE Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately :moo' i iLf "7 t51 doe-rev.6116 Title 5 Official lnspection 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 20 North Cross Property Address Marc Ouellette Owner Owner's Name infoTation is North Andover MA 01845 5-30-2018 requ red for every page Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water Z Check cellar E Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: z Obtained from system design plans on record 4-19-1985 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: -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. t5ins doc-rev.8118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ..... 20 North Cross ---------- ----------------- Property -------------------Property Address Marc Ouellette __...._-.______.__---.--------------._.__-- o erOwners Name inf, mation is MA 01845 02018 re ired for every North Andover 5-3 - pa (,I. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist [E inspection Summary: A, B, C, D, or E checked E inspection Summary D (System Failure Criteria Applicable to All Systems)completed Z System information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file tr)in do(;-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts 0 CHY/Town of . Sy tem Pumping.Record Form 4 DEP has provided this form for use-by local Boards 6.Mealth. Other forms maybe 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 t© the local Board of Health or other approving authority. A. I*aciIity. InforMi ation 1. System Location: Left/Right front of Mouse, Left/Right rear of house,/rlght ide of haus Left/ R� ,Yt Right side of building, Left/R196t ht front of buldirigr g Left/Right rear of building, Under ec Address OVUM state - Zip Code 2. System Owner: Name' Address(if different from location) Cityl'r'own State Telephone Number B. Pumping Record 1. Date of Pumping pate 2. Quantity Pumped: Gallons 3. Type,of system: ❑ Cesspool(s) tic Tank [I Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yeas o if yes, was 9t cleaned? ❑ Yes ❑ Na 5. Condition of.System: ` J 6. system Pumped By: Neil.Bateson ' F5821 { Nam® Vehicle License Number Bateson Enterprises Ina Company 7. Locatio contents-were disposed: Lowell Waste Water MOAf Sign a HaulWU Date t5form4.d o•06/03 System Pumping Record•Page 1 of 1 ................Parcel ld 13252 Town of North Andover Tax Map # 210-038.0-0182-0000.0 � 20 NORTH CROSS ROAD OUELLETTE, MARC PO BOX 1994 01810 class 101 Single Family Property Type 1 Residential Size To'al I Acres FY 2018 UB ailina Index Namel,A ddress Typo Loan Number Active/Inact. From Until OUEL ETTE,MARC Payor 0,18101 UB Account Maint. Accou'r t No Cycle Occupant Name Active/inactive Bldg It. 14003.0-20 NORTH CROSS ROAD Last Billing Date 3/20/2018 2�1 005 02 Cycle 02 Active UB Services Maint. Accoun No.2100533 Servic I e Code Rate Charge Multi plier]Users WTR k�r—TER 01 ALL METER SIZE 6080 Serial 0 Status Location Brand Type Size YTD Cons 353524 7 a Active ERT HH b Badger w Water 1372 D I ate Reading Code Consumption Posted Date Variance 51 /2018 1384 a Actual 14 -4% 262018 1370 a Actual 16 3/28/2018 -77% 111.3/2017 1354 a Actual 69 12/2912017 38% 862017 1285 a Actual 50 9/20/2017 272% 5/�1/2017 1235 a Actual 13 6/26/2017 49% 2/�12017 1222 a Actual 9 3/14/2017 -90% 11;/ /2016 1213 a Actual 88 12/19/2016 -39% 143 9/21/2016 -100% 8/ 1,2016 1125 a Actual 5)(/2016 982 a Actual 0 6/21/2016 -100% 21,/2016 982 a Actual 0 3/28/2016 -100% 1 3/2015 982 a Actual 118 12/30/2015 53% 8/1 /2015 864 a Actual 79 9/1412015 -100% 5� /2015 785 a Actual 0 6/2212015 .100% 2/ /2015 785 a Actual 1 3/2012015 -99% 11 3/2014 784 a Actual 103 12/15/2014 65% 8 /2014 681 a Actual 61 9/11/2014 -100% 5 /2014 620 a Actual 0 6/12/2014 -100% 2&2014 620 a Actual 1 3/17/2014 -98% 1 112013 619 a Actual 54 12/20/2013 53% 8 /2013 565 a Actual 38 9/18/2013 -100% 5:/2013 527 a Actual 0 6/18/2013 -100% 21,l/2013 527 a Actual 1 3113/2013 -99% it 31/2012 526 a Actual 92 12/13/2012 179% 8�(/2012 434 a Actual 36 9/26/2012 -100% Q,/2012 398 a Actual 0 6120/2012 -100% 2�1,/2012 398 a Actual 2 3/1412012 -98% 11,2/2011 396 a Actua 1 118 12/15/2011 181% 8/A/201 1 278 a Actual 43 9/14/2011 2003% 5�-/2011 235 a Actual 2 6/13/2011 109% , �p�Tl1 'W,4F W k 3;ap4tfYd�N�o Town of North Andover HEALTH DEPARTMENT � �`�sAGWus I CHECK# DATEMo (' (( LOCATION: H/(NAME: ;,, µ e" CONTRACTOR TAME: .. Type of Permit gr_License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner - ❑ Dunipster $ ❑ Food Service- 0 er vice-❑ Funeral Directors $ ❑ Massage Establishment $. ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $—_ -- ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report ❑ Other:(Indicate)—� _ $ Heac"l°tIS-Agent Initials 9 White-Applicant Yellow-ITealth Pink.-Treasurer