Loading...
HomeMy WebLinkAboutTitle V Inspection Report - 64 WHITE BIRCH LANE 7/5/2018 , Commonwealth of Massachusetts ` N tH5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lane Property Address Owner Owner's Name information i's required for every '`=="''"",=' —'' - '- - 6-27-2018 ------------ page — --1- puOw ",r."_. State Zip Code ___ _ _ n 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. Imporitant:When filling out forms A. General Information 1A on the computer, use only the tab I. Inspector: \09, V0 key to move your cursor-do not Neil James Bateson use the return Name of Inspector W d`-� Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 Cityrrown State Zip Code 978-4754786 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 sit sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 6(310 CMR 15.000). The system: 0 Passes F-1 Conditionally Passes Fails El Needs Furth Evaluation by the Local Approving Authority 6-27-2018 -insIfect&A,Signatu 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 approprie te 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. "h"= report only describes c~"=°"~=^"°=°~=~ ="^^==" inspection and °"=°=" the conditions=^ use ^ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lane Property Address Charles )rTlsby Owner Owner's Name information is mqu|��for�vnry '""'"' "''~�^�' —' ' 01845 - - - page. ~`r.~~, 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. 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 structu-ally 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 o *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate o Compliance indicating that the tank is less than 20 years old is available. N ND (Explain below): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lane Property Address Charles Owner Owners Name information is North Andover MA 01845 6-27-2018 required for every State Zip Code Date of 1nspec66n---------7" page. Cityrrown B. Certification (cont.) El Pump Chamber pumps/alarms not operational, System will pass with Board of Health approw I if pumps/alarms are repaired. 13) System Conditionally Passes (cont.): le F1 Observation of sewage backup or break out or high static water level in the distribution box du 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): El broken pipe(s) are replaced Ej Y F N El ND (Explain below): ❑ obstruction is removed El Y [I N El ND (Explain below): ❑ distribution box is leveled or replaced E] Y ❑ N ❑ ND (Explain below): El 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 El N n ND (Explain below): ❑ obstruction is removed El 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 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'he Ith, safety and the environment: • Cesspool or privy is within 50 feet of a surface water • 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 3 617 Commonwealth of Massachusetts T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lane Property Address Charles Ormsby- Owner Owner's Name information is MA 01845 6-27-2018 required for every North Andover page. Cityfrown 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: n 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. n The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. n The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ 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 fepal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen if, equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis m ist 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 n z 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 overloa ed El Z or clogged SAS or cesspool i EJ H Liquid depth in cesspool is less than 6" below invert or available volume is le s than Y2day flow_ t5ins.doe•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 64 White Birch Lane Property Address Charles Ormsby ............ Owner Owners Name information is North Andover MA 01845 6-27-2018 required for every page. dty/Town — State Zip Code Date of Inspection — - B. Certification (cont.) Yes No E-1 E Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: _. F1 E Any portion of the SAS, cesspool or privy is below high ground water elevation. El 2 Any portion of cesspool or privy is within 100 feet of a surface water supply c r tributary to a surface water supply. El N 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 ell. El E 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. 11 his system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria Indicates absent and the presenc of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppni, 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- M E 10,000gpd. El 0 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. Th 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 [I EJ 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 the system is located in a nitrogen sensitive area (Interim Wellhead Protection El 1:1 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 thr at, or answered"yes" in Section D above the large system has failed. The owner or operator of any la ge 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. t51ns.doc•rev.6156 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 64 White Birch Lane ...... Property Address Charles Ormsby Owner Owner's Name �Narne- information Is I MA 01845 6-27-2018 every required for eveNorth Andover page. -6 Vi /T own 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 ❑ Pumping information was provided by the owner, occupant, or Board of Healtl I El 0 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? 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 Z available note as N/A) 0 El Was the facility or dwelling inspected for signs of sewage back up? E El Was the site inspected for signs of break out? 0 El Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tan< 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: 0 El Existing information. For example, a plan at the Board of Health. E 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): N/A Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x#of bedrooms): N/A -- t6ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 if 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lane Property Address Charles Owner Owner's Name information is North Andover MA 01845 6-27-2018 required for every page. bifyi:rown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 o Is laundry on a separate sewage system? (Include laundry system inspection E] Yes o information in this report.) Laundry system inspected? ❑ Yes 0 Seasonal use? 0 Yes qo Yes Water meter readings, if available (last 2 years usage (gpd)). Detail: Sump pump? El Yes 0 qo Vacant one Last date of occupancy: month, owner 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? El Yes El 4o Industrial waste holding tank present? El Yes E] \lo Non-sanitary waste discharged to the Title 5 system? F] Yes F] No Water meter readings, if available: t6ins.doc,•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lan e i5r-operty Address- Owner Owner's Name infonmmUonis MA 01845 -2O18 required xmvu� ^~="' '^'~~`~' page. ~~/'^—^ State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Source of information: Was system pumped as part of the inspection? ED Yes E] Np 1500 How was quantity pumped determined? -Measured tank ­- 1 1. Inspect tank&tees Type of System: Septic tank, distribution box, soil absorption system El Single cesspool Overflow cesspool Privy EJ Shared system (yes or no) (if yes, attach previous inspection records, if any) r-1 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 ! [l Tight tank. Atb3ch a copy ofthe DEP approval. [l Other`—_--__': o�f 17 t5i*^ooc`rev.omu '"~,Official Inspection^Form:Subsurface Sewage Disposal System`~~`� ^ � / &\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lane ---------- Property Address Charles Ormsby Owner Owner's Name information is North Andover MA 01845 6-27-2018 required for every State Zip Code Date of Inspection ❑ page. CityTrown D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 23 years old, 7-17-1995, as built _plan _ Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): 1.8 Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): — - ❑ Distance from private water supply well or suction line: —t Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall to septic tank, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): 0.8 Depth below grade: feet—-------- Material of construction: concrete El metal © fiberglass ❑ polyethylene F-1 other (expla n) ---------- If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes n N� 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 IN- 111- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lane Property Address Charles Ormsp_y_____, Owner Owners Name information Is North Andover MA 01845 6-27-2018 required for every ---- page. 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 Scum thickness 8" Distance from top of scum to top of outlet tee or baffle --------------- Distance from bottom of scum to bottom of outlet tee or baffle 1311 How were dimensions determined? jape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integr ty, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet cover broken, replaced it. Inlet tee clogged, clean same, now ok. Outlet tee ok. Depth of liquid at outlet invert, No evidence of leakage. Pumped septic tank. Grease Trap(locate on site plan): Depth below grade: Material of construction: n concrete El metal El fiberglass El polyethylene El other(expla n): 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. Date t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 0 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lane---—-----—--- Property Address Charles Ormsby Owner Owners Name information is North Andover MA 01845 6-27-2018 required for every page. dii—y/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: F1 concrete D metal F1 fiberglass ❑ polyethylene ❑other(expla n): Dimensions: ❑ Capacity: allonS 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.): 7­ Attach copy of current pumping contract(required). Is copy attached? El Yes ❑ No - t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 0�17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lane Property Address Charles Ormsby Owner Owner's Name information Is North Andover MA 01845 6-27-2018 required for every page. Gityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): T Depth of liquid level above outlet invert 0 -- L Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, ny evidence of leakage into or out of box, etc.): D-box level &distribution equal. Evidence of carryover, pumped d-box to clean. No evidence of leakage. D-box cover broken, replaced it. ------------------------------- Pump Chamber(locate on site plan): Pumps in working order: F-1 Yes El No* Alarms in working order: El Yes F1 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: 16ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 A 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lane Property Address Charles )g-nsby Owner Owner's Name information is required for every North Andover MA 01845 6-27-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: El leaching pits number: El leaching chambers number: El leaching galleries number: --- leaching trenches number, length: 2 trenches 45 ❑ leaching fields number, dimensions: El overflow cesspool number: El innovative/alternative system Type/name of technology: —----- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition "f vegetation, etc.): Soil ok. Vegetaion 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 ❑ Yes ❑ No t5ins.doc-rev.6116 Title 5 Official Mspection Form:Subsurface Sewage Disposal System-Page 13 a 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lane Property Address Charles Ormsby Owner Owner's—Name information is North Andover MA 01845 6-27-2018 required for every page. Cityrrown ——--—------ 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 vegetatic n, etc.): 151ns,cloc rev.6/16 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 64 White Birch Lane -------- Property Address Charles ----------- Owner Owner's Name information is North Andover MA 01845 6-27-2018 required for every --- - page. Cityfrown 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. Loca e where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately As- VA-) I De- (IN -,314rr au rT 16 11 t5ins,doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 0 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 64 White Birch Lane Property Address Charles Ormsby Owner Name infoma§onisO1845 6-2/-2018 mquiedfor ave� '~~'~' ' '^'~~`~ State Zip Code Date of page. City/TownD. SVstem Information (cont.) Site Exam: Z Check Slope ED Surface water Z Check cellar Z Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: E-1 Obtained from system design plans on record 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) Essex County Soil Map -—----- You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet#23, Windsor Soil, Water>6' Deep Before filing this Inspection Report, please see Report Completeness Checklist on next pa e. emouo ^w°uns Title-Official Inspection---'Form:—Subsurface--Sewage ' 'stem-Page 16 | Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 64 White Birch Lane Property Address Charles Owner Owners Name information is North Andover MA 01845 6-27-2018 required for every page. cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist • 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 t5ins.doo-rev.8118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 �f 17 Commonwealth of Massachusetts City/Town of . sy.Mem Pumping.Record Form 4 DEP has provided this form*for use-by local Boards of•Health.other form's may•be'used,but the Informatiorr must be substantially the game as that provided here. Before using.this form,check with your Iacal Board of Health to determine the forrh they use.The;System Pumping Record must be submitt tf to the local Board of Health or other approving authority. A. Facfl t . Information 1. System Location: Left/Right front of house, Left]Rig ear f house, Left/ fight side of house eft/ Right side of building, Left/Right front of builditrg, Leftlg t rear of building, eck Address t r .. gal�_ La4 clty/Town state Zip Code Z. System Owner. Name' Address Of different from location) City/Town Stater �'�-•v`L � ��Zip Cade .' Telephone Number # B. Pumping Rpcolyd 1. bate of Pumpingt7ate �. %KuanUty Pumped: Gallons • r 3. Type-of system. ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank % ❑ Other(describe): 4. Effluent Tee Fitter present? E] Yes if yes, was it cleaned? ❑ Yes d Na 5. Condition of System: CA., 6: System Pumped By: Neil.Bateson F5M Name Vehicle License Number _Bateson Enterprises Inc' Company 7. Locatio here dontents�were disposed: S: Lowell Waste Water Sfgn a HbuleV bate WfarmCcloc►06/03 System Pumping Record•page 1 of Summary Record Card generated on 6/1212018 1:53:26 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-061.0-0096-0000.0 Parcel Id 12736 64 WHITE BIRCH LANE ORMSBY, CHARLES 64 WHITE BIRCH LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Resi lential Zoning2 1 Residential Zonlng3 1 Resi lential Size Total 0,5 Acres FY 2018 UB Mailing Inde Name/Address Type Loan Number Activellnact. From Until ORMSBY,CHARLES Payor 64 WHITE BIRCH LANE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 15362,0-64 WHITE BIRCH LANE Last Billing Date 6/12/2018 2120175 02 Cycle 02 Active UB Services Maint. Account No.2120175 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0,635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 34.20 UB meter maintenance Account No.2120175 Serial No Status Location Brand Type Size YTD Cons 36388171 a Active ERT HH b Badger w Water 0.630.63 � 745 Date Reading Code Consumption Posted Date Valance 5/10/2018 736 a Actual 9 6/20/2018 -29% 2/8/2018 727 a Actual 13 3/28/2018 -17% 11/7/2017 714 a Actual 15 12/29/2017 �-13% 8/10/2017 699 a Actual 18 9/2012017 14% 5/9/2017 681 a Actual 15 6/26/2017 0% 2/10/2017 666 aActual 16 3/14/2017 7% 11/8/2016 650 aActual 14 12/19/2016 -19% 8/12/2016 636 aActual 18 9/21/2016 10% 5/12/2016 618 a Actual 16 6/21/2016 6% 2/1212016 602 a Actual 16 3128/2016 -8% 11/9/2015 586 aActual 16 12/30/2015 -6% 8/1412015 570 a Actual 18 9/14/2015 10% 5/14/2015 552 a Actual 16 6/22/2015 -23% 2/1312015 536 a Actual 23 3/20/2015 5% 11/612014 513 aActual 19 12115/2014 -11% 8/12/2014 494 a Actual 22 9/11/2014 -14% 5/15/2014 472 a Actual 26 6112/2014 11% 2/14/2014 446 a Actual 26 311712014 10% 11/6/2013 420 aActual 20 12/20/2013 -14% 8/13/2013 400 a Actual 25 9/18/2013 6% 5/14/2013 375 a Actual 23 6/18/2013 0% 2/14/2013 352 a Actual 26 3/13/2013 -16% 11/5/2012 326 aActual 25 12/13/2012 17% 8/15/2012 301 a Actual 24 9/26/2012 -9% 5/116/2012 277 a Actual 26 6/20/2012 -2% 2114/2012 251 a Actual 29 3/14/2012 -1% 11/7/2011 222 a Actual 26 12/15/2011 .24% 8/11/2011 196 aActual 35 9/14/2011 18% 5/13/2011 161 a Actual 29 6/13/2011 11% Commonwealth of Massachusefts w C i " own of i aSY,4tem Pumping. r' Form a . DEP has provided this form for use-by local Boards of Health. Other forms may be'used,but the information'must be substantially the tame as that provided here. Before using.this form,check with your lord 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. Cift f C fi I. System Location: Lift f 4 7h)tront of fico ;�Left/Right rear of house, Left/right side of house, Left Right side of building, Left/Rig, ran('of building, Left/Right rear of building, Under deck Address � /•� Cm.�'' �� �l°"�,.. (�� �'� � ,, , �. Cib#Town state Zip Code 2. System Owner: � Lem Name` Address(if different from location) cityfrown sM tea. ` Zip t Telephone Number r+ "x Pumping�.,.- r 9. late of Pumping Date <<<✓✓✓ 2. Quantity Pumped: Gallons 3. Type-of systefft ® Cesspool(s) [ is Tank El Tight Tank ,• Q Other(describe): 4. Effluent Tee Filter present? es ® No if yes, was it cleaned? [g-YNQ 5. Conditio of Syste 6: Systeurge Sy: Neil.Bateson ' F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Lo tia here contents-were disposed: CLS: Lowen Waste Water Sign a Whole Cate t5forrn4.doc-06/03 System Dumping Record•Page 1 of 1 Commonwe.Alth of Massachusefts C4/Town o a aSY,4tem Pumping.Record "... Form DEP has provided this form`for use-by local Boards of 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 Ioca 'I Hoard of Health to determine the forrh they use.The System Pumping Record must be submitted t,0 the local Board of Health or other approving authority. 1. System Location: Left/Right front of house, Left/Rig ear' f house, Leff/ fight side of house Left Right side of building, Left I Right front of building, Left I g t rear of building, eck Address r t - City/Town State Zip code 2. System Owner: Name' Address(if different from location) CityfTown C ' Stater � Zip Code , p Telephone Plumber r ' . Pumping Rgeord . 1. Gate of Pumping oats 2. Quantity Pumped: Gallons ` 3. Type-of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present`? ❑ Yes o if yes, was it cleaned? ❑ Yes ❑ Na 5. Condition ofsystem: Com, 6; System Pumped By: Neil.Bateson F5821 Name Vehicle License Dumber Bateson Enterprises Inc Company 7, Locatio ere contents-were disposed: Lowell Waste Water F Sign a liule ®ate tftrm4.doo-06/03 System Pumping Record a Page 1 of 1 i Commonwealth of Massachusetts ow n. Pumping.Record Form 4 DEP has provided this forrrifor uswby local Boards 6f-Health. lather forms maybe used,but the information,must be substantially the tame as that provided here. Before using.this form,check with your local ward of Health to determine the fortis 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: Left �Rlght front of hodi MLett I Right rear of house, Left/right side pf house, LeftRight side of building, LRight fr6nt of buildirig, Left/Right rear of building, Under deck Address City/Town state Zip Code 2. System Owner ' Ptarvra' . Address(if different from 10080 n) City/Town ' Stater Zip Code 'telephone Number ing Ripcord fu � i. Cate of Pumpingnate R uantity Dumped; Gallons�j -�{--i 3. Type-of system: Cesspool(s) Septic Tank 0 Tight Tank Ej Other(describe): 4. Effluent Tee Filter present? ® Yep No If yes, was it cleaned? E Yes F1 No, 5. Condition of System: ) 6: System bumped By: Nell.Bateson ' F5621 I Name Vehicle License Number Bateson Enterprises Inc- Company l , 7. Locati here contents-were disposed: Lowell Waste Water Sign a Hiaul Crate l5fbrm4.dot-, 06/03 System Pumping Record g Page 1 of 1 Commonwealthof u wn of i aSY,4tem Pumping. r' W Form a - DEP has provided this forrei for use-by local Boards of Health. Other forms may be'used,but the information-must be substantially the tame as that provided here. Before using.this faun,check with your ioc6l Board of Health to determine the forrh they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Factoty informationP. 1. Syitem Location: Loft/Right front of house, Left I Right rear of house, Left is a of boos , Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck cityy/'rown state Zip Co'e 2. System Owner: �aame Address Of different from location) City/Town State z{➢ a�� ., Telephone Number P -13. Pumping Rgeord 1. Cate of Pumping 2. Quantity Pumped: Date Gallons 3. Type.-of system: Cesspool(s) eptic Tania (l Tight Tank Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ® Yes ❑ No, ' 5. Condition of system: 6: System Pumped By: Nell.Batesicn F5621 Name Vehicle t_icense Number Bateson Enterprises Ina Company 7. Lo ,7o' Qere ntents-were disposed:GLS. Lowell Waste Water _OGSign a tete t5fomn4.doc-06/03 System Pumping Record.Mage 1 of 1 Commonwealth w i Wn , eSpkem Pumpling.Record Form 4 DEP ha'provided this farm far use-by local Boards bf-Health. Other forms may be'used,but the information,trust be substantially the same as that provided here. Before using.this form,chock with your local Board of Health to determine the forrn they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. cfl�ty Inform' ation 1. System Location: Left/Flight front.of house, Left ' hfi r , Left/right side of house, Left Right side of building, Left/Right front of building, Left/Fright rear df building, Under deck Address city/Town State zip Code 2. System Owner: Name' address(if different from location) city/'rown ' state �,ZI Code 6 5-Y& 'telephone Number ll ._ r ` — � , ) 1. bate of Pumping 2. Q-uantify Pumped: Gallons 3. TYpe•of systemEl Cess ooi(s) 66 .tic Tank ® Tight Tank -----�----� Other(describe): 4. Effluent Tee Filter present? ® Yep o If yes, was it cleaned? ® Yes ❑ No, 5. Condition of Sys 6. System Pumped By: Neil.Bateson n F'58 1 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Lana h a contents were disposed: S Lowell Weste Water Sign a HOUINU Date • t0brmit.doc-06/03 system Pumping Record 'age 1 of 1 ,AORTH ("i a I Town of North Andover HEALTH DEPARTMENT CHECK#: -Z DATE: ILA,_L 1 LOCATION: 6 _AL. 0� H/O NAME: "I X) CONTRACTOR NAME: 0/ Type of Permit or License: (Check box) • Animal • Body Art Establishment • Body Art Practitioner 0 Dumpster • Food Service-Type:____ • Funeral Directors • Massage Establishment • Massage Practice • Offal(Septic)Hauler • Recreational Camp • Sun tanning • Swimming Pool • Tobacco • Trash/Solid Waste Hauler $ • Well Construction $ SEPTIC System;s,' * Septic-Soil Testing * Septic®Design Approval $ * Septic Disposal Works(7onstruction(DWC) $ * Septic Disposal Works Installers{DWI) $ * Title 5 Inspector $__ S g"/"" ,:::, $ Title 5 Report ) 0 Other. (Indicate)---- $ Health Agent Initials White Applicant Yellow. Health Pink-Treasurer