HomeMy WebLinkAboutTitle V Inspection Report - 91 JOHNNY CAKE STREET 7/19/2018 Commonwealth of Massachusetts
.__...u_... .. y Title 5 Official inspection Farm
m- A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•° 91 Johnnycake Street
Property Address
Michael Howard
Owner Owners Name
information is North Andover MA 01845 7-11-2018
required far every _ .
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When
lto A. General Information
on the o
e comtpur,
use only the tab 1 Inspector:
ke to move our jwjjk Ib)p�I I NDN' i�l
cur�or-do not Neil James Bateson I I'°'I IX:r°PiF " ME W
use the return Name of Inspector
key.
Bateson Enterprises Inc.
r� 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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Ne?Vs Further Evaluation by the Local Approving Authority
�- 7-11-2018
Isp ct rs Signat r Date
k
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection.does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�
� Commonwealth of Massachusetts
'
Title 5 Official Inspection F
m
,
Subsurface Sewage DlsposaKSystwmxFmrnm - NotforVo|untaryAssessments
Q1Johnnycake Street
Property Address
Michael Howard
Owner
information/m
requiredhor every North Andover,-.--,,----,--,--- -MA---- 01845 7-11-2018
page._~�
B. Certification (cont.)
Inspection Summary: Check A'B'C,DorE/always complete all ofSection D
A) System Passes:
Z I have not found any information which indicates that any of the failure criteria described
� |O31OCMR 15.3O9oriO31OCMR 15.304exist. Any failure criteria not evaluated are
indicated below.
/
Comments:
|
B) System Conditionally Passes:
Fl
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
unnnuMd, exhibits substantial infiltration orexfi|tradion ortank failure is imminent. System will pass
inspection ifthe existing tank|mreplaced with acomplying septic tank asapproved bythe Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
COrnp||enue indicating that the tank is less than 20 years old is oxa||mb)e.
Fl y Fl N Fl WD (Explain be|owA:
t6ins.doc-rev.6/16 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2mn
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
91 Johnnycake Street
Property Address
Michael Howard
OwnerOwners Name
infor
req' fired for every North Andover MA 01845 7-11-2018 --—-------
page.mation is City/Town State Zip Code Date of Inspection
B. Certification (cont.)
E-1 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):
El broken pipe(s) are replaced El Y F-1 N n ND (Explain below):
El obstruction is removed F-1 Y 0 N E] ND (Explain below):
F-1 distribution box is leveled or replaced ❑ Y n N F1 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):
E] broken pipe(s) are replaced F] 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
15.303(1)(b)that the system is not functioning In a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t61hs,doc-rev.6/16 Title 5 official lnspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
91 Johnnycake Street
Property Address
Michael Howard
OwperOwner's Name
information is
reqUired for every North Andover MA 01845 7-11-2018
page, City/town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, If any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
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.
El The system has a septic tank and SAS and the SAS is within a Zone I 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.
n The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
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 0 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
n z
than %day flow
t6l ps.doe-rev.6116 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System-Pqge 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
91 Johnnycake Street
Property Address
Michael Howard
Owner Owner's Name
information is
required for every North Andover MA 01845 7-11-2018
page. CitylTown Stat-e 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: —.
El 0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
El 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
E-1 0 Any portion of a cesspool or privy is within a Zone 1 of a public well.
E] 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.)
El 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
El E The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
F] 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.
151i Aoc-rev,6116 Title 5 Official btspaction Form:Subsurface Sewage Disposal SYstern-page 5 of 17
SCommonwealth of Massachusetts
...........
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
91 Johnnycake Street
'Property Address
Michael Howard
Owner Owners Name
info rmation is
req�ired for every North Andover MA 01845 7-11-2018
page. 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
E M Pumping information was provided by the owner, occupant, or Board of Health
El M Were any of the system components pumped out in the previous two weeks?
Z F Has the system received normal flows in the previous two week period?
El Z Have large volumes of water been introduced to the system recently or as part of
this inspection?
E El Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z F-1 Was the facility or dwelling inspected for signs of sewage back up?
Z E] Was the site inspected for signs of break out?
Z F Were all system components, excluding the SAS, located on site?
Z El 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 El 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:
ED El 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:
5 5
Number of bedrooms (design): -- Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x,#of bedrooms): 550
t51ns.doc-rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
91 Johnnycake Street
Property Address
Michael Howard
Owner Owners_Name
iN
nformation Is MA 01845 7-11-2018
eq
ruired for every North Andover
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
3
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes E No
information in this report.)
Laundry system inspected? F Yes El No
Seasonal use? El Yes E No
Yes
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
----------
Sump pump? Yes El No
Current
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
---------
Design flow(based on 310 CMR 15.203): Gallons p-
er 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? 0 Yes ❑ No
Water meter readings, if available:
t5ihs.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
91 Johnnycake Street
Property Address
Michael Howard
Owner Owner's Name
information is
req ire
for every North Andover MA 01845 7-11-2018
p a Cityrrown State Zip Code -Date-6f-Inspection
D. System Information (cont.)
Last date of occupancy use:
Date
Other(describe below):
—-—---------
----------
General Information
Pumping Records:
_Pumped 2016, owner ------
Source of information: -
Was system pumped as part of the inspection? Yes No
If yes, volume pumped: 1500gallons—------
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank& tees
Type of System:
z Septic tank, distribution box, soil absorption system
El Single cesspool
r-1 Overflow cesspool
0 Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
EJ 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):
t5lns.doc-rev.6/16 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
91 Johnnycake Street
i5roperty-Address
Michael Howard
Owner Owner's Name
information is
required for every North Andover MA 01845 7-11-2018
page. Cityrrown State Yip Code Date of inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
System installed in 2002 , info at B.O.H.
..........—Were sewage odors detected when arriving at the site? El Yes Z No
Building Sewer(locate on site plan):
1.6
Depth below grade:
Material of construction:
El cast iron 0 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
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):
0.6
Depth below grade: feet -—
Material of construction:
concrete El 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) El Yes ❑ No
10' x 5' x 4'
Dimensions:
3-4
Sludge depth:
t5insAoc-rev,6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
91,Johnnycake Street
Property Address
Michael Howard
Owner Owners Name
information is
required for every North Andover MA 01845 7-11-2018
page. Cityrrown 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
31'
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 1311
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. Pumped septic
tank.
-----------
------------
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete F-1 metal F] fiberglass F1 polyethylene ❑ other(explain):
..............
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle -------
Date of last pumping:
15ins.doo-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
91 Johnnycake Street
Property Address
Michael Howard
owner Owner's Name
information is
re#red for every North Andover. ............. MA 01845 7-11-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete F] metal El fiberglass ❑ polyethylene other(explain):
-----......
Dimensions: -------
Capacity: gancrns
Design Flow: gallons per day
Alarm present: n Yes ❑ No
Alarm level: Alarm in working order: F-1 Yes El No
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? El Yes ❑ No
t5ins.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
91 Johnnycake Street
Property Address
Michael Howard
OwnerOwner's Name
information is
req:uired for every North Andover ------- MA 01845 7-11-2018
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, pumped d-box
to clean.
-----------
----------
Pump Chamber(locate on site plan):
Pumps in working order: D Yes F-1 No*
Alarms in working order: F-1 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:
151'ps.doc-rev.6/16 Title 5 Official Inspeclion 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
91 Johnnycake Street
Property Address
Michael Howard
Owner Owner's Name
info,rmation is
required for every North Andover MA 01845 7-11-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
El leaching pits number:
❑ leaching chambers number:
leaching galleries number:
❑ leaching trenches number, length:
1 field 20'x 46'
leaching fields number, dimensions:
❑ overflow cesspool number:
❑ 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. 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
t5i I hs.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
91 Johnnycake Street
V
roperiymW�jl ress
Michael Howard
Owner dwnersName
information is, North Andover MA 01845 7-11-2018
req
pired for every
page. 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.):
-----------
t5ms.doo-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 14 of 17
<CN Commonwealth of Massachusetts
Title 5 Official Inspection Form
mm" mm Subsurface Sewage Disposal System Form Not for Voluntary Assessments
91 Johnnycake Street
Property Address
Michael Howard
Owner Owners Name
intormation is
hired for every North orth Andover MA 01845 7-11-2018
page. dityfrown 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
U,
40 t4 It
t6ins,doc rov.6116
Title 5 Official Inspection Farm: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
91 Johnnycake Street
Property Address
Michael Howard
Owner Owner's Name
information is
req6ired for every North Andover MA 01845 7-11-2018
pa�e. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
0 Check Slope
0 Surface water
0 Check cellar
Shallow wells
4
Estimated depth to high ground water: 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: 4-17-2002
Date
F] Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Desi n Ian
El Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database-explain:
---------- ——-------—You must describe how you established the high ground water elevation:
Test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins.cloc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
91 Johnnycake Street
Property Address
Michael Howard
OwnerOwner's Name
inf6rmation is
required for every North Andover —----- MA 01845 7-11-2018 —------------ ------
page. City/Town 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
• Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doo•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts
Cityffown of .
Sy teim Pumping.Record
Fonn 4
DEP has provided this for m for use. local Boards of'Health, Other farm's may'be'used,but the
information'must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authorlty.
A. Facility. Information
I. System Location: Loftlght frau#dfi Left 1 Right rear of house, Left/right side of house, Left/
Right side of building, Le ight�ront of building, Left/Right rear of building, Under deck
Address �.---
City/Irown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Civrown ' Stater e, ^� 21P�Code
s -
Telephone Number
ti
B. P'umpling l--ecord ,
1. bate of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: [ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L_140_ If yes, was it cleaned? ]' Yes ❑ No.
' S. Condition of Sy tem: ,,, �y • '����� � � ,__�L' �`-- ,
C)S -
6. System Pumped By:
Nell.Batesbn ' r✓5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7, Locati here contents were disposed:
M L Lowell Waste Water
Sign a H9ul date
5form4.doc+003 system Pumping Record•Page 1 of 1
Town of North Andover
Tax Map # 210-107.A-0183-0000.0
Parcel Id 18011
91 JOHNNY CAKE STREET
HOWARD, MICHAEL
91 JOHNNY CAKE STREET
N. ANDOVER, MA
01846
Class 101 Single Family Property Type I Residential
ZonIng2 I Residential ZonIng3 I Residential
Size Total 1,01 Acres
FY 2018
UB Mailing Index
Name/Address Type Loan Number Activelinact. From Until
HOWARD, MICHAEL Payor
91 JOHNNY CAKE STREET
N.ANDOVER, MA
01845
1.1113 Account Maint.
Tc'count No Cycle Occupant Name Active/Inactive
Bldg Id', 141183,0-91 JOHNNY CAKE STREET Last Billing Date 6/12/2018
2100168 02 Cycle 02 Active
UB Services Maint.
Account No. 2100168
Service Code Rate Charge Multiplier/Users
MISCFFE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 45.60 /1
I
UB Meter Maintenance
Account No.2100168
Serial No Status Location Brand Type Size YTD Cons
19554370 a Active ERT HH METE METE w Water 0.630.63 2682
Date Reading Code Consumption Posted Date Variance
5/3/2018 3601 a Actual 12 6/2012018 -31%
212/2018 3589 a Actual 18 3/28/2018 17%
11/11/2017 3571 a Actua 1 15 12/29/2017 -31%
862017 3556 aActual 22 9/20/2017 52%
562017 3534 a Actual 14 6/26/2017 -19%
262017 3520 a Actual 14 3/14/2017 -86%
111�,122/2016 3506 a Actual 156 12/19/2016 -41%
8/2/2016 3350 a Actual 216 9/21/2016 1100%
5/b/2016 3134 a Actual 18 6/21/2016 -43%
2/2//2016 3116 a Actual 32 3/28/2016 -87%
111/212015 3084 a Actual 240 12/30/2015 1028 25%%
8/4/2015 2844 a Actual 196 9/14/2015
1 -36%
5/4/2015 2648 a Actual 17 6/22/2015
2/{3/2015 2631 a Actual 27 3/20/2015 -81%
11!13/2014 2604 a Actual 144 12/15/2014 39%
8/1/2014 2460 a Actual 97 9/11/2014 267%
5/5/2014 2363 a Actual 27 6/12/2014 -10%
2/4/2014 2336 a Actual 32 3/17/2014 12%-26%
10/31/2013 2304 a Actual 27 12/20/2013
8/1/2013 2277 a Actual 37 9/18/2013 8%
5/1/2013 2240 a Actual 31 6/18/2013 7%
2/7/2013 2209 a Actual 35 3113/2013 -72%
10130/2012 2174 a Actual 113 12/13/2012 -19%
8/2/2012 2061 a Actual 145 9/26/2012 467%
-
5/2/2012 1916 a Actual 25 6/2012012 22%
2/2/2012 1891 a Actual 33 3/14/2012 -35%
11/1/2011 1858 a Actual 50 12/15/2011 -51%
302%
8/1/2011 1808 a Actual 101 9/14/2011
5/212011 1707 a Actual 24 6/13/2011 -3%
04
Town of North Andover
HEALTH DEPARTMENT
CHECK#: DATE:/
LOCATION: --- e:L�A
1-1/0 NAME:
CONTRACT OR NAME: -z3.a-,-k<
Type of Permit or License: (Check box)
0 Animal
• Body Art Establishment
• Body Art Practitioner
0 Dumpster
0 Food Service-
• Funeral Directors
• Massage Establishment
• Massage Practice $
• Offal(Septic)Hauler
• Recreational Camp
• Sun tanning
• Swimming Pool
D Tobacco
0 Trash/Solid Waste Hauler
0 Well Construction
SEPTIC5ytein,:
• Septic-Soil Testing
• Septic-Design Approval
EJ Septic Disposal Works Construction(DWC)
* Septic Disposal Works Installers(DWI)
* Title 5 Inspector
Title 5 Report $
0 Other. (Indicate).---.--.—
Hea-hh"Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
..............
