HomeMy WebLinkAboutTitle V Inspection Report - 59 ROCKY BROOK ROAD 8/15/2018 Commonwealth of Massachusetts
CEIVED
Title 5 Official Inspection Form RE
Subsurface Sewage Disposal System Form Not for Voluntary Assessments AUG' 15 201(3
59 Rocky Brook Road
Property Address KALM,f 1)@',1AR
Jamie Norris
OwnerOwners Name
information is
required for every North Andover ---------- MA 01845 7-31-2018 ---------------
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Iportant:When
fmilling out forms A. Inspector Information
on the computer,
use only the tab Neil James Bateson
key to move your Name of Inspector
cursor-do not Bateson Enterprises Inc.
use the return Company Name -----------------
key. 111 Argilla Road
VQ Company Address
Andover MA 01810
City/Town State Zip Code
relrrn 978-475-4786 SI-15
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system Inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. 0 Passes
2, F1 Conditionally Passes
3. r_1 Needs Further Evaluation by the Local Approving Authority
4. n F ils
7-31-2018
In ear'
r 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
condition%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.
t5insp.doc-rev.7/26/2018 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 Rocky Brook Road
Property Address
Jamie Norris
Owner Owner's Name
information is
required for every North Andover MA 01845 7-31-2018
page. CityfTown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
Z I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 16.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
F-1 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.
Y ❑ IN ND (Explain below):
t5insp.doo rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 Racky Brook Road
Property Address
Jamie Norris
OwnerOwner's Name
information is
required for every North Andover MA 01845 7-31-2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
r-1 Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
F-1 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 ❑ Y n N ❑ ND (Explain below):
n obstruction is removed ❑ Y n N ND (Explain below):
F] distribution box is leveled or replaced F1 Y F] N F1 ND (Explain below):
n The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
F broken pipe(s) are replaced ❑ Y n N E] ND (Explain below):
❑ obstruction is removed Y Ej N El ND (Explain below):
3) 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.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(9)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
®R Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59_Ro�cy_Brook Road
Property Address
Jamie Norris
Owner .__._--... .__.__-------
Owner's Name
information is
required for every —North Andover MA 01846 7-31-2018
page. CityrTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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:
El The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
n 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 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) 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
z due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
❑ 59 Rocky Brook Road
Property Address
Jamie Norris
Owner Owners Name
information is
required for every North Andover MA 01845 7-31-2018
page. difyr—ro—wn State -tip Code DateofInspection—""-'
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
EJ 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
than %day flow
M 0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El E Any portion of the SAS, cesspool or privy is below high ground water elevation.
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 water supply
well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
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. [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 2000 gpd-
10,000 gpd.
E-1 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.
5) 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 CA.
Yes No
EJ D 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
El 0 Area—IWPA)or a mapped Zone 11 of a public water supply well
15insp.doe rev.712612018 Titto 6 Official Inspection Form;Subsurface Sewage Disposal System-Page 5 Of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 Rocky Brook Road ------ ................
Property Address
Jamie Norris
Owner Owner's Name
information is North Andover MA 01846 7-31-2018
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section GA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections*
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 E 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)
0 El Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
Z 11 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)1310 CMR 15.302(5)]
t5insp.doc-rev.7126/2018 Title 5 Officlat Inspection Form:Subsurface Sewage Disposal System-Page 6 Of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 Rocky Brook Road
Property Address
Jamie Norris
Owner Owners Name
information i's
required for every North Andover MA 01845 7-31-2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1 Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15,203(for example: 110 gpd x#of bedrooms): 550---
Description:
Number of current residents:
Does residence have a garbage grinder? Yes ❑ No
Does residence have a water treatment unit? F-1 Yes No
If yes, discharges to: -------
Is laundry on a separate sewage system? (include laundry system inspection 0 Yes No
information in this report.)
Laundry system inspected? ❑ Yes n No
Seasonal use? El Yes M No
Water meter readings, if available(last 2 years usage (gpd)): Yes
Detail:
Sump pump? El Yes E No
Current
Last date of occupancy: Date
t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of la
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
i5noperty Address
Jamie Norris
Owner Owners Name
information is
required for every North Andover MA 01845 7-31-2018
page, Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commerciallindustrial 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 [_1 No
Water treatment unit present? El Yes ❑ No
If yes, discharges to: - --_----------
Industrial
--------------
Industrial waste holding tank present? n Yes El No
Non-sanitary waste discharged to the Title 5 system? El Yes El No
Water meter readings, if available: --------- ----
Last
---------
Last date of occupancy/use: Date _.---..-----
Other
-----------Other(describe below):
-—----------
...........
3. Pumping Records:
Source of information: EyTped_Nov.2015, owner
Was system pumped as part of the inspection? 2 Yes El No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank &tees.
t5inap.doo-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 Rocky Brook Road
Property Address
Jamie Norris
Owner Owner's Name
information is
required for every North Andover MA 01845 7-31-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
z Septic tank, distribution box, soil absorption system
R Single cesspool
E-1 Overflow cesspool
F-1 Privy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
El Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
D Other(describe):
Approximate age of all components, date installed (if known) and source of information:
14 years old, 7-6-2004, as built !a,n-- ------
Were sewage odors detected when arriving at the site? El Yes El No
5, Building Sewer(locate on site plan):
1.5
Depth below grade: feet
Material of construction:
❑ cast iron 12 40 PVC n 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.
t6inrp.doc•rev.7/2 612 01 8 Title 5 Official inspection Form:Subsurface sewage Disposal system-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 Rocky Brook Road .... ---- ------------
Property Address
Jamie Norris
Owner Owners Name
information is
required for every North Andover MA 01845 7-31-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
0.5
Depth below grade: feet
Material of construction:
concrete ❑ metal F1 fiberglass El polyethylene n other(explain)
------ -—-----
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
30"
Distance from top of sludge to bottom of outlet tee or baffle
3"
Scum thickness .......
811
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 12"
How were dimensions determined? japeMeasure
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 olk. Depth of liquid at outlet invert. No evidence of leakage. Pumped septic
tank.
15insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 Of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 Rocky Brook Road
Property Address
Jamie Norris
OwnerOwner's Name
information is
required for every North Andover MA 01845 7-31-2018
page. Cityrrown State Zip Code Date of Inspection..
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade:
Material of construction:
El concrete ❑ metal ❑ fiberglass ❑ polyethylene E] 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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
F] concrete ❑ metal F] fiberglass F] polyethylene F1 other(explain):
Dimensions:
Capacity:
Design Flow: -gallons
t5insp.doc-rev,712612018 Title 5 01ficial Inspection Form:Subsurface sewage Disposal system-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 Rocky Brook Road
Property Address
Jamie Norris
Owner Owner's Name
information is
required for every North Andover MA 01845 7-31-2018
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: El Yes Q No
Alarm level: Alarm in working order: El Yes [-I No
Date of last pumping: -6ate- ------------
Comments(condition of alarm and float switches, etc.):
----------
Attach copy of current pumping contract(required). Is copy attached? C] Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
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.
t5insp.doc rev.7/2612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 12 of 18
Commonwealth of Massachusetts
I----------- Title 5 Official Inspection Form
I ulr�I
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 Rqcky,Brook Road
Property Address
Jamie Norris
Owner Owners Name
information
required for every North Andover MA 01845 7-31-2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: F1 Yes F-1 No*
Alarms in working order: 0 Yes 0 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
-------—-----
Type:
❑ leaching pits number:
leaching chambers number:
El leaching galleries number:
n leaching trenches number, length:
1
leaching fields number, dimensions: field 25'x 37'
El overflow cesspool number:
F] innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/2612018 We 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 19 of 16
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 Rocky Brook Road
Property Address
Jamie Norris
OwnerOwner's Name
information is
required for every North Andover MA 01845 7-31-2018
page. Cltyfrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
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.
12. 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 0 Yes El No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15insp.doo-rov.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
699 Rocky
_ Brook Road
Property Address
Jamie Norris
Owner Owner's Name
information is
required for every North Andover MA 01845 7-31-2018-----
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
------- ------ ——--------
t5insp.doc•rev,712612018 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 15 Of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 Rocky Brook Road
Property Address
Jamie Norris
Owner Owners Name
information is North Andover MA 01845 7-31-2018
required forevery —------
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
CY) V
CJ
i4it
Lk
A �Sa�'4 IC
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 16 of 18
Commonwealth of Massachusetts
2 ......... Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
..... .....
59 Rocky Brook Road
Property Address
Jamie Norris
OwnerOwner's Name
information is
required for every North Andover MA 01845 7-31-2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Z Check Slope
Z Surface water
Z Check cellar
Shallow wells
4
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
z Obtained from system design plans on record
11-18-2003
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 on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doo-rev.712612018 Title 5 official inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
----------
pIi tie 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 Fpcqk _BrDoik Road
Property Address
Jamie Norris
Owner Owners Name
information is NAndover MA 01845 7-31-2018
required for every North A -------
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
• A. Inspector Information: Complete all fields in this section.
• B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
C. inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
(6insp.doc•rev.7126/2018 Title 5 Official inspection Form Subsurface Sewage Disposal Systern-Page 18 of 18
Summary Record Card generated on 712312UIO 11:41:41)AM Dy Karen"anion
Town of North Andover
Tax Map # 210-090.A-0048-0000.0
Parcel Id 14412
59 ROCKY BROOK ROAD
JAMIE & RUSSELL NORRIS
69 ROCKY BROOK ROAD
NORTH ANDOVER, MA 01846
Class 101 Single Family Property Type I Residential
Zoning2 1 Residential ZonIng3 1 Residential
Size Total 1.49 Acres
FY 2018
UB,Mailing Index
Name' lAddress Type Loan Number Activelinact. From Until
JAMIE&RUSSELL NORRIS Owner
59 ROCKY BROOK ROAD
NORTH ANDOVER,MA 01845
POWELL,ROBERT&JOANNE Previous Customer Inactive 7/29/2004
59 ROCKY BROOK RD
NO,ANDOVER,MA
01845
UB Account Maint. Activelinactive
Account No Cycle Occupant Name
Bldg Id. 18062.0-59 ROCKY BROOK ROAD Last Billing Date 7/18/2018 Active
3180091 . 03 Cycle 03
UB:Services Maint.
Account No.3180091
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0,635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 131.12 /1
UB Meter Maintenance
Account No. 3180091 Brand Type Size YTD Cons
Serial No Status Location w Water 0,630.63 2343
32588673 a Active 00 b Badger
Consumption Posted Date Variance
Date Reading Code 164.%
6112/2018 2789 a Actual 30 7/23/2018
2759 a Actual 11 4/23/2018 -55%
3/12/2018
12/1312017 2748 a Actual 25 1/2512018 -83%145 10/18/2017 199%
9/13/2017 2723 a Actual 363%
6/13/2017 2578 a Actual 50 V25/2017 -82%
3/10/2017 2528 a Actual 10 4/12/2017 -71%
12/11212016 2518 a Actual 56 1/23/2017 279%
9/12/2016 2462 a Actual 184 10/24/2016 291%
6/17/2016 2278 a Actual 53 8/2/2016 -71%
3/14/2016 2226 a Actual 13 4/22/2016 -55%
12/14/2015 2212 a Actual 46 1/20/2016 99 10/16/2015 45%
9/11/2015 2166 a.Actual 63 7/24/2015 360%
6/1112015 2067 a Actual 15 4/28/2015 -40%
3/1812015 2004 a Actual 24 1115/2015 -80%
12/15/2014 1989 aActual 128 10115/2014 18%
9/116/2014 1965 a Actual 102 7116/2014 565%
6/12/2014 1837 a Actual 15 4111/2014 -54%
3/14/2014 1735 a Actual 35 11117/2014 -62%
12116/2013 1720 a Actual go 10/15/2013 166%
9/1312013 1685 a Actual 32 7/24/2013 64%
6/14/2013 1595 a Actual 22 4/22/2013 -54%
3/20/2013 1563 a Actual 42 1/9/2013 -72%
12113/2012 1541 a Actual 163 10/15/2012 617%
9119/2012 1499 a Actual 22 7/16/2012 18%
6/18/2012 1336 a Actual 19 4/14/2012 -22%
3/2012012 1314 a Actual
—.W...............--.I I.H I.Y I-'.4y".,—I IwY well W.,
Town of North Andover
Tax Map # 210-090.A-0048-0000.0
Parcel Id 14412
69 ROCKY BROOK ROAD
JAMIE & RUSSELL NORRIS
59 ROCKY BROOK ROAD
NORTH ANDOVER, MA 01846
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zonlng3 I Residential
Size Total 1,49 Acres
FY 2018
12/19/2011 1295 a Actual 25 1/17/2012 -86%
9116/2011 1270 a Actual 178 10/13/2011 224%
6/13/2011 1092 a Actual 52 7/20/2011 300%
3/15/2011 1040 a Actual 13 4113/2011 -70%
12/15/2010 1027 a Actual 44 1/12/2011 -74%
9/16/2010 983 a Actual 179 10/15/2010 281%
6/14/2010 804 a Actual 44 7/15/2010 104%
3118/2010 760 a Actual 23 4/14/2010 -36%
12/14/2009 737 a Actual 34 1/12/2010 -51%
9/16/2009 703 a Actual 77 10/15/2009 55%
6/10/2009 626 a Actual 43 7/20/2009 122%
3/17/2009 583 a Actual 21 4/29/2009 -7%
12/15/2008 562 a Actual 22 1/20/2009 -59%
9/16/2008 540 a Actual 58 10/10/2008 45%
6/10/2008 482 a Actual 36 7/16/2008 112%
3/14/2008 446 a Actual 17 4/11/2008 -66%
12/17/2007 429 a Actual 53 1/22/2008 -62%
9/14/2007 376 aActual 125 10/1212007 217%
6121/2007 251 a Actu a 1 45 7120/2007 105%
3/16/2007 206 a Actual 21 4/16/2007 -34%
12/1312006 185 a Actu a 1 29 1/19/2007 -64%
9119/2006 156 a Actual 87 10/20/2006 115%
6/2012006 69 a Actual 41 7/10/2006 112%
3/2012006 28 a Actual 16 4/17/2006 12%
1/3/2006 12 a Actual 12 1/17/2006 -100%
10/31/2005 0 n New Meter 0 1117/2006 -100%
10/31/2005 2317 r Replacement 32 1/17/2006 -67%
9/15/2005 2285 a Actual 198 10114/2005 650%
Trouble Code:03
6/14/2005 2087 a Actual 23 7/15/2005 89%
3/25/2005 2064 a Actual 15 4/5/2005 -55%
12/15/2004 2049 m Manual estimate 30 1/14/2005 -51%
MSG
Commonwealth of Massachusetts
City/Town of
H.
System Pumping.Record
Form 4
DEP has provided this foim'for use.by local Boards of Health. Other form's 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 to
the local Board of Health or other approving authority.
A. Facl•lity Information
1. System Location: Left/ i t fro , Left/Rlghi rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
cltyTrown State Zip Code
2. System Owner.
1 jc c -15
Name'
Address(if different from location)
CityTrown State- Zip Cod
Telephone Number
.B. Pumping Record
1. Date 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 0-90 if yes, was it cleaned? ❑ Yes ❑ Na
` 5. Condition of System:
r
6. System Pumped By.,
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatiere contents•were disposed: _
--V/GL Lowell Waste Water
signAqe CfHaulwuDate
t5form4.doco 06103 System Pumping Record•Page 1 of 1
0 Other:~ ,~ d~~_' -