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HomeMy WebLinkAbout- Title V Inspection Report - 1041 JOHNSON STREET 9/4/2018 Commonwealth of Massachusetts , I le 5 Official Inspection Form r , '0 r Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1041 Johnson St Property Address J m Kaeral J, Owner Owner's Name information is required for every Andover MA 01845 07-31-2018 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 AA filling out forms . Inspector Information on the computer, use only the tab John DiVincenzo key to move your Name of Inspector cursor-do not use the return J & S Development/Stewart's Septic Service ....................................... ........ key. Company Name 58 So. Kimball St. VQ Company Address Bradford MA 01835 City/Town State Zip Code 978-372-7471 S113386 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 15.000); 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. r_1 Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. Fails ------------ ................ Inspeddr4s,Signature Date The ystem inspector shall submit' a copy of this inspection report to the Approving Authority (Board of ealth or DEP)within 30 days of completing this inspection. If the system has a design flow of 10, 00 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 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. t5insp.doc-rev.7126/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts � itW5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1O41Johnson St Property Address Kam | Owner Owner's Name information is ;WA 01845 -�O emui�d�rm"a� '`" page. CityfTuwn State Zip Code Date ufInspection C. Inspection Summary � Inspection Summary: Complete 1. 2. 3. or5and all of4and 6. 1\ System Passes: | have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 3) System Conditionally Passes: [l OnnormVrosyabamoomponenhamedesohbadinthe °Conditiona| Paoo^ secUonneedtobe 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 unoound, exhibits substantial infiltration orexfi|tration 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. ^ Ameba| septic tank will pass inspection if it is structurally sound. not leaking and if Certificate of Compliance indicating that the tank is less than 20 years old is available. [1 y [l N [l NO (Explain be|ow): Commonwealth of Massachusetts =�'=��0�� �� u����'=�����U N������������=���� ����0~0�� 0 ��N�� �� �=�� � ������� Inspection 0—��� mmm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1041 Johnson St Property Address Kam | Owner Owner's Name information i's No AndoverK8A 01845 O 18 �qui�U�rmmm ---�� ------- ' page. City/Town State Zip Code Date ofInspection C. UK��������^��� ���K�K���� (cont.) � ~�~ Inspection�. Summary ` ./ � 2) System Conditionally Passes (conL): [l Pump Chamber pumps/alarms not operational, System will pass with Board of Health approval if pumps/alarms are repaired. Fl Observation of sewage backup or break out or high static water level in the distribution box due bJbroken orobstructed pipe(m) ordue to broken, settled oruneven distribution box. System will pass inspection if(with approval ofBoard ofHea|th\: Fl broken pipe(a) are replaced [l Y |l N [l NO (Explain bm|om): [I obstruction is removed n Y El N F-1 ND (Explain be|mw): F-1 distribution box ieleveled orreplaced [l Y E] N E] ND (Explain be|ow): Fl 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 ofthe Board ofHea|th): El broken pipa(a) are replaced F� Y F� N El ND (Explain be|uw): F� obstruction is removed F1 Y n N 0 ND (Explain be|nw): 3) Further Evaluation is Required by the BmmmW of Health: [l Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public heo|th, safety or the environment. a. System will pass unless Board ofHealth determines inaccordance with 310CMR | 15.3W3(1)(b)that the system isnot functioning inamanner which will protect public health, safety and the environment: ,e^sp.uoc'rev,ruemuw Title,Official Inspection Form:Subsurface Sewage Disposal System'Page nm10 Commonwealth of Massachusetts ------------- Title 5 Official Inspection =.,h Subsurface Sewage Disposal System Form Not for Voluntary Assessments F' 1041 Johnson St Property Address Kamperal Owner Owner`s Name information is No Andover MA 01845 07-31-2018 i required for every . �....._. ......._.. . _...... ...,_ –_.- ... ..... .._..e .............. -_.._�...— page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) F� 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 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: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **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. 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 due to an overloaded or clogged SAS or cesspool t5lnsp.doe-rev.7126/2018 Title 5 Official inspection Form;Subsurface Sewage Disposal System+Paye 4 of 16 i 4 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r- ., 1041 Johnson St Property Address Kamperal Owner Owner's Name information is No Andover MA 01845 07-31-2018 requiredfor every .�.. _..._�._ ..._._ .............. ....___ _..__..— _...__.. _._ ......_.. ......_ .......... 1 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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. El ® 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. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. © ® 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 ❑ ❑ 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 El n the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.712612016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 � � Commonwealth of Massachusetts Title5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1O41Johnson St Property Address Kamp_eral ... Owner Owner's Name information is Andover MA 01845 07-31-2018 �quie����m� ---�� ------ pnge City/Town ���m Zip Date � � | C. Inspection Summary (cont.) � |fyou have answered "ves" toany question |nSection C.5the system isconsidered asignificant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner oroperator nfany large system considered gsignificant threat under Section C.5nrfailed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office ofthe Department. 8. You must indicate^'yem" or"no"for each wfthe following for all inspections: Yes No IN El Pumping information was provided bythe owner, occupant, orBoard ofHealth D Z Were any ofthe system components pumped out inthe previous two weeks? E 7 Has the system received normal flows inthe previous two week period? �l �� Hevelarge volumes ofvvoherbeen introduced tothe ayahennrecently ormspa�of �� �� this inspection? �� Fl Were eabuilt plans ofthe system obtained and examined? (if they were not available note aoN/A) �� [l Was the facility ordwelling inspected for signs ofsewage back up? Z [l Was the site inspected for signs ofbreak out? Z 0 Were all system oompVngOts, excluding the SAS. located on site? Z [l Were the septic tank manholes uncovered, opened, and the interior ofthe tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth ofliquid, depth ofsludge and depth ofscum? �� VVaothe facility nvvner(and occupants ifdifferent�onnowner) provided w/ith �� �� information onthe proper maintenance ofsubsurface sewage disposal systems? The size and location ofthe Soil Absorption System (SAS) mnthe site has been determined based on: Z D Existing information. For example, a plan at the Board of Health. �� �l C�atermined in the field (if any ofthe failure criteria related to Part is at issue �� `� approximation ofdistance is unacceptable) [810 CMR 15.302(5)l mm,p.uoo'rev.nmmm,o Title sOfficial Inspection Form:Subsurface Sewage Disposal System'Page om,u Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1041Johnson St ............. Property Address Kamperal .............—------- Owner Owner's Name information is No. Andover MA 01845 07-31-2018 required for every .............. page. City/Town State Zip Code Date of Inspection ------------------ D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms (design): — Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: .............. ............ Number of current residents: 6 Does residence have a garbage grinder? Yes 0 No Does residence have a water treatment unit? El Yes 0 No If yes, discharges to: ...... Is laundry on a separate sewage system? (Include laundry system inspection El Yes Z No information in this report.) Laundry system inspected? El Yes E] No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: ................... Sump pump? Z Yes E] No Last date of occupancy: Da..te.Occupied t5insp.doc-rev,712612018 Title 5 Official inspection Form:Subsurface sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments .......... 1041 Johnson St ........... Property Address Kamperal OwnerOwner's Name information is required for every No, Andover MA 01845 07-31-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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? ❑ Yes E] No Water treatment unit present? El Yes El No If yes, discharges to: Industrial waste holding tank present? ❑ Yes D No Non-sanitary waste discharged to the Title 5 system? El Yes Ej No Water meter readings, if available: Last date of occupancy use: Date Other(describe below): 3. Pumping Records: Source of information: Stewart's -------- ----------- Was system pumped as part of the inspection? 0 Yes El No If yes, volume pumped: 1000gallons ...... How was quantity pumped determined? Site gauge on truck Reason for pumping: inspect tank ................. t5insp.doe-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 / Commonwealth of Massachusetts ~�=�Q�� � ����=�=�Q N�������=��� ������� Title �� q��� � ������0 Inspection �-��mmm � Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1041 Johnson St Property Address Kamperal Owner Owner's Name information i's MAA O184� -�U naquiedfor eve� No. Andover ~' ~' 18 page. Cityfrmmn State Zip Code Date ofInspection D~ System Information /OoOt.\ | 4. Type mfSystem: �0 Septic tank, distribution box, soil absorption system FT Single cesspool E-1 Overflow cesspool El Privy R Shared system (yes or no) (if yes, attach previous inspection naoorda. if any) [l 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 ofthe |/Asystem bvsystem operator under contract [| Tight tank. Attach gcopy Vfthe DEP approval. F7 Other(describe): Approximate age ofall components, date installed (if known) and source ofinformation: 1B7� VVeremewagaodorsdetecbadwhenarrivingatthes|ha? [l Yee 0 No 5. Building Sewer(locate on site plan): 2011 Depth below grade: feet Material ofconstruction: Ecast iron E4OPVC F-1 other(explain): Distance from private water supply well or suction Un�� � feet Comments (on condition ofjoints, venting, evidence ofleakage, gtcj: | t5insp.doc rev,712,612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 / Commonwealth of Massachusetts Title 5 Official Inspection Form . ...... Subsurface Sewage Disposal System Form Not for Voluntary Assessments KY 1041 Johnson St Property Address Kamperal Owner Owner's Name information is required for every No. Andover MA 01845 07-31-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet ...... Material of construction: E concrete F-1 metal n fiberglass n polyethylene ❑ other(explain) 1000 gallc�n..tank. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No Dimensions: 5' X 8' X 48" 18" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 20" ............ Scum thickness 0 6" Distance from top of scum to top of outlet tee or baffle 1011 Distance from bottom of scum to bottom of outlet tee or baffle ----- How were dimensions determined? Tape measure/sludge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both tees in good shape, no leakage. Liquid levels are good. Outlet has filter in it. Outlet is built to Rr ................ .ade for easy access to filter, Should be cleared every vear. ........... -------------- ........... ............. ............................... . ........... 15insp.doo-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments .. ...... ..... 1041 Johnson St Property Address Kamper@1 Owner Owner's Name information is No. Andover MA 01845 07-31-2018 required for every --------- page. CityfTown State Zip Code Date of Inspection ........... D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: 1.feet Material of construction: 0 concrete R metal ❑ fiberglass El 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: Date 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: M concrete ❑ metal F-1 fiberglass ❑ polyethylene E] other(explain): Dimensions: ......... Capacity: ..gallons ........... Design Flow: gallons per day t5insp.doc rev,712612.018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts u =,rTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - ,� 1041 Johnson St Property Address Kamperal Owner Owner's Name information is required for every No Andover MA 01845 07-31-2018 _. page. City/Town State Zip Code Date of Inspection ------- ----- D. System Information 8. Tight or Holding Tank(cont.) 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.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. 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.): Equal distribution, no leakage Liquid level is good, no solids carryover. j _ _.... ......... ........ _.,.. _............_... ............... i t5insp.doc•rev,712612016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1041 Johnson St Property Address Kqm"peral Owner Owner's Name information is required for every No, Andover MA 01845 07-31-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: El Yes F1 No* Alarms in working order: [I Yes F-1 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: 6 -50' El leaching fields number, dimensions: ------------.. ❑ overflow cesspool number: El innovative/alternative system Type/name of technology: (Sinsp,cloc rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts NIL�� it fficial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4: ,. 1041 Johnson St Property Address Kamperal Owner Owner's Name information is No. Andover MA 01845 07-31-2018 required for every _......_ _,....... __— 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.): No hydraulic failure, no ponding, no damp soils 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 ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,): 15insp.doc-rev.7/26/2018 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 1041 Johnson St ...............- Property Address Kamperal OwnerOwner's Name information is No. Andover MA 01845 07-31-2018 everyrequired for eve page. city/Town 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.7/26/2018 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 1041 Johnson St Property Address Kamperal ........ Owner _.. Owner's Name information is required for every No. Andover 01845 07-.31.-2018 page. di"t"y" ifown 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 ........... t5insp.doc rev,7/2612018 Title 5 Official Inspection Few Subsurface sewage Disposal System-Page 16 of 16 c,. \ Commonwealth of Massachusetts y Title Official l I i r Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1041 Johnson St Property Address Kamperal Owner Owner's Name information is No Andover _ _ MA 01845 07-31-2018 required for every _..- .._..... _.._..._ page. Cityrrown State Zip Code Date of Inspection D. System Information (cant.) 15. Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 5' Estimated depthto 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: _......... _ ......_ Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Pulled file for adjacent properties [� Checked with local excavators, installers- (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Water table taken from 1029 Johnson St Estimated seasonal high water table @ 5'. 1057 Johnson St, estimated seasonal high water table @ 5'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doe-rev.7/28!2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1041 Johnson St Property Address Kampe al ............ Owner Owner's Name information is No. Andover MA 01845 07-31-2018 required for every ........ page. City/Town ----- -------- State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Z A. inspector information: Complete all fields in this section. Z B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ED C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed Z 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 t5insp doc•rev,7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 dd P ( G! 9 � 1 P 1 I ! -PRI Oe .w.,..r,. r..,,, w. .. .. .. ,. .._ ..r....r..., ..,M ..., „u*.a+�° ;ti.Ca,p .w".".L'., bbSy��"�S«".k:8}M..y9tf:S��V+:;,'";,.^1,J'-°{a'",'�rw!'•r m. rv,�. Po4 /a ..M Nh W.�,ew rw,.N, hnw.w.r Ikrs w 0 rr , i i ti4y` _, ..r..... ...... .....r. Summary Record Card generated on 5/101201311,40:20 AM by Karen Hanlon page 1 Town of North Andover Tax Map # 210-107.A-0160-0000.0 Marcel Id 17976 1041 JOHNSON STREET KLAPES, JEANNETTE 1041 JOHNSON STREET N. ANDOVER, MA 01846 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1,04 Acres FY 2013 a 1.18-Mailing Index Name/Address Type Loan Number Active/Inact, From Until KLAPES,JEANNETTE Payor 1041 JOHNSON STREET N.ANDOVER,MA 01845 U" ACCt)Unt ll�aint. Account No Cycle Occupant Name Active/Inactive Bldg Ida 13307.0»1041 JOHNSON STREET Last Bllling°Bate 3/6/2013 1 2100300 02 Cycle 02 Active UB gervices.Maint, Account No:2100300 s Service Code Rate Charge MuitlpliedUsers MISCFEE ADMIN FEE 0.63 6/8 7.82 1/ WTR WATER 01 ALL METER SIZE 15,20 /1 UB Meter Main+enartc2 Account No,2100300 Serial No Status Location Brand Type Size YTD Cons 13242622 a Active ERT HH METE METE w Water 0,63 0.63 148 Date Reading Code Consumption Posted Date Variance 5/1/2013 263 a Actual 2 -43% 2/6/2013 261 a Actual 4 3/13/2013 -8% 10/31/2012 257 a Actual 4 12/13/2012 38% 8/3/2012 253 a Actual 3 9/26/2012 .1% 5/3/2012 260 a Actual 3 6/20/2012 .39% 2/2/2012 247 a Actual 6 3/14/2012 -81% 11/1/2011 242 a Actual 26 12/16/2011 17% 8/2/2011 216 a Actual 22 9/14/2011 $1% 6/4/2011 194 a Actual 16 6/13/2011 66% 2/7/2011 178 a Actual 11 3/16/2011 163% 11/1/2010 167 a Actual 4 12/13/2010 -42% 8/3/2010 163 a Actual 7 9/13/2010 75% 5/4/2010 156 a Actual 4 6/9/2010 1% 2/2/2010 152 a Actual 4 3/11/2010 -3% 11/2/2009 148 a Actual 4 12/11/2009 -30% 8/5/2009 144 a Actual 6 9/11/2009 -37% 6/4/2009 138 a Actual 9 6/16/2009 88% 2/5/2009 129 a Actual 6 3/16/2009 -16% 11/6/2008 124 a Actual 6 12/10/2008 21% 8/4/2008 118 a Actual 6 9/12/2008 -68% 6/2/2008 113 a Actual 11 6/18/2008 63% 2/6/2008 102 a Actual 8 3/14/2008 26% 11/2/2007 94 a Actual 6 1/15/2008 50% 8/3/2007 88 a Actual 4 9/14/2007 5% 5/4/2007 84 a Actual 3 6!22!2007 •22% 2/21/2047 81 a Actual 6 3/23/2007 -18% 1111/2006 76 a Actual 6 12/22/2006 43% 8/1/2006 69 a Actual 4 9/13/20060 5/5/2006 65 aActual 5 6/20/2006 27% 2 Town of North Andover HEALTH DEPARTMENT CHECK#: DATE: LOCATION: r.)-, I ...... H/0 NAME: CONTRACTOR NAME: j jc- iypp�ermit car License: (Check box) 0 Animal 0 Body Art Establishment E3 Body Art Practitioner • Dumpster • Food Set-vice-Type:- 0 Funeral Directors El Massage Establishment • massage Practice • offal(Septic)Hauler 0 Recreational Camp • Suit tanning • Swimming Pool 0 Tobacco 0 Trash/Solid Waste Hauler 0 Well Construction sfEpf S1Lstems.- 0 Septic-Soil Testing [3 septic-Design Approval 0 Septic Disposal Works Construction(DW0 C] Septic Disposal Works installers(DWI) 0 Title 5 Inspector Title 5 Report $:9 P [I Other. (Indicate)---- HeWth,,Agent ni ta itialss� White-Applicant Yellow Health Pink-Treasurer