HomeMy WebLinkAbout- Title V Inspection Report - 336 CANDLESTICK ROAD 10/4/2018 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
OF
336 Candlestick Road
rb -Property Address —
Jack Madden
Owner Owner's Name
informationis required for every North Andover MA 01845 9-29-2018 _
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 A. Inspector Information
filling out forms
on the computer,use only the tab Neil James Bateson
key to move your Name of Inspector
cursor-do not Bateson Enterprises Inc.Company Name
use the return ____,___------------------
key.
111 Argilla Road
r� Company Address
Andover MA 01810
Cityrrown State Zip Code
rerun 978-4754786 SI-15
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 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. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
l
9-29-2018
Inspector Signatur � 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.
J
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.
t5lnsp.doo rev.7126/2018 Title 5 OiAclal Inspection Form:Subsurface Sewage Disposal System+Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
336 Candlestick Road
Property Address
Jack Madden
Owner
information is North Andover MA 01845 9-29-2018
required for every Date of lnspe�eton
page. City[rown State Zip Code
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist, Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
El 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.
n Y F] N ❑ ND(Explain below):
-—--------
Wnsp.doc rev.7/26/2018 Title 5,0Mcial 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
336 Candlestick Road
Property Address
Jack Madden
Owner Owner's Name
information is North Andover MA 01845 9-29-2018
required for every
page. State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
n Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
n Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
• broken pipe(s)are replaced El Y ❑ N ND (Explain below):
• obstruction is removed 0 Y ❑ IN ❑ ND (Explain below):
• distribution box is leveled or replaced El Y n N El 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):
n broken pipe(s) are replaced El Y 0 N El ND (Explain below):
EJ obstruction is removed El Y El 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(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
336 Candlestick Road
Property Address
Jack Madden
Owner Owners Name
information is North Andover MA 01845 9-29-2018
required for every -s�tjfe--- -fip-do-dei-- --da-t—eof-1n-s-p—ection ----------
page. diiyrrown
C. Inspection Summary (cont.)
[:1 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
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:
0 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.
R The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
[I 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.
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.doc-rev,7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
OR Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
336 Candlestick Road
Property Address
Jack Madden
Owner ersName
information is
required for every North And -MA 01845 9-29-2018 ------
page. d7ityf over
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
E] z Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 dayflow
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
E] 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.
z Any portion of a cesspool or privy is within a Zone I of a public water supply
well.
F1 z 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 6 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.
6) 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
El E] 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 ❑ 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
t6lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
336 Candlestick Road
Property Address
Jack Madden ——--------
Owner Owner's Name
Information Is North Andover MA 01845 9-29-2018
required for every -§iit-e— -Zip Code Date of inspection
page. City/Town
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 CA 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 aff inspections:
Yes No
0 E] Pumping information was provided by the owner, occupant, or Board of Health
F1 [D Were any of the system components pumped out in the previous two weeks?
E El Has the system received normal flows in the previous two week period?
El 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
F-1 Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
ED El Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
E E] Were all system components, excluding the SAS, located on site?
M 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 ❑ 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:
• EJ 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
• El approximation of distance is unacceptable) [310 CMR 15.302(5)]
t51nsp.doc rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
336 Candlestick Road
Property Address
Jack Madden
Owner Owners Name
information is MA 01845 9-29-2018
every required for eve North Andover
State Zip Code Date of Inspection
page. Cityrrown
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660
Description:
2
Number of current residents:
Does residence have a garbage grinder? 0 Yes El No
Does residence have a water treatment unit? El Yes Z No
If yes, discharges to: —-------
Is laundry on a separate sewage system? (Include laundry system inspection El Yes E No
information in this report.)
Laundry system inspected? El Yes F] No
Seasonaluse? F] Yes E No
Water meter readings, if available (last 2 years usage(gpd)): Yes
Detail:
------------
Sump pump? 0 Yes E No
Last date of occupancy: CurrentDate
t5insp.doo rev.7/26/2018 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
336 Candlestick Road
Property Address
Jack Madden
Owner Owner's Name
information is
required for every North Andover MA 01845 9-29-2018
page. Cityrrown 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): —per
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes El No
Water treatment unit present? ❑ Yes E] No
If yes, discharges to: ------____
Industrial waste holding tank present? Fl Yes [I No
Non-sanitary waste discharged to the Title 5 system? El Yes El No
Water meter readings, if available: ------...... —-----
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Pumped 2017, owner
Was system pumped as part of the inspection? Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank&tees
15insp.doc-rev.7126/2018 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
336 Candlestick Road
Property
Madden
Owner Owner's Name
information i MA 01845 9-29-2018
required for every
North Andover ---
every
page. d7it-yrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
ED Septic tank, distribution box, soil absorption system
El Single cesspool
R Overflow cesspool
El Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the [/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
25 Years old, 8-16-1993, as built plan
Were sewage odors detected when arriving at the site? R Yes Z No
5. Building Sewer(locate on site plan):
1.9
Depth below grade: feet
Material of construction:
E cast iron E 40 PVC El other(explain):
Distance from private water supply well or suction line: -Feet ------------
Comments (on condition of joints, venting, evidence of leakage, etc.):
Unable to see piping leaving foundation, finished cellar. 4" PVC pipe to septic tank.
-------------
t5insp.doc-rev.712612018 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
336 Candlestick Road
Property Address ___
Jack Madden
Owner Owner's Name
information Is North Andover MA 01845 9-29-2018 —---------
required for every —
page. tyrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
0.9
Depth below grade: feat
Material of construction:
concrete F] 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 [I No
1 O'x 5'x 4'
Dimensions:
Sludge depth: 311.............
Distance from top of sludge to bottom of outlet tee or baffle 30"
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 12"
How were dimensions determined? Tame
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.
-----------------
---------- ----------------------1--------------------- -----
t5insp.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
5 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
336 Candlestick Road
Property Address
Jack Madden
Owner Owner's Name
information Is
required for every 'North Andover MA 01845 9-29-2018
page. dit-yfrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade:
Material of construction:
F-1 concrete El metal El 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: 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:
0 concrete F1 metal El fiberglass El polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day ------
t5insp.doe-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
336 Candlestick Road
Property Address
Jack Madden
Owner Owner's Name
Information Is
required for every North Andover MA 01845---- 9-29-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: n Yes E] No
Alarm level: Alarm in working order: E] 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? F] Yes El 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.):
D-box cover broken, replaced it. D-box level & distribution equal. No evidence of leakage. Evidence
carryover, pumped d-box to clean.
t5insp.doc rev.7126/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 12 of 18
Commonwealth of Massachusetts
a T = Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
336 Candlestick Road
Property Address
Jack Madden _--
Owner Owner's Name
information is North Andover MA 01845 9-29-2018
required for every --
page. CityfTown State Zip Code Date of Inspection
D. System Information(cons.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ 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:
leaching galleries number: ---- . ---.-.--_.__-._
® leaching trenches number, length: 2 trenches 64'
long
❑ leaching fields number, dimensions: --- ---------
❑ overflow cesspool number: —
❑ innovative/alternative system
Type/name of technology: -._..._------------------------_.__----------- ----.-------..
t5insp.doc•rev.7126M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
rATitle 5 Official Inspection Form
e
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
336 Candlestick Road
Property Address
Jack Madden
Owner Owners Name
information is North Andover MA_ 01845 9-29-2018
required for every
page 6tyfraw—n State_ — Zip Cade Date of Inspection
1
D. System Information (cost.)
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 ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
----------.. _
i
I
i
Wnsp.doc•rev.7126/2018 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
336 Candlestick Road
Property Address
Jack Madden
Owner Owners Name
information is
required for every North Andover MA 01845 9-29-2018
page. &tift6wn 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 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
+- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
336 Candlestick Road
Property Address
Jack Madden _..--_---___--
Owner Owner's Flame
information is North Andover MA 01845 9-29-2018
required for every _.._ __.
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
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
ow
L
c tw 0 r
, o- 2>5
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1; Subsurface Sewage Disposal System Form Not for Voluntary Assessments
336 Candlestick Road
Property Address
Jack Madden
Owner Owner's Name
information is North Andover MA 01845 9-29-2018
required for every ------ --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Check Slope
Surface water
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: 4-18-1989
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
n Ian
-----------------
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
As per design plan test pit data
--------------- —-------------
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
tSinsp.doo-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
336 Candlestick Road
Property Address
Jack Madden
Owner Owner's Name
information is MA 01845 9-29-2018
required for every North Andover
page. CityfTown 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
Z 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
t5insp.cloc•rev,7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Summary Record Card generated""m20ooa9:12:4mmwoy Karen Hanlon Page
Town nf North Andover
Tax Map # 210-106~A-0250-0000,0
. Parcel Ud17398
336CANDLESTUCK ROAD
MADDEN, JACK
336 CANDLESTICK RD
N- ANQOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 1 Acres
FY 2019
iling Ind
Name/Address Typo Loan Number AoUwe/|nmct. From Until
MADDEN,JACK Paymr Active
838 CANDLESTICK RD
N.ANDOVER. MA
01845
Account No Cycle Occupant Name Active/Inactive
Bldg |d 17s5o.o-3xo CANDLESTICK ROAD Last Billing Date 7/1&2O1V
3170329 03 Cyc|uV3 Active
Account No. 3170029
Service Code Rate Charge Multiplier/Users
M|GOFEEADM|NFEE 11 9.18 1/
VVTRVVArER O1 ALL METER SIZE 19618 /1
8cnnuntNn.3170329
Serial No Status Location Brand Type Size YT8Conm
33525476 aActive snTH1-1 b Badger wVYater 11 3063
Date Reading Code Consumption Posted Date Variance
9/12/2018 3252 uActua[ 134 205%
6/11/2018 3128 aActwo| 42 7/23/2018 294%
3/712018 3086 aAcma| 10 4/23/2018 -88Y6
12/712017 3076 eActum| 40 1/25/2018 '44%
9/12/2017 3028 oActua| $6 10/18/2017 411%
6/8/2017 oyoo wAmuo| 18 7/25/2017 g%
3/8/2017 2914 mAotua| 16 4/1212017 '079&
13/9/2016 2898 aAotua| 50 1/2312017 '73%
09/2018 2840 oAntum| 177 1024/2016 284%
8/13/2016 2671 oAutuu| 49 8/2/2016 20894
3/9/2016 2622 mAoba| 15 4/22/2016 '76%
12/102015 2607 n8utuo| 64 1/202016 -5896
9/912015 2543 uAoba| 151 10/16/2015 91%
8/102015 2392 oxctua| 79 7/24/2015 388Y6
3/11/2015 2313 o8ntom| 16 4/28/2015 -80%
12/11/201* 2297 aActua| 81 1/15/2015 ~53Y6
9/11/2014 2216 oActua| 233 1015/2014 272%
6/11/2014 1983 aActuu| 00 7/16/2014 296%
3/11/2014 1933 aActua| 15 4/11c014 -69%
12/10/2013 1818 aAntua| 48 1117/2014 -64%
9/11/2013 1870 mActuo| 135 1015/2813 181%
6/1212013 1735 aActua| 48 7/24/2013 121%
3/13/2013 1087 eActum| 22 4/22/2013 -59m
12/11/2012 1065 aActua| 52 1/9/2013 '68%
9/130012 1013 oActuoV 178 10162012 105%
6/1212012 1435 aActuu| 65 7U6/2012 149%
3/14/2012 1370 aActua| 27 4/14/2012 43%
12/1212011 1343 aAntuo| 46 1/17/2013 '63%
Commonwealth of Massachusetts
City/Town of .
System Pumping,Record
Form 4
DEP has provided this foirri for useaby 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
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. Facilsty. Information`
1. System Location: Left/Right front.of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown State r Zip Code
Telephone Number
.B. Pumping record
. 1
1. Date of Pumping crate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
Q Other(describe):
4. Effluent Tee Filter present? ❑ Ye,p If yes,was it cleaned? ❑` Yes ❑ No,
'S. Condition of System: �,(
6: System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Luca' here contents-were disposed:
+ Lowell Waste Water
E
Sign a Hl�ut Date
15fnrm4.dav 08/03 System Pumping Record Page 1 of 1
of
1r
Town of North Andover
HEALTH DEPARTMENT
y'SSACHUgE4
CHECK #: ; p DATE: ,ry4. � j
LOCATION: ; .si��
H/O NAME:
CONTRACTOR NAME: _u �*� A'�
Type of Permit or License: (Check box)
Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ .Food Service-Type:___ _ $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage.Practice $
❑ Offal(Septic)Hassler $
Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $_
❑ Well Construction $
SEPTIC Systelus.°
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector
Title 5 Report $ i
❑ Other:(Indicate)
HeahhAgent Initials
a
White-Applicant Yellow-Health Pink-Treasurer