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Home My WebLink About- Title V Inspection Report - 74 FULLER ROAD 10/31/2018 Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 312018 74 Fuller Road OF NORTH ANDOVER Property Address HEALTH DEPARTMENT Pam Rasetta Owner Owner's Name Information is required for every North Andover MA 01845 10-29-2018 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 filling out forms In. 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 OQCompany Address Andover MA 01810 CltylTown State Zip Code return 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. F-1 Passes 2. Z Conditionally Passes 3. F] Needs Further Evaluation by the Local Approving Authority 4. n Fails Inspebt6rd'sSig9nai_ur 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 DEP. 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. tirinsp.doc^rev,7126/2018 Title 5 Official 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 74 Fuller Road _w....._.._._.. -- ------------___— -._.. -----....... ------------ Property Address Pam Rasetta Owner „__ _..-------------------- ------- __ _._� Owner's Name information is North Andover MA 01845 10-29-2018 required for every _......_.__ _.___..,.. page, City/Town 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: ❑ 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: ® 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. 0 Y ® N ❑ ND (Explain below): 15insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts =�"��N�� N 0��"�� N~N�� N �� Official� Inspection mm �-��m � ww ' �� wm�~�� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Fuller Road Property Address Pam Raeetta Owner Owner's Name information is North Andover MAO1O4S 10-29-2018 mqu|rn�formmary ��-- D��|nspacUon pagm� ~'^'''``~' —' --- C. Inspection Summary (cont.) 2) System Conditionally Passes (conL): El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if � pumps/ab3rn1nane 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) nr due to o brnken, settled or uneven distribution box System will pass inspection if(with approval nf Board ofHea|th): [l broken pipe(s) are replaced [-] Y Z N Fl NU (Explain below): F� obstruction imremoved E] Y Z N [| WD (Explain be|oxv : [l distribution box io leveled urreplaced El Y Z N Fl NO (Explain bm|ow): � 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 ofHea|th): F-1 broken pipe(s) are replaced El Y 0 N 0 NO (Explain Ue|nw): Ej obstruction iaremoved Y Z N Fl ND (Explain bo|ow): 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 heo|th, safety ortheenvironment. a. System will pass unless Board of Health determines in aGCordance with 310 CMR 15.383(1)(b)that the system is not functioning in m manner which will protect public health, safety and the environment: mmsp.u"°'rev.,omo",o n'moomm=/Inspection Form:Subsurface Sewage Disposal Systern-Page 3 of 18 / CoNNmonwealth ,of Massachusefts ��=��0 �� Official N Inspection �~ Title 0��0�� N�� U�� /� � �� m m�m � ��m m Form m m m m . m �� m m �� m Subsurface Sewage Disposal System Form Not for Voluntary Assessments 74 Fuller Road Property Address PomRasetta Owner Dwne,'nN"m= information is required for every North Andover MA 01845 10-29-2018 page, hoTowo State Zip Code Date mInspection C. Inspection Summary (cont.) || Cesspool o[privy |s within 5U feet of8 surface water F-1 Cesspool or privy ia within 5O feet of a bordering vegetated wetland ora salt marsh b. System will fall unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning ina manner that protects the public health, safety and environment: n The system has o septic tank and soil absorption oymbern (SAS) and the 8A8 is within 108 feet ofo surface water supply or tributary hom surface water Supply. Fl The system has a septic tank and SAG and the SAS is within a Zone 1 of public water supply. Fl The system has a septic tank and SAS and the SAS is within 6O feet ofa private water supply well. F] The system has a septic tank and SAS and the SAS is less than 1OO feet but 5O feet nr more from a private water supply vve||°^ Method used 10 determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal oo|ifnrnn 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. o. Other: Outlet tee in septic tank & d-box needs tobereplaced. 4) System Failure Criteria Applicable toAll Systems: You must indicate"Yms'' or'^Nm" tm each ofthe following for all inspections: Yes No Backup nfsewage into facility or component oVo[|Oadad or � clogged SAS or cesspool � Discharge or pondinQ of effluent to the surface of the ground or surface waters �� due to an overloaded or clogged SAS or cesspool / ' d� Commonwealth of Massachusetts ��N�� *��"�� 0�� U�� N �� Official� Inspection �-��mmmm' �� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 74 Fuller Road P@nlRGmettm Owner Owner's Name information is North Andover ��A O184� 10-29-2018 ,o*uimu�,owm� N ��-- Date nf|nupvuivn page. ~''r'~'~' -' --- C. Inspection Summary (cont.) 4) System Failure Criteria Applicable koAll s: (cont.) Yes No [l �� S�at� |iqu� level in the d�tdbu�onbox above ouUetinve�due toanovedoaded �� or clogged SAS orcesspool �� Liquid depth in cesspool is less than O" below invert or available volume in |eoa �� than }6 day flow [l �� Required pumping rnorothan 4t|[nenin the last year/VOTdue to clogged 0[ �� obstructed pipe(s). Number of times pumped: _____ El 2 Any portion of the SAS, cesspool or privy is below high ground water elevation. Fl �� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary toa surface water supply. �l �� Any po�|onofa cesspool orphvyiovvithina Zone 1ofa public vvatersupply �� well. El 0 Any portion of cesspool or privy is within 5D feet V[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 o private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed ataDEPcertified laboratory,for fecal coliform, bacteria indicates absent and the presence mf ammonia nitrogen and nitrate nitrogen im equal bour less than 5 ppmn, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this tmrmm] The system isa cesspool serving m facility with a design flow of2UOOgpd- 10.000gpd. �� The symtonmfmUa. | have determined that one or more of the above failure �� criteria exist asdescribed in 310C&1R 15.303. therefore the system fails. The system owner should contact the Board Of Health ho determine what will be necessary to correct the failure. 5) Large Systems: Tobm considered a large system the system must serve m facility with a � design flow mf10,000gpdbm1S,O00 gpd. � For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the � questions in Section C-4. Yes No El Fl the system ia within 4OO feet ofa surface drinking water supply � El EJ the system is within 200 feet 0fG tributary to 8 surface drinking water supply [l [l the system is located in a nitrogen sensitive area (interim Wellhead Protection Area-|VVP/) o[a mapped Zone || ofo public water supply well m/^"pmm^rev.712612018 Title u Official Inspection mmr Subsurface Sewage Disposal System`pao"o°/m Commonwealth of Massachusetts Title 5 official Inspection Form T.=- n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments z W 74 Fuller Road Property Address Pam Rasetta Owner Owner`s Name ____......_._-.-. __.._...__ information is required for every North Andover MA 01845 10-29-2018 ...� __..... . .___,._..- _.___-- _...._ _ page, City/Town State Zip Code Date of Inspection C. Inspection Summary (cant.) 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. C. 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? Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Z Were as built plans of the system obtained and examined? (If they were not available note as N/A) Z ❑ Was the facility or dwelling inspected for signs of sewage back up? Z ❑ Was the site inspected for signs of break out? Z ❑ 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. ® ❑ Existing information. For example, a plan at the Board of Health. El approximation' in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] l5insp.doc•rev.7126/2018 Title 5 Official tnspeclion 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 74 Fuller Road Property Address Pam Rasetta Owner Owner's Name information is required for every North Andover MA 01845 10-29-2018 - -271p�o-de Date of Inspection page. ityfTown State 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): 600 Description: ---------- ------------ Number of current residents: Does residence have a garbage grinder? El Yes 0 No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection F1 Yes 0 No information in this report.) Laundry system inspected? El Yes ❑ No Seasonal use? El Yes No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? M Yes El No Current Last date of occupancy: Date II t5insp.doe-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Myw: ❑ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Fuller Road Property Address Pam Rasetta Owner Owner's Name ......_.___..__....___. _......�... __.._..._,..,_..,. _.. information is North Andover NIA 01845 10-29-2018 required for every -. _._._....__ ........._._._,._ -- . page, City/Town State Zip Code pate of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: __.-__-------- _.___... design flaw(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): _.._..___. Grease trap present? ❑ Yes El No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: .._.,_,_____ Last date of occupancy/use: bate __._ ..-____..._-- Other(describe below): 3. Pumping Records: Source of information: Pumped 2007, owner Was system pumped as part of the inspection? F1 Yes Z No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: tSinsp.doc rev.7126/2018 Title 5 official inspection Form:Subsurface Sewage Disposat System-Page 8 of 18 | � / Commonwealth of Massachusetts ~��N�� `��~��0 0��=^�°�� N�8M�h . Title �� y� � ��m� Inspection 0—�pmmmm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Fuller Road �roperty Address Pam Rosettm Owner Owner's Name information is No�h /\n�ov�r MA O1�45 1U-28-2D18 vmqui�dmreve� ��— ��m page. ~'^'''~^`'' -- CodeInspection D, Syste00 Information (cont.) 4. Type of : 0 Septic tank, distribution box, soil absorption system || Single cesspool [l Overflow � �� E-1 Privy F� Shared system kxas 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 o copy oflatest inspection of the |X\system by system operator under contract E-1 Tight tank. Attach copy of the DEPapproval. F� Other(describe): Approximate age of all components, date installed (if known) and source of information: original, no as built Ian Were sewage odors detected when arriving at the site? [l Yes No 5. Building Sewer(locate on site plan): 1.8 Depth below grade: Material of construction: cast iron 40PVC other(explain): ' Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, eto.): 4"Cast iron through vvo||. 3" PVC in house. no leaks visible `sn°p,*"c'rev./oo20`o ntle»Official inspection po,rm Subsurface Sewage Disposal Sys/"rn'Page oum Commonwealth of Massachusetts ► Title 5 Official Inspection Farm — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments x 74 Fuller Road Property Address Pam Rasett a_.__.._........_._._ ...._._.._.__. .._.. _..................__�.__._......_ __.........__-._.-- Owner Owner's Name information is North Andover MA 01845 10-29-2018 „ required for every _._ __._._...._.__._-__._-. page Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) 6. Septic Tank(locate on site plan): 0.8 Depth below grade: fet....-- ----._....._..-_ Material of construction: ❑ concrete ❑ 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) ❑ Yes ❑ No 10' x5'x4' Dimensions: 4" Sludge depth: _.._. _-.. Distance from top of sludge to bottom of outlet tee or baffle NlA= Outlet tee corroded off 3" Scum thickness Distance from top of scum to top of outlet tee or baffle NIA Distance from bottom of scum to bottom of outlet tee or baffle N/A Tape Measure How were dimensions determined? _._...-.-- 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 corroded off, needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. 15insp.doc-rev,7126/2018 Title 5 Offidal Inspection norm: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 74 Fuller Road ---------- Property Address Pam Rasetta Owner information is required for every North Andover ---------- MA 01845 10-29-2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet et Material of construction: ❑ concrete ❑ metal 0 fiberglass El polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle --------- Distance from bottom of scum to bottom of outlet tee or baffle ------------ Date of last pumping: -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: El concrete El metal E] fiberglass F1 polyethylene El other(explain): .......... Dimensions: .............. Capacity: -iiiko-n-s - --- Design Flow: -6-a-11ons per day t6insp.doc-rev.712612018 '1 file 5 official Inspection Form:Subsurface Sewage Disposal Systern-Pago 11 Of 10 Commonwealth of Massachusetts ixM== Title 5 Official Inspection Form T _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „� - 74 Fuller Road Property Address Pam Rasetta Owner Owner"s Name information is North Andover MA 01845 10-29-2018 required for every __.w..__._... _.._..._., , -.___-- -_.__...._ _. �_....._._ �._.,.. page CltylTown State Zip Code Date of Inspection D. System Information (coot.) 8. Tight or Holding Tank(coat.) Alarm present: ❑ Yes ❑ No Alarm level: — -._ Alarm in working order: ❑ Yes ❑ No Date of last pumping: .-bateComments(condition(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.): D-box cover broken, replaced same. D-box level &distibution equal. Evidence of carryover. Evidence of leakage, corrosion holes in d-box. D-box needs to be replaced. i I, I i l5insp.doc-rev.712 612 01 8 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 K� c, ❑ 74 Fuller Road Property Address Pam Rasetta Owner Owner's Name - information is North State Zi Code [late o-2018 required for every North Andover MA 01845 10-2'3 page. y p.... f Inspection D. System Information (cent.) -____. _ 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: 1 field 20' x 45' ❑ leaching fields number, dimensions: ------ ❑ overflow cesspool number: ❑ innovative/alternative system I Type/name of technology: ---_ —w.._�_..,...._._ _-....—.....w...._ t5lnsp.tloe•rev.112612018 Tide 5 Official Inspection Form;Subsurface Sewage Disposal Systom Pogo 13 of 18 Commonwealth of Massachusetts 5 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 74 Fuller Road Property Address Pam Rasetta Owner Owner's Name information is required for every North Andover MA 01845 10-29-2018 .......... ------ page. 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 D Yes El No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp,doc•rev.7/2612018 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 74 Fuller Road Property Address Pam Rasetta Owner Owner's Name information is North Andover MA 01845 10-29-2018 required for every 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.): ----------- II t6insp,doc-rev.7/26/2018 Title 5 Official inspection rorm:Subsurface Sewage[)isposal Systern-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments z. 74 Fuller Road ------------- Property Address Pam Rasetta Owner er's Name information is North Andover MA 01845 10-29-2018 required for every page. City/Town 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: Z hand-sketch in the area below ❑ drawing attached separately 0, �7 L4 t5insp.doc•rev.7/26/2018 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 74 Fuller Road Property Address Pam Rasetta ................... .... ........ Owner Owner's Name information is required for every North Andover MA 01845 10-29-2018 -------- ------ 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 5-31-1 If checked, date of design plan reviewed. Date 980 .......... F] Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: plan El 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 data on design plan ........... Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.712612.018 Title 5 official inspection Form:Subsurface Sewage Disposal Systern-Page 17 of 18 Commonwealth of Massachusetts x _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Fuller Road Property Address Pam Rasetta Owner _.._...____..__.._ .____ ._..____........,..__ -_ .- Owner's Name information is required for Query North Andover MA 01845 10-29-2018 � page. City/Town 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 t5insp.doe•rev.7/2612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Town of North Andover Tax Map # 210-065.0-0085-0000.0 Parcel ld 15309 74 FULLER ROAD RASETTA, PAMELA 74 FULLER ROAD N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential ZonIng2 1 Residential Zoning3 1 Residential Size Total I Acres FY 2019 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until RASETTA, PAMELA Payor Active, 74 FULLER ROAD N.ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id, 17212.0-74 FULLER ROAD Last Billing Date 10/4/2018 3160290 03 Cycle 03 Active UB Services Maint. Account No. 3160290 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 38.00 /1 UB Meter Maintenance Account No. 3160290 Serial No Status Location Brand Type Size YTD Cons 32707562 a Active 00 b Badger w Water 0,630.63 543 Date Reading Code Consumption Posted Date Variance 9/7/2018 644 a Actual '10 10/15/2018 11% 6/6/2018 634 a Actual 9 7/23/2018 -3% 3/5/2018 625 a Actual 9 4123/2018 11% 12/5/2017 616 a Actual 8 1/25/2018 -23% 9/7/2017 608 a Actual 11 10/18/2017 33% 6/5/2017 597 a Actual 8 7/25/2017 -13% 3/6/2017 589 aActual 9 4/12/2017 3% 1217/2016 580 a Actual 9 1/23/2017 -42% 916/2016 571 a Actual 16 10/24/2016 72% 6/3/2016 555 a Actual 9 8/2/2016 -7% 3/3/2016 546 a Actual 9 4/22/2016 -1% 1218/2015 537 a Actual 10 1/20/2016 20% 9/4/2015 527 a Actual 8 10/16/2015 -20% 6/512015 519 a Actual 10 7/24/2015 12% 3/6/2015 509 a Actual 9 4/28/2015 20% 12/4/2014 500 a Actual 7 1/15/2015 -14% 9/9/2014 493 a Actual 9 10/15/2014 23% 6/6/2014 484 a Actual 7 7/1612014 -12% 3/7/2014 477 a Actual 8 4/1112014 -13% 12/5/2013 469 a Actual 9 1/17/2014 10% 9/6/2013 460 a Actual 8 10/15/2013 -21% 6/1012013 452 a Actual 11 7/24/2013 13% 3/6/2013 441 a Actual 9 4/22/2013 4% 12/7/2012 432 a Actual 9 1/9/2013 -41% 9/512012 423 a Actual 15 10/15/2012 -22% 6/612012 408 a Actual 19 7/16/2012 98% 3/812012 389 a Actual 10 4/14/2012 5% 121512011 379 a Actual 9 1/17/2012 -65% 9/712011 370 a Actual 27 10/13/2011 176% 4 ate . `�qMa Town of North Andover HEALTH DEPARTMENT 9SSAGNUS�'S CHECK#: ° DATE .. ' LOCATION: H/O DAME: r ' CONTRACTOR NAME: Type of Permit or License: (Check box) Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dunrpster $ ❑ Food Service-Type:____ $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid'Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Reports( a $ ❑ Other:(Indicate)— $ HeaIthAgent Initials White-Applicant Yellow-Health Pink- Treasurer