The URL can be used to link to this page

Home My WebLink About- Title V Inspection Report - 90 LOST POND LANE 11/26/2018 L Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ❑ 90 Last Pond Road Property Address F � Julgit Kalkat Owner Owners Name information is North Andover MA 01845 11-8-2018 required for every __.._._ ...... _....__._ J page. CitylTown 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, Neil James Bateson use only the tab ...... key to move your Name of Inspector cursor-do not Bateson Enterprises Inc. use the return - _._. — _._..._..__ _.. ...,.._ key. Company Name 111 Argllla Road ,an Company Address Andover MA 01810 city/Town State Zip Code ,army 978-4754786 S 115 _..__.__. __---- -- ___.._._... _...._._... 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. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fail X R� L 11-8-2018 Ins ct is ignature 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. t5insp.doc rev,712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 , Commonwealth of Massachusetts =�"=��N �� Official 0 Inspection �� Title ��N�� 0�� 0°�� y@ � � �� 0—�� ' m �� m mm �� n�� Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80Loat Pond Road Ju| it Km|h8t Owner Own e/eNe Fri' -- information iu required for every North Andover MA 01845 11-8-2018 age. State— Zip Code Date of Inspection - C~ Inspection Summary Inspection Summary: Complete 1, 2. 3, nr5 and all of4 and 8. 1) System Passes: 1 have not found any information which indicates that any of the failure criteria described in310CPNR15.383orin31OCK8R15.304 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) iestructurally 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 Certificate of CO0p|ioDoa indicating that the tank is less than 20 years old is available. El Y n N El ND (Explain ba)mw): Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Lost Pond Road Property Address Julgit Kalkat _____......e._ ..____.._. _-------- Owner Owner's Name information is North Andover MA 01845 11-8-2018 required for every ....._.___ ....__-- _...__ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cant.) 2) System Conditionally Passes (cant.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: t ❑ 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: 15insp.doe-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Lost Pond Road Property Address Julgit 14alkat __._.... Owner Owner's game information is North Andover MA 01845 11-8-2018 required for every .-�..._ _......._. _..._._,__ __...__ _—. __._...__ ............._.._ page Cltyrrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) 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: ® 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 ❑l ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts f - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 90 Lost Pond Road Property Address Julgit Kalkat Owner owner's Name information is North Andover MA 01845 11-8-2018 required for every ._ .__.._ _w_.... _ ......_..._— �. ._.. �_..— _....� page. City/Town State Zip___Cod�e Date of Inspection C. Inspection Summary (cost.) 4) System Failure Criteria Applicable to All Systems: (cunt.) Yes No ❑ ® 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 '/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. ® E 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 CM 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. I 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 ❑ 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 � Commonwealth of Massachusetts ��N� � ��=�°�N N��~�� , � N�� y� � N��m� �mw��0�~mm N-�.mmmm Subsurface Sexxage [�imposmUSystenmFormn - No�forVV|�Ot�ry/\o��snDlont� SO Lost Pond Road . ..'~.,'~...~. Ju[ itKa|hut Owner Owner's Name inh'nnnVo»|»required for every North Andover MAO1845 11-8-2018 -- page. `'^''~`~' State Zip Code Date 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 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 GA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. O. You must indicate"yes" or"no" for each of the following for all inspections: Yes No E El Pumping information was provided by the owner, occupant, or Board of Health El Were any ofthe system components pumped out in the previous two weeks? 0 Fl Has the system received normal flows in the previous two week period? F7 �� Have large vo|unnexufvmtg[been introduced to the avetenmreoenUyoroSp8�rf �� " this inspection? �� VVereas built plans of the system obtained and examined? (If they were not �� available note oaN/A) • E-1 Was the facility or dwelling inspected for signs ofsewage back up? • El Was the site inspected for signs of break out? � • El Were all system components, excluding the SAS, located oDsite? • 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 ofscum? Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance Vfsubsurface sewage disposal systems? The size and location ofthe Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, e plan at the Board ofHealth. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance in unacceptable) [31OCK8R15.3O2(S)] m/np^wvo'rev.n/mum^ Title s Official Inspection rw=Subsurface Sewage Disposal System'Page owm Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 90 Lost Pond Road Property Address Julgit Kalkat Owner Owner's Name information is North Andover MA 01845 11-8-2018 required for every -- page. City/Town State Zip Code Date of Inspection 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: Number of current residents: 5 Does residence have a garbage grinder? Yes Na Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection F1 Yes E No information in this report.) Laundry system inspected? El Yes [:] No Seasonaluse? El Yes M No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: ........... Sump pump? ❑ Yes No Last date of occupancy: Current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts 4R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Lost Pond Road _......._.._...-.— Property Address Julgit Kalkat Owner Owner's Name information is North Andover MA 01845 11-8-2018 required for every page CltylTown 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 perday(gpd) Basis of design flow (seats/persons/sq.ft., etc.): ------ Grease trap present? ❑ Yes ❑ 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 ❑ Na Water meter readings, if available: _...._. _-- Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 2016, owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp,doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 8 of 18 Commonwealth of Massachusetts ��N�� `��N 0��*�� N�� . Title �� °�� m��0��mm 0-��mmmm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 0Q Lost Pond Road JulProperty Address git Ka|kat Owner Owner's Name information is �� mquimd�rm�� North Andover MAO1845 11-8-2018 - page. City/Townp Code Date of Inspection D. System Information (cont.) 4. Type of System: E Septic tank, distribution box, soil absorption system [] Single cesspool �l Overflow cesspool Fl Privy El Shared system (yes or no) (if yes, attach previous inspection records, if any) �l |nnovaUve/A|to[nativeteohno|ogy. Attach e copy of the current operation and maintenance contract(to be obtained from system owner) and a copy nflatest inspection of the |64 system by system operator under contract Tight tank. Attach a copy of the DEPapproval. F1 Other (describe): Approximate age of all components, date installed (if known) and source of information: 22 Years old, 6261998 as built plan Were sewage odors detected when arriving ai the site? El Yen M No 5� Building Sewer(locate on site plan): Depth below grade: - K8otahe| of construction: El cast iron H4DPVC El other(exp|ain): 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 hnk. 3" PVC in house, OO leaks visible Commonwealth of Massachusetts 6 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 90 Lost Pond Road Property Address .J.4.19't Kalkat ----—-------- Owner Owner's Name information is required for every North Andover MA 01845 11-8-2018 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: Z concrete n metal F-1 fiberglass ❑ polyethylene Fj other(explain) ----------- If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 0 Yes F1 No Dimensions: 10'x 5'x 4' Sludge depth: 4"__ " Distance from top of sludge to bottom of outlet tee or baffle 29 411 Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle ill, How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert, No evidence of leakage. ----------------------—------ ----------------- t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form 1? Subsurface Sewage Disposal System Form Not for Voluntary Assessments 90 Lost Pond Road Property Address Julgit Kalkat ............------------- Owner Owner's Name information is North Andover MA 01845 11-8-2018 required for every ----------........ page. City/Town State Zip Code Date of Inspection D. System Info (cont.) 7. Grease Trap (locate on site plan): Depth below grade: Material of construction: El concrete El metal El fiberglass El polyethylene F-1 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 F1 fiberglass 0 polyethylene F-1 other(explain): Dimensions: Capacity: ........ ................-------- gallons Design Flow: gallons per day t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts °��0� � �� 0�� N�� y� � �� mm��N��nm �-��m � � w Subsurface Sewage Disposu| SystemFormn - NotforVo|VntaryAooeaamentu QO Lost Pond Road Property Address Ju| itKa|kat Owner Owner's Name information is required for every North Andover MA 01845 11-8-2018 Code Date of Inspection page. city State Zip D. System Information (cont.) 8. Tight orHolding Tank (cont.) Alarm present: El Yes El No Alarm level: Alarm in working order: El Yon [l No Date of last pumping: Comment (condition of alarm and float switches, etcj: ------------- °/#hauh copy of current pumping contract (requirad). |n copy attached? [lYes [l No A. Distribution Box (if present must be opened) (locate on site p|on): Depth Cf 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 ur out of box, et .): 0-box level & distribution equal. No evidence of leakage. Evidence of carryover. D-boxonver broken, replaced same. t5insp.coc-rev,712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 � Commonwealth of Massachusetts �ti ❑ r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Lost Pond Road Property Address Julgit Kalkat Owner Owner's Name informrequired tion is North Andover MA 01845 11-8-2018 required for every .___.____._.._ �_.n_.__._.._,___—_._._._......__..._.. page, Cityffown State Zip Code Date of Inspection D. System Information (cant) 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 79' long ❑ leaching fields number, dimensions: _..............._.r.,,.._..___—__....._____-- ❑ overflow cesspool number: - ❑ innovative/alternative system Type/name of technology: _.._....... t5insp.doc•rev,7/2612018 'title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts it Title 5 Official Inspection Form Nh Subsurface Sewage Disposal System Form Not for Voluntary Assessments 90 Lost Pond Road Property Address Julgit Kalkat ...... Owner owner's Name information is required for every North Andover MA 0.1845 11-8-2018 page. iao—wn 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 ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.0cc-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 .............. 90 Lost Pond Road j5iop®rtyAdj'r-ess—, Julgit Kalkat Owner Owner's Name information is North Andover MA 01845 11-8-2018 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.): 15insp.doe-rev.712.612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form Not for Voluntary Assessments 90 Lost Pond Road Property Address Julgit"Ikat Owner Owner's Name information is North Andover MA 01845 11-8-2018 required for ever/ ---._.... _ _..�_ ..,.__ —_......_� page Cdyfrown _ State Zip Code {date of Inspection D. System Information (coat.) f 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 w. 3 � (0t l ILI r � tt t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ` 90 Lost Pond Road Property Address Julgit Kalkat Owner Owner's Name information i e North Andover MA 01845 11-8-2018 _.--- required far every _..._._ _._._. ---� _........___._..- page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 15. site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 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: 4-26-1995 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 data on design plan. ..._.. _ .__�..__.. __-..w_.__ .._..__.... _...... .._ ... ------------------------- .............. ........... -------------------......-...._........._._._..--._.___ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/2612018 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 90 Lost Pond Road.--- .......... Property Address— Jyj9it Kalkat Owner Owner's Name information is required for every North Andover MA 01845 11-8-2018 page. Cityrro-wn- 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.doo•rev.712612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Summary Record Card generated on 10125/2018 216:45 PM by Karen Hanlon rage i Town of North Andover Tax Map # 210-1043-0212-0000.0 Parcel Id 16514 90 LOST POND LANE KULJIT KAUR TARLOCHAN SINGH KALKAT 90 LOST POND LANE NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential ZonIng2 I Residential ZonIng3 I Residential Size Total 0.87 Acres FY 2019 UB Mailing Index Name/Address Type Loan Number ActivelInact. From Until KULJIT KAUR Owner Active TARLOCHAN SINGH KALKAT 90 LOST POND LANE NORTH ANDOVER MA 01845 GOLD,ALAN Previous Customer Inactive 6/30/2005 90 LOST POND LANE NORTH ANDOVER,MA 01845 M I RCEA IVAN Previous Customer Inactive 2/12/2009 90 LOST POND LANE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name AGtivelinactive Bldg Id. 17995.0-90 LOST POND LANE Last Billing Date 10/4/2018 3180024 03 Cycle 03 Active UB Services Maint. Account No.3180024 Service Code Rate Charge Multiplier/Users MISCIFEEADMIN FEE 0,635/8 7,82 1/ WTR WATER 01 ALL METER SIZE 685.35 /1 UB Meter Maintenance Account No. 3180024 Serial No Status Location Brand Type Size YTD Cons 13242430 a Active 00 METE METE w Water 0.630.63 1514 Date Reading Code Consumption Posted Date Variance 9/14/2018 2080 a Actual 130 10/15/2018 123% 6/12/2018 1950 a Actual 57 7/23/2018 84% 3/1212018 1893 a Actual 30 4/23/2018 33% 12/13/2017 1863 a Actual 23 1/25/2018 47% 9/13/2017 1840 a Actual 16 10/18/2017 -26% 6112/2017 1824 a Actual 22 7/25/2017 -18% 3/1012017 1802 a Actual 25 4/12/2017 44% 12/1212016 1777 a Actual 18 1/23/2017 -22% 9/12/2016 1759 a Actual 22 10/24/2016 20% 6/17/2016 1737 a Actual 20 8/2/2016 -20% 3/14/2016 1717 a Actual 24 4/22/2016 24% 12/14/2015 1693 a Actual 20 1/20/2016 -42% 9/11/2015 1673 a Actual 34 10/1612015 8% 6/11/2015 1639 a Actual 29 7/24/2015 44% 3/1812015 1610 a Actual 22 4128/2015 6% 12/15/2014 1588 a Actual 20 1/15/2015 -41% 9116/2014 1568 a Actual 36 10/15/2014 87% 6112/2014 1532 a Actual 18 7/16/2014 10% 3/14/2014 1514 a Actual 16 4/11/2014 -5% 12116/2013 1498 a Actual 18 1/17/2014 -27% p4aTbl oq{ 0 0 7pC Town of North Andover HEALTH DEPARTMENT CHECK DATE: // LOCATION: (I(Y. H/O NAMES ' : CONTRACTOR NAME: Type of Permit or License: (Check box) 0 Animal • Body Art Establishment • Body Art Practitioner $ EJ Dumpster $--- • Food Service- $ • Funeral Directors $— • Massage Establishnient $ • 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(DW0 $ • Septic Disposal Works Installers(DWI) $ • Title 5 Inspector $ Title 5 Report $ 0 Other. (Indicate)---,-- "'It '"Agent Initials White-Applicant Yellow-Health Pink-Treasurer