Loading...
HomeMy WebLinkAbout- Title V Inspection Report - 94 WINDKIST FARM ROAD 11/26/2018 Commonwealth of Massachusetts % �y Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� "� 41 x„eW 94 Windkist Farm Road t ` Property Address Hillary McCarragher Owner Owner's Name information is North Andover MA 01845 11-8-2018 required for every _...._...._ �_�____..._. ...___..�...._.____...._ page. City/Town State Zip Code Crate 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. Importgnt:When A. Inspector Information filling out forms on the computer, use only the tab Neil James Bateson key to move your Name of Inspector __._...._m_.....__._. ._. .... cursor-do not Bateson Enterprises Inc. usethe return -- _....._. ., .._._,,,,.,._ ......................... .. ..... . _.. ,.... _ _..... _ _._..,...,,....__.. key.. Company Name 111 Argilla Road rad Company Address Andover MA 01810 City/Town State Zip Code reran °s``4= 978-4754786 S115 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. ❑ Fails i ---' 11-8-201 s Insp t 's S gnature 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.712612D18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts =�~���0�� �� ��^���=�����N 0����������������� �������� ' � N���� �� ��/� � �����mN �mw�����~���0��nm N-��mmm � Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments 04VVindkiet Farm Road -�5-r-operty Address Hillary MnCarme h r Owner Owners Name |nfonna8o»|»required for every North Andover MA O184� 11-8-2018 �_ page. ~'y''~`~' �� Zip Code D C, Inspection Summary Inspection Summary: Complete 1. 2. 3. or5 and all of4 and 0. 1) System Passes: �U | have not found any information which indicates that any of the failure criteria described in 310 CK8R 15.303 or in 310 CK4R 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2> System Conditionally Passes: �l 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 detarmined,'' 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 in structurally sound, not leaking and if Certificate of Compliance indicating that the tank is less than 2O years old isavailable. El Y 0 N n ND (Explain be|ovv : � Commonwealth mfMassachusetts ^ Title =tl 5 Official Inspection Form Subsurface Sevmm8mDisposal SystemmForrn - NotK»rVo|untaryAe�os�m�n�e 84VNndkiot Farm Rood -- Hillary K8 C her ownmr owne~mmmmv information is required for every North Andover MA 01845 11'8-2018 page, ~'v''`'~' State —' Code __' of Inspection C' Unspect'on Summary (cont.) 2) System Conditionally Passes (oont): * Pump Chamber pumps/alarms not operational. Svabam will pass with Board of Health approval if ' punnps/a|armnana repaired. * Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(a) or due to a brnhen, settled or uneven distribution box. System will pass inspection if(with approval of Board mfHea|th): El broken pipe(a) are replaced El Y F1 N n ND (Explain below): Fl obstruction iaremoved El Y El N Fl ND (Explain be|ovv : �l distribution box is leveled or replaced F] Y F-1 N F-1 NO (Explain below): � F1 The system required pumping more than 4 times a year due to broken or obstructed 9ipe(s). The system will pass inspection if(with approval of the Board ofHea|th): Fl broken pipe(s) are replaced El Y 0 N El NO (Explain below): � obstruction is removed El Y El N Fl ND (Explain be|Vw): 3\ Further Evaluation is Required bm the Board ofHealth: [] 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. m. System will pass unless Board of Health determines im accordance with 31OCK0R 15.303(1)(b)that the system |m not functioning ina manner which will protect public health, safety and the environment: Commonwealth of Massachusetts ��°/�N�� �� ��^���~�����0 0������������~���� �����Q�� ' NN�N�� �� ��/N � ���N��0 Inspection 0-��� p �w Subsurface Sewage Disposal System Form 'Not for Voluntary Assessments Q4VVindhist Farm Road Property Address Hillary K8cCorro hr Owner 0wne/aNamo infomoouinnin ��� North Andover [NA Oi845 11-8-2018 �quimdfo/evn� ��� � PmQo. ~^/''~~'' Z- - Inspection C. Inspection Summary (cODf] [| Cesspool or privy ka within 5O feet ofe surface water Fl 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 isfunctioning in a manner that protects the public health, safety and environment: Fl The system has a septic tank and soil absorption system (SAS) and the SAS is within 1OO feet[fa surface water supply ur tributary toa surface water supply. The system has a septic tank and SAS and the SAS is within u Zone 1 of public water supply. n The system has a septic tank and SAS and the SAS is within 50 feet ofm private water supply well. |l The system has e septic tank and SAG and the SAS is |eeo than 100 feet but5O feet or more from a private water supply vve||°°. Method used to determine distance: ^°This system passes if the well water analysis, performed ata 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 ba attached to this form. o. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"Nm''bo each of the following for all inspections: Yea No �l Backup of sewage into f8CUityor system connpVneDt due toovedoodedor �� �� clogged SAS orcesspool Discharge or ponding of effluent to the surface of the ground or surface waters due hnan overloaded or clogged SAS orcesspool te/nsp.uoe'rev.na612n10 Title e Official Inspection Form:Subsurface Sewage Disposal System'Page 4mm Commonwealth of Massachusetts ��°��N�� �� ��.���~��~��N 0������������~���� ����N�N1K� ^ � � �N�� �� �°�� N ��r���0 Inspection 0—��mmmn Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94VVindkist Farm Road Preperty Address Hillary K8C b mwner Owner's Name information is required for every North Andover MA 01845 11-8-2018 page. ~'v''~`~' ��_ —, __- ---of Inspection' _ C. Inspection Summary (cont.) 4) System Failure Criteria Applicable tmAll : (cont.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS orcesspool El F� Liquid depth in cesspool im less than 6" ba|ovvinve�oravei|oNe volume ieless �� �� than 1/2duyf|ow F� �� Required pumping nnorethan 4tirneein the last year 8kDTdue to clogged or �� �� obstructed p|pe(s). Number nftimes pumped: ____. El 0 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 hza surface water supply. Any portion of cesspool or privy is within o Zone 1 of public water supply well. El M Any portion of a cesspool or privy is within 50 feet of a private water supply well. El N 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 |f the well water analysis, performed ataDEP certified laboratory,for fecal om|ifurmm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppnn' provided that nw other failure criteria are triggered. A copy mfthe analysis and chain wf custody must heattached to this fmrnm.] E-1 �� Thesyatemieaceaspoo| aan/inOafaoi|ih/vvithadesiQnf|ovvnf20OOgpd- �� 1O.ODOgpd. �l C� The wystmmof*dm. | have determined that one or more uf the above failure �� �� criteria exist am described in 310 CK4R 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: Tobe considered m large system the system must serve a facility with a design flow of1O,0Q0 gpdbm15,08OQpd. 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 El the system is within 400 feet ofa surface drinking water supply Fl El the system is within 200 feet ofa tributary to o surface drinking water supply �l �� the system ia located inandrogenugneiUve area UnterimVVe||headProtection �� �� Area—|VVPA) Ora mapped Zone |i of public water supply well mn°p.uon'rev.»zoumo wu°s Official Inspection Form:Subsurface Sewage Disposal System'Page o"/,o � Commonwealth of Massachusetts =, Title 5 Official Inspection Farm mm n Subsurface Sewage Disposal System Form Not for Voluntary Assessments 94 Windkist Farm Road Property Address Hilla Oc ra_ hg er _ Owner Owner's Name information is required for every North Andover MA 01845 11-8-2018 page Cltyrrown State Zip Code Date of Inspection C. Inspection Summary (cant.) i 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 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? M 0 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? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® © Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] { t5insp.doe•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts ,T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 94 Windkist Farm Road Property Address Hillary McCarragher Owner Owner's Name information is North Andover MA 01845 11-8-2018 required for every ._l n_ _.__... ......... — _ page ctyffow State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions. Number of bedrooms (design): NIA Number of bedrooms (actual): -5-._.___ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: _.._.___-- __._.__._._. _...._ ...-----_..r._._-------..---..__. ._ Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? © Yes ❑ No Seasonal use? ❑ Yes Z No Water meter readings, if available last 2 ears usage d _Yes--— 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts T Tide 5 0fficial Inspeci n Farm - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'c r� 94 Windkist Farm Road Property Address Hillary McCarra her ' Owner Owner's Name f information is North Andover MA 01845 11-8-2018 required for every __..._ _..__ _ _._— ..._._— _..__,__ — .....__„�, — page City/Town State Zip Code hate 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 ❑ 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? F1 Yes ❑ No Water meter readings, if available; _..._..... __._.._nw.......— Last date of occupancy/use: -Dat ._­.__­­__­­ 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 Howwas quantity pumped determined? --..............._....._,_.._...._..------------_- -------------_._..__._..._,__.._.,_...__._..m.._ _._._...._.__...___._.,,..._._..... Reason for pumping; t5insp,doe rev.7128f2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 � Commonwealth of Massachusetts Title�����N�� �� ��`���°�����N 0������������~���� �������N �� ��y� N0��N�mN Nmw���������N��mm Form Subsurface Sexnmge ��imposalSystenmForrn -NothJrVu|unt�ryAnaomornan(o Q4VVindhiet Farm Road HiU K0cCarrs her Ownor Owner's Name information ia required for every North Andover MA 01845 11-8-2O18 state _ Zip Code Date of Inspection page- ~.^,.^~,.. D. System Information (cont.) 4. Type of System: E Septic tank, distribution box, soil absorption system [| Single cesspool Fl Overflow cesspool [] privy � Shared system (yes or no) (if yes, attach previous inspection records, if any) Fl 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 |64 system by system operator under contract Tight tank. Attach a copy of the DEPapproval. F� Other(describe): Approximate age of all components, date installed (if known) and source of information: 29 |d 6241098 certificatenf compliance atB (} H Were sewage odors detected when arriving ot the site? Yes El No 5. Building Sewer(locate on site plan): Depth below grade: feet Material ofconstruction: El cast iron El 40 PVC El other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): Finished cellar, unable tO see piping leaving foundation. t5insp,doe-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposat System-Page 9 of 18 Commonwealth of Massachusetts x � Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Windkist Farm Road Property Address Hillary McCarragher Owner owner's Name information is North Andover MA 01845 11-8-2018 required for every w..._. . .._._._— �._...__ _...._-. ......_ page CltylTown State Zip Code Date of Inspection D. System Information (cant.) 6. Septic Tank(locate on site plan): 2 Depth below grade: feet _...,.....--- —.__.__..... -.------. 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: 29"' Distance from top of sludge to bottom of outlet tee or baffle 4" Scum thickness _._.........._.__ __._.....____ 8" Distance from top of scum to top of outlet tee or baffle _-_-.._ _.......______... 11'" Distance from bottom of scum to bottom of outlet tee or baffle — --.._....__.. _... -----_----------- __—.._..... 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. —— —_ - ----- ........_...__..n .w....w.. _... _ .._.._...._._ t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 x�^ Co[�monnvealth of Mamsachusefts ' Tit�������� �� ��^4��������0 N��������^�4�~���� �������� le �� �°�� 0 ���N��N N� m���������N��mm Form Subsurface SwvxegeOispPsa| SymtemnForrn -NotforVo|unbaryAasemsments Q4VVindkimt Farm Road Property Address Hillary M Carna h r Owner Owne(oNmme --- information is North Andover [NA 01845 11-8-2018 required for every State__ Zip Code Date of Inspection page. ~''''~'~' D. System Information (cont.) 7. Grease Trap(locate on site p|un\: Depth below grade: Material 0fconstruction: El concrete El metal Elfiberg|mss Flpolyethylene other(explain): Dimensions: Scum thickness Distance from top uf scum to top Vf outlet tee orbaffle Distance from bottom of scum bo bottom nf outlet tee orbaffle Date nf last pumping: Cmnnments (onpumpingnacomnmendat|onm. in|e(andout|etbaeorbaff|eoondition, struotuna) integrity. liquid levels as related to outlet invert, evidence ofleakage, etc.): O. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan)� Depth below grade: � Material ofconstruction: � El concrete Flmetal Rfibarglamo El polyethylene other(explain): Dimensions: ----------- Design Flow: Commonwealth of Massachusetts l Title 5 Official Inspection Form -: Subsurface Sewage Disposal System Form Not for Voluntary Assessments z, ❑ 94 Windkist Farm Road Property Address Hillary McCarragher �w __.__ _ --._ _._.__.—..._ Owner Owners Name information is North Andover MA 01845 11-8-2018 required for every .. —... _... �.r.. page Cltyrrown State Zip Code Date of Inspection D. System Information (cant.) 8. Tight or Holding Tank(coat.) 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.): D-box level & distribution equal. No evidence of leakage. Evidence of light carryover. t5insp.doc rev.7126/2018 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts x � Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Windkist Farm Road Proper#y Address H illary,--McCarrag her Owner Owners 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.) 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: ___.—.....-..-_. ® leaching fields number, dimensions: _1 field 20'x 45' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — -- I Wnsp,doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts 27' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 94 Windkist Farm Road Property Address Hillary_A AcCa��ra�jh r Owner Owner's Name information is North Andover MA 01845 11-8-2018 required for every -—--------- State Zip Code Date of Inspection page. biymo—wn 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 El Yes El No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form . .......... Subsurface Sewage Disposal System Form Not for Voluntary Assessments 94 Windkist Farm Road ---------- Property Address Hillary_M_qqarra�qher Owner Owner's Name information is North Andover MA 01845 11-8-2018 required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of poncling, condition of vegetation, etc.): t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection or x 4 = Subsurface Sewage Disposal System Form - Not for Voluntary Assessments z 94 Windkist Farm Road Property Address Hillary McCarragher 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 (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 w J ` ` S(,, Nc H k3sc a 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage disposal System I Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 94 Windkist Farm Road --------- Property Hillary PilcCa�T_qher,,___.._ Owner Owner's Name information is required for every North And MA 01845 11-8-2018 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 5-12-1 If checked, date of design plan reviewed: Date 997 E] Observed site (abutting property/observation hole within 150 feet of SAS) El Checked with local Board of Health -explain: F-1 Checked with local excavators, installers -(attach documentation) El Accessed USGS database-explain: .......... You must describe how you established the high ground water elevation: As per test pit data. ... .................. ------ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5irisp.doG-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-flags 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 94 Windkist Farm Road Property Aid"res_`s__­ Hillar_yl\,cCarraaher Owner Owners Name information is North Andover MA 01845 11-8-2018 required for every page. 67ii-yfTown 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 Town nf North Andover Tax Map # 210-109,0-0057-0000,0 . Parcel [d1O874 94V0NDN]ST FARM ROAD BRENA0 & H|LARYK8CBARRAGHER 94WINDK|ST FARM ROAD NORTH ANDOVER. KOA01845 class 101 Single Family Property Type 1 Residential Zon|ngo 1Rooidnnho| ZoninA3 1RenidanUo| Size Total 1.41 Acres FY 2019 UB Mailing Index Name/Address Type Loan Number Activo |neut. From VutU BnENAN&H|LARYMCGARRAGUER Owner xcuve 94VV|NnK|ST FARM ROAD NORTHANDDVER. MAO1a4s oEMA0. FRANK& p4UL|NE Previous Customer Inactive 12/15/2008 94VV|NDK|ST FARM gD NORTH ANDOVsR. Mx 01845 DEUTSCHE BANK NATIONAL TRUST C Previous Customer Inactive 1/28/2010 OOD EAST WALNUT STREET PAGADENA. CA91101 Account No - Cycle Occupant Name Active/Inactive Bldg |d� 13771O 94VV|NDK|ST FARM ROAD Last Billing Date 11/Omn10 1090450 01 Cycle 01 Active � Account No. 1090450 Service Code Rate Charge Mv|dpUmr/Uvwm M|SCFEEADM|NFEE 11 9]8 U vvTRVVKTER Q1 ALL METER SIZE 57.00 � UB Meter Maintenance Account No. 1090450 Serial No Status Location Brand Type Size vTDcvns 32$4$522 amctive ooERTHn beod3m w Water 1 1 1839 Date naadmV unoo Consumption Posted Date Variance 10/2312018 17*5 axutua| 15 11/19/2018 'zO% 7/19/201e 1730 mxnma| 18 8/15/2018 GO% */18/2018 1712 eAoma| 11 5/17/201e '6Y6 1/18/2018 1701 wActuo| 12 2/20/2018 -60% 10/18/2017 1688 oAmum| no 11/13/2017 xo% 7/19o817 1659 axmua| 24 8/15/2017 197% 4/1912017 1655 wActua| 8 5/17/2017 '48% 1/19/2017 1627 oAmue| 16 2/16/2017 -57% 10/19/2018 1611 uxoma| 36 11/16/2010 'azm 7/22/20 s 1575 aAomal 54 8M6/2016 440% 4/22/2016 1521 uxutuu[ 10 5/25/2816 -6*% 1/22/2016 1511 n&ctum| 29 2/19/2016 48m 10o2o015 1482 nActuao o* 11/202015 7396 7/24/2015 1427 a8doa| 31 8/14x2015 92% 4/27/2015 1390 oActue| 10 5/19/2015 M% 1/30/2015 1380 aActua| 17 2/20/2015 '*2% 10/24/2014 1308 aAdua| o 11/14/2014 '9% 7125/2014 1338 a8mua| oD 8/13m014 77% 4/24/2014 1306 aActua| 16 5/1512014 '7% 1/27/2014 1280 uAmmu| 19 2/14/2014 -27}6 102312013 1271 aActua| 25 11n8/2013 '36% 7123/2013 1246 uAcmm| 38 8n5/2013 79m Commonwealth of Massachusetts • City/Town of W° System Pumping Record Farm 4 DEP has provided this form for use-by 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. Facility Information 1. System Location: Left/Right front of house, Left I Right rear of house, Left/Oht side of hour eft I Right side of building, Left/Right front of building, Left/Right rear of building, Un erk Address Cityrrown State Zip Code 2. System Owner: Name' Address Of different from location) City/Town Stater Cp Code Telephone Number B. Pumping Keeord 1. Date of Pumping oat 2. Quantity Pumped: Gallons / a ns 3. Type-of system: ElCesspool(s) [.(],..Sept cc Tank ❑ Tight Tanis [] Other(describe): 4. Effluent Tee Filter present? [] Yes o if yes, was it cleaned? [] Yes ❑ No 5. Condition of System: v , C S. System Pumped By: Neil.Bates7on F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. Lo fiop-W er` contents-were disposed: C L a. Lowell Waste Water Sign a Hi3ule Date t5fbrm4.doc•06103 System pumping Record•page 1 of 1 � 4 Town o North Andover HEALTH DEPARTMENT CHECK#: DATE: CONTRACTOR NAME: Type of Permit or License: (Check box) • Body Art Establishment • Body Art 111ractitioner 0 Food Service- 0 Funeral Directors • Massage Practice • Offal(Septic)Hauler • Recreational Camp • Sun tanning • Swimming Pool 0 Tobacco __ --_.,- —d Waste Hauler � � u Well Construction SEP77C Systems: * Septic-Design Approval * Septic Disposal Works Construction(DW0 * Septic Disposal Works Installers(DWI) [3 Title 5 Inspector Title 5 Report ~~-----~m-- -''-- Applicant Yellow-Health Pink--Treasurer | �