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Home My WebLink About- Title V Inspection Report - 42 WINDKIST FARM ROAD 11/26/2018 ^ ' Commonwealth _- Massachusetts , Title 5 Official Inspection . o~ ~ ~ ~Subsurface Sewage Disposal System Form Not for Voluntary Assessments c� Brian �p 42 Windkist Farm Road Property Address Owner Owner's Name information is North Andover MAO184� �1-9-2018 age. mqu|nudoorove� S��—�' 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 mf the form. Important:When A. UK��0�«�� UKD�^��-��U� hUio0out forms ^ ^~ ^Inspector Information ~^ on the computer, use only the tab Neil James Bateoon keymmovvyn"r Name ofInspector cursor'uvnot Bat Bateson Enterprises Inc. use the return Name ^oy� Company 111 Argilla Road -Q Company Address Andover yWA 01810 ------------ City/Town State Zip Code 978-4754786 S115 Telephone Number License Number B. Certification | certify that: \ ammmQEpapproved system inspector in full compliance with Section 15.340of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below ia true, accurate and complete aoof the time ofnny 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. El Needs Further Evaluation by the Local Approving Authority 4. Fl Fails L 11-0-2O18 Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health orOEP) within 3O days of completing this inspection. |fthe system has a design flow of 18.00Ogpdor greater, the inspector and the system ownershall submit dhereportto{heappropriate regional office of the DER The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ' Please note: This report only describes conditions mt the time mf inspection and under the conditions ofuse at that time.This inspection does not address how the system will perform |n the future under the same nr different conditions mfuse. w""n.uoc'rev.rovou,n "Title 5 Official/"sp°"u"v Form:Subsurface Sewage Disposal System'Page,",p ^ Commonwealth of Massachusetts ~��N �� Official N Inspection �� Title N��N�� N�� V 0 �0 �� =, � mm Form ' � �� m�*�� ww ��°�� m�� ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42VVindkist Farm Road ---- Property Address Brian Lucy Owner Owner's Name information is North Andover MAU184� 11 92 1 ,oqoimdh`r�we� ` S��-- omoo,|nypaobon page. City/Town -,--- ' C. Inspection Summary Inspection Summary: Complete 1. 2. 3. or5 and all of4 and G. 1} System Passes: �3 I have not found any information which indicates that any of the failure criteria described in31OCK8R15.3O3urin31DCW1R15.3O4 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. Theayshem, uponcomplebunofthenap|aoemantorrepair, meappnovodby the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not datmnnined.^ 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 2O years old in available. �l y N Fl ND (Explain be|om/): c Commonwealth of Massachusetts Title 5 Official Inspection Form - n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t % 42 Windkist Farm Road .._.,..--- 15raperty Address Owner Brian Lucy_..__._,.. _,...... .-_-- Owner's Name information is North Andover MA 01845 11-9-2018 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 pipes)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: ❑ 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: t5insp.doc•rev.712612018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - mm 42 Windkist Farm Road Property Address Brian Lucy _ Owner __� _..__ . ........_..... __. __. ._........_ i Owners Dame information is North Andover MA 01845 11-9-2018 requiredfor every ._.......__ .__.__..._.__ .__.—. ..___.....__...._... _.� ._...._..._. .... page, Cityffown State Zip Code Date of Inspection C. Inspection Summary (cunt.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. El The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: —...... ..._..---- ---...._ _.. 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp.doc-rev,7/26/2018 `ride 5 official Inspection Form:subsurface sewage disposal System•Page 4 of 18 Commonwealth of Massachusetts �u~� =�'��N�� ^��N ��-=�� 1�\ . � � �� o� � �� Inspection �-��mmmm ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42VVindNnt Farm Road Property Address 8ri�nLuc Owner Owner's Name information is required for every North Andover lMA -- U1845 11820 1- page. State Zip Date oyInspection C. Inspection Summary (cont.) 4} System Failure Criteria Applicable to All Systems: (cont.) ' Yes No [l �� Static liquid level |nthe d|othbutionbox above ouUotinve�due toanovedoeded �� nr clogged SAS orcesspool [l �� Liquid depth in cesspool ie less than 8" below invedor available vo|umneinless �� than 1/2day flow � l �� Required pUDnpingnoorethan 4 times in the last year/VC>Tdue to clogged Vr �� obstructed pipe(n). Number nftimes pumped: El 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. �l �8 Any Vn�innof cesspool or privy isvvithin1OO feet ofaou�ace water supply or �� tributary tom surface water supply. El �� Any podionnfa cesspool or privy im within a Zone 1Vfm public vvatersupply �� well. El 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. Fl �� Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet � from u private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed mt aDEPcertified laboratory,for fecal cmOformmbacteria indicates absent and the presence mf ammonia nitrogen and nitrate nitrogen {s equal tmor less than 5ppmm, provided that no other failure criteria are triggered. ^4 copy ofthe analysis and chain of custody must be attached to this formn.] �� Theaynhamismcesspoo| uen/ingotaui|ih/w\thadosignf|ovvof20OOQpd- �� 10.000Qpd. The system fails. | 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 tm determine what will be necessary to correct the failure. S) Large Systems: Tobe considered mlarge system the system must serve a facility with a design flow mf1O,0000pdbo 15,000gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions |n Section CA. Yes No E-1 El the system io within 4OO feet ofm surface drinking water supply El Fl the system is within 200 feet of a tributary to a surface drinking water supply [l �� the system ia located inanihogenuenoidve area (|nterinoVVe||headProteoUon �� ^ Area-\VVPA) orm mapped Zone || ofa public water supply well mn,pu""'rev.nz61mw rwion^mm"/inspection Form:Subsurface Sewage Disposal System'Page nw,v Commonwealth of Massachusetts Tide 5 Official Inspection Farm r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments R 42 Windkist Farm Road f Property Address Brian Lucy Owner Owner's Name information is required for every ...North Andover MA 01845 11-9-2018 . --__...__. _ _.. 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. 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 Q ® 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? ® Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® (❑ 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.doc-rov,7126/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•k'ape 6 of 18 Commonwealth of Massachusetts ............. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 42 Windkist Farm Road Property Address Brian Lucy Owner Owner's Name information is North Andover MA 01845 11-9-2018 required for every page. CityfTown 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 CIVIR 15,203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: Does residence have a garbage grinder? El Yes E No Does residence have a water treatment unit? El Yes E No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes 0 No information in this report.) Laundry system inspected? ❑ Yes F No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail:. Sump pump? E] Yes E No Current Last date of occupancy: t5insp,doc-rev.7/2612018 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 42 Windkist Farm Road ............ Property Address Brian Lucy Owner Owner's Name information is required for every North Andover MA 01845 11-9-2018 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): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? El Yes El No Water treatment unit present? El Yes EJ Pilo If yes, discharges to: Industrial waste holding tank present? ❑ Yes n No Non-sanitary waste discharged to the Title 5 system? El Yes E] No Water meter readings, if available: -__-®_a_._ __ ----------- Last date of occupancy/use: Date Other(describe below): .......... .......... .......... .............. 3. Pumping Records: Source of information: Pumped 2014, owner----, Was system pumped as part of the inspection? n Yes Z No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: (5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Far Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - ' 42 Windkist Farm Road Property Address Brian Lucy Owner Owner's Nam e information is required for every North Andover MA 01845 11-9-201$ .._....__ page, Cltyfrown State Zip Code Date of Inspection D. System Information (cant.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ 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 I/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: 19 gears old, $-19-1999, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1.4 Depth below grade: feet -- Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): _.._— Distance from private water supply well or suction line: feet _.-. _-._-_ i Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall to septic tank. 3" PVC in house, no leaks visible l5iosp.doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts lr WUP ^ 'p Title 5 Official Inspection Fear 4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments -� 42 Windkist Farm Road J Property Address Brian Lucy .._.._....m _....._.... _ Owner Owner's Name information is North Andover MA 01845 11-5-2018 required far every - _..._....._......__..__. � .__. page, City/Town State Zip Code C7ate_of inspection D. System Information (cant.) 6. Septic Tank (locate on site plan): 0.4 Depth below grade: 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 E-1 No Dimensions: 10' x 5' x 4' 4" Sludge depth: — _......... _. - — Distance from top of sludge to bottom of outlet tee or baffle 2 4" Scum thickness 811 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. I I t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage uisposal System-Page 10 of 18 Commonwealth of Massachusetts 4 ❑�2 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 42 Windkist Farm Road ........... Property Address Brian Lucy Owner Owner's Name information is North Andover MA 01845 11-9-2018 required for every --- page. City/Town State----,- Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: Material of construction: El concrete El metal n fiberglass E] 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: -bate 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: E] concrete El metal E] fiberglass El polyethylene El other(explain): Dimensions: Capacity: -�a—llons-- Design Flow: gallons per day 15insp,doc rev.712612018 'Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Far - subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Windkist Farm Road Property Address Brian Luc Owner Owner's Name information is t required for every North Andover MA 01845 11-9-2018 page. CdylTown Skate Zip Cade Date of Inspection D. System Information (cant.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes El No Alarm level: — —.-._._._----- ...._....._ Alarm in working order: ❑ Yes ® No Date of last pumping: Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes F1 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 carryover. D-box cover broken, replaced same. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 12 of 18 Commonwealth of Massachusetts 7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 42 Windkist Farm Road ------------------ —----- Property Address Brian Lucy Owner Owner's Narne information is required for every North Andover MA 01845 11-9-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: El Yes El No* Alarms in working order: El Yes E] 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: El leaching pits number: El leaching chambers number: n leaching galleries number: E leaching trenches number, length: 2 trenches 62' n leaching fields number, dimensions: n overflow cesspool number: E-1 innovative/alternative system Type/name of technology: 15insp.dDr•rev.MW2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Pago 13 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 42 Windkist Farm Road ------------------- Property Address Brian Lucy Owner Owner's Name information is required for every North Andover MA 01845 11-9-2018 page. Cityfrown 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 EI Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ............ —-—--------- t5fnSp.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 42 Windkist Farm Road . __._ _._____._.aw_..w Property Address Brian Luc Owner y .._....... ....__._.. Owner's Name _.._.—. information is North.Andover MA 01845 11-9-2018 requiredfor avert' �.. _.�..._......_�._ __,__.__ .....__— _._.. ....._......_.__...._... page. Cttyffawn State Zip Cade Date of Inspection _....D. System Information (cunt.) 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 1itle s ofriciai inspection Form Subsurface Sewage oisposai System•Page 15 of 18 Commonwealth of Massachusetts F Title 5 0"Wicial Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 42 Windkist Farm Road Property Address Brian_Luc -------- Owner Owner's Name information is required for every North Andover MA 01845 11-9-2018 page. CityrTown 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: M hand-sketch in the area below E] drawing attached separately Ftlj C) Ilk C)'�>O/ 7) 0 vevil t5insp.doc-rev.7/2612018 Title 6 official inspeGlion Form;Subsurface Sewage Disposal System-Page 16 of is m Commonwealth of Massachusetts 3� Title Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Windkist Farm Road Property Address Brian Lucy Owner _,,...___..__...__._._,..._..,_......_-- -- ----------- Owner's Name information is required for every North Andover MA 01845 11-9-2018 f page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 15. Site Exam: ® Check Slope Surface water Check cellar ® Shallow wells 4 ..... .. _..._ Estimated depth to high group 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: 5-13-1997 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. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc+rev,712612018 Title 5 Official Inspection Corm:Subsurface Sewage Disposal System•Pago 17 of 18 Commonwealth of Massachusetts - ------ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Windkist Farm Road Property Address ------- Brian-Lucy Owner Owner's Name information is required for every North Andover MA 01845 11-9-2018 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 15insp.doo-rev,712612016 Title 5 Official Inspection Form Subsurface Sewage Disposal System-page 18 of 18 Town of North Andover Tax Map # 210-109.0-0061-0000.0 Parcel Id 18878 42 WINDKIST FARM ROAD LUCY, BRIAN & SUSAN 42 WINDKIST FARM ROAD NORTH ANDOVER, MA 01845 —----------Class 101 Single Family Property Type 1 Residential Zonin92 1 Residential Zonjng3 1 Residential Size Total 1.01 Acres IFY 2019 UB Mailing Index Name/Address Type Loan Number Active/Inact, From Until LUCY, BRIAN&SUSAN Payor Active 42 WINDKIST FARM ROAD NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name AGtivelinactive Bldg Id. 13795.0-42 WINDKIST FARM ROAD Last Billing Date 11/6/2018 1090471 01 Cycle 01 Active UB Services Maint. Account No. 1090471 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 418.18 /1 UB Meter Maintenance Account No. 1090471 Serial No Status Location Brand Type Size YTD Cons 32948539 a Active 00 b Badger w Water 1 1 2461 Date Reading Code Consumption Posted Date Variance 10/23/2018 2759 a Actual 82 11/19/2018 -2% 7/19/2018 2677 a Actual 80 8/15/2018 459% 4/18/2018 2597 a Actual 14 5/17/2018 -16% 1/18/2018 2583 a Actual 17 2/20/2018 110% 1011812017 2566 a Actual 8 11/13/2017 -38% 7/19/2017 2558 a Actual 13 8/15/2017 -8% 4119/2017 2545 a Actual 14 5/17/2017 -25% 1/19/2017 2531 a Actual 19 2/16/2017 -77% 10/19/2016 2512 a Actual 80 11/16/2016 -32% 7/22/2016 2432 a Actual 121 8/16/2016 290% 4122/2016 2311 a Actual 131 5125/2016 1% 1/22/2016 2280 a Actual 31 2/19/2016 -75% 10/22/2015 2249 a Actual 120 11/20/2015 .13% 7124/2015 2129 a Actual 135 8/14/2015 345% 4/27/2015 1994 a Actual 30 5/19/2015 -1% 1/30/2015 1964 a Actual 34 2/20/2015 -65% 10/24/2014 1930 a Actual 91 11/14/2014 16% 7/2512014 1839 a Actual 79 8/13/2014 133% 4/24/2014 1760 a Actual 32 5/15/2014 -2% 1/27/2014 1728 a Actual 36 2/14/2014 -72% 10/23/2013 1692 a Actual 123 11118/2013 63% 7/23/2013 1569 a Actual 74 8/15/2013 115% 4/24/2013 1495 a Actual 34 512012013 3% 1/25/2013 1461 a Actual 35 2/13/2013 -30% 10/23/2012 1426 a Actual 49 11/9/2012 -32% 7/23/2012 1377 a Actual 71 8/14/2012 109% 4/2312012 1306 a Actual 34 5/9/2012 3% 1/23/2012 1272 a Actual 33 2/13/2012 -43% 10/24/2011 1239 a Actual 60 11/14/2011 -32% Commonwealth of Massachusefts City/Town of w° System Pumping Record Foram 4 DEP has provided this form for use-by local Boards of Health. Other forms maybe`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 Inform' ation 1. System Location: Left fight ont of ilouse Left/Right rear of house, Left/right side of house, Left Right side of building, Left ig rout of building, Left/Right rear of building, Under deck Address L( City/Town State Zip Code 2. System Owner: Name. Address(if different from location) Cityfrown State Zip code Telephone Number .B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type-of system: ❑ Cesspool(s) O eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o I#yes, was it cleaned? C} Yes (l No 5. Condition of System: 6, System Pumped By: Nell.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Lo o` he a contents-were disposed: 4SIgn Lowell Waste Water aA. 1. c -c Hsu! Date t5farm4.doc-06/03 System Pumping Record•Page 1 of 1 n aft. .gtia i Town of Forth Andover ��"•a,,.a.�"�. HEALTH DEPAIITMENT AsxneMu%e� CHECK #. DATE H/O NAME; _ CONTRACTOR NAME: —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)Hauler $ ❑ Recreational Camp ❑ Sun tanning $. ❑ Swimming fool ❑ 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 ' $- ) ❑ Other:(Indicate)._ ____— $ -- R IHealfh'Agent Initials White-Applicant Fellow-health Pink Treasurer