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HomeMy WebLinkAbout- Title V Inspection Report - 178 GRANVILLE LANE 11/29/2018 V-1411) co Commonwealth of Massachusetts PY Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 178 Granville Property- Address RyanMyers n __ye__- ------ ......... Owner Owner's Name information is required for every North Andover Ma 01845 11/12/2018 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Warren R. Pearce Jr. key to move your Name of Inspector 0 0, rs or-do not Pearce Construction cue key.the return Company Name �A 196 Park St Cam pan Address- _ North Reading MA ----_----_-- City/Town State Zip Code rsdian 978-664-5264 S11959 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 6 (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. F-1 Conditionally Passes 3. F-1 Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails -Inspecto r"'s"S"Sqnature Tate The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 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.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 19 Commonwealth of Massachusetts ' =�"°��@ �� Official � Inspection Form � Title N����� ���������� 0���� ��N�0�� � u ���� �� q��� Nm�� ��@ �mu�� � nm ���� nmm ' m ������ m�� m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178GramviUe Property Address Ryan KU Owner Owner's Mumm information is required for every North Andover Ma 01845 11/12/2018 page. C|$vTown State Zip Code Date nyInspection C. Inspection Summary Inspection Summary: Complete 1, 3, 3, or and all of and 8. 1) System Passes: | have not found any information vvh|nh indicates that any of the failure criteria described in 310CMR 15.383orin 310 CW1R 15.304exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: F-1 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 Heo|th, 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 bank is nneba| and over2O years old* or the septic tank (whether nneba| or not) is structurally uoaound, exhibits substantial infiltration orexfi|tration 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 Compliance indicating that the tank is less than 20 years old is available. �l Y N NO (Explain below): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 178 Granville ----------------- Property Address Ryan Myers Owner Owner's Name information is required for every North Andover Ma 01845 11/12/2018 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ 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): n broken pipe(s) are replaced El Y F1 N El ND (Explain below): El obstruction is removed n Y M N F-1 ND (Explain below): ❑ distribution box is leveled or replaced F-1 Y El N El ND (Explain below): -------------- F1 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): El broken pipe(s) are replaced 0 Y El N R ND (Explain below): ❑ obstruction is removed 0 Y n N F1 ND (Explain below): 3) Further Evaluation is Required by the Board of Health: EI 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.7/2612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 3 of 16 Commonwealth of Massachusetts Title 5 Off"Icial Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 178 Granville Property Address Ryan Myers Owner Owner's Name information is reqUired for every North Andover Ma 01845 11/12/2018 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) [I 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. El 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, n The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DIP 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ` �❑ 178 Granville Property Address Ryan,Myers Owner Own er-'sName information is required for every North Andover Ma 01845 11/12/2018 -—-------------- page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El Z Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or El M obstructed pipe(s). Number of times pumped: El M Any portion of the SAS, cesspool or privy is below high ground water elevation. El M Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El M 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. El 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 falls. I have determined that one or more of the above failure criteria exist as described in 310 CM R 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: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No El 0 the system is within 400 feet of a surface drinking water supply ❑ E] the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 16 Commonwealth of Massachusetts r_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ q 178 Granville Property Address Ryan Myers Owner Owner's Name information is North Andover Ma 01845 11/12/2018 required for every — w..w..... __ _.._ page. Cltylrawn State Zip Code Date of Inspection C. Inspection u ry (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 ❑ (� 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 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)] 15insp.doe•rev.7/2612018 Tille 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts - subsurface sewage Disposal System Form - Not for Voluntary Assessments 178 Granville Property Address Ryan Myers Owner Owner's Name information is required for every North Andover Ma 01845 11/12/2018 page. Cityfrown — State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3._ __--- ___........_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#k of bedrooms): 330 Description: Number of current residents: Does residence have a garbage grinder? Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: _. ..............._ __ ._._.._...... .._._.. 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 ® No Water meter readings, if available last 2 years usage d 100 GPD avg Detail: 9/7/2015 to 9/1 1/201 8 73,304 Gallons i Sump pump? ❑ Yes ® No Last date of occupancy: Current Date i i l5insp.doe-rev.712612018 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 178 Granville Property Address Ryan__Myers Owner Owner's Name information is required for every No A 01845 11/12/2018. rth Andover Ma page. City/Town 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? R Yes Ej No Water treatment unit present? 0 Yes E] No If yes, discharges to: Industrial waste holding tank present? El Yes F] No Non-sanitary waste discharged to the Title 5 system? R Yes F] No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): —---------__ —---------__--- ------------------ ........ —--——-----_------------------------------------- ................ 3. Pumping Records: Source of information: -Pumped in 2016 per the owner Was system pumped as part of the inspection? El Yes M 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments T 1 178 Granville Property Address Ryan Myers Owner Owner's Name information is North Andover Ma 01845 11/12/2018 required for every . ........____._. _...._____. _._. ..._. page. cityrrown State Zip Code Date of Inspection J D. System Information (cant.) 4. Type of System: Septic tank, distribution box, soil absorption system [l Single cesspool ❑ Overflow cesspool ❑ Privy ❑ 0 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: Installed in 1979 per BOH records, as built. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 511 Depth below grade: feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): — __...__. _ _......._.._.-._. Distance from private water supply well or suction line: — ---___ feet Comments (on condition of joints, venting, evidence of leakage, etc.), All appears In good shape Inside the house. t5insp.doc•rev.7/2612018 7itte 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts TWe 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 178 Granville Property Address Ry-an Myers .............. Owner Owner's Name information is North Andover Ma 01845 11/12/2018 required for every --------- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 4" Depth below grade: feet Material of construction: M concrete El metal El fiberglass ❑ polyethylene ❑ other (explain) -------------- ........... ---------------- ............. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes n No Dimensions: 6' by 10' by 4' deep, 1000 Gallon Sludge depth: 311 2111 Distance from top of sludge to bottom of outlet tee or baffle - -- Scum thickness Distance from top of scum to top of outlet tee or baffle 7" 14" 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 is OK. Outlet is PVC tee. Liquid is at the outlet invert, inlet is partialy submerged as the tank is not level. No evidence of leakage_Tank appears -goad shape. ----------- ---------- t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts ( Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments 178 Granville __----- -----------.- - --._ — ,._.,. Property Address RY an M e_.. y_....rs.......,_...... ... _.._. .,__,_ Owner Owner's Name information is North Andover Ma 01845 11/12/2018 requiredfor every _..._ w_.�......_.._�______ _....._..�_.__ ..._____...__.._ _....._� . page, Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7, Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene © other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: _......, Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): B. Tight or Molding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity, _ __.__ - ..._.._ _. ....... ,._ gallons Design Flow: _ _ ....... ___. gallons per day t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts J— T"tie 5 Officual Inspect"on Form M Subsurface Sewage Disposal System Form m Not for Voluntary Assessments 178 Granville Property Address Ryan Myers Owner Owner's Name information is required for every North Andover Ma— 0.1845 11/12/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: El Yes E] No Alarm level: Alarm in working order: El Yes E] No Date of last pumping: ........... Date Comments (condition of alarm and float switches, etc.): ............ ------------------- ----------- Attach copy of current pumping contract(required). Is copy attached? El Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert oil 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.): There are 3 distribution boxes. All appear to be working properly. All were recently replacd. There is no evidence of back up in any of the d-boxes. There are no solids in any of the d-boxes. There is no jeak -.-. ---------- in any of the boxes- .......... t5insp.doc•rev,7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _- Subsurface Sewage Disposal System Form Not for Voluntary Assessments 178 Granville .. ....... _....w_ Property Address Ryan M ers OwnerOwner's Name .__._...._.._..__.......____._._.....-._._-- -._.. _...____.._.__._. information is required for every North Andover Ma 01845 11/12/2018 ._....�......_ _... _.. __........ page. City/Town State zip Code Date of Inspection D. -.System Information (cant.) 10. Pump Chamber(locate on site plan); Pumps in working order: F-1 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: O 88' long ❑ leaching fields number, dimensions: --._._.._....._..m.._.._...w.�. ❑ overflow cesspool number: innovative/alternative system Type/name of technology: _._......_ _.-. t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts p Tftle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 178 Granville �roperty'A-­d`diress .................. Owner Owner's Name information is required for every North Andover Ma 01845 11/12/2018 page. City/Town 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.): There is no surface sign of problems and no evidence in the d-boxes of back up_._ 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 E-1 Yes R No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ------------- t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts 4w InspectionTitle 5 Official n Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 178 Granville _,........ _....__ __.. _ ........._ _...._ __..__... Property Address R an M ers y..._.. _..w........ Owner __...... Owner's fume information is Ma 01845 11/12/2018d North Andover required for every _......w_._ page. City/Town State Zip Code Date of Inspection D. System Information (cant.) �_ 1 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.): i t5insp.doc«rev.7126/2018 Titte 5 Official Inspection Farm:Subsurface Sewage Disposal System«Page 15 of 18 Commonwealth of Massachusetts T'tie 5 Off"Idal Inspection Form t Subsurface Sewage Disposal System Form Not for Voluntary Assessments 178 Granville Property Address Ryap,Mye,rs­,,,,__._ Owner Owner's Name information is required for every North Andover Ma 01845 11/12/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet, Locate where public water supply enters the building. Check one of the boxes below: H hand-sketch in the area below El drawing attached separately M'VA- 2_ pooy,;W I —D OOY3—75.S- 0 -T MQ it, 01.00/3 f 6-(?aeU.Q I(Aie I-A,"IT l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Fli T"Ve 5 Official Inspection Form VA Subsurface Sewage Disposal System Form Not for Voluntary Assessments 178 Granville Property Address Owner Owner's Name information is required for every North Andover Ma 01845 11/12/2018 page. dk�ffo—wn ­ "sit-a t—e "Z-i p -— Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope Surface water Check cellar Shallow wells 61 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 5/28/1 If checked, date of design plan reviewed: Date 976 Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Review files EJ Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: USGS maps You must describe how you established the high ground water elevation: Test hole data from the design plan dated 5/28/1976. Leach area was built up for proper separation to 2rounAwater, USGS maps indicate a water table >6' below grade. -—-------- ------------ Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doe-rev.7/2612018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts T"Itle 5 Officulal Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 178 Granville Property Address Ryan Myers OwnerOwner's Name information is North Andover Ma 01845 11/12/2018 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: E A, Inspector Information: Complete all fields in this section. M 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.doc-rev.7/2612018 rille 5 Official Inspection Form Subsurface Sewage Disposal System-Page 16 of 19 5urmary Record Card generated an 111191201e 9:04:56 AM by Karon Hanlon I'agr:1 Town of North Andover Tax Map # 210-100.Cw0076-0000.0 Parcel Id 17711 178 GRANVILLE LANE RYAN MY RS CHRISTINE SULLIVAN 178 GRANVILLE LAND NORTH ANDOVER MA 01845 rt Class 101 Single Family Property Type Zoni Zoning2 1 Residential g 1 Residen 3 1 Residential at Size Total 1.03 Acres FY 2019 Up Mail�� Name/Address Type Loan Number Active/Inact. From Until RYAN MYERS Owner r.li n CHRISTINE SULLIVAN 178 GRANVILLE LANE NORTH ANDOVER MA 01845 CINSERULI,JOSEP!i Previous Customer Inactive 1/13/2011 178 GRANVILLE LANE N.ANDOVER,MA ° 01845 MARC BOURASSA Previous Customer Inactive 8/30/2018 178 GRANVILLE LANE NORTH ANDOVER,MA 01845 UB Account Maint, Account No Cycle Occupant Name Active/Inactive Bldg Id. 17389.0-178 GRANVILLE LANE Last Billing Date 10/4/2018 3170059 03 Cycle 03 Active UB Services Maint, Account No.3170059 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE 3.80 11 UB Meter Maintenance Account No.3170059 Serial No Stators Location Brand Type Size YTD Cons 34644431 a Active ERT 1-114 b Badger w Water 0.63 0.63 567 � Date Reading Code Consumption Pasted Date Variance 9/11/2018 684 a Actual 1 10/15/2018 , a 8/22/2018 5133 f Final Bill 8 8/22/2018 �200 6/7/2018 575 aActual 10 7/23/2018 2oa 3/6/2018 565 aActual 12 4/23/2018 -194b 12/6/2017 553 aActual 13 1/25/2018 12% 2 1 9/11/2017 540 a Actual 12 10/18/2017 9 6/6/2017 528 a Actual 14 7/25/2017 3% j 3/6/2017 514 a Actual 13 4/12/2017 9 1218/2016 501 aActual 15 1/23/2017 5% 91712016 486 aActuat 13 10l24/2016 15tia 617/2016 473 a Actual 17 8!2l2416 24u� � 3l7l2016 456 a Actual 15 4/22/2016 -5% 12/8/2015 441 aActual 16 1120/2016 -boa 9/8/2015 425 aActual '14 10/16/2015 160� 618/2015 411 a Actual 5 3/9/2015 17 7/24/201a �20% I 394 a Actual 14 4/28/2015 a 12/9/2014 380 a Actual 22/a 18 1/15/2015 9/10120'44 362 aActuai 9% 17 10/1512014 m 6/912014 345 a Actual 16 7/16/2014 40 je 3/1012014 329 aActual 16 4/11/2014 -1% �}b4�fsa.°•��44L Q N� Town of North Andover HEALTH DEPARTMENT ��sncHuat� CHECK #: DATE- 12V' 6�_ LOCATION: H/0 NAME: CONTRACTOR NAME: d411115,r r . ,.m , Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $-- ❑ Food Service ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Mauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash,/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ 01 Title 5 Inspector $ Title 5 ReportP $ m ,w ❑ Other:(Indicate)._.. $ Lth,Agent Initial White-Applicant Fellow-Health Pink®Treasurer N c*J c2 C1 N N YNI-) L9 toy I L-J==