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HomeMy WebLinkAbout- Title V Inspection Report - 1055 SALEM STREET 1/8/2019 . ' Commonwealth of Massachusetts =�`���N�� �� ��^���������N ���������^������� ����B~8�� . � ����� �� ��/NNN��0�m0 Inspection N-��wwm � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1O55 Salem Street Property Address Rebecca Moore Owner Owner's Name information is required for every North Andover MAO1845 1-4-2019 page. St ate Date ofInspection Inspection results must be submitted on this form. Inspection forms may not be altered |nany way. Please see completeness checklist at the end mf the form. Important:When �~ U�������� K����K��t~on filling out opnnx ^ ~ Inspector~ Information - ` Umcomputer, - —use only the tab �Neil key to move your Name mInspector 1"OVW4 W-NUK|MANuuvEm oumor-domot Bateson Enterprises Inc. RTM�T use the return key� Company_ _ Name_ 111 Arqilla Rood VQ _66-mpany Address Andover MA 01810 Cityrrown State Zip Code 979-4754786 S115 phone Number B. CertificationLicense Number | oertify that: | anmaOEPapproved system Inspector|m full compliance with Section i5.340of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below |s true, accurate and complete aaof the time ofmy 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 symhmnn: 1. Z Passes 2. Conditionally Passes 3. Fl Needs Further Evaluation by the Local Approving Authority ' El Fail 1-4-2O1Q e � Date. � - � �es��mi h�| oubm�m �p of ��� ApprovingAuthority (Board of Health or DEP\ within 30 days of completing this inspection. If the system has aoos/gn flow of 1O.OQUgpdor greater, the |nmpantormndtheoyetamownershaUeubmitthereporttotheapppoprisde 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 ot use mt that time, This inspection does not address how the system will perform |n the future under the same or different conditions mfuse. ` . Commonwealth of Massachusetts =�'=��N�� �� ������������0 N������������"���� ������N�� 0 � �N �� Official� Inspection 0-��� mmm �� �� �m mm������ Subsurface Sewage Disposal System Form ~Not for Voluntary Assessments 1055 Salem Street Rebecca Moore Owner Owner's Name information is North Andover MA 01845 1-4-2019 required for every page. ~^^r'``~' Statep Code Date of Inspection- C. Unsped~on Summary Inspection Summary: Complete 1, 2. 3. or 5 and all of and 8. 1\ System Passes: | have not found any information which indicates that any of the failure ohbaho described -- in 310CK8R 15.303DriV 310CKAR 15.3048XimL Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: �l one or systemmore components as described in the"Conditional Pass" section need to be replaced or repaired. The amtem, 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 detmrmined." 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 infi|kaUonorexƒi|trationor tank failure is imminent, Systanovvi|| pass inspection if the existing tank |a replaced with a complying septic tank en approved by the Board of Health. ° A metal septic tank will pass inspection if it is structurally sound, not leaking and if Ced|fioobm of | Compliance indicating that the tank is less than 20 years old is available. El y El N El ND (Explain below): / m*sp.d" .*~712612018 Title*Official Inspection Form:Subsurface Sewage Disposal System'Page cmm Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1055 Salem Street Property Address Rebecca Moore Owner Owner's Name information is North Andover MA 01845 1-4-2019 required for every C7jjvjf0-w—n --­"---- State Zip Code -Da-ti-R,In—spe-ct—lon --- page. 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N FIND (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($). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced ❑ Y ❑ NEI ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N FIND (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: Wnsp.doc,rev,71261201a Title 5 Official Inspection Form:Subsurface Sewage Disposal SYMORI,page 3 of 18 G . Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y $ 1055 Salem Street Property Address Rebecca Moore Owner Owner's Name information is North Andover MA 01845 1-4-2019 required for every _ver page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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. ❑ 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 DP 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 El Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp.doc+rev.712612018 Tilie 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 4 of 18 . . ' Commonwealth of Massachusetts ��°��0�� �� ��^���������0 N����������������� ����U���h ' � ����� �� �~�� � ���@��� �mw���������N��mm Form Subsurface Sewage Disposal System Form `Not for Voluntary Assessments 1055 Salem Street 0—roperty Address Rebecca Moore Owner 6wner'sNamn information is North Andover MA 01845 1-4-2010 required for every page. ~^r.,,.. state Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable hm All Systems: (cont') Yes No Static liquid level in the distribution box above outlet invert due to an overloaded y�[l �� �� or clogged SAS urcesspool Fl Liquid depth in cesspool is less than S'' below |nve�or available vnlunla is |osm �� �� than |6dayflow Required pumping noorothan 4tinnem |n the last year NOT due to clogged or �� �� obstructed pipe(a). Number of times pumped: Fl El Any portion of the SAS, cesspool or privy is below high ground water elevation. �l �� /\nypodionof cesspool or privy |o within 1OO feet nfmou�ocevvater supply or �� �� tributary tOa surface water supply. � �l �� /\nypo�i0nofo cesspool u[phvyiovvith|na Zone 1ofa public water oupp|y �^ �" well. Fl E Any portion of a cesspool or privy is within 50 feet of a private water supply well. �� Any podionofm cesspool nr privy in less than 1O0 feet but greater than 5Ofeet -- -- from a private water supply well with no acceptable water quality analysis, [This system passes |f the well water analysis, performed at DEP certified laboratory,for fecal coUformm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal towr less than 5pprn, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this formm] [l �� The system is a cesspool serving m facility with a design flow of20OOgpd- 10.000gpd. �� �� The system | have determined that one or more of the above failure `� �� criteria exist _-desoribmd in 310 C;NR 15.303. therefore the system fails. The system owner sou contact h |dthe8ourdnfHeo|thtVdetarminevvhatwi|[ bo necessary to correct the failure. � | S) Large SVabmrns: Tobo considered alarge system the system must serve m facility with a design flow wf10'0O0gpd1u15,0ODgpd. For large ayatems, you mu et indicate either"yes" or"no" to each of the fo||owing, in addition to the questions in Section CA. Yes No Fl the system io within 4OO feet ofa surface drinking water supply ' �l [J the system is within 2OO feet ofa tributary tnn surface drinking water supply the Synt8nO is located in a nitrogen sensitive area (Interim Wellhead Protection El n Area— |VVPA) o[a mapped Zone || ofu public water supply well n"°o Official inspection Form S"»°"m*ceu"°"o°m,v"°ma,,,°ly''Page 5°/`o / . Commonwealth of Massachusetts ' Tit=�'°��N�� �� ��^��'������N N����������������� ����0r0�� le �� �=�@ � �����m� �� m������������wm N|��rm � mm Subsurface SoVxageDisposa| SysbarnFormm - NotfVrVm|untaryAsseaamento 1055 Salem Street Proiper—ty Address Rebecca Moore Owner Owner's Name information is No page. MAO1845 1-4-2019 mqo|redfor ove� pagu City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C,5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5orfailed 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"nm"for each of the following for all inspections: Yes No M n Pumping information was provided by the owner, occupant, or Board of Health M Were any of the system components pumped out |n the previous two weeks? � El Has the system received normal flows in the previous two week period? [� [� Have large volumes ofvvater been introduced to the system nauenUyVraepa�of �� �� this inspection? [l VVgn� aa built plans of the system obtained and examined? (If they were not [� `� available note asN/A) F] Was the facility n[dwelling inspected for signs of sewage back up? D Was the site inspected for signs of break out? �� Fl Were all system components, excluding the SAS, located onsite? | Were the septic tank manholes uncovered, opened, and the interior of the tank � inspected for the condition of the baffles or tees, material ofconstruction, � dimensions, depth of liquid, depth of sludge and depth ofscum? � Was the facility owner/undoccupants if different h h from owner) �� [l information on the proper maintenance nf subsurface sewage disposal systems? The size and location of the Sm|| Absorption System (SAS) on the site has been determined based on: Existing information. For example, u plan at the Board ofHealth. Determined in the field Ufany of the failure criteria related toPa�C |eatissue �� 0approximation of distance is Vnn000ptab|o\ [310CK8R 15.302(5)] ntte 6 Official Inspection Form:oUbsurmce Sewage Disposal system.Page s*m Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1055 Salem Street Property Address Rebecca Moore ----------------- Owner Owner's Name information is required for every North Andover MA 01845 1-4-2019 page. state Z.ip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x#of bedrooms): 550 Description: Number of current residents: Does residence have a garbage grinder? Yes Fj 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 F1 Yes Z No information in this report.) Laundry system inspected? F1 Yes F1 No Seasonal use? El Yes Z No Yes Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? F] Yes Z No Current Last date of occupancy: oats t6insp.doc rev.712612018 Title 5 official inspection Form:Subsurface Sewage Disposal Systern-Page 7 of 18 Commonwealth of Massachusetts clip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments v. 1055 Salem Street i5rape_rty Address Rebecca Moore Owner Owner's Name information is North Andover MA 01845 1-4-2019 required for every State Zip Code e f Inspection page. City[Town 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? R Yes E] No If yes, discharges to: Industrial waste holding tank present? R Yes E] No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Other(describe below): ............ 3. Pumping Records: Pumped August 2018, owner Source of information: Was system pumped as part of the inspection? El Yes No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: t5insp.doe•rev.7126/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System,Page 6 of 16 Commonwealth of Massachusetts = � Title 5 Official Inspection Farr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �w. *m 1055 Salem Street Property Address 1 Rebecca Moore Owner Owner's Name information is MA 01845 1-4-2019 required for every North Andover page City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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: 5 years_old, 4-18-2014, as built lan� Were sewage odors detected when arriving at the site? ❑ Yes Z No 5, Building Sewer(locate on site plan): 2.5 __.. Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC other(explain): Distance from private water supply well or suctionline: feet Comments (on condition of joints, venting, evidence of leakage, etc.): I 4" PVC through wall to septic tank, 4" $,, 3" PVC in house, no leaks visible, 15insp.doc+rev.7126/2014 �� — _. .. Title 5 Official Inspection Form:Subsurface SeWaOa Disposal Syslom•Pago 9 of 18 ` Commonwealth of Massachusetts =� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w� 1055 Salem Street Property Address Rebecca Moore Owner Owner's blame information is North Andover MA 01845 1-4-2019 required for every __..-_.-_—_._-_ _.__ __._..-.— ...__._ —__ �..,, ._ ... ..___... I page City/Town State Zip Code Date of Inspection 1 D. System Information (cont.) 6. Septic Tank (locate on site plan): 1.5 Depth below grade: Material of construction: M concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: ears v Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) © Yes ❑ No 10' x5' x4' Dimensions: 1° Sludge depth: �.. __.. 30" Distance from top of sludge to bottom of outlet tee or baffle _.... — 1" 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 14 — -- _.-. easure How were dimensions determined? -T....-.a eM --.- 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. Inlet & Outlet covers has risers to grade. I t5insp.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface sewaga Disposal system Page 10 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection or Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1055 Salem Street ------- P-r-o-perty Address Rebecca Moore Owner Owner's Name information is North Andover MA 01845 1-4-2019 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: ❑ concrete F-1 metal n fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle ...... Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8, Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: F-1 concrete ❑ metal ❑ fiberglass ❑ polyethylene E] other(explain): ... ........ Dimensions: Capacity: gallons Design Flow: gallons per day l5insp,doc,rev.712612018 Title 5 official Inspection Form:Subsurface Seveago Disposal system,Pago 11 of 18 Commonwealth of Massachusetts - Title Official Inspection r i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1055 Salem Street _.__--------.__._-- _.__ __------- Property Address Rebecca Moore Owner Owner's Name information is North Andover MA 01845 1-4-2019 required far every _.......... .....___ .. ...__�.w.. _-- _... page City/Town State Zip Code Date of Inspection D. System Information (cant,) 8. Tight or Holding Tank (cunt.) Alarm present: ❑ Yes ❑ No Alarm level: — — - - — Alarm in working order: ❑ Yes ❑ Na Date of last pumping: gate -. ---..,-.------- ___— _,--. 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 has flow levelers. No evidence of leakage. Evidence of light carryover, t5insp.doc rev.V26f2016 Title 5 Official inspection Form:Subsurface Sewage nisposal System.Page 12 of 1 B ' . Commonwealth of Massachusetts =0�=��N�� �� �°���.��*°��N N����������°�=���� ��������H Title �� Official� Inspection N—��nmmm ~ �� �° �� mw������ Subsu �n��� m�mQi���m�� �ymtemmFoy(n ~ NOtfo[VV|Unt�ryASnessnO8nts � vn 1055 Salem Street RabeocaW1oon* Owner Owner's Name information is North MA 01845 1-4-2019 requimafor ova� page. ~'v''~'''' State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: [l yoo [l No* | |Yes Alarms in working order: �Fl� �� No* Comments (note condition of pump chamber, condition ofpumps and appurtenances, eto.): ^ |f pumps or alarms are not in working order, system iaa conditional pass, 11, Soil Absorption System (SAS) (locate on site plan, excavation not requinad): |f SAS not located, explain why: Type El leaching pits number: Fl leaching chambers number: -------�� El leaching galleries number: 2 trenches 62' leaching trenches number, length: | n � -- El leaching fields number, dimensions: overflow cesspool number: ------- Fl innovadive/o|ternehvosymtwm Type/name oftechnology: Title n Official inspection Form:Subsurface Sewage Disposal System'Page'"^m Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1055 Salem Street Property Address Rebecca Moore Owner Owner's Name information is required for every North Andover MA 01845 1-4-2019 page. CityfTown ---------- State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. ——------------- 12, Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert ------ Depth of solids layer ............ Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15insp.doc rev,712 612 01 8 Title 5 Official hspection Form:Subsurface Sewage Disposal SYstern Pago 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1055 Salem Street -------------- Property Address Rebecca Moore Owner owner's t�tame information is [North Andover MA 01845 1-4-2019 required for every -ba-Wof—Insplac6o--n—­---­'------- page. State Zip Code D. System Information (cont.) 11 Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15insp.doc,rev,712612018 Tillo,5 Official inspection rorm:Subsurface Sowago Disposal Sysion) Page 15 Of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1055 Salem Street Property Address Rebecca Moore OwnerOwner's Name information is required for every North Andover MA 01845 1-4-2019 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: M hand-sketch in the area below El drawing attached separately s. (D C-A 6VQ-4 t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1055 Salem Street Property Address Rebecca Moore Owner Owner's Name information is North Andover MA 01845 1-4-2019 required for every page, State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Z Check Slope Z Surface water Z Check cellar Z Shallow wells >4 Estimated depth to high ground water: Please indicate all methods used to determine the high ground water elevation: z Obtained from system design plans on record 8-15-2013 If checked, date of design plan reviewed: F-1 Observed site (abutting property/observation hole within 150 feet of SAS) El Checked with local Board of Health -explain: ❑ 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. l5inbp.doc-rev.712612016 'ritio 5 official inspection Form:Subsurface Sewage Disposal System•Page 17 Of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposai System Form Not for Voluntary Assessments 1055 S alern Street Property Address Rebecca Moore Owner Owner's Name information is North Andover MA 01845 1-4-2019 required for every page, CttylTawn State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Z A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked Z C. inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp,doe,rev.712612018 Title 5 omciat inspection Form:Subsurface Sewage Disposal System-Pago 18 of 18 Summary Record Card generated on 12/11/2018 2:20:01 PM by Karen Hanlon Page 1 Town of Borth Andover Tax Map # 210-104.p-0069-0000,0 Parcel Id 16757 1055 SALEM STREET REBECCA & TYSON MOORE 1055 SALEM STREET NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 .1 Residential Zoning3 1 Residential Size Total 0,56Acres FY 2019 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until REBECCA&TYSON MOORE Owner Active 1055 SALEM STREET NORTH ANDOVER MA 01845 JEFFCO Previous Customer Inactive 6/5/2014 PO BOX 802 ANDOVER,MA 01810 UB Account Malnt. Account No Cycle Occupant Name Activelinactive Bldg Id. 3651,0- 1055 SALEM STREET Last Billing Date 10/4/2018 3160602 03 Cycle 03 Active UB Services Maint. Account No. 3160602 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE 530.33 1/1 UB Meter Maintenance Account No. 3160602 Serial No Status Location Brand Type Size YTD Cons 45286572 a Active ERT HH b Badger w Water 0.63 0.63 519 Date Reading Code Consumption Posted Date Variance 12/6/2018 555 a Actual 34 -66% 9/7/2018 521 a Actual 102 10/15/2018 104% 6/6/2018 419 a Actual 50 7/23/2018 246% 315/2018 369 a Actual 14 4123/2018 -66% 12/5/2017 355 a Actual 41 1125/2018 -48% 9/7/2017 314 a Actual 84 10/18/2017 85% 615/2017 230 a Actual 44 7/25/2017 231% 3/6/2017 186 a Actual 13 4/12/2017 -57% 12/7/2016 173 aActual 31 1/23/2017 -9% 9/6/2016 142 a Actual 35 10/24/2016 161% 6/3/2016 107 a Actual 13 8/2/2016 1 3/3/2016 94 a Actual 12 4/22/2016 -3% 12/8/2015 82 aActual 14 1120/2016 -1% 912/2015 68 a Actual 13 10/16/2015 -5% 6/5/2015 55 a Actual 14 7/24/2015 18% 3/6/2015 41 a Actual 12 4/28/2015 -10"/0 12/4/2014 29 a Actual 13 1/15/2015 -3% 9/5/2014 16 a Actual 14 10/15/2014 578% 6/312014 2 f Final Bill 2 6/3/2014 3/4/2014 0 n New Meter 6/3/2014 4 • � Town of North Andover HEALTH p� DEPARTMENT T J, i CHECK #: DATE: ' ., ... LOCATION: "' """ r H/O NAME: CONTRACTOR NAME: jyR of Permit or Ucense (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 Pool ❑ Tobacco i ❑ Trash/Solid Waste Hauler $ ❑ Well Construction SEPTIC Systems: © Septic-Soil Testing ❑ Septic--Design ApprovaI ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) ❑ Title 5 Inspector Title 5 Report �� ( "i ❑ Other;(Indicate) — __-- � ! Heath-Agent Initials White-Applicant Yellow--health Pink-Treasurer