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HomeMy WebLinkAbout- Title V Inspection Report - 500 REA STREET 3/13/2019 Commonwealth of Massachusetts �o i m - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 500 Rea Street Property Address William McManus Owner Owner's Name information is 1 required for every North Andover MA 01845 3-7-2019 page Clty/fown State Zip Code Date of Inspection i Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when A. inspector Information filling out forms on the computer, Neil James Bateson use only the tab . key to move your Name of Inspector cursor-do not Bateson Enterprises Inc. use the return ---.-_..p-__.any_ ,Na m__e ___....._._ key. Comp __.. ._.__..._._...__._._ ..__,__............. 111 Argilla Road _._............. ----- Q Company Address - - Andover MA 01810 CitylTown State Zip Code rr� 978-475-4786 _ SI-15 _..._._._... _.__... . ._.__ -- -- - - ---- 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, 0 Needs Further Evaluation by the Local Approving Authority 4. eto i - ­) 3-7-2019 Ingnatur Date i 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. 15insp.doc•rev,7/28/2018 1itle 5 Official inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ��° N�� �� �`�J��������N N������������°���� ����U��N� / Title �� ���@ � �����mN Inspection Form ' Subsurface SexxageDisposal Syshmm0Formm ~ No�fo[Vo|uutaryAaem�am�nta 50OReaStnaet William MuK4enum ---- Owner Owner's Name information is North Andover MA 01845 3-7-2019 required�rmm� — pogo. ~`r'~`~' �� Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1. 2. 3. o[5 and all of4 and B. 1) System Passes: F-1 | have not found any information which indicates that any of the failure criteria described in 310 CK8R 15.303 or in 310 CPNR 15.384 exist, Any failure criteria not evaluated are indicated below. Comments: 2} System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or nepaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years cild* or the septic tank (whether metal or not) is structurally unsmund, exhibits substantial infiltration Oroxfi|(nation 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. ^/\rn8ta| aaodn tank will pass inspection if it is struob/[8|k/ sound, not leaking and if a Certificate of Compliance indicating that the tank iG less than 20 years old is available. �� Y N ND (Explain be|ow): Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 500 Rea Street Property Address William McManus Owner Owner's Name information is North Andover MA 01845 3-7.-201 --------- required for every 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. El 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 0 Y 0 N [] ND (Explain below): ❑ obstruction is removed E] Y 0 N El ND (Explain below): ❑ distribution box is leveled or replaced Ej Y 0 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): Ej broken pipe(s) are replaced El Y 0 N [:1 ND (Explain below): ❑ obstruction is removed F1 Y Ej N El 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 ' Commonwealth of Massar-husetts Title �� ��.���°�����N N����������������� ����N��0� . � NlkN�� �� �=�� � ������� 0nm���������N��nm Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 500 F<ae Street VVi||imm W1oKAanua Owner owner's Name i»i»m«ati«»io Nnrh Andover K4A 01845 3-7-2019 i dho eqom rev=� �-- Andover State Zip Code Date of Inspection -�- page. —' —' C. Inspection Summary (cont.) E] Cesspool orprivy ia within 5O feet ofo surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh h. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in m manner that protects the public hea|th, safety and environment: n The system has a septic tank and soil absorption system (SAS) and the SAS is within --Ofeatof a surface water supply or tributary toa surface water supply. n The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. � n The mynt8nn has septic tank and SAS and the GAS is within 50 feet ofo private water � supply well. n The syobann has o meodo hank and SAS and the SAG is |eam than 100 feet but 50 feet or more from o private water supply vveU^°. Method used tV determine distance: *°This system passes if the well water an8|ysi6, performed at OEP certified |ab0ratory, for fecal oo|iform 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 ofthe analysis must � be attached to this form. c. Other: D-Box needs toboreplaced. 4> System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No l �� . Backup nfoewage into facility or system component due to overloaded or � �� �� clogged SAS Vrcesspool F� �� Discharge O[pondingofe�uenttO the ou�aCeofthe ground orsU�acevvaba[s �� �° due to an overloaded or clogged GAS or cesspool Commonwealth of Massachusetts I ^ _ Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` 500 Rea Street Property Address William_McManus Owner Owner's Name information is MA 01$45 3-7-2019 North Andover required for every page CityFrown _. State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow © ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ElAny portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 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 ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 15insp.doe•rev.712612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments j 500 Rea Street ._._a___—.. Property Address William McManus Owner Owner's tVame _. information is North Andover MA 01845 3-7-2019 required far every _._ page Cltyfrown State Zip Code Date of Inspection C. Inspection Summary (cons.) 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? E ❑ 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? El information 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 15.30Z(5)) 15insp.doc-rev.7128/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 500 Rea Street OFc�p-erty William McManus Owner Owner's Name information is North Andover MA 01845 3-7-2019 required for every page. difyi�Dwn State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 6 5 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 Description: Number of current residents: 2.---............. Does residence have a garbage grinder? ❑ Yes Z No Does residence have a water treatment unit? F-1 Yes Z No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection n Yes Z No information in this report.) Laundry system inspected? F-1 Yes R No Seasonal use? El Yes Z No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: ---------- ------------- Sump pump? ❑ Yes ❑ No Last date of occupancy: Current t5insp.doc-rev.7/2612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 7 of 16 (C-4 Commonwealth of Massachusetts Title icial Inspection Form n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 500 Rea Street Property Address William McManus Owner Owner's Name information is North Andover MA 01845 3-7-2019 required for every _ __.._..� page Cityrrown State Zip Code Date of Inspection 3 D. System Information (cant.) 2. Commercial/industrial Flow Conditions: Type of Establishment: .--------.—... Design flow(based on 310 CMR 15.203): aiions per day(9pd) Basis of design flow (seats/persons/sq.ft., etc.): - -...--------- Grease trap present? © Yes F1 No Water treatment unit present? ❑ Yes El No If yes, discharges to: ___.--- Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 2018, owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons -.— _._ ._._._.... _._...___,.._.... How was quantity pumped determined? Reason for pumping: -- _..... t6insp.doc-rev.712612018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title ftle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 500 Rea Street jProperty Address i William McManus Owner Owner's Name information is North Andover MA 01845 3-7-2019 required for every -6 7tfiffown State Zip Code —6afe-of—lns�p—ecfior- page. D. System Information (cont.) 4, Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El 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: 22 years old, 9-23-1997, as built plan_,_ Were sewage odors detected when arriving at the site? El Yes 0 No 5. Building Sewer(locate on site plan): 2 Depth below grade: Material of construction: n cast iron [Z 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet -—----- Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall to septic tank. 4" & 3" PVC in house, no leaks visible ------------ --------------- t5insp.doe-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 16 cry Commonwealth of Massachusetts _-r Title 5 Official Inspection Form Tu � Subsurface Sewage Dispersal System Form - Not for Voluntary Assessments 4� 500 Flea Street - Property Address William McManus _......._—__ Owner Owner's Name information is North Andover MA 01845 3-7-2015 required for every N _ _ _— .. _,_...._ �.. page City/Town State Zip Code Date of Inspection D. System Information (cant.) 6. Septic Tank (locate on site plan): 1 Depth below grade: Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: M Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes F1 No 10' x5' x4' Dimensions: 0" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3311 -._.... _ _.,...._._ 0„ Scum thickness _.....__._.... _...__$ _- Distance from top of scum to top of outlet tee or baffle - - 15" Distance from bottom of scum to bottom of outlet tee or baffle ------- — -- Haw 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 15insp.doc•rev.'112612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .. 500 Rea Street c Property Address William McManus _...__ Owner Owner's Name , information is North Andover MA 01845 3 7-2019 required for every ._ _ page CityfTown State Zip Code Date of Inspection I D. System Information (cant.) 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.): 8. Tight or Holding 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: ga llans Design Flow: -- - ...... gallons per day I t5insp.doc•rev.7 12 812 0 1 8 Title 5 Official Inspection Form:subsurface Sewage Disposal Systern-Page 11 of 18 Commonwealth ©f Massachusetts T-tie 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 500 Rea Street Property Address William McManus Owner bwner's—Name information is North Andover MA 01845 3-7-2019 required for every page. City—IT6� n - State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: El Yes ❑ Na Alarm level: Alarm in working order: El Yes E] No Date of last pumping: Comments (condition of alarm and float switches, etc.): .................. Attach copy of current pumping contract(required). Is copy attached? n Yes El 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. Evidence of carryover. No evidence of leakage. D-box cover broken, replaced same. D-box has bad corrosion , needs to be replaced. .......... t5insp.doc-rev.7/26/2018 "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 500 Rea Street -—---------- Ad—dr­esi----------------- -­ - Property William McManus Owner Owner's Name information is required for every North Andover MA 01845 3-7-2019 State Zip Code Date of Inspection page. &I-t—ylTown D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No* Alarms in working order: 0 Yes El 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: E-1 leaching chambers number: El leaching galleries number: ---------- F1 leaching trenches number, length: 4 trenches 50' long E-1 leaching fields number, dimensions: ------ ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts it 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 500 Rea Street Property Address __ William McManus Owner Owner's Name information is North Andover MA 01845 3-7-2019 required for every .-- -----, I page, '6 Ftyffown 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.): Lawn covered in snow. 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.): ........... ------ --------- ------------- Wrisp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposat System-Page 14 of 18 Commonwealth of Massachusetts Title f i ial Inspection rm Subsurface Sewage disposal System Form Not for Voluntary Assessments 500 Rea Street Property Address ..— _.. William McManus — Owner Owner's Name _..��._. _ information is North Andover MA 01845 3-7-2019 required for every _ — page Cttiff own State Zip Code Date of Inspection I D. System Information (cons) 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 i I i t5insp.doc-rev.7/2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 500 Rea Street Property Address William McManus ----—----- Owner Owner's Name information is North Andover MA 01845 3-7-2019 required for every State ZipGode Date of Inspection page. 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: F-1 hand-sketch in the area below Z drawing attached separately Vj -:r LIL/ t6insp.doc rev.7126/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal Systain Page 16 Of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 500 Rea Street PropertyAddress William McManus Owner Owner's Name information nfo mation is required for every North Andover MA 01845 3-7-2019 page. City/Town State Zip Code _Date of Inspection D. System Information (cont) 15. Site Exam: Z Check Slope 0 Surface water Z Check cellar Shallow wells Estimated depth to high ground water: 4 et Please indicate all methods used to determine the high ground water elevation: z Obtained from system design plans on record If checked, date of design plan reviewed. 9-11-1996 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) z Checked with local Board of Health -explain: Design plan......... -------- El Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 151nsip.doc rev.7/26120,18 Title 5 Official inspection Form:Subsurface Sewage Disposal System,Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 500 Rea Street Property-Address -- - William McManus ---------- Owner er's Name information is North Andover MA 01845 3-7-2019 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: • 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 Z 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 i5insp.doc rev.7126/201 8 TR10501rdal Inspection Form:Subsurface Sewage DISPOsal system,Page 18of 18 Summary Record Card generated on 11/14/2018 2:12:51 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-038.0-0315-0000.0 Parcel Id 10312 500 REA STREET MGMANUS, BILL 500 REA STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential ZonIng2 1 Residential ZonIng3 1 Residential Size Total 1.06 Acres FY 2019 ------------ QI3 Mailing Index Until Name/Address Type Loan Number Active/Inact, From McMANUS, BILL Payor Active 500 REA STREET NORTH ANDOVER,MA 01845 LIB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 16156.0-500 REA STREET Last Billing Date 10/4/2018 3160201 03 Cycle 03 Active UB Services Maint. Account No, 3160201 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9,18 1/ WTR WATER 01 ALL METER SIZE 241,73 /1 UB Meter Maintenance Account No. 3160201 Serial No Status Location Brand Type Size YTD Cons 32948534 a Active 00 b Badger w Water 1 1 2059 Date Reading Code Consumption Posted Date Variance 9/6/2018 2669 a Actual 50 10/15/2018 253% 6/512018 2619 a Actual 14 7/23/2018 -9% 3/5/2018 2605 a Actual 15 4/23/2018 14% 12/5/2017 2590 a Actual 13 1/25/2018 -75% 9/7/2017 2577 a Actual 55 10118/2017 41% 6/512017 2522 a Actual 39 7/25/2017 16% 3/3/2017 2483 a Actual 31 4/12/2017 -32% 12/612016 2452 a Actual 50 1/23/2017 -57% 9/212016 2402 a Actual 108 10/24/2016 391% 6/6/2016 2294 a Actual 24 8/2/2016 -17% 3/2/2016 2270 a Actual 26 4/2212016 .34% 12/7/2015 2244 a Actual 43 1/20/2016 -65% 9/4/2015 2201 a Actual 120 10/1612015 271% 6/4/2015 2081 a Actual 32 7/2412015 60% 3/5/2015 2049 a Actual 20 4/28/2015 -10% 12/4/2014 2029 a Actual 22 1/15/2015 -79% 9/5/2014 2007 a Actual 106 10/15/2014 452% 615/2014 1901 a Actual 19 7/16/2014 -5% 3/6/2014 1882 a Actual 20 4/11/2014 -24% 12/5/2013 1862 a Actual 26 1/1712014 -63% 9/6/2013 1836 a Actual 68 10/15/2013 95% 6110/2013 1768 a Actual 38 7/24/2013 2% 3/6/2013 1730 a Actual 35 4/22/2013 17% 1216/2012 1695 a Actual 30 1/9/2013 .64% 9/7/2012 1665 a Actual 86 10/15/2012 166% 617/2012 1579 a Actual 32 7/16/2012 .3% 3/8/2012 1547 a Actual 34 4/14/2012 -7% 12/5/2011 1513 a Actual 34 1/17/2012 -64% 9/9/2011 1479 a Actual 107 10/13/2011 189% l �. 'yaORTF/ � .� 3� sQ p4 p • M� Town of North Andover HEALTH DEPARTMENT �SSNCHU`.rt� g CHECK #: ._.. ,a ..:� ��.. SATE: 2� LOCATION: Al CONTRACTORNAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Bach Art Practitioner $ ❑ Dumpster $ ❑ Food Service ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $— ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool ❑ Tobacco $_ ❑ Trash;/Solid Waste hauler $ ❑ Well Construction $ _ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic a Design Approval $ ❑ Septic Disposal Works Construction(DW0 $ ❑ Septic Disposal Works Installers(DWI) $ f ❑ Title Slnspector l ()CyfV $ ee Title 5 Deports $ ❑ Other. (Indicate)— _ $ 00, IlelthaAgent Initials White®Applicant Yellow-Ilealth Pink-Treasurer