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Home My WebLink About- Title V Inspection Report - 104 COLONIAL AVENUE 3/13/2019 Commonwealth of Massachusetts =� Title 5 Official Inspection r =- n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address r b J d Scott Hansen Owner Owner's Name -____._._.._...__...._.._._..__._.___ _�_...._...._._. _..._�. 45 required for is every NNorth�wnndoyer _..__... -M��-..-. 018 ode Doe of Inspection 9 required for page, y p 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 filling out farms A. Inspector Information , on the computer, Neil James Bateson use only the tab _lJ .....___..._........... key to move your Name of Inspector cursor-do not Bateson Enterprises Inc. use the return _ key. Company Name 111 Argilla. Road _---_- ran Company Address Andover MA 01810 City/Town State Zip Code rams 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 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3, Needs Further Evaluation by the Local Approving Authority 4. Q Fails 3-6-2019 Inspector' n ture Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to r the buyer, if applicable, and the approving authority. 1 Please note: This report only describes conditions at the time of inspection and under the i conditions of use at that time.This ins�pectlon does not address how the system will perform in the future under the same or different conditions of use. t6insp.doc rev.7/26/2018 Title 6 official tnspeclion Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts 'Title 5 Official Inspection For " - - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address Scott Hansen Owner Owner's Name t information is North Andover MA 01845 3-6-2019 required for every .__,__ _.w.... page Gty/"rown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 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 repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," 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 20 years old is available. El Y ❑ N ❑ ND (Explain below): 15insp.doc+rev.712612018 Tilla 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 104 Colonial Avenue Property Address Scott Hansen ........... Owner Owner's Name ------- information is North Andover MA 01845 3-6-2019 required for every 6 page. - -1t-y[Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): F1 Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. Fj 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): Ej broken pipe(s) are replaced E] Y F-1 N F-1 ND (Explain below): F1 obstruction is removed n Y F] N E] ND (Explain below): F-1 distribution box is leveled or replaced F] Y F1 N E] ND (Explain below): El 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): F-1 broken pipe(s) are replaced F] Y n N M ND (Explain below): ❑ obstruction is removed F] Y Ej N F-1 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.7/2612018 Title 5 Official inspection Forrn:Subsurface Sewage Disposal System,Page 3of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 104 Colonial Avenue —----- Property Address Scott Hansen Owner owner's Name information is North Andover MA 01845 3-6-2019 required for every —---------- page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) D Cesspool or privy is within 50 feet of a surface water F1 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: R 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. F1 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. R The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. E] 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 E-1 clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters El 0 due to an overloaded or clogged SAS or cesspool t5insie.doo rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 4 of 16 Commonwealth of Massachusetts =0�=��0�� ^��N N��=��"�� U�N�� Title �� *�� 0�� Inspection Form , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1O4 Colonial Avenue Property Address Scott Hansen Owna/ Owmer'eMam* information is required for every North Andover MA 01845 3'8-2019 s��— page. ~'`'''`-'' ' Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable hmAll : (cont.) Yee No � 5baUo liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS orcesspool Liquid depth in cesspool is less than O° be|Vvv invert or available volume is less than >6dayflow Fl �� Required pumping more than 4 times in the last year NOT due to clogged or obstruchedp|po(o). Number 0f times pumped: _____. El E Any portion of the SAS, cesspool or privy is below high ground water elevation. �� Any pV�iVnof cesspool orpdvyisvvithin1OO feet ofaau�ooev*oter supply nr �� tributary toa surface water supply. � Any portion of oemepmo| or privy is within a Zone 1 of public water supply well. El El Any portion of a cesspool or privy is within 50 feet of a private water supply well. �l �� Any portion of o cesspool or privy is |eao than 180 haot but greater than 50 feet -- � from a private water supply well with no acceptable water quality analysis, [This system passes |f the well water analysis, performed at 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 ppno' provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached tu this fmrrnJ The system iaa cesspool serving m facility with a design flow of 2000gpd- 10.000Opd. Fl �d The system | have deternninedthat one nr more of the ab�vafaUuna criteria exist as---described in 310CW4R 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: Tmhe considered alarge system the system must serve e facility with a design flow of10,0O0 gpdto16,O00gpd. For large syutenmm, you must indicate either"yes" or"no" to each of the fo||ovving, in addition to the | questions in Section CA. Yes No � El 11 the system |s within 4UD feet ofa surface drinking water supply � El El 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 �� Fl Area-!VVP/Ao[u mapped Zone || ofo public water supply well Title o official Inspection Form:subsurface Sewage Disposal mys/"*'Page ymw � Commonwealth of Massachusetts =N�°��N�� ^��N 0��^��°�� 7k� ' Title �� V0 � ��m@ �mm��mm Form . ' i Subsurface Sewage Disposal System Form~ Not for Voluntary Assessments 1O4 Colonial Avenue Property Address Scott Hansen Owner Owner's Name � information is North Andover MA 01845 3-6-2018 required for every page. ~`r'~`~' state Zip Code Date of Inspection C. Inspection Summary (cont.) |f you have answered "ves' to any que�k}nin Section �� thei considered significant threat, or answered " ' ^ ho any question |n Section Cabove the large systemhas failed. The owner or operator of any large system considered a significant threat under Section u.00rfailed under Section O4 �haUupQnsdethesyot�rnimanoordanoevvith31OCK8� 15�3D4� Theayatem owner | � should contact the appropriate regional office of the Department. D. You must indicate "yem,' mr"no"for each wfthe following for all inspections: � Yes No 0 Fl Pumping information was provided by the owner, occupant, or Board of Health El E Were any of the system components pumped out in the previous two weeks? El Has the system received normal flows in the previous two week period? Have |arQevolumes ofvvmter been introduced to the system rece0U d recently �l �� ! �� this inspection? Were as built p|mnsof the system obtained and examined? Uf�hmyvver� ngt �� . � �� available note as N/A) El Was the facility or dwelling inspected for signs of sewage back up? � VVmmthea|t� inop��tedf�r�\gnsofbr8�kout? | Were all system components, excluding the SAS, located nn site? � �� [l VVensthe septic tank manholes unnovan»d. 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 nfscum? Was the facility owner(and occupants |f different from owner) provided with information On the proper maintenance of subsurface sewage d|apVsm| s? The size and location pfthe SoQ Absorption System (SJ\S) on the site.has been determined based on: El Existing information. For example, a plan at the Board of Health. � | Determined in the field (if of the haUuns criteria related to ad C is at issue �� [l distance io unacceptable) [310CK8R153O7(5)] � mle,Official Inspection,wm Subsurface Sewage Disposal aYm*'Page vmm Commonwealth of Massachusetts Title 5 official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address Scott Hansen Owner Owner's Name information is North Andover MA 01845 3-6-2019 required for every �_m._.____-- _._.._.__...... page Cit f6w-n- State Zip Cade Date of Inspection 4 D. System Information 1. Residential Flow Conditions: 4 Number of bedrooms (design): 4 -— — Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes El 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? R Yes Z No Water meter readings, if available (last 2 years usage (gpd)): _— Detail: Sump pump? ❑ Yes No Current Last date of occupancy: Date t5insp.doc rev.7/2 612 01 8 ritlo 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 18 Commonwealth of Massachusetts Tide 5 official Inspection For - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ e 104 Colonial Avenue Properly Address Scott Hansen Owner Owner's Name information is North Andover MA 01845 3-6-201 g required for every _. _.__. _.__.._.___ _.._ _.w.._ .._-- Cily/Town State Zip Code Dale of Inspection page D. System Information (cunt.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow based on 310 CMR 15.203 : ...--day- Basis g ( ) Gallons per (gpd} of design flow (seats/persons/sq.ft., etc.); Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: _.--- Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? [❑ Yes ❑ No I Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): i 3. Pumping Records: Pumped 2015, owner Source of information: Was system pumped as part of the inspection? ® Yes ❑ No 1500 ..... �._... If yes, volume pumped: allons _..— Measured tank How was quantity pumped determined? Inspect tank&tees Reason for pumping: —..... - 15insp.doc.rev.7126/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal system,Page 8 of 18 � � Commonwealth of Massachusetts ~�°�^�N�� N N��^��°�� 0r�0� Title�� Official� ��w� Inspection m��N��m m Form m m � u . Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 1O4 Colonial Avenue | Scott Hansen Owner Owner's Name information is nequi�dfor nve� NodhAndn«8r MA 01845 3-6-2019 State Zip Code Date of Inspection page. ~^''~~^ D. System Information /cODt.\ 4. Type of System: Septic tank, distribution box, soil absorptionaystem El Single cesspool 1-1 Overflow cesspool || Privy F1 Shared system (yes or no) (if yes, attach previous inspection records, if any) �l Innovative/Alternative technology, Attach o copy of the ounantope[aUonand � �� maintenance contract(to be obtained from system owner) and a copy of latest / inspection of the VA system by system operator under contract � � � Fl Tight tank. Attach a copy of the DEP approval. Fl Other(describe): Approximate age of all components, date installed (if known) and source of information: |d 8301897 as b i|t |an Were sewage odors detected when arriving at the site? Fl Yes 0 No 5. Building Sewer (locate on site plan): 1.3 Depth below grade: veeu�� Material of construction: El cast iron Z40PVC F] other(axp|ain): O|ghsnoa from private water supply well or suction line: Comments (on condition of joints, venting, evidence uf leakage, eto.): � 4" PVC through wall, 3" PVC in house, no leaks visible. Title o Official Inspection Form:Subsurface Sewage Disposal oYs*m'Page omm Commonwealth of Massachusetts � Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1O4 Colonial Avenue Scott Hansen Owner Owner's Name information is North Andover MA 01845 3-6-2018 required for every '`''``^' p Code Date of Inspection page. ~ D. System Information (cont.) 0. Septic Tank(locate on site plan\: 0.3 Depth below grade: K8atRho|of construction: R concrete El metal Flfiberglass polyethylene other(explain) If tank is metal, list age: yeum Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) R Yes [l No lO' x5' x4' Dimensions: ------- 3" Sludge depth: ----�� 30" Distance from top of sludge ho bottom of outlet tee orbaffle 3" Scum thickness ------- EY' Distance from top ofscum to top of outlet tee or baffle Diahanw*from bottom of scum h) bottom uf outlet tee orbaffle T K0masunm Hovvvvergdinnensionsdetermined? 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. Pumped septic tank. m/"°po='°~, `18 Tim onmmo inspection Form:Subsurface xmwas Disposal vysmm.nage,o*`o Commonwealth of Massachusetts Title 5 Official Inspection Far F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address Scott Hansen Owner owner's Name - information is North And MA 01845 3-6-2019 required for every over _. -- __ page. CitylTown State Zip Code Date of Inspection D. System Information (cant.) 7. Grease Trap (locate on site plan): Depth below grade: 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.): I 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: ---....,_�.__.—._...—......—w_.—..._ Capacity: Design Flow: gallons per day t5insp.doc•rev,7/2612018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•r'age 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 104 Colonial Avenue Oroperty Address Scott Hansen Owner Owner's Name information is North Andover MA 01845 3-6-2019 required for every page. State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: r-1 Yes El No Alarm level: ----------- Alarm in working order: n Yes El No Date of last pumping: bate ---- Comments (condition of alarm and float switches, etc.): .......... --------- ---------- Attach copy of current pumping contract(required). Is copy attached? El Yes E] No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box level & distribution equal. No evidence of leakage. Evidence of light carryover. 151nsp.dDa-rev.7/26/2016 Titie s ofricw tnspection Form:SLJbSUff2CG SOWR99 c)isposai system Page 12 of 16 Commonwealth of Massachusefts Title 5 Official Inspection Form ti Subsurface Sewage Disposal System Form Not for Voluntary Assessments 104 Colonial Avenue Property Address Scott Hansen Owner Owner's Name information is required for every North Andover MA 01845 3-6-2019 page. ityj7own State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: F-1 Yes E-1 No* Alarms in working order: n Yes 0 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: El leaching galleries number: 3 trenches 62' leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: El innovative/alternative system Type/name of technology: t5insp.doe•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 104 Colonial Avenue Property Address Scott Hansen Owner Owner's Name information is North Andover MA 01845 3-6-2019 required for every page. �5iFyf—Town 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 ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i5insp.doc rev.712612M Title 5 Official inspection Form Subsurface Sewage Disposal SYMOM Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection or Subsurface Sewage Disposal System Form Not for Voluntary Assessments 104 Colonial Avenue Property Address Scott Hansen ---- - Owner Owner's Name information is North Andover MA 01845 3-6-2019 required for every -- -- page. state Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids —------ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): trolrrsp.doc•rev.7126/2010 1 R105 official Inspection Farm:Subsurface Sewage Disposal System^Page 15 Of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 104 Colonial Avenue Property Address Scott Hansen --------------- Owner owner's Name information is North Andover MA 01845 3-6-2019 required for every 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: 0 hand-sketch in the area below Z drawing attached separately 0 7 L4 -y- W 0L� t5insp.doc-rev.712612018 Title official inspection Form:Subsurface Sewage Disposal System,Page 16of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 104 Colonial Avenue Property Address Scott Hansen Owner Owner's Name information is required for every North Andover MA 01845 3-6-2019 -------------- page. C1tylTownState Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope Surface water Check cellar Shallow wells 4 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: bi—W 6-11-1993 7 El Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: -DeA!qn ------ 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. 151nsp.doc-rev,7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal SYslOm'Page 17 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 104 Colonial Avenue W6per-t—y—Aid—r—ess —--------- Scott Hansen Owner Owner's Name information is North Andover MA 01845 3-6-2019 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 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 l6insp.doc•rev.7/2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal SYsliefn•Page 18 Of 18 Summary Record card generated on 31111120119 11:11:39 AM by Karon Hanlon Page 1 Town of North Andover Tax Map # 210-107.B-0139-0000.0 Parcel Id 18255 104 COLONIAL AVENUE SCOTT & CAROLINE HANSPN 104 COLONIAL AVENUE NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.6 Acres FY 2019 UB Mailing Index Name/Address Type Loan Number Activelinact. From Until SCOTT&CAROLINE HANSEN Owner Active 104 COLONIALAVENUE NORTH ANDOVER MA 01845 GIUFFRIDA, BRIAN&SHARON Previous Customer Inactive 7/22/2009 104 COLONIAL AVE NORTH ANDOVER,MA 01846 JEAN FAMIGLIETTI Previous Customer Inactive 3/18/2010 104 COLONIALAVENUE NORTH ANDOVER,MA 01845 WILLIAM POWERS Previous Customer Inactive 10/16/2015 104 COLONIAL AVENUE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13306.0-104 COLONIAL AVENUE Last Billing Date 3/8/2019 2100033 02 Cycle 02 Active UB Services Maint. Account No.2100033 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE 45.60 11 UB Meter Maintenance. Account No.2100033 Serial No Status. Location Brand Type Size YTD Cons 35644527 a Active ERT HH b Badger w Water 0,63 0.63 1952 Date Reading Code Consumption Posted Date Variance 2/1/2019 1948 a Actual 12 3/19/2019 -77% 53 12/12/2018 -24% 11/l/2018 1936 aActual 421% 8/1/2018 1883 aActual 70 6/20/2018 5/1/2018 1813 aActual 13 3/28/2018 9% 2/1/2018 1800 a Actual i4 12/29 201 36% 10123/2017 1786 a Actual 54 9120/20177 04% 8/1/2017 1732 a Actual 44 6/26/2017 211% 5l1/2017 1688 a Actual 14 3/14/2017 11% 211/2017 1674 aActual 13 3111912 7 -$1% 11/1/2016 1661 aActual 65 9121/20/ G 431% 8/1/2016 1596 aActual 93 612112016 418% 5/2/2016 1503 a Actual 16 3/28/2016 22% 211/2016 1487 aActual 14 12/301201 -80% 10/30/2015 1473 a Actual 4 12/30/2015 86% 10/9/2015 1469 f Final Bill 63 10/9/2015 3 83 9/14/2016 -8% 19 6122/ 0% 8l3/2015 1406 a Actual 2016 -8°/a 5/1/2015 1323 aActual 22 6/2212015 -78% 2/4/2015 1304 a Actual ., Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use-by local Boards of Health. Other farms may be'used, but the Information,must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the forth 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/ i ht front of h suo a eft/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of bulldlfig, Left/Right rear of building, Under deck Address log em�..,z Cltylrown state Zip Code Z. System Owner. Name' Address of different from location) City(rown State Zip Cade Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank i ❑ Other(describe): 4, Effluent Tee Filter present? ❑ Yes E�11�0 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company i 7. 7G, h contents-were disposed: Lowell Waste Water signitufe I Hbul Date t5form4.doc►06/03 System Pumping Record+Page t of 1 , µ4RTry 'Town of North Andover HEALTH DEPARTMENT �S�acwus'�i M CHECK.#: ��! .:-,� ,, �:. DATE r" LOCATION: H/O NAME: _ CONTRACTOR NAME: Type.of Permit or License: (Check boas) ❑ Animal $-- ❑ Body Art Establishment $ ❑ Body 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-Design Approval $ ❑ Septic Disposal Works Cottstruetion(DWC) $ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report ❑ Other:(Indicate).---,— He IthAgent Initials 'White®Applicant Yellow,-health pi' nk-Treasurer