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Home My WebLink About- Title V Inspection Report - 25 SUNSET ROCK ROAD 3/18/2019 � / Commonwealth of Massachusetts �0� � ��N N��^�� w�� N�� m��mn �-��mmmm - Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2S Sunset Rock Road Property Address Al Grimes Owner Owner's Name inhonnahonio North Andover MAO1845 3-14-2019 mquimdfnrmm� ��-- omp'�ur�e�� paqe� ~.�'.~.. _- _ _ Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist atthe end #f the form. Important:When A. U�� U��KD�00��~��n �||ingout�nnu ^ ~~ ^Inspector Information — on the computer, use only the tab Neil James B"="""' ' key to move your Name mInspector cursor-do not Bateson Enterprises Inc. 't, use the return key. 111-Argilla Road Company Address - «�--� Andover MA 01810 /11 City/Town State Zip Code 078-475-4788 S|-15 | Telephone Number License Number / B. Certification | oertif that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CM R 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 nyshem: 1. Z Pe0000 2. Fl Conditionally Passes 3. 0 Needs Further Evaluation by the Local Approving Authority 4. []dFils 3-14-2O1Q 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 mn different conditions of use. ,o/nsp^=^m°.7/26u018 Title o Official Inspection Form Subsurface Sewage Disposal System^Page 1w,v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 25 Sunset Rock Road Property Address Al Grimes Owner Owner's Name information Is North Andover MA 01845 3-14-2019 required for every �_-- _ ._-------..----_.-_-- page. City/Town State Zip Code rate of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I 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: El 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 Hoard 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. i 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. ❑ Y ❑ N ❑ ND (Explain below): I 15insocloc•rev.7/2,6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage disposal System•Page 2 of 18 Commonwealth of Massachusetts Title f i i l Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °4 25 Sunset Rock Road Property Address Al Grimes Owner Owner's Dame information is North Andover MA 01845 3-14-2019 1 required for every — -------� .. --� - �_._..__ _.. page. State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Rump 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 El Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed El Y ❑ N ❑ ND (Explain below); ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): E] 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 3 of 18 � ~ /�~ Commonwealth of Massachusetts U� ��N�� `��~��~��N N��~�� 0°�nMV Title �� Official 0 Inspection��0�� m 0-��mmmm �� m � �� ' Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 25 Sunset Rock Road Property Address A] Grimes Owner Owner's Name |nhonnationi's North Andover MA 01845 3-14-2019 required for every __- page. ~',''.~. State Zip Code Date _ Inspection C. Inspection Summary (cont.) [l Cesspool or privy is within SO feet ofa surface water Fl Cesspool or privy is within 5O feet ofa bordering vegetated wetland oro salt marsh h. System will fail unless the Board of Health band Public Water Supplier, If any) determines that the system hm functioning ima manner that protects the public health, safety and environment: Fl The system has a septic tank and soil absorption system (SAS) and the SAS is within 100feet of surface water supply mr tributary tno surface water supply. Fl The system has o septic tank and SAS and the SAS |a within o Zone 1 ofa public water supply. El The system has a septic tank and SAS and the SAS is within 50 feet ofo private water supply well. [l 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 vve||^^ 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. o. Other: 4) System Failure Criteria Applicable toAll Systems: You must indicate "Yes" mr"Nw"to each ef the following for all I/s : Yes No �7 �� Backup of sewage into haoi|hxor system oonlponantdue b) overloaded or �� clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to3n overloaded or clogged SAS orcesspool emsp,00e',ov.7126a018 Title o Official inspection Form:Subsurface Sewage Disposal System^Page*m1* Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form » Not for Voluntary Assessments 25 Sunset Rock Road Property-Address Al Grimes —------------- Owner Owners Name information is required for every North An MA 01845 3-14-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No 0 M 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 1/2 day flow El 0 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. El E 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 19 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. El Z The system falls. 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 E-1 El the system is within 400 feet of a surface drinking water supply 1-1 R the system is within 200 feet of a tributary to a surface drinking water supply F-1 F1 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 15!nsp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 16 Commonwealth of Massachusetts b ITm❑ Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Sunset Rock Roadw - Property Address Al Grimes Owner Owner's Name information is North Andover MA 01845 3-14-2019 required for every .__.. _ __ __.._..___.— --- page, Clty/town State Zip Code Date of Inspection C. Inspection Summary (cant.) 1 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? ED ❑ 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)] t5insp.doc•rev,712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts H T "L Off ie 5 icial Inspection Form EF i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25 Sunset Rock Road Property Address A[Grimes --------- Owner bwner's Name information i MA 01845 3-14-2019 is required for every North Andover - 7------- ------- page. ;571t-yfrown'--- State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 Description: ---------- ------- .......... Number of current residents: Does residence have a garbage grinder? Z Yes El No Does residence have a water treatment unit? R Yes Z No If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection [] Yes 0 No information in this report.) Laundry system inspected? D Yes F] No Seasonal use? El Yes Z No Water meter readings, if available (last 2 years usage (gpd)): Detail, ------------- Sump pump? El Yes Z No Last date of occupancy: CurrentDate t5insp,doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of Is Commonwealth of Massachusetts T _: _ Title ffii l l Inspection Form =- Subsurface Sewage disposal System Form Not for Voluntary Assessments 25 Sunset Rack Road _.._...-- Property Address Al Crimes Owner Owner's Name information is North Andover MA 01845 3-14-2019 required for every _...__._ _ page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 2. Commercial/industrial Flaw 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? ❑ Yes ❑ 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; Pumped 2018, owner Source of information: _ Was system pumped as part of the inspection? ❑ Yes Z No If yes, volume pumped: gallons — How was quantity pumped determined? Reason for pumping: ---- t5insp,doc-rev,7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 � x�^ Commonwealth of Massachusetts ��*^�N�� `��N �� U��h� NN�� =�� mm�p��w�N�� m 0—��mmmm ' Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 25 Sunset Rock Road OroOerty Address Al Grimes Owner Owner's Name information is required for every North Andover MAO1D45 3-14-2018 Code Date of Inspection page. ~'^r'~''. State Zip D. System Information (cont.) 4. Type ofSystem: Septic tank, distribution box, soil absorption eyeham El Single cesspool Fl Overflow cesspool 0 Privy El Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to he obtained from system owner) and e copy oflatest inspection of the |A\system bv system operator under contract El Tight tank. Attach a copy of the DEPapproval. [l Other(describe): Approximate age of all components, date installed (if known)and source of information: 23 years olq 9-231996 as builtplan Were sewage odors detected when arriving at the site? Yes No 5. Building Sewer (locate on site plan): 1.8 Depth below grade: ------ Material of construction: D cast iron 40PVC other(explain): Distance from private water supply well nr suction line: feet Comments (on condition of joints, venting, evidence of leakage, etn]: 4" PVC through wall [O septic tank, 3" PVC iO house, Do leaks visible. m/°w.doo'rev./a6u0/0 Title s Official Inspection Form:Subsurface Sewage Disposal System^Page yw10 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25 Sunset Rock Road Property-Address Al Grimes Owner Owner's Name information is required for every North Andover MA 01845 3-14-2019 page, Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 0.6 Depth below grade: feet—--------- Material of construction: El concrete El metal n fiberglass El 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: 10'x 5'x 4' ------- W Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle 33" ...................------------ lit Scum thickness ---------- 811 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1411 How were dimensions determined? Take 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. . ------------ —------- t5insodoc-rev.712612018 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25 Sunset Rock Road Property-Address----, Al Grimes Owner Owner's Name information is required for every North Andover MA 01845 3-14-2019 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: El concrete n metal n fiberglass El polyethylene F1 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: 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: El concrete El metal n fiberglass El polyethylene n other(explain): ------------ ........ Dimensions: Capacity: -.gallons Design Flow: gallons per day t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title f i i l Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ry 25 Sunset Rock Road Property Address Al Grimes Owner Owner's Name information is North Andover MA 01845 3-14-2019 required for every _ _ page Cltyfrown State Zip Code Date of Inspection D. System Information (cost.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: — — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date --..___.__._ _._. 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 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. 1 I t5insp.doc rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Y Title 5 Official Inspection Farm = n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Sunset Rock Road Property Address Al Grimes Owner Owner's fume information is required for every North Andover MA 01845 3-14-2019 page. CityfTown State Zip Code Date of Inspection D. System Information (cant.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes E] No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number; _..__.._..._._._ ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 77' ❑ leaching fields number, dimensions: - _---.--- overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp,doc-rev,712612018 "title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pane 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25 Sunset Rock Road Proy Address Al Grpert imes ——------------- Owner Owner's Name information is North Andover MA 01845 3-14-2019 required for every Date of Inspection page. -Citjlfr-oWn State Zip Code D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of poncling, 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 ❑ No Comments (note condition of soil, signs of hydraulic failure, level of poncling, condition of vegetation, etc.): 15insp.doc•rev.712612018 Title 5 Offi6al Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25 Sunset Rock Road Property Address Al Grimes Owner Owner's Name information is North Andover MA 01845 3-14-2019 required for every State Zip Code --Date of._._I.__.Inspection ........... page. CItylTown 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.): ----------- ------------------- t5insp.cloc-rev.712612018 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 25 Sunset Rock Road Property Address Al Grimes Owner Owner's Name information is North Andover MA 01845 3-14-2019 required for every page. d_ty_rr;6w_n 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: hand-sketch in the area below drawing attached separately '3DIS E)4`1 7 eAv ,C)-P)O)C -7, S cl t5insp.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25 Sunset Rock Road Property Address Al Grimes Owner Owner's Name information is required for every North Andover MA 01845 3-14-2019 page. City[T.own State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope Surface water Check cellar Shallow wells Estimated depth to high ground water: 4 tit...................-f Please indicate all methods used to determine the high ground water elevation: F1 Obtained from system design plans on record 5-4-1994 If checked, date of design plan reviewed: F1 Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Design plan ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. ------ ---------- ---------- ............ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7126/2018 Title 5 Official inspection Forn Subsurface Sewage Disposal Systern,Page 17 of 16 Commonwealth of Massachusetts x __ ✓_ mm. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments S 25 Sunset Rock Road Property Address Al Grimes Owner Owner's Name information is North Andover MA 01845 3 14-2019 required for every _ _ —.._....... page Cltyfrown 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. Z 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 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 15insp.doe•rev.712812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Summary Record Card generated on 3/1512019 10:39:36 AM by Joanna Sallb Page 1 Town Of North Andover Tax Map # 210-106.A-0219-0000.0 Parcel Id 17360 25 SUNSET ROCK ROAD GRIMES, ALLEN F. Since Jan 2018 GRIMES, DIANE M. 25 SUNSET ROCK ROAD NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential 1 Zoning2 1 Residential Zoning3 1 Residential Size Total 1.34 Acres FY 2019 UB Mailing Index Name/Address Type Loan Number Active/inact. From Until ALLEN&DIANE CRIMES Owner Active 25 SUNSET ROCK ROAD NORTH ANDOVER,MA 01845 FIERAMOSCA, MICHAEL Previous Customer Inactive 5/19/2008 25 SUNSET ROCK ROAD NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17681.0-25 SUNSET ROCK ROAD Last Billing Date 1/16/2019 3170351 03 Cycle 03 Active UB Services Maint. Account No, 3170351 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE 87.10 /1 UB Meter Maintenance Account No.3170351 Serial No Status Location Brand Type Size YTD Cons 35078163 a Active ERT HH METE METE w Water 0.63 0.63 2261 Date Reading Code Consumption Posted Date Variance 3/8/2019 2313 aActual 18 -17% 12/10/2018 2295 a Actual 22 1/22/2019 -74% 9/12/2018 2273 a Actual 89 10/15/2018 267% 6/11/2018 2184 aActual 25 7/23/2018 56% 3/7/2018 2159 a Actual 15 4/23/2018 -61% 12/7/2017 2144 aActual 37 1/25/2018 -46% 9/12/2017 2107 a Actual 77 10/18/2017 269% 6/8/2017 2030 a Actual 20 7/25/2017 38% 3/8/2017 2010 a Actual 14 4/12/2017 -59% 12/9/2016 1996 aActual 35 1/23/2017 -79% 9/9/2016 1961 a Actual 159 10/24/2016 221% 6/13/2016 1802 a Actual 54 8/2/2016 216% 3/9/2016 1748 a Actual 16 4/22/2016 -62% 12/10/2015 1732 aActual 43 1/20/2016 -58% 9/9/2015 1689 aActual 101 10/16/2015 84% 6/10/2015 1588 a Actual 55 7/24/2015 240% 3/11/2015 1533 aActual 16 4/28/2015 -33% 12/11/2014 1517 a Actual 24 1/15/2015 -80% 9/11/2014 1493 aActual 123 10/15/2014 208% 6/11/2014 1370 aActual 40 7/16/2014 204% 3/11/2014 1330 aActual 13 4/11/2014 -70% 12/10/2013 1317 aActual 42 1/17/2014 -50% 9/12/2013 1275 a Actual 86 10/15/2013 55% 6/12/2013 1189 a Actual 55 7/24/2013 165% 3/13/2013 1134 a Actual 21 4/22/2013 -3% �HG NTty 1- 97 Town of North Andover HEALTH DEPARTMENT �SSACNUSEA 9 CHECK.##: , `49 DATE: ,. LOCATION CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ • Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ __ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $.____... ❑ Well Construction $ SEPTIC Systems: ❑ Septic-W.Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector Title 5 Report ° q„n ❑ Other:(Indicate). __ $ I-e'41th Agent Initials White-Applicant Yellow-Health :Fink Treasurm- 1