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HomeMy WebLinkAbout- Title V Inspection Report - 487 WINTER STREET 4/3/2019 Commonwealth of Massachusetts - Title Official Inspection Form1 � 'fM ` subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p y y 487 Winter Street r*f Property Address <1 Elaine Haddad i1 Owner Owner's Name_. ...__—__.w.. information is North Andover MA 01845 3-27-2019 required for every __ _-. _.._._ _ _.�_._ ___ _. ... - City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When 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 ------ompany Name key. C 111 Argilla Road r Company Address Andover MA 01810 City/Town State Zip Code r�rn 978-475-4786 S115 Telephone Number License Number B. Certification I certify that: I am a DEiP 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. Needs Further Evaluation by the Local Approving Authority 4. Fail 3-27-2019 s ct is Sign a 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 the buyer, if applicable, and the approving authority. 1 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. 15iosp.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 487 Winter Street -___— Property Address Elaine Haddad — owner owner's Name information is North Andover MA 01$45 3-27-2019 required for every Mort._._— page City/Town 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: ❑ 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: ❑ 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. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/2 61201 8 Title 6 Ofriciat Inspection Form;Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts . Title wtNe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 487 Winter Street Property Address Elaine Haddad Owner Owner's Name iuf»nnat|mniu required for every North Andover MA 01845 3-27-2019 State Zip Code Date of Inspection page. ~',''—.. C. Inspection Summary (cont.) 2\ System Conditionally Passes (cmni): R Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpx/a|annnana repaired. R Obnemodonof sewage backup or break out or high static water level |n the dintribuUonbox 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): R broken pipe(s) are replaced [l Y F1 N [] ND (Explain below): F-1 obstruction is removed El Y El N NO (Explain below): distribution box is leveled or replaced Y F| N ND (Explain bS|ovv\: The system required pumping more than 4 times a year due to broken or obstructed p|pe(u). The system will pass inspection |f(with approval of the Board ofHaa|th): El broken pipe(s) any replaced El Y R N El ND (Explain below): �l obstruction iuremoved El Y 0 N [l ND (Explain be|ow>: 3) Further Evaluation is FKwqu1omd by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system im failing to protect public health, safety or the environment. m. System will pass unless Board of Health determines in accordance with 310 CMR 15.3O3/1\/b\that the system is not functioning |nm manner which will protect public health, safety and the environment: ,am"v.o"p^rev.romnv^o Title oomo/m Inspection Form:Subsurface Sewage Disposal System^Page ow1n Commonwealth of Massachusetts Title 5 Official Inspection Farm T a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 487 Winter Street .................tee...._ ...,...___ ......_.. Property Address Elaine Haddad Owner Owner's Name information is er MA 01845 3-27-2019 required for every North Andover_.-. _. __.......___.__ ..---�.._w_... ...___ ._ page City/Town State4 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. a 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 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 ® ElBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool © ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection corm:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts ^ Tit~�~*��N�� �� �~����~��~��N 0������������~���� ����U���� le �� �°�� � ���N��N Nmm���m�����0�*� � Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 487 Winter Street Property Address Elaine Haddad Owner Owmo/aName information iu North Andover MA 01845 3-27-2019 required for every \��—' Zip Code Date of Inspection page. ~'`'''own C. Inspection Summary (cont.) 4) System Failure Criteria Applicable bm All Systems: (omnt.) Yes No �� Static liquid level in the distribution box above outlet inwa�due toonowadouded �� �� n/clogged SAS or cesspool �� �� Liquid depth in cesspool io less than 8" ba|nvw|nved uravmi|8Nnvo|Vnoeialess �� �� than 1/2deyflow Fl �� �<equiredpumping more than 4Ummsin the last year NCJTdue tV clogged or �� �� obstructed pipe(s). Number oftimes pumped: El Z Any portion of the SAS, cesspool or privy is below high ground water elevation, �� �� Any po�|onof cesspool or privy isvviihim1OO feet nfasu�aoemu*ter supply or � �� �" tributary tma surface water supply. � � l �� Any po�ionnfa cesspool or privy isvvithine Zone 1 of public water supply � �� �� well. F] 0 Any portion of a cesspool or privy is within 60 feet of a private water supply well. | El Z 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 ataDEPcertified laboratory,for fecal cm|itmrrn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal toor less than 6 ppnm, provided that no other failure criteria are triggered. A copy of the analysis and chain mf custody must hmattached tm this Ymrm.] �l �� Theaynhemisaoeoopoo| uemingahaoi|itywithadnoiOnf|owof20OOgpd- �� �� 10,000gpd. �� �� The system | have determined that one ur more ofthe above failure �� �� criteria exist aodescribed in 310 CW1R 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary ho correct the failure. 5\ Large Systems: To he considered a large system the system must serve m facility with a design flow of10,0000pd tm16.0DUgpd. 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 �l �l the system is within 400 feet ofa surface drinking vvebor supply [l �� the system is within 200 feet of a tributary to a surface drinking water supply �� �� the system is located iOa nitrogen sensitive area (Interim VVa||headProtection �� �� Area—|VVPA) Or8 mapped Zone || Vfa public water supply well Commonwealths of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 487 Winter Street Property Address Elaine Haddad Owner Owner's Name information is MA 01845 3-27-2019 North Andover required for every �.. page City! own 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.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 NIA) ® ❑ 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)] t5lnsp.doe•rev.712612,018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts __❑� Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 487 Winter Street Property Address Elaine Haddad---,--..-------- Owner Owner's Name information is North Andover MA 01$45 3-27-2019 required for every .. page City/Town T _— - State Zip Code Date of Inspection - i 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): 440 Description: 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Z No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): ------ — - Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insp.doc•rev.712812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 487 Winter Street Property Address Elaine Haddad Owner Owner's Name information is MA 01845 3-27-2019 required for every North Andover page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes El No Water treatment unit present? ❑ Yes n No If yes, discharges to: Industrial waste holding tank present? El Yes E] No Non-sanitary waste discharged to the Title 5 system? El Yes E] No Water meter readings, if available: Last date of occupancy/use: Other(describe below): 3. Pumping Records: Source of information: Pumped three years, owner Was system pumped as part of the inspection? EJ Yes E No If yes, volume pumped: ig_al_1onS­_____________­ ............. How was quantity pumped determined? Reason for pumping: ---------- 15insp.doc-rev,7126/2018 'Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 8 of 16 � � CmM0NNK»nmmea|th of Massachusetts � ~�"���N�� 0� ��^��'���°��N 0����������������� ������nMh ^ � N�0�� �� ��'N � N��0��N Nmm���������N��mm Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4O7 Winter Street Property Address Elaine Haddad Owner Owom/uName information im North Andover MAO1845 3-27-2019 �quimdfor every State Zip Code Date of Inspection page. ~'^'''—~' D. System Information (cont.) 4. Type of System: z Septic tank, distribution box, soil absorption system FJ Single cesspool [l Overflow cesspool [] Privy Fl Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology, Attach a copy ofthe current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the |/4 system by system operator under contract El Tight tank. Attach @ copy of the DEPapproval. [] Other(describe): ApproxinnateageofmUoornponent . dab+ inetaUed (ifknovvn) ondsourcenfinfVrn1ation: Tank oriainal, d-box & leach area 27 years old, 5141902 b i|t plan Were sewage odors detected when arriving at the site? Yes No S. Building Sewer(locate on site p|an): 2 Depth below grade: feet Material ofconstruction: 0 cast iron Z4OPVC other (explain): OimhanoehomprivatevvahermuppWwe| ormunUnn |ina: feet Comments (on condition uf joints, venting, evidence Of leakage, etC]: 4" Cast |[On UlnDUgh VVaU' 3" PVC in house, OO leaks visible umsp.*m^rev.7/2612018 Title o Official Inspection mrm�Subsurface Sewage Disposal System'Page ou1n | � Commonwealth of Massachusetts m❑ ---- Title 5 Official Inspection Form mm- W Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 487 Winter Street Property Address Elaine Haddad Owner Owner's Name mfV— information is MA 01845 3-27-2019 North Andover required for every -�_ _ ._.-- _.__._— _._.... — page City/Town State Zip Code Date of Inspection D. System Information (cunt.) 6. Septic Tank(locate on site plan): 1.6 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: _....__-- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 7' x5' x4' Dimensions: _.............. _..._— 2" Sludge depth: 30„ Distance from top of sludge to bottom of outlet tee or baffle --- - - - 6, Scum thickness 8" Distance from top of scum to top of outlet tee or baffle --- --- 11" Distance from bottom of scum to bottom of outlet tee or baffle ---- — - — How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet bafffle ok. Outlet tee ok. Depth of liquid above outlet invert. Camera outlet pipe to d-box and found box flooded, No evidence of leakage. i _._�...__ -._._.--. I t5insp.doc+rev.712612018 Title 5 Official Inspection farm:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 487 Winter Street —Property Address Elaine Haddad Owner owner's Name ­--'------ information is 1845 3-27-2019 required for every North Andover MA 0 -Date of In"P �t-- page. Cityrrown State Zip Code ton D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: Material of construction: F] concrete ❑ metal El 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: batfe"­­­ 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 ❑ fiberglass ❑ polyethylene El 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 5 Official Inspection Form 'A Subsurface Sewage Disposal System Form Not for Voluntary Assessments 487 Winter Street Property Address Elaine Haddad Owner Owner's Name information is MA 01845 3-27-2019 required for every North Andover State Zip Code Date of Inspection page. d7lt�ifo—wn D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: D Yes El No Alarm level: Alarm in working order: El Yes [I No Date of last pumping: Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? El Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 6" 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 cover broken, replaced. D-box flooded above all inverts 6". D-box in bad shape, heavy corrosion. ---—-------- t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 16 Commonwealth of Massachusetts -- � ~ N Inspection �� ��°��N�� �� �~����N��N��� ������������N���� �~��H���� mm�m�� �� ~�~ pmw���~� � ~����~~ _ -- - - Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 487 Winter Street Property Address Elaine Haddad Owner Owne/mNmme information is North Andover MA 01845 3-27-2019 required for every Yafe of inspection page. ~'`''-- D. System Information (cont.) 10. Pump Chamber(locate mn site p|an): Pumps in working order: [l Yes i] No* Alarms in working order: ���� Yea �|l� No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ° |f pumps or alarms are not in working order, system isa conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): |f SAS not located, explain why: Type: [� leaching pits number: �l leaching chambers number: El leaching galleries number: F� leaching trenches number. length: leaching fields number, dimensions: 1 field 20' x45' F1 overflow cesspool number: |( innovetive/a|hernativemymtenl Type/name oftechnology: m/nsn.00c'rev.nmmwu Title o Official Inspection Form:Subsurface Sewage Disposal»v"*m^Page 1uu1n C Commonwealth of Massachusetts =:- Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form Not for Voluntary Assessments �. 487 Winter Street —.._...._-._.. .�_. - Property Address Elaine Haddad Owner Owner's Name information is North Andover NIA 01845 3-27-2019 required for every page. Clty/Tawn _ _ State Zip Code Date of Inspection D. System Information (cons) 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. Evidence of hydraulic failure of leach area, liquid above inverts in d-box. 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.): t5insp.doc rev.7126/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 487 Winter Street Praperi—y—Address Elaine Haddad Owner Owner's Name information is MA 01845 3-27-2019 required for every North Andover -2$1 -do—de page. Cityrrown State 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.): t5msp,doc•rev.712612018 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Z Subsurface Sewage Disposal System Form Not for Voluntary Assessments 487 Winter Street ----------- Property Address Elaine Haddad ....... Owner Owner's Name information is MA 01845 3-27-2019 required for every North Andover 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: E hand-sketch in the area below M drawing attached separately we 4K t6lnsp,doc rev.7/26/2018 "rifle 5 Official inspection Form,Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - A Subsurface Sewage Disposal System Form Not for Voluntary Assessments °4 487_Winter Street Property Address Elaine Haddad -- — Owner Owner's Name information is North Andover NIA 01845 3-27-2019 required for everypage _..—_...__�... w— equi GIty/Town __. State .m_. 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: fee#_.__� 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: 4—Dateate 92 _^ —_.....__..__ ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Desi n olan ❑ 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. Shows ground water at 8'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp,doc rev.712612018 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 x 487 Winter Street Froperty Address Elaine Haddad Owner Owner's Name information is North Andover MA 01845 3-27-2019 required for every �r. _ _.._.__— _._�.. —. ._—...__.__—... page Clty/Town � -- �w — 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 ® 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 it 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Summary Record Card generaled on 41112019 1:32:64 PM by Joanna Salib Page 1 Town of North Andover Tax Map # 210-104.A-0071-0000.0 Parcel Id 16298 487 WINTER STREET HADDAD, WILLIAM P Since Jan 2003 ELAINE M HADDAD 487 WINTER STREET 1 NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential 3 1 Residential Zoning2 1 Residential Zonin g Size Total 1.01 Acres FY 2019 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until HADDAD,WILLIAM R Payer Active 487 WINTER STREET N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg id. 18012.0-487 WINTER STREET Last Billing Date 1/16/2019 3180041 03 Cycle 03 Active UB Services Maint. Account No.3180041 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE 137.05 /1 UB Meter Maintenance Account No.3180041 Serial No Status Location Brand Type Size YTD Cons 32707714 a Active 00 b Badger w Water 0.63 0.63 1564 Date Reading Code Consumption Posted Date Variance 3/12/2019 1821 a Actual 21 -33/o 12/12/2018 1800 a Actual 31 1/22/2019 -32% 9/14/2018 1769 a Actual 48 10/15/2018 124% 6/1212018 1721 a Actual 21 7/23/2018 7% 3/12/2018 1700 a Actual 19 4/23/2018 -35% 12/13/2017 1681 aActual 30 1/25/2018 -55% 9/13/2017 1651 a Actual 68 10/18/2017 227% 6/12/2017 1583 a Actual 21 7/25/2017 -6% 3/10/2017 1562 a Actual 21 4/12/2017 -49% 12/12/2016 1541 aActual 43 1/23/2017 -37% 9/12/2016 1498 a Actual 65 10/24/2016 109% 6/17/2016 1433 a Actual 34 8/2/2016 92% 3/14/2016 1399 a Actual 17 4/22/2016 -37% 12/1412015 1382 a Actual 28 1/20/2016 -64% 9/11/2015 1354 a Actual 77 10/16/2015 345% 6/11/2015 1277 aActual 16 7/24/2015 -27% 3/18/2015 1261 a Actual 24 4/28/2015 -27% 12/15/2014 1237 aActual 32 1/15/2015 -48% 9/16/2014 1205 a Actual 66 10/15/2014 123% 6/12/2014 1139 aActual 28 7/16/2014 11% 3/13/2014 1111 aActual 25 4/11/2014 -23% 12/13/2013 1086 aActual 33 1/17/2014 -58% 9/13/2013 1053 a Actual 78 10/15/2013 71% 6/14/2013 975 a Actual 43 7/24/2013 94% 3/20/2013 932 a Actual 25 4/22/2013 -9% 12/13/2012 907 aActual 24 1/9/2013 -68% 9/19/2012 883 a Actual 81 10/15/2012 131% 1 6/18/2012 802 a Actual 34 7/16/2012 66% 3/20/2012 768 a Actual 21 4/14/2012 19% "ptbR7Mw m,a,F ,:.. 3 Town of North,Andover NT �`S�ACW14MSt� HEALTH DEPAwrME CHECK#: DATE: ° 1 CONTRACTOR NAME. � ��� ��� -(9 Tvve of Permit or License: (Check box) ❑ AnimalAnimal ,. ❑ Body Art Establishment _ ❑ Body Ail Practitioner $ ❑ Dunipster . ❑ 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 Construction(DWC) ❑ Septic Disposal Works Installers(DWI) 0 Title 5 Inspector $ _ Title 5 Report ❑ Other:(Indicate)..---,.- $ _ ._aith Agent Initials White Applicant Yellow-Ilealth Pink- Treasurer