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Home My WebLink AboutConditional Pass - Title V Inspection Report - 135 ACADEMY ROAD 11/19/2019 I` i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 135 Academy Road Property Address David Pickul Owner Owner's Name information is North Andover MA 01845 11-5-2019 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altgred in any way. Please see completeness checklist at the end of the form. G�wG Important:When filling out forms A. Inspector Information N�V 191 QOV 'i on the computer, PN use only the tab Neil James Bateson NOON tutF key to move your Name of Inspector 0 DE cursor-do not NF��N I' use the return Bateson Enterprises Inc. Company Name key. 111 A A Road r� Company Address Andover MA 01845 IL City/Town State Zip Code 978-475-4786 SI-15 Telephone Number License Number j 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: j 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails C. 11-5-2019 _ Inspector's Sig ature 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 I 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate i 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I II Commonwealth of Massachusetts i, Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 135 Academy Road Property Address David Pickul Owner Owner's Name information is required for every North Andover MA 01845 11-5-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary ection Summary: Ins lete 1 2 3, or 5 and all of 4 and 6. III I, p rY Comp 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: I i 2) System Conditionally Passes: I' ® 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): is I t5insp.doc•rev.7/26/2018 Title 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 135 Academy Road Property Address David Pickul f Owner Owner's Name E. information is North Andover MA 01845 11-5-2019 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. I ❑ 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): I ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): I ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): i ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): I I i ❑ 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): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): I, 3) Further Evaluation is Required by the Board of Health: i ❑ 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 'v j - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Academy Road Property Address David Pickul Owner Owner's Name information is North Andover MA 01845 11-5-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: *"This system passes if the well water analysis, performed at a 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: Riser cover on septic tank&d-box needs to be replaced i i 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: i Yes No El ® Backup 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 Form:Subsurface Sewage Disposal System•Page 4 of 18 I. i Commonwealth of Massachusetts l Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Academy Road Property Address David Pickul Owner Owner's Name information is required for every North Andover MA 01845 11-5-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ElStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 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. ❑ ® 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. ❑ ® 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 systemllthe 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 El ❑ 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 it t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts r p Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary As sessments 135 Academy Road Property Address David Pickul Owner Owner's Name information is required for every North Andover MA 01845 11-5-2019 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) jll I 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? ❑ Y P Have large volumes of water been introduced to the system recently or as part of El ® 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? i ® ❑ 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)] �i I I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` ., 135 Academy Road Property Address David Pickul Owner Owner's Name information is� required for every North Andover MA 01845 11-5-2019' page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A Description: i 2 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: I Sump pump? ❑ Yes ® No Current Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 i I; Commonwealth of Massachusetts p Title 5 Official Inspection Form 1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 135 Academy Road Property Address David Pickul Owner Owner's Name information is required for every North Andover MA 01845 11-5-2019 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? ❑ 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: 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: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �y Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Academy Road Property Address David Pickul Owner Owner's Name information is required for every North Andover MA 01845 11-5-2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Tank original, d-box & leach area 7-14-1970 as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 5 Depth below grade: feet Material of construction: ® cast iron ❑ 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" Cast Iron through wall l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� �. � 135 Academy Road Property Address David Pickul Owner Owner's Name information is required for every North Andover MA 01845 11-5-2019 page. Cityfrown State Zip Code Date of Inspection Li D. System Information (cont.) i, 6. Septic Tank(locate on site plan): Depth below grade: 4 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 Dimensions: 6' x 4' Sludge depth: 2 - Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 13" 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.): i Inlet baffle ok. Outlet baffle ok. Depth of liquid at outlet invert. No evidence of leakage. Risers and cover in bad shape, needs to be replaced. t5insp.doc•rev.7/26/2018 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 135 Academy Road Property Address David Pickul Owner Owner's Name information is required for every North Andover MA 01845 11-5-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): III 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: gallons Design Flow: gallons per day III t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts r : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Academy Road Property Address David Pickul Owner Owner's Name information is North Andover MA 01845 11-5-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No i Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I I, *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 'i 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 light carryover. Evidence of leakage, liquid level below outlet inverts. D-box& riser needs to be replaced. t 1 ''. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts _ x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ...........c 135 Academy Road Property Address David Pickul Owner Owners Name information is required for every North Andover MA 01845 11-5-2019 _._. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ 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. I 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): i If SAS not located, explain why: I i Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 6 trenches 33' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �x ,e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. 135 Academy Road Property Address David Pickul Owner Owner's Name information is required for every North Andover MA 01845 11-5-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetaion ok. No sign of ponding to surface. i 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 i Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doe•rev.7/26/2018 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 f 135 Academy Road Property Address David Pickul Owner Owner's Name information is required for every North Andover MA 01845 11-5-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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.doc-rev.7/2 612 0 1 8 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 11 4l` 135 Academy Road Property Address David Pickul Owner Owner's Name information is required for every North Andover MA 01845 11-5-2019 j page. City/Town State Zip Code Date of Inspection D. System Information (cont.) j ; 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 (' Ui 0 I L' Li I'. 'i. I I N t t 33511 1 j t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 19 {i Ifi - Commonwealth of Massachusetts i Title 5 Official Inspection Form = w, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Academy Road Property Address David Pickul Owner Owner's Name information is required for every North Andover MA 01845 11-5-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) j 15. Site Exam: ® Check Slope Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 1.3 to 3' 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: Date i ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ' I !I ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database -explain: I Eseex County Soil Map You must describe how you established the high ground water elevation: Essex county Soil Map, Sheet#30, Woodbridge Soil, Water 1.3' to 3'deep. System is elevated in rear yard above water table I ' i l 1 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 135 Academy Road Property Address David Pickul Owner Owner's Name information is required for every North Andover MA 01845 11-5-2019 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 i For 15: Explanation of estimated depth to high groundwater included i r; 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Town of North Andover Tax Map # 210-096.0-0039-0000.0 Parcel Id 15876 135 ACADEMY ROAD PICKUL, DAVID 135 ACADEMY ROAD N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 0.961 Acres FY 2020 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until PICKUL, DAVID Payor Active 135 ACADEMY ROAD N.ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18555.0-135 ACADEMY ROAD Last Billing Date 10/3/2019 3180729 03 Cycle 03 Active UB Services Maint. AccountNo. 3180729 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE -11.40 /1 UB Meter Maintenance Account No.3180729 Serial No Status Location Brand Type Size YTD Cons 3180729 a Active 00 HH#135 METE METE w Water 0.63 0.63 1026 Date Reading Code Consumption Posted Date Variance 9/17/2019 2232 a Actual -3 10/10/2019 -111% 6/26/2019 2235 m Manual estimate 33 7/25/2019 102% MSG 3/19/2019 2202 m Manual estimate 16 4/16/2019 -8% 12/12/2018 2186 a Actual 16 1/22/2019 -11% 9/14/2018 2170 a Actual 19 10/15/2018 -44% 6/12/2018 2151 a Actual 33 7/23/2018 194% 3/12/2018 2118 m Manual estimate 10 4/23/2018 -20% 12/20/2017 2108 m Manual estimate 15 1/25/2018 -38% MSG 9/13/2017 2093 a Actual 21 10/18/2017 33% 6/20/2017 2072 m Manual estimate 19 7/25/2017 62% MSG 3/10/2017 2053 a Actual 10 4/12/2017 -5% 12/13/2016 2043 aActual 11 1/23/2017 -50% 9/13/2016 2032 a Actual 22 10/24/2016 16% 6/14/2016 2010 a Actual 19 8/2/2016 37% 3/15/2016 1991 a Actual 14 4/22/2016 10% 12/14/2015 1977 aActual 13 1/20/2016 -47% 9/11/2015 1964 aActual 23 10/16/2015 53% 6/15/2015 1941 a Actual 15 7/24/2015 -2% 3/19/2015 1926 a Actual 16 4/28/2015 32% 12/17/2014 1910 aActual 12 1/15/2015 -18% 9/17/2014 1898 a Actual 15 10/15/2014 -24% 6/16/2014 1883 a Actual 19 7/16/2014 12% 3/18/2014 1864 a Actual 17 4/11/2014 -21% 12/18/2013 1847 a Actual 22 1/17/2014 -37% 9/17/2013 1825 a Actual 35 10/15/2013 88% 6/17/2013 1790 a Actual 19 7/24/2013 2% 3/15/2013 1771 a Actual 18 4/22/2013 -5% Of MON7/r,M 87 '_ . O • Town of North Andover S.,..U`+tt HEALTH DEPARTMENT �SgCN CHECK#: 27oz DATE: a/g LOCATION: Zi : H/O NAME: /"i Cc CONTRACTOR NAME: S�� 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 $ ❑ Tras4lSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector CC>r)Gk $ 0 Title 5 Report ()�,5J $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer