HomeMy WebLinkAboutconditional pass - Title V Inspection Report - 1761 SALEM STREET 6/15/2020 Commonwealth of Massachusetts
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W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is required for every North Andover Ma 01845 5/21/20
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be alte,g��d in any
way. Please see completeness checklist at the end of the form. REC'E'vEV
Important:When A. General Information 11 2
filling out forms �UN 15
on the computer, W VA
use only the tab 1 ,.,u�,1 OF��
. Inspector: ptAE�
key to move your �v"
cursor-do not Dean Dynan
use the return Name of Inspector
key.V11 Company Name
2 Suntaug Street
Company Address
Lynnfield Ma 01940
City/Town State Zip Code
508-726-9935 S 112837
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
n GL
pector s ignature 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 is a shared system or
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 should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1761 Salem Street _
Property Address
1761 Salem Street Realty Trust_ _
Owner Owner's Name
information is North Andover _ Ma 01845 5/21/20
ery required for eve.,
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) 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:
B) 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):
t51ns•3i13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is required for every North Andover Ma 01845 5/21/20
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
® 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
Concrete outlet baffle of tank is corroded and broken need to be replaced with PVC T/gas baffle
D Box is cracked and corroded sidewalls and cover/needs to be replaced with like and kind D Box
See pics attached
❑ 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):
C) 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.
1. 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:
❑ 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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner _ _ -
Owner's Name
information is required for every North Andover _ Ma 01845 5/21/20
page. CityrTown State Zip Code Date of Inspection
B. Certification (cont.)
2. 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.
3. Other:
D) 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
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
❑ ® 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 'Y2 day flow
t5ins•3,'13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner — --
Owner's Name
information is required for every North Andover Ma 01845 5/21/20
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 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 2000gpd-
10,000gpd.
❑ ® 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.
E) 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 D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 1761 Salem Street
Property Address
1761 Salem Street Realty Trust _
Owner Owner's Name
information is North Andover Ma 01845 5/21/20
required for every _
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3 -
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 450 GPD
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is North Andover Ma 01845 5/21/20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
3 bedroom single family dwelling 1500 gallon tank with pipe in stone 1000sgft drainfield
Number of current residents: vacant
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes Z G1No�
Water meter readings, if available (last 2 years usage (gpd)): ja i�s �
Detail:
go
, ��
Sump pump? ❑ Yes ® No
Last date of occupancy: D
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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is required for every North Andover Ma 01845 5/21/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Homeowner/ Board of Health
last pumped 6 months ago as per homeowner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is required for every North Andover Ma 01845 5/21/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
installed per plan 1985
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: at gradefeet
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.):
building sewer in good condition no evidence of leaks
Septic Tank(locate on site plan):
3"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500 gallon concrete septic tank
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 11'X 5'8"X 68"
Sludge depth:
3"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
S% 1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is required for every North Andover Ma 01845 5/21/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness 0
11
Distance from top of scum to top of outlet tee or baffle 6 -
Distance from bottom of scum to bottom of outlet tee or baffle 16"
How were dimensions determined?
infield with measure stick and tape
-
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic tank should be pumped every 2-3 years depending on number of occupants and usage
Liquid is at bottom of pipe on outlet line with separation from inlet and outlet
Tank shows no evidence of leakage
Baffles are concrete / Inlet baffle OK
Outlet baffle is compromised and needs to be replaced / see pics attached
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
t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is required for every North Andover Ma 01845 5/21/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is required for every North Andover Ma 01845 5/21/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert liquid is at bottom of outlet lines
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.):
Concrete D box is 12" below grade with 4 outlet lines /box is level with equal distribution/ little
evidence of carryover/evidence of leakage out of box from cracks and hole in side walls from
corroded concrete
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is required for every North Andover Ma 01845 5/21/20
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 @ 20'X50'1000 sgft
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS in working condition/no evidence of breakout / no ponding
SAS located in green grass area with no damp soil and vegitation in good condition
located in sloping lawn area
SAS is pipe in stone drainfield
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is North Andover Ma 01845 5/21/20
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is required for every North Andover Ma 01845 5/21/20
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is North Andover Ma 01845 5/21/20
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4'+ as per plan on file
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: 1980
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
checked with health dept plans on file dated 1980
System is a gravity mound as per plan on file
The only way to determine ESHGW is with a deep hole and soil expert
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1761 Salem Street
Property Address
1761 Salem Street Realty Trust
Owner Owner's Name
information is required for every North Andover Ma 01845 5/21/20
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
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1 .4
Summary Record Card generated on 6J812020 9 12:27 AM by Karen Hanlon Pope 1
Town of North Andover
• Tax Map # 210-1063-0089-0000.0
Parcel Id 17493
1761 SALEM STREET
TOSCANO, CARMEN
1761 SALEM STREET
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 4.52 Acres
FY 2020
UB Mailing Index
Name/Address Type Loan Number Activelinact. From Until
TOSCANO,CARMEN Payor
1761 SALEM STREET
N.ANDOVER,MA
01845
UB Account Maint,
Account No Cycle Occupant Name Activelinactive
Bldg id.17469.0.1761 SALEM STREET Last Billing Date 4/1/2020
3170139 03 Cycle 03 Active
UB Services Maint.
Account No.3170139
Service Code Rate Charge MultipiierlUsers
MISCFEE ADMIN FEE 0.63 5/8 7.82 1/
WTR WATER 01 ALL METER SIZE -76.00 /1
UB Meter Maintenance
Account No.3170139
Serial No Status Location Brand Type Size YTD Cons
50610972 a Active HH#1761 PIT METER b Badger w Water 0.63 0.63 -20
Date Reading Code Consumption Posted Date Variance
3/5/2020 0 a Actual 0 4 8/2020 -100%
1/29/2020 0 n New Meter 0 4/8/2020 -100%
1/29/2020 8553 r Replacement -20 4/8/2020 -496%
1/10/2020 8573 m Manual estimate 29 1/15/2020 44%
MSG
9/23/2019 8544 m Manual estimate 20 10/10/2019 -10%
MSG
6/7/2019 8524 aActual 19 7/25/2019 -60%
3/7/2019 8505 a Actual 46 4/16/2019 53%
12/7/2018 8459 aActua1 29 1/22/2019 111%
9/11/2018 8430 aActual 15 10/15/2018 6%
6/8/2018 8415 a Actual 14 7/23/2018 -29%
3/612018 8401 a Actual 19 4/23/2018 57%
12/6/2017 8382 a Actual 12 1/25/2018 -30%
9/8/2017 8370 a Actual 18 10/18/2017 9%
6/6/2017 8352 a Actual 16 7/25/2017 -8%
3/7/2017 8336 a Actual 17 4/12/2017 16%
12/8/2016 8319 a Actual 15 1/23/2017 -4%
9/8/2016 8304 a Actual 16 10/24/2016 6%
6/7/2016 8288 a Actual 15 8/2/2016 32%
3/7/2016 8273 a Actual 11 4/22/2016 -13%
12/9/2015 8262 aActual 13 1/20/2016 -13%
9/8/2015 8249 a Actual 15 10/16/2015 24%
618/2015 8234 a Actual 12 7/24/2015 -15%
319/2015 8222 a Actual 14 4/28/2015 8%
12/9/2014 8208 aActual 13 1/15/2015 -4%
9/10/2014 8195 a Actual 14 10/15/2014 -98%
6/912014 8181 aActual 896 7/16/2014 81%
3/10/2014 7285 m Manual estimate 512 4/11/2014 -27%
12/612013 6773 a Actual 646 1/17/2014 26%
Of MOR TM 7y
• Town of North Andover
HEALTH DEPARTMENT
CHU`+�4
CHECK#: �607 DATE: 6.Xd• ;too-
LOCATION: /76 Steen1 5.4 7"
H/O NAME: /-)6 /e Sf-&L1 4
CONTRACTOR NAME: 2.'1
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/SoIid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installerss(DWI) $
❑ Title 5Inspector ,7
ql Title 5 Report won S5 $ O
❑ Other. (Indicate) $
health Agent Initials
White-Applicant Yellow-Health Pink- Treasurer