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HomeMy WebLinkAboutPass - Title V Inspection Report - 1049 SALEM STREET 7/19/2021 c Commonwealth of Massachusetts 11 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1049 Salem Street Property Address Song Huh Owner Owner's Name information is North Andover MA 01845 6-10-2021 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 alte any way. Please see completeness.checklist at the end of the form. �G�w Important:When filling out forms A. Inspector Informationon the J O PN� use only tabs Neil James Bateson k .- ZM�� key to move your Name of Inspector (0 N�y(N cursor-do not Bateson Enterprises Inc. use the return Company Name key. 111 A Road a Company Address Andover MA 01810 Cityrrown State Zip Code aV�r 978-475-4786 SI-15 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 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. ❑ RFai _) 7-10-2021 Inspenatur 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 ownerstratt-sutrmit i teFvrtto e regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, ifapplicable, 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. Y 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts 71 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I� 1.� 1049 Salem_tcee t Property Address Song Huh Owner Owner's Name inftfmation is North Andover MA 01845 6-10-2021 regaired1efeveq---- 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. �) 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 insoecthri if the-existing_tank is replaced_with-a-complying-septic tank..aas_appcoved-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.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form t. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / 1049 Salem Street Property Address Song Huh Owner Owner's Name irtfprmation is North Andover MA 01845 6-10-2021 required-fof-evefy- page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): Q Pump 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑__ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions-exist_whichlequire further evaluation by the.Board.nf_Hea&in_nrder 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1049 Salem Street _ Property Address Song Huh _ Owner Owner's Name information is North Andover _MA 01845 6-10-2021 required for every page. CitylTown 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 1 q0 feet of a surface water supply or tributary to a surface water supply. 0 Thesystern has-a-s�nkand-SAS-arntthe-S-AS iswithin-a-Zone-'I-ofa-pvbiic�ater 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 faifure-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 followingfor.aUinspections: Yes No Backup-al<sewage-into-fasiRy—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.7/2 61201 8 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 18 c� Commonwealth of Massachusetts �n Title 5 Official Inspection Form w' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1049 Salem Street _ Property Address Song Huh _ Owner Owner's Name information is North Andover MA 01845 6-10-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 '/2 day flow Required pumping more than 4 times in-the-last year-NOT due to clogged or Q— - obstructed pipe(s). Number of timespumped- - ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation, El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® 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 withttr-50-feet-ofa 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 ces-spool-servinga#ao+lity with a design flow of-2-000 gpd- 10,000 gpd. ❑ ® The system fails. f fiave determined-that owor 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<'-Qr"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 Q Q 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C / 1049 Salem Street Property Address Song Huh ------ Owner Owner's Name information is North Andover MA 01845 6-10-2021 required for every page. Cityfrown State Zip Code Data 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 ® 0 Pumping information was provided bythe-owner, oceupant,-or Board of-Hea+fh ❑ ® 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 piarrsof-the=systemDbtairred-and-examined? (If they were not available note as N/A) ® ❑- Was the facility or efling inspected for-signs-of-sewage-back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were afl systerri"components, exclucting 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 a - information on-tire proper maintenance of-subsurface sewage disposat;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.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 18 101, Commonwealth of Massachusetts +� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �r 1049 Salem Street Property Address Song Huh Owner Owner's Name information is North Andover MA 01845 6-10-2021 required for every page. City/Town State Zip,Code Date of Inspection D. System Information 1. Residentiatftow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN 11"bw based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 44.0- Description: 1 Number of current residents: Does residence have.a_garbage grinder? ❑ Yes Does residence have a water treatment unit? ❑ Yes ® No If yes, dim-charges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insp.doc•rev.7/26/2018 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 1049 Salem Street Property Address Song Huh Owner Owner's Name information is Nodh-Andouec MA 01845 6-10-2021 required brevery State Zip Code Date of Inspection page. Cityfrown D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: DesigRAGw-4basedon 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Qrpase 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 two years ago , owner Vii system pumped as part of the inspection? ® Yes ❑ No rtyes, volttmL-pumped. 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 4�n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1049 Salem Street Property Address Song Huh Owner Owner's Name information is North Andover MA 01845 6-10-2021 required for every page. City/Town 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 operatorunder contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed-(4-known)and source of information: 7 years old, 6-20-2014, as built plan Were sewage odors detected when arriving at the site? El Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 5 feet gpterial of construction: ❑ cast iron- - JK 49-PVC ❑ otheF-(exp4a I.- ----- Distance from private water supply well or suction line: feet Comments.(on.condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall, 4" & 3" PVC in house. No leaks visible. t5insp.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 1049 Salem Street Property Address Song Huh Owner Owner's Name information is MA 01845 6-10-2021 required for every North Andover page. City[Town State Zip.Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 4 Depth below grade: feet Mgterial 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 10' x5'x4' Dimensions: 1" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 32" 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 8° Distance from bottom of scum to bottom of outlet fee or baffle. 14" 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.): Depth of liquid above outlet invert, found outlet filter clogged, clean same, level back to normal. Inlet tee ok. Outlet tee ok. No evidence of leakage. Inlet cover has riser 2"deep. Outlet cover has riser 8" deep. Pumped septic tank. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �. p Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1049 Salem Street Property Address -- Song Huh Owner Owner's Name information is North Andover MA 01845 6-10-2021 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): pppth below grade: feet UntimirmM of uctian. ❑ 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.): 8. Tight or Holding Tan#• f- -be-pufnped-at-time of-irtspectiony(locate on site plan-): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26W8 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1049 Salem Street . Property Address Song Huh Owner Owners Name information is North Andover MA 01845 6-10-2021 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or-+loping-Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm lav - 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? ElYes ElNo 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level &distribution equal, has flow levelers. No evidence of leakage. Evidence of light carryover. D-box3' deep_-- t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �d Title 5 Official Inspection Form I- I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1049 Salem Street Property Address Song Huh Owner Owner's Name information is North Andover MA 01845 6-10-2021 required for every 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 alarmsare not in working order,-system-is aconditianal 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 gafheries number: [] leaching trenches number, length: le-8(Ching fields number, dimarrs'i6ns: 1 field 15'x 40' ❑ 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1049 Salem Street Property Address Song Huh Owner Owner's Name information is North Andover MA 01845 6-10-2021 required for every- page. Citylrown State Zip Cade Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Gpmments (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. 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1049 Salem Street Property Address Song Huh Owner Owner's Name information is North Andover MA 01845 6-10-2021 required for every page. CitifTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Rimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1049 Salem Street Property Address Song Huh Owner Owner's Name information is North Andover MA 01845 6-10-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Sty'C, y 3 a 1 A (Jr:vew� j4Ao lc 3- 461 p+Z" 3';:: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1049 Salem-Street Property Address — - Song Huh Owner Owner's Name information is North Andover MA 01845 6-10-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar Z Shailowwells aftimated depth to high ground water: 3.8 feet Please indicate—all—methods.used to deterraine-the-high-grouad wate-elevation_ ® Obtained from system design plans on record If checked;date of design-pla4Teviewed: 10-10-2013 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Chee th-=--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 shows water @ 46" 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 Commonwealth of Massachusetts �d Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1049 Salem Street Property Address Song Huh Owner Owner's Name information is North Andover MA 01845 6-10-2021 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts City/Town of System P-umping Record Form 4 DEP has provided this form for use=by local Boards of Health. Other forms may be Used,but the information must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the forrh they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address f d Citylrown State Zip Code 2. System Owner. \^ Name Address(if different from location) CitylTown State Zip Code 49 L.f-20 L-f 3 Telephone Number B. Pumping Record 1. Date of Pumping Date 2 Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) M-eeptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By., Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio ere contents-were disposed: L S Lowell Waste Water Signitute cf Haul Date t5f6rm4.docr 06/03 System Pumping Record•Page 1 of 1 bummary necoro uaro 9erwialeo—w rwcvc 1 r 1--w rao wr-an I--, ' Town of North Andover Tax Map # 210-104.D-0070-0000.0 Parcel Id 16758 1049 SALEM STREET SUE LEE 1049 SALEM STREET NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 0.386 Acres FY 2021 Account No.3160377 Serial No Status Location Brand Type Size YTD Cons 45320721 a Active 00 ERT HH b Badger w Water 0.63 0.63 34 Date Reading Code Consumption Posted Date Variance 3/3/2021 745 a Actual 18 4/21/2021 16% 12/4/2020 727 a Actual 16 1/13/2021 -48% 9/3/2020 711 a Actual 31 10/14/2020 153% 6/3/2020 680 a Actual 12 7/15/2020 33% 3/5/2020 668 a Actual 9 4/8/2020 -24% 12/6/2019 659 aActual 11 1/15t202O -55% 9/13/2019 648 a Actual 29 10/10/2019 42% 6/6/2019 619 a Actual 19 7125/2019 24% 3/6/2019 600 a Actual 15 4/16/2019 36% 12/6/2018 585 a Actual 11 1/22/2019 -85% 9/7/2018 574 a Actual 75 10/15/2018 400% 6/6/2018 499 a Actual 15 7/23/2018 32% 3/5/2018 484 a Actual 11 4/23/2018 -36% 12/5/2017 473 aActual 17 1/25/2018 -46% 9/7/2017 456 a Actual 33 10/18/2017 14% 6/5/2017 423 a Actual 28 7/25/2017 61% 3/6/2017 395 a Actual 17 4/12/2017 -37% 12/7/2016 378 a Actual 28 1/23/2017 -72% 9/6/2016 350 a Actual 102 10/24/2016 219% 6/3/2016 248 a Actual 31 8/2/2016 70% 3/3/2016 217 a Actual 17 4/22/2016 -63% 12/8/2015 200 aActual 52 1/20/2016 -33% 9/2/2015 148 a Actual 71 10/16/2015 91% 6/5/2015 77 a Actual 38 7/24/2015 83% 3/6/2015 39 a Actual 21 4/28/2015 -20% 12/4/2014 18 aActual 18 1/15/2015 -100% 10/2/2014 0 f Final Bill 0 10/2/2014 -100% 8/29/2014 0 n New Meter 0 10/2/2014 -100% 1/28/2014 460 aActual 27 4/11/2014 133% 12/5/2013 433 aActual 12 1/17/2014 4% 10/10/2013 421 f Final Bill 7 10/10/2013 44% 9/6/2013 414 a Actual 13 10/15/2013 33% 6/7/2013 401 a Actual 10 7/24/2013 59% 3/6/2013 391 aActual 6 4/22/2013 23% 12/7/2012 385 aActual 5 1/9/2013 28% 9/7/2012 380 a Actual 4 10/15/2012 -22% 6/6/2012 376 aActual 5 7/16/2012 2% 3/7/2012 371 a Actual 5 4/14/2012 -32% 12/5/2011 366 aActual 7 1/17/2012 -19% ' NORTH 1 I `• I F2 a + • . L' • Town of North Andover HEALTH DEPARTMENT s�C.0 CHECK#: .3583 DATE: LOCATION: /Oy9 5 xwle./n SY/eerT H/O NAME: AY /? CONTRACTOR NAME:. .�e„or> 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 $ ❑ TrashlSolid 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 $ S �o Q. Title 5 Report ❑ Other:(Indicate) $ i e- lth Agent Initials White-Applicant Yellow-Health Pink-Treasurer