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HomeMy WebLinkAboutPass - Title V Inspection Report - 48 WINDSOR LANE 11/30/2021 Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Prop2Lk,Address i m ��on�c� prey Owner Owner's Name information is n —(a required for every ' ��W page. 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 filling out forms A. Inspector Information on the computer, c� use only the tab key to move your Name of Inspe cursor- not use the return urn key. Com y Name an W_tZeJ1 „ Company Address City/Town State Zip Code � C,oa- a9 - Telephone Number License Number B. Certification 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. 93 Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector's Signatdre -Date7/­�;/ 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. 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 c Commonwealth of Massachusetts it Title 5 Official Inspection Form �1, Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address -'ICY1 SS QC�e Owner Owner's Name information is C\ required for every � 1 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or and all of and 6. 1) System Passes: y e S EjKl 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: CYO- any re,,, I [mil!� 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address 1 SON Owner Owner's Name information is ��� Ay (� _(j� required for every , 1 1..��►�( j r page. CitylTown 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. ❑ 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 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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts 1= Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner Owner's Name information is f required for every page. Cityfrown 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: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ E?— 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 Commonwealth of Massachusetts 1� ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. CityTrown 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 ❑ [Er- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow ❑ ER- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ER' Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Ep,,- 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. ❑ Eg" 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.] ❑ EI-1 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 system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ix Title 5 Official Inspection Form 1; Subsurface Sewage Disposal System Form- Not for Voluntary Assessments S� LC) Property Address -T�m t9�\Qs Owner Owner's Name information is !1 _/1—`�11� /yr ] ► 1 1 G required for every � 1 l 1. page. City/Town 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 No I� ❑- Pumping information was provided by the owner, occupant, or Board of Health ❑ I� 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) El][-�''� Was the facility or dwelling inspected for signs of sewage back up? I�I ❑ 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: L� ❑ 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.M612018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 2,341 via Billing � °�'�"•='• °oz TOWN OF NORTH ANDOVER Information 120 MAIN STREET (978)688-9570 NORTH ANDOVER MA 01845 Reading Information ON OR ► *" (978)688-9570 BEFORE 10/09/20 $732.02 978-688-9550 � ".��r•�� OFFICE HOURS asweNus`t Mon,Wed,Th 8-4:30 ACCOUNT NO. BILLING DATE Tue 8-6:00,Fri 8-12:00 2100064-416704945 9/9/2020 RETAIN THIS PORTION FOR YOUR RECORDS SERVICE DATES DUE DATE MOVING?PLEASE CALL 978-688-9570 IN ADVANCE 6/1/2020-8/31/2020 10/09/20 SERVICE ADDRESS 48 WINDSOR LANE TIMOTHY&KRISTEN STONECIPHER TRANSACTION THIS PERIOD AMOUNT 48 WINDSOR LANE Previous Balance 57 NORTH ANDOVER MA 01845 Payments Through 09/09/2020 (111.57) Adjustments/Late Charges - Interest as of: 10/9/2020 - Balance Forward _ Previous Current Consumption Nb of Current Bill Detail Usage/Unit Reading Reading Days Amount WATER USAGE WATER 137 724.20 ADMIN FEE �918 1055 137 Actual 94 7.82 Sub-Total 732.02 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX ()a P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units $3 . 80 Over 20 units a $5 . 55 Sewer rate : First 20 units 3 $5 . 95 Over 20 un-its 3 $9 .24 Bypass Meter Water rate : all units C $5. 55 PLEASE RETURN THIS PORTION WITH PAYMENTS TOWN OF NORTH ANDOVER Billing Reading 9 120 MAIN STREET Information Information " .,�6�.,.��,, • NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 978-688-9550 416704945 sS+ICHssB *416704945* SERVICE ADDRESS ACCOUNT NUMBER 48 WINDSOR LANE 2100064416704945 =BEFORE ► TIMOTHY&KRISTEN STONECIPHER 0/09/20 $732.02 48 WINDSOR LANE NORTH ANDOVER MA 01845 AMOUNT PAID 2,a4► 5 66 04167049452020000000000000000000000402100064000000073202009 2,975 Billing Information TOWN OF NORTH ANDOVER (978)688-9570 .° 120 MAIN STREET Reading Information ON OR , " - �' s NORTH ANDOVER MA 01845 BEFORE 10/21/21 $710.97 7 978-688-9550 (978)688-9570 OFFICE HOURS ACCOUNT NO. BILLING DATE Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100064416704945 9/21/2021 RETAIN THIS PORTION FOR YOUR RECORDS SERVICE DATES DUE DATE 6/1/2021 -8/31/2021 10/21/21 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE SERVICE ADDRESS 48 WINDSOR LANE TIMOTHY&KRISTEN STONECIPHER TRANSACTION THIS PERIOD AMOUNT 48 WINDSOR LANE Previous Balance 100.47 NORTH ANDOVER MA 01845 Payments Through 09/21/2021 (100.47) Adjustments/Late Charges - Interest as of: 10/21/2021 - Balance Forward - Previous Current Consumption Nb-of Current Bill Detail Usage/Unit Amount Reading Reading Days WATER USAGE WATER 133 703.15 a'1 9/3/21 ADMIN FEE 7.82 1130 1269 133 Actual 91 Sub-Total 710.97 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units $3 .80 Over 20 units a $5 . 55 Sewer rate : First 20 units $5 .95 Over 20 units 3 $9. 24 Bypass Meter Water rate : all units @ $5 . 55 PLEASE RETURN THIS PORTION WITH PAYMENTS TOWN OF NORTH ANDOVER Billing Reading i 120 MAIN STREET Information Information ' + NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 978-688-9550 +..,,..�' 4l 6704945 °a�cwus� *416704945* SERVICE ADDRESS ACCOUNT NUMBER 48 WINDSOR LANE 2100064-416704945 =BEFORE TIMOTHY&KRISTEN STONECIPHER 10/21/21 ► S710.97 48 WINDSOR LANE NORTH ANDOVER MA 01845 AMOUNT PAID 2,975 1 60 041,67O494520220000000000000000000004021000L400000007109?003 2,874 Billing Information TOWN OF NORTH ANDOVER (978)688-9570 "A 120 MAIN STREET ON OR NORTH ANDOVER MA 01845 Reading Information BEFORE 01/15/21 *�'•"�-=- �' 978-688-9550 (978)688-9570 , $128.22 $sweNust~ OFFICE HOURS Mon,Wed,Th 8-4:30 ACCOUNT NO. BILLING DATE Tue 8-6:00,Fri 8-12:00 2100064-416704945 12/16/2020 RETAIN THIS PORTION FOR YOUR RECORDS SERVICE DATES DUE DATE 9!1/2020- 11/30/2020 O1/15/21 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE SERVICE ADDRESS 48 WINDSOR LANE TIMOTHY&KRISTEN STONECIPHER TRANSACTION THIS PERIOD AMOUNT 48 WINDSOR LANE Previous balance 732.02 NORTH ANDOVER MA 01845 Payments Through 12/16/2020 (732.02) Adjustments/Late Charges - Interest as of 1/15/2021 - Balance Forward - Previous Current Consumption Nb of Current Bill Detail Usage/Unit Amount Reading Reading Days WATER USAGE WATER 28 120.40 1112r20 ADMIN FEE 7.82 1083 28 Actual 91 Sub-Total 128.22 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL (Qa 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX Q P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units Q $3 .80 Over 20 units �a $5 . 55 Sewer rate : First 20 units Q $5 .95 Over 20 units ca $9. 24 Bypass Meter Water rate : all units Q $5 . 55 „oF�h PLEASE RETURN THIS PORTION WITH PAYMENTS TOWN OF NORTH ANDOVER Billing Reading a 120 MAIN STREET Information Information NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 + '� `a';;,•��,$ 978-688-9550 416704945 �Ss�eftugs� *416704945* SERVICE ADDRESS ACCOUNT NUMBER 48 WINDSOR LANE 2100064-416704945 7BEFORE701/15/21 TIMOTHY&KRISTEN STONECIPHER $128.22 48 WINDSOR LANE NORTH ANDOVER MA 01845 AMOUNT PAID 2•s74 t 66 04lk7O494520210000000000000000000004021000L4000000012822001 904 "'' Billing + Information TOWN OF NORTH ANDOVER •. °� (978)688-9570 a 120 MAIN STREET Reading Information ON OR « ; NORTH ANDOVER MA 01845 (g78)688-95T0 BEFORE 04/15/21 ► $138.75 978-688-9550 aSAel� OFFICE HOURS ACCOUNT NO. BILLING DATE Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100064-416704945 3/16/2021 RETAIN THIS PORTION FOR YOUR RECORDS SERVICE DATES DUE DATE 12/1/2020-2/28/2021 04/15/21 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE SERVICE ADDRESS 48 WINDSOR LANE TIMOTHY&KRISTEN STONECIPHER TRANSACTION THIS PERIOD AMOUNT 48 WINDSOR LANE Previous ance NORTH ANDOVER MA 01845 Payments Through 03/16/2021 (128.22) Adjustments/Late Charges 0.19 Interest as of 4/15/2021 0.01 Balance Forward 0.20 Previous Current Consumption Nb of Current Bill Detail Usage/Unit Amount Reading Reading Days WATER USAGE WATER 30 130.73 !I ' "' 2 /21 ADMIN FEE 7.82 1083 1113 30 Actual 93 Sub-Total 138.55 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units @ $3 . 80 Over 20 units @ $5 . 55 Sewer rate : First 20 units c $5 . 95 Over 20 units ® $9.24 Bypass Meter Water rate : all units @ $5 . 55 ,%ORTN PLEASE RETURN THIS PORTION WITH PAYMENTS TOWN OF NORTH,c*•_ g Billing Reading 120 MAIN STREET Information Information NORTH ANDOVER MA 01845 978 688-9550 (978)688-9570 978-688-9550 416704945 -ACM *416704945* SERVICE ADDRESS ACCOUNT NUMBER 48 WINDSOR LANE 2100064416704945 7BEF07RE104/15/21 TIMOTHY&KRISTEN STONECIPHER ® $138.75 48 WINDSOR LANE NORTH ANDOVER MA 01845 AMOUNT PAID 2,904 2 66 04lk7O49452021000000000000000000000402100064000000013875004 2,Y43 Billing NORTy 1 +.•':+ '•." TOWN OF NORTH ANDOVER Information F (978)688-9570 120 MAIN STREET f NORTH ANDOVER MA 01845 Reading Information ON OR , $100.47 978-688-9550 (978)688-9570 BEFORE 07/15/21 OFFICE HOURS ACCOUNT NO. BILLING DATE Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100064-416704945 6/15/2021 RETAIN THIS PORTION FOR YOUR RECORDS SERVICE DATES DUE DATE MOVING?PLEASE CALL978-688-9570 IN ADVANCE 3/1/2021 -5/31/2021 1 07/15/21 SERVICE ADDRESS 48 WINDSOR LANE TIMOTHY&KRISTEN STONECIPHER TRANSACTION THIS PERIOD AMOUNT 48 WINDSOR LANE Previous Balance NORTH ANDOVER MA 01845 Payments Through 06/15/2021 (138.75) Adjustments/Late Charges 0.01 Interest as of. 7/15/2021 - Balance Forward - Previous Current Consumption Nb of Current Bill Detail U e/Unit Reading Reading bays Amount WATER USAGE WATER 23 92.65 5/4nl ADMIN FEE 7.82 1 I 1136 23 Actual 90 Sub-Total 100.47 Total 11 MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX Q P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units $3 . 80 Over 20 units $5 . 55 Sewer rate : First 20 units @a $5 . 95 Over 20 units 3 $9. 24 Bypass Meter Water rate : all units Q $5 . 55 PLEASE RETURN THIS PORTION WITH PAYMENTS TOWN OF NORTH ANDOVER ��' r •�`� Billing Reading i 120 MAIN STREET Information Information NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 978-688-9550 416704945 s�cwus *416704945* SERVICE ADDRESS ACCOUNT NUMBER 48 WINDSOR LANE 2 1 00064-4 1 6704945 ON OR TIMOTHY&KRISTEN STONECIPHER BEFORE 07/15/21 ► S100.47 48 WINDSOR LANE NORTH ANDOVER MA 01845 AMOUNT PAID 2,943 3 66 04167049452021000000000000000000000402100064000000010047006 46 2'7 Billing MQ� Information TOWN OF NORTH ANDOVER . y 120 MAIN STREET (978)688-9570 ON OR }; NORTH ANDOVER MA01845 Reading Information =BEFOREOl/06/20 978-688-9550 (978)688-9570 ► $294.44 34ewwu OFFICE HOURS ACCOUNT NO. BILLING DATE Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100064-416704945 12/5/2019 RETAIN THIS PORTION FOR YOUR RECORDS SERVICE DATES DUE DATE MOVING?PLEASE CALL 978-688-9570 IN ADVANCE 9/1/2019- 12/9/21 O1/06120 SERVICE ADDRESS 48 WINDSOR LANE SUSAN KELLY-WEEDER TRANSACTION THIS PERIOD AMOUNT 48 WINDSOR LANE vtous Balance 3 2 01 ANDOVER,MA Payments Through 12/05/2019 (38.22) 01845 Adjustments/Late Charges - Interest as of: 1/612020 Balance Forward _ Previous Readin urrent Readin Consumption Nb of. Current Bill Detail Usage/Unit g g Days Amount WATER USAGE WATER 54 25l.62 It 1'1 1) 12/4/19 ADMIN FEE 827 881 54 Final Bill 125 7.82 FINAL READINGS 35.00 Sub-Total 294.44 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units 3 $3 . 80 Over 20 units (a� $5 . 55 Sewer rate : First 20 units a $5.95 Over 20 units (a3 $9. 24 Bypass Meter Water rate : all units @ $5 . 55 e yORrk PLEASE RETURN THIS PORTION WITH PAYMENTS �r°•'"`-"•.ryO6l TOWN OF NORTH ANDOVER Billing Reading A 1.20 MAIN STREET Information Information { ° f; NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 978-688-9550 ctwstc'� 416704945 *416704945* SERVICE ADDRESS ACCOUNT NUMBER 48 WINDSOR LANE 2100064-416704945 ON OR , SUSAN KELLY-WEEDER BEFORE 01/06/20 $294.44 48 WINDSOR LANE N.ANDOVER,MA AMOUNT PAID 01845 2,746 1 6 04167049452020000000000000000000000402100064000000029444000 2,711 Billing •,<.•�..;�a Information . .. ° TOWN OF NORTH ANDOVER (978)688-9570 120 MAIN STREET ON OR NORTH ANDOVER MA 01845 Reading Information BEFORE 10/28/19 00. $3812 978-688-9550 (978)688-9570 ss�ctr�SEt OFFICE HOURS ACCOUNT NO. BILLING DATE Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100064-416704945 9/26/2019 RETAIN THIS PORTION FOR YOUR RECORDS SERVICE DATES DUE DATE6/1/2019-8/31/2019 10/28/19 MOVING?PLEASE CALL 978-688-9570 IN ADVANCE SERVICE ADDRESS 48 WINDSOR LANE SUSAN KELLY-WEEDER TRANSACTION THIS PERIOD AMOUNT 48 WINDSOR LANE Previous Balance 42.02 N.ANDOVER,MA Payments Through 09/26/2019 (42.02) 01845 Adjustments/Late Charges - Interest as of 10/28/2019 - Balance Forward Previous Current Consumption Nh of Current Bill Detail Usage/Unit Amount Reading Readin, Days WATER USAGE WATER 8 30.40 1 8/1i1 9 ADMIN FEE 7.82 819 827 8 Actual 92 Sub-Total 38.22 Total ; MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units $3 . 80 Over 20 units a $5 . 55 Sewer rate : First 20 units @}a $5 .95 Over 20 units g $9 . 24 Bypass Meter Water rate : all units @ $5 . 55 µOR4y PLEASE RETURN THIS PORTION WITH PAYMENTS p'�y« n t•AH .•:{ °o� TOWN OF NORTH ANDOVER Billing Reading 120 MAIN STREET Information Information * NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 M a ; 978-688-9550 416704945 ��sACHub£` *416704945* SERVICE ADDRESS ACCOUNT NUMBER 48 WINDSOR LANE 2100064-416704945 ON OR SUSAN KELLY-WEEDER BEFORE 10/28/19 ► 538.22 48 WINDSOR LANE N.ANDOVER,MA AMOUNT PAID 01845 2,711 2 66 041670494520200000000000000000000004021000L4000000003822008 2,778 yq°fiTk Billing 04.«.. • r Information TOWN OF NORTH ANDOVER (978)688-9570 A 120 MAIN STREET =ISEFORE ' ° NORTH ANDOVER MA 01845 Reading Information 04/15/20 , $53.42 -' 978-688-9550 (978)688-9570 S$gruus�' OFFICE HOURS ACCOUNTNO. BILLING DATE Mon,Wed,Th 8-4:30 Tue 8-6:00,Fri 8-12:00 2100064-416704945 3/16/2020 RETAIN THIS PORTION FOR YOUR RECORDS SERVICE DATES DUE DATE MOVING?PLEASE CALL 978-688-9570 IN ADVANCE 12/9/2019-2/29/2020 04/15/20 SERVICE ADDRESS 48 WINDSOR LANE TIMOTHY&KRISTEN STONECIPHER TRANSACTION THIS PERIOD AMOUNT 48 WINDSOR LANE Previous Balance 294.44 NORTH ANDOVER MA 01845 Payments Through 03/16/2020 (294.44) Adjustments/Late Charges - Interest as of 4/15/2020 - Balance Forward - Previous urren ading Days t Consumption Nb of Reading Re Current Bill Detail Usage/Unit Amount WATER USAGE WATER 12 45.60 1 1 1) 2i3n0 ADMIN FEE 7.82 881 893 12 Actual 61 Sub-Total 53.42 Totat MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL C 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX cQ P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units a $3 . 80 Over 20 units $5 . 55 Sewer rate : First 20 units 3 $5 . 95 Over 20 units 3 $9. 24 Bypass Meter Water rate : all units cQr $5 . 55 PLEASE RETURN THIS PORTION WITH PAYMENTS TOWN OF NORTH"g Billing Reading i 120 MAIN STREET Information Information NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 978-688-9550 416704945 �ss�cn41 *416704945* SERVICE ADDRESS ACCOUNT NUMBER 48 WINDSOR LANE 2100064-416704945 ON OR TIMOTHY&KRISTEN STONECIPHER BEFORE 04/15/20 , $53.42 48 WINDSOR LANE NORTH ANDOVER MA 01845 AMOUNT PAID 2,778 3 66 041,67049452020000000000000000000000400100064000000005342005 2,809 wanr Billing TOWN OF NORTH ANDOVER Information (978)688-9570 h i 120 MAIN STREET 7BEFORE # ' NORTH ANDOVER MA 01845 Reading Information , $111.57 978-688-9550 (978)688-9570 07/10/20 �soereu OFFICE HOURS Mon,Wed,Th 8-4:30 ACCOUNT NO. BILLING DATE Tue 8-6:00,Fri 8-12:00 2100064-416704945 6/10/2020 RETAIN THIS PORTION FOR YOUR RECORDS SERVICE DATES DUE DATE MOVING?PLEASE CALL 978-688-9570 IN ADVANCE L 3/l/2020-5/31/2020 07/10/20 SERVICE ADDRESS 48 WINDSOR LANE TIMOTHY&KRISTEN STONECIPHER TRANSACTION THIS PERIOD AMOUNT 48 WINDSOR LANE Previous Balance 53.42 NORTH ANDOVER MA 01845 Payments Through 06/10/2020 (53.42) Adjustments/Late Charges - Interest as of 7/10/2020 - Balance Forward _ Previous Current Consumption Nb of Current Bill Detail Usage/Unit Reading Reading Days Amount WATER USAGE WATER 25 103.75 891) 5918 25 Actual 88 ADM1N FEE 7.82 Sub-Total 111.57 Total MESSAGE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @a P.O. BOX 184, MEDFORD, MA 02155 Water rate : First 20 units $3 . 80 Over 20 units $5 . 55 Sewer rate : First 20 units @ $5 . 95 Over 20 units 4§ $9. 24 Bypass Meter Water rate : all units Q $5 . 55 PLEASE RETURN THIS PORTION WITH PAYMENTS lj' i .o•a r $ TOWN OF NORTH ANDOVER o g`- a Billing Reading 120 MAIN STREET Information Information �e NORTH ANDOVER MA 01845 (978)688-9550 (978)688-9570 978-688-9550 416704945 SACHWU *416704945* SERVICE ADDRESS ACCOUNT NUMBER 48 WINDSOR LANE 2100'064-416704945 =BEFORE TIMOTHY&KRISTEN STONECIPHER /10/20 $ll 1.57 48 WINDSOR LANE NORTH ANDOVER MA 01845 AMOUNT PAID 2,809 4 66 041,670494520200000000000000000000004021,00064000000011157008 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner Owner's Name information is f '6 r-(� r� M �tl I required for every ' ` u�� 1 , v� V page. C1ty/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): �J Number of bedrooms(actual). DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 4/ Description: Number of current residents: Does residence have a garbage grinder? [Res ❑ No Does residence have a water treatment unit? ❑ Yes 2- No If yes, discharges to: 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 ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes R�No Last date of occupancy: Cr(e Date t5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 cam., Commonwealth of Massachusetts +n Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 13 t., .) i �.Srx Ln Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. CommercialAndustrial 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: Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: / oo gallons How was quantity pumped determined? m e-f eT o -% -lfi l c Reason for pumping: r k 0 6 tk -` '�S'����►�n t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 ., Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address "1 cM S*00 c P\,r\-Q-r Owner Owner's Llame information is \ ��0 , � required for every — { A( � U�� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type,of System: L7 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: 61/ 566 Were sewage odors detected when arriving at the site? ❑ Yes E No 5. Building Sewer(locate on site plan): Depth below grade: feet rvi e r\ ' 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.): 0.tt t Or ' 00 C Cy ticJrt4'Ci1°1 - t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts iw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Li 1Q0 Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): N e �t 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 Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 ly " How were dimensions determined? :7z& k7 YY1 eCks� U Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 00d C6 In �`:k l b n - t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts 1� , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address -r� M Owner Owner's Name information is `n required for every mil. �v-U, 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.): 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1% Ll 1i L-0 (\�N CT Ln Property Address T,�'M Owner Owner's Name information is 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 Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): y e S Depth of liquid level above outlet invert n 0 f TYVA I level 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.): t7 ):�(D< iS Con Ur) �C) x t'� fir, C4 ✓ e �o,�-► cLkM CG.a\1 © VC, -Pcvm Se,= - t5insp.doc-rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner Owner's Name ,Q f� (� ^�information is 0— J ►{�V� (�/�7` 6 1'_l.S I �""�S-a) required for every �•�l �� 1 lJ i 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): 'k,e S If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: sv 10""'i ❑ 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 1 ;Y� Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name information is f� a1��cs I I` S-c� required for every �1, t...�s. 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.): N0 S,`G nS 0•-P any F4 AAfe G 0 ��.r C) :7 � � t, S;2 CC 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 Commonwealth of Massachusetts .1 Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form- Not for Voluntary Assessments L-1 Property Address C m Sinn ��ph� Owner Owner's^Name information is 1 1 . ^ ^�^��� Y �� l V �S - ' '_ t C, 1 required for every l ' (,;1r� i �J S page. City/Town State Zip Code 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 15 of 18 t s rr ,t d _ f I l t - DISTRIBUTION Box INLET ELEV. f: e fx3 1 1. INLET E LEv. 9 6,0 a, 011111 1 1 [EV., .87 0 e NFW I ( )I INDATION a:1 1 : 1 c �14� �':�.ATI N T` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Li S LA-)AdSOf- L n Property Address T � M S�O��e C�phter Owner Owner's Name information is ,(1 �)1 �.� 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 Rdrawing attached separately t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts 1M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Jc \�f,; u, Li% ly c n�S�c' L--�1 Property Address `T►M S� CT1R.e� Owner Owners nName information is 1 ' „/ ��D� p l�tC 1 �- I S_a- required for every 1.1 wca —ter—` page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope r=I a ❑ Surface water Nu ❑ Check cellar a'-( ❑ Shallow wells NJ Estimated depth to high ground water: y / 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 ❑ 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: rSSE'X coun+l sG 4�CL S kcww S N �,v" i S �a t t U f �a c,���• (e"(N r �N v n t e C (US c - CG a;yac'r...�y S�.yL✓ S N VJ-T »' c,re Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts 1� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1, Property Address i� 0') Owner Owner's Name information is .�1 _ ��• l -b1� ' l ' , required for every 1 ► _7'\ZO page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: [R"'A. Inspector Information: Complete all fields in this section. E! B. Certification: Signed & Dated and 1, 2, 3, or checked nrC. 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 t , -1 1C3 <1? r1� NORTp ` 7! 1 /// 1 111� ti:• • cs * Town of North Andover � '••;;;;.. HEALTH DEPARTMENT ,SS^CNUS'- CHECK#: /668 ' DATE: LOCATION: H/O NAME: (YXC GQ elm CONTRACTOR NAME: All(&A 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 $-- 0 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 $ ❑ Title 5 Report $ •s� ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer i