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HomeMy WebLinkAboutPass - Title V Inspection Report - 153 MILL ROAD 6/26/2023 Commonwealth of Massachusetts O� Title 5 Official Inspection Form N� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �;. 153 Mill Rd. RrjUjET Property Address Asim Ghani UN2 6 Owner Owner's Name information is required for every North Andover MA 01845 6/7/2023 —_-- 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, use only the tab Warren R. Pearce Jr. key to move your Name of Inspector cursor-do not Pearce Construction use the return key. Company Name Park St Company Address North Reading______ MA 01864 City/Town State Zip Code / 978-664-5264 S11959 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. Z Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 2j_ 2 ct,-� A 6 1 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 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.712 612 01 8 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form i;' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v� 153 Mill Rd. ---- - - —. - _ - Property Address Asim Ghani _ --- -- Owner Owner's Name information is North Andover MA 01845 6 7 .,3 required for every --- State Zip Code Date of Inspection page. Cityrrown C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the ''Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined,' please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5mspdoc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 153 Mill Rd. Property Address Asim Ghani Owner Owner's Name information is required for every North Andover MA 01845 6/7/2023 - -_- page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form — , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 153 Mill Rd. Property Address Asim Ghani Owner Owner's Name information is required for every North Andover MA 01845 6/7/2023 ------ - - - - - - page. CltyRown 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doe•rev 7/2612 01 8 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 153 Mill Rd. Property Address Asim Ghani Owner Owner's Name information is North Andover MA 01845 6/7/2023 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 '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large 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 t5mso doe•rev.71262018 -rdle 5 official Inspection Form,sumurtace Sewage Disposal System•Faye 5 yr 16 Commonwealth of Massachusetts - - ; Title 5 Official Inspection Form ( - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 153 Mill Rd. Property Address Asim Ghani Owner Owners Name information is required for every North Andover MA 01845 6/7/2023 -- - -- - - - page. City[Town State Zip Code Date of Inspection C. Inspection Summary (cost.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ❑ Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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)) t5insp.doc•rev 7/2 6120 1 8 Title 5 Official Inspection Forms Subsurface Sewage Disposal System•Page 6 of 18 ` Commonwealth of Massachusetts _.y Title 5 Official Inspection Form _ 1? Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 153 Mill Rd. _ Property Address Asim Ghani Owner Owner's Name information is North Andover MA 01845 6/7/2023 required for every - - -- - — --— -- page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 ----- DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x#of bedrooms): 550 Description. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: -_ Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 349 GPD 9 ( Y 9 (9P ))� ---- -- Detail: 5/2/2021 to 5/11/2023 255,068 Gallons see attached Sump pump? ❑ Yes ® No Current Last date of occupancy: Date --._ t5nsp.doc•rcv 712CI2018 Tdle 5 Official Inspection Form:SuDsurface Sewage Disposal 5ystem•Page 7 of 18 Commonwealth of Massachusetts -;_ Title 5 Official Inspection Form 1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ��. 153 Mill Rd. Property Address Asim Ghani _ Owner Owner's Name information is North Andover MA 01845 6/7/2023 required for every -- ---- page. Clty(Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): --- - -- - Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): - ------ -- - - - Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: -- --- - Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - — --- - Last date of occupancy/use: Date Other (describe below): 3. Pumping Records: Source of information: Last pumped May 2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes; volume pumped: - -- gallons How was quantity pumped determined? - - - -- - Reason for pumping: ----- - --- -- -- t5insp.doc•rev.7t26l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 ' Commonwealth of Massachusetts - _ Title 5 Official Inspection Form - — 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 153 Mill Rd. Property Address Asim Ghani Owner Owner's Name information is North Andover MA 01845 6/7/2023 required for every d - - —.. -- -- 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 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: Original system from 1980. New Distribution box in 2020. Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan). 18" _ Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): --- Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No access, Finished Basement. t5insp.doc•rev.7126/2018 Titte 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts =, Title 5 Official Inspection Form h - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 153 Mill Rd Property Address Asim Ghani Owner Owner's Name information is required for every North Andover MA 01845 6/7/2023 _ -- - - - - - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 12" 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: 10'6" X 5'8"X 5'deep 1500 gallon 7" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" --- — - Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Polylok filter Distance from bottom of scum to bottom of outlet tee or baffle 14" Polylok filter 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.): The tees are in place and the liquid is at the proper level. The outlet is a Polylok filter. The tank appears in good shape with no evidence of leaks. 11"to fluid. t5insp.doc•rev.7262018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 153 Mill Rd. Property Address Asim Ghani Owner Owners Name information is North Andover MA _ 01845 6/7/2023 required for every _ page. Cityrrown 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.MZW018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal S wa e Dis stem Form - Not for Voluntary Assessments y 153 Mill Rd. Property Address A_sim Ghani_ Owner Owner's Name information is North Andover MA 01845 6/7/2023 _ required for every --- "— page. Cityrrown 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: bate 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): 0" Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.)'. The distribution box is level and the distribution is equal. There are speed levelers in use. There are no solids in the distribution box and no evidence of leaks. New distribution box in 2020. 36" below rah de,risers_to 5". l5insp.doc•rev.712612018 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 153 Mill Rd. Property Address Owner Asim Ghani - --- - _ _ Owners Name information is North Andover MA 01845 6/7/2023 required for every _ _ - __-_- page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 10. Pump Chamber (locate on site planj: 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): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number. — --- ❑ leaching trenches number, length: - ® leaching fields number, dimensions: (1) 15-X50'-- ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: --- ------- t5insp.doc•rev.71261201 6 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Paoe 13 of 16 Commonwealth of Massachusetts J; Title 5 Official Inspection Form =1 = Subsurface Sewage Disposal System Form Not for Voluntary Assessments 153 Mill Rd. _ - Property Address Asim Ghani Owner Owner's Name information is North Andover MA 01845 6/7/2023 required for every _ -- -- -- __ - - - - -- __ --- --- page. Cltyrrown 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.): There is no surface sign of problems and no sign in the distribution box of back up. _ 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 Fonn Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form 21 :4 I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 153 Mill Rd. Property Address Asim Ghani Owner Owners Name information is North Andover MA 01845 6/7/2023 required for every ----- page. Clty/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.7l26t201B Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 cf 16 Commonwealth of Massachusetts Title 5 Official Inspection Form i- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments lD' __ �J Y/I 153 Mill Rd. Property Address Asim Ghani Owner Owner's Name information is North Andover MA 01845 6/7/2023 required for every -- - - - - page. Cltyffown 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 I tbinsp noc•rev 7/26/2016 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 16 of I Commonwealth of Massachusetts Title 5 Official Inspection Form — � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t<< z � 153 Mill Rd. _ Property Address Asim Ghani _ _ - Owner Owner's Name information is North Andover MA 01845 6/7/2023 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 ® Shallow wells 8+ ft Estimated depth to high ground water: 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: .a _- Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) © Checked with local Board of Health - explain: Review Files ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain. You must describe how you established the high ground water elevation: Dry basement, no sump pump. Site slopes down in the rear to an elevation well below the bottom of the system. No standing water._ Before filing this Inspection Report, please see Report Completeness Checklist on next page. r5lnsc doc•rep. ;f°ol"201E Title 5 Official Inspection Form Subsurface Sewage Disposal system•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 153 Mill Rd. Property Address Asim Ghani Owner --- Owner's Name information is required for every North Andover MA 01845 6/7/2023 - ---- ---- page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Z A. Inspector Information: Complete all fields in this section. F1 B. Certification: Signed & Dated and 1, 2, 3, or 4 checked Z 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 t5mso.00c•rev 7i2,ron1 n Titlo 5 Official Inspection Forth-SLjbSUffAcA Sewage Disposal Syslem•Page 18 of 18 I ij"I a' h 1 i � f { iIi i i 1 { t5lnsp.Cx•rev.7126MI8 Tab 3 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 18 Summary Record Card genera!ed on 611312023 3:56:20 PM by Jennifer Bracero Page Town of North Andover Tax Map # 210-107.C-0080-0000.0 Parcel Id 18361 153 MILL ROAD THU TRUONG 2013 TRUST Since Apr 2013 SUI V. THU & MUOI TRUONG, TRUE 153 MILL ROAD NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.02 Acres FY 2023 US Mailing index Name/Address Type Loan Number Active/Inact. From Until THU,SUI Payor Active TROUNG,MUOI 153 MILL ROAD N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Activellnactive Bldg Id. 14324.0-153 MILL ROAD Last Billing Date 6/7/2023 2100325 02 Cycle 02 Active UB Services Maint. Account No.2100325 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE 22.80 /1 UB Meter Maintenance Account No.2100325 Serial No Status Location Brand Type Size YTD Cons 33530276 a Active ERT HH b Badaer w Water 0.625 0.625 382 Date Reading Code Consumption Posted Date Variance 5/11/2023 1595 aActual 6 6/1412023 -72% 2/2/2023 1589 a Actual 20 3/14/2023 -80% 11/2/2022 1569 aActual 1.01 12/19/2022 67% 8/3/2022 1468 a Actual 61 9/20/2022 298% JI JILULL 1407 aAi,ivai v!<„<..« 2/2/2022 1392 a Actual 16 3/15/2022 -65% 11/2/2021 1376 a Actual 37 12/7/2021 -37% 8/2012021 1339 aActual 85 9/21/2021 186% 5/5/2021 1254 a Actual 25 6115/2021 61% 2/412021 1229 a Actual 16 3/16/2021 -59% 11/312020 1213 a Actual 38 12/16/2020 -76% 8/4/2020 1175 a Actual 161 9/9/2020 775% 5/4/2020 1014 a Actual 18 6/1012020 8% 2/4/2020 996 a Actual 17 3/16/2020 -53% 11/4/2019 979 a Actual 37 12/23/2019 126% g;2/oQ10 942 a.Actual 16 9/26/2019 8% _ s .;92b a-h1 tual � ,.W v - _ "'14-- dt13i2U 1a _ _ - - r t so- 2l4/2019 912 aActual _-- - i r 3n 9rzu1 a 11/2/2018 895 a Actual 16 12/12/2018 -S°/0 8/3I2018 879 a Actual 17 9/20/2018 4% 5/312018 862 a Actual 16 6/2012018 -4% 2/2/2018 846 a Actual 17 3/28/2018 29% 11/212017 829 a Actual 13 12/29/2017 -11% 8/3/2017 816 a Actual 15 9/2012017 -4% 5/2/2017 801 a Actual 15 6/26/2017 -9% 2/2/2017 786 a Actual 17 3/14/2017 -1% 11/212016 769 a Actual 17 12/19/2016 120/0 8/3/2016 752 aActual 15 9/21/2016 -6% 5/4/2016 737 aActual 16 6/21/2016 -9% 6/13/2023 Page 1 ofMl lJ Town of North Andover M S G ove rn us Summary Card 2100325 Billing Cycle, 02 For service at: 153 MILL ROAD THU,SUl Send Bill to: TROUNG,MUOI 153 MILL ROAD N.ANDOVER,MA 01845 Billing Message: BILLING SERVICES SERVICE CODE RATE CODE MULTIPLIER COMMENTS ADMIN FEE 0.63 1.00 WATER 01 METER# 33530276 Location: ERT HH TRANSPONDER#22404928 Route/Sequence 000010/011600 BILLING HISTORY READING HISTORY CONSURIPTION/DAYS DATE AMOUNT BALANCE 5/11/2023 1595 Actual 6 -72% WATER 12/19/2022 $525.55 $0.00 98 MISCELLANEOUS 12/19/2022 $7.82 $0.00 2/2/2023 1589 Actual 20 -80% 92 Paid 01/17/2023 ($533.37) 11/2/2022 1569 Actual 101 67% WATER 03/14/2023 $76.00 $0.00 91 MISCELLANEOUS 03/14/2023 $7.82 $0.00 8/3/2022 1468 Actual 61 298% Paid 04/06/2023 ($83.82) - -- 92 VVHt ChC 06/142023 $2290 _, _ a22.0v Historical Readings MISCELLANEOUS 06/14/2023 $7.82 $7.82 30 - - 250 200 - 150 c p° 100 r-u �' _ ��..... - - ,.. ... .a •_ cca - —zs �4 -50 .100 ` Reading Dot `I V9.5.001 \\TNA-GOVERN\Govern\GovernReports\ubcard.rpt