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HomeMy WebLinkAboutConditional Pass - Title V Inspection Report - 30 ANNE ROAD 6/1/2023 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen)g PL'\N 30 ANNE ROAD Property Address VICTORIA VISSERING Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 JUNE 1, 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 A. Inspector Information filling out forms on the computer, Todd James Bateson use only the tab _ key to move your Name of Inspector cursor-do not Bateson Enterprises_ Inc. use the return Company Name key. 111 A A Road Company o � Companyny Address Andover _ MA 01810 City/Town State Zip Code 978-475-4786 SI-16 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. ❑ Fails JUNE 1, 2023 Insp ors Signa 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.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System.Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ll Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 ANNE ROAD _ Property Address VICTORIA VISSERING Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 JUNE 1, 2023 _ -- 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. 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth: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 30 ANNE ROAD Property Address VICTORIA VISSERING _ Owner Owner's Name information is NORTH A_NDOVER MA 01845 _ JUNE 1, 2023 required for every _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 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 ❑ ® 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 ANNE ROAD Property Address VICTORIA VISSERING Owner — - - ---. Owner's Name information is required for every NORTH ANDO_VER MA 01845 JUNE 1, 2023 page. Cityrrown 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): SEPTIC TANK LEAKING, NEEDS REPLACED D-BOX ROTTED AND NEEDS REPLACED ❑ 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 30 ANN E ROAD Property Address VICTORIA VISSERING Owner -- - - --- Owner's Name information is required for every NORTH ANDOVER MA 01845 JUNE 1, 2023 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 Y2 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 t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �r Title 5 Official Inspection Form ! io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 ANNE ROAD Property Address VICTORIA VISSERING Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 JUNE 1, 2023 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 ® ❑ 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)] l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 ANNE ROAD Property Address VICTORIA VISSERING Owner - - - - - Owner's Name information is required for every NORTH ANDOVER _ MA _ 01845 JUNE 1, 2023 _—_— page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): NA____ Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA Description: Number of current residents: 0 - 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d SEE ATTACHED 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy'. Date R 2022 ate 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 l0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 ANNE ROAD _ Property Address VICTORIA VISSERING Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 JUNE 1, 2023 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other (describe below): 3. Pumping Records: Source of information: BATESON ENTERPRISES INC JUNE 2000 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: --- — t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r, R Rio Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 ANNE ROAD Property Address VICTORIA VISSERING Owner -- - — Owner's Name information is required for every NORTH ANDOVER _ MA 01845 JUNE 1, 2023 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: 32 YEARS, INSTALLED 1991, FROM PREVIOUS TITLE 5 REPORT Were sewage odors detected when arriving at the site? ❑ Yes ® No 5 Building Sewer(locate on site plan): Depth below grade: 2 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.): JOINTS OK VENTING OK NO EVIDENCE OF LEAKAGE 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 30 ANNE ROAD Property Address VICTORIA VISSERING Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 JUNE 1, 2023 ----- ---- -- -- - -- page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 1 --- 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' X 5' X 4' --_ Sludge depth: 6 -- Distance from top of sludge to bottom of outlet tee or baffle - Scum thickness Distancefrom top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? TAPE MEASURE AND SLUDGE JUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): BAFFLES DETERIORATING TANK IS LEAKING AND NEEDS REPLACED t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f; 30 ANNE ROAD u— - Property Address VICTORIA VISSERING Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 JUNE 1, 2023 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 lie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. 30 ANNE ROAD Property Address VICTORIA VISSERING Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 JUNE 1, 2023 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): 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 WAS DRY, DISTRIBUTION NOT EQUAL NO EVIDENCE OF SOLIDS CARRYOVER EVIDENCE OF LEAKAGE D-BOX IS ROTTING AND NEEDS REPLACED t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 ANNE ROAD Property Address VICTORIA VISSERING _ Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 JUNE 1, 2023 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): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: 2; 48'6" El leaching galleries number: TRENCHES ® leaching trenches number, length: ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 ANNE ROAD - - - -- Property Address VICTORIA VISSERING Owner ------- Owner's Name information is required for every NORTH ANDOVER MA 01845 JUNE 1, 2023 _ __-- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOIL AND VEGETATION GOOD NO EVIDENCE OF HYDRAULIC FAILURE OR PONDING LEACH TRENCHES HAVE SEEN NO WATER SINCE OCTOBER 2022 CONDITION OF TRENCHES UNKNOWN 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.7/26/201B Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,s 30 ANNE ROAD Property Address VICTORIA VISSERING Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 JUNE 1, 2023 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 ANNE ROAD Property Address VICTORIA VISSERING Owner Owner's Name information is required for every NORTH ANDOVER _ MA 01845 JUNE 1, 2023 page. Citylrown 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 500 a�� � a 1 ( a W A f' [�Jj �' (> k r<Act too) JjQf Cb 33 } - 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 ANNE ROAD Property Address VICTORIA VISSERING Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 JUNE 1, 2023 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 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. 1991 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: TITLE 5 ON FILE ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: PREVIOUS TITLE 5 REPORT HAD DESIGN PLAN INFO 4' ABOVE GROUND WATER 1991 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 =,T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 ANNE ROAD Property Address VICTORIA VISSERING _ Owner __-- Owner's Name information is required for every NORTH AND_OVER _ MA 01845 JUNE 1, 2023 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Summary Record Card generated on 6/1/2023 1:15:34 PM by Karen Hanton Page 1 Town of North Andover Tax Map # 210-037.B-0035-0000.0 Parcel Id 12871 30 ANNE ROAD VISSERING, CARL 8,VICTORIA 30 ANNE ROAD NO.ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 2.45 Acres FY 2023 UB Mailing Index Name/Address Type Loan Number Activelinact. From Until VISSERING,CARL&VICTORIA Payor Acttv«: 30ANNE ROAD NO.ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 16052.0-30 ANNE ROAD Last Billing Date 4/5/2023 3160108 03 Cycle 03 Active UB Services Maint. Account No.3160108 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE /1 UB Meter Maintenance Account No.3160108 Serial No Status Location Brand Type Size YTD Cons 32707680 a Active 00 b Badger yr Water 0.625 0.625 107 Date Reading Code Consumption Posted Date Variance 3/2/2023 1584 a Actual 0 4/12/2023 -100% 12/2/2022 1584 aActual 4 1/16/2023 -60% 9/6/2022 1580 a Actual 11 10/18/2022 -19% 6/2/2022 1569 a Actual 13 7/18/2022 -13% 3/2/2022 1556 a Actual 14 4/13/2022 19% 12/6/2021 1542 aActual 13 1/17/2022 40% 9/2/2021 1529 a Actual 9 10/15/2021 -25% 6/2/2021 1520 a Actual 12 7/27/2021 -45% 3/2/2021 1508 aActual 21 4/21/2021 117% 12/3/2020 1487 a Actual 10 1/13/2021 -37% 9/2/2020 1477 a Actual 16 10/14/2020 11% Summary Record Card generated on 6/1/2023 1:15:34 PM by Karen Hanlon Page 2 Town of North Andover Tax Map # 210-037.B-0035-0000.0 Parcel Id 12871 30 ANNE ROAD VISSERING, CARL & VICTORIA 30 ANNE ROAD NO. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 2.45Acres FY 2023 6/1/2020 1461 aActual 14 7115/2020 15% 3/3/2020 1447 a Actual 12 4/8/2020 13% 12/5/2019 1435 a Actual 10 1115/2020 -9% 9/12/2019 1425 a Actual 13 10/10/2019 -14% 6/5/2019 1412 a Actual 14 7/25/2019 -2% 3/5/2019 1398 a Actual 14 4/16/2019 29% 12/5/2018 1384 a Actual 11 1/22/2019 -38% 9/5/2018 1373 a Actual 18 10/15/2018 -7% 6/5/2018 1355 a Actual 20 7/23/2018 -23% 3/2/2018 1335 a Actual 24 4123/2018 43% 12/4/2017 1311 a Actual 17 1/25/2018 15% 9/6/2017 1294 a Actual 16 10/18/2017 -20% 6/2/2017 1278 a Actual 19 7/25/2017 22% 3/3/2017 1259 a Actual 15 4/12/2017 0% 12/5/2016 1244 a Actual 16 1/23/2017 -25% 9/2/2016 1228 a Actual 20 10/24/2016 15% 6/6/2016 1208 a Actual 19 8/2/2016 11% 3/2/2016 1189 a Actual 16 4/22/2016 -10% 12/3/2015 1173 aActual 18 1/20/2016 -46% 9/3/2015 1155 a Actual 34 10/16/2015 87% 6/3/2015 1121 a Actual 18 7/24/2015 10% 3/4/2015 1103 a Actual 16 4/28/2015 -8% 12/5/2014 1087 aActual 18 1/15/2015 -76% 9/4/2014 1069 a Actual 75 10/15/2014 364% 6/4/2014 994 a Actual 16 7/16/2014 -6% 3/5/2014 978 aActual 17 4/11/2014 -1% 12/4/2013 961 a Actual 17 1/17/2014 -78% 9/5/2013 944 a Actual 76 10/15/2013 104% 6/7/2013 868 a Actual 38 7/24/2013 90% 3/7/2013 830 a Actual 20 4/22/2013 -11% 12/5/2012 810 aActual 22 1/9/2013 -660/. 9/6/2012 788 a Actual 66 10/15/2012 175% 6/7/2012 722 a Actual 24 7/16/2012 0% 3/8/2012 698 a Actual 24 4/14/2012 14% 12/8/2011 674 a Actual 21 1/17/2012 -25% 9/8/2011 653 a Actual 30 10/13/2011 53% 6/2/2011 623 a Actual 18 7/20/2011 2% 3/4/2011 605 a Actual 17 4/13/2011 -76% 12/7/2010 588 aActual 78 1/12/2011 -26% 9/3/2010 510 a Actual 103 10/15/2010 523% 6/2/2010 407 a Actual 16 7/15/2010 -6% 3/4/2010 391 a Actual 17 4/14/2010 -2% 12/4/2009 374 aActual 18 1/12/2010 -32% 3r O. N011TH, L w 4 ' yy0 (7) GG. O � 9 Town of North Andover HEALTH DEPARTMENT CHU CHECK#: c/ / DATE: LOCATION: .30 H/ONAME: iSSe,l'inq CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ _ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid 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 $ l Title 5 Report 6y?j . $.SO ❑ Other:(Indicate) $ Heaifih-Agent Initials White-Applicant Yellow-Health Pink-Treasurer