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HomeMy WebLinkAboutConditional Pass - Title V Inspection Report - 110 FULLER ROAD 8/21/2023 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assess�7ertts 110 FULLER ROAD --------------Property Address RONN FAIGEN Owner 6 n_er­a_ Name— information is NORTH ANDOVER MA 01845 AUGUST 17, 2023 required for every page, 'S"ie-te dap Cade ba"'"t-e",—of'I n s"p-ec"6on ............ 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, use only the tab Todd James Bateson key to move your Name of Inspector cursor-do not Bateson Enter rises Inc. ........ ............. use the return ­­­ ­­ - ­11�__�p_.__ _ , _ _ _ _ key. Company Name 1 Argilla Road Company Address Andover MA ....... 6, ­_­ __ ­­­ ­­, '""" "'"' _­___ ­"__­­­' Zip Code dyrrown State 978-475-4786 Telephone Number Ucense Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 6 (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: I pasqps, 2. Conditionally Passes 3. El Needs Further Evaluation by the Local Approving Authority 4, Fails AUGUST 17, 2023 I nsodf re Clete 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. 6 nap dcc rev,712.6f201 8 Tde 5 Offic4al inspectk)n Fomv SubsLxiace Sawage Dis;x)sM System-Page I of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form M Subsurface Sewage Disposal System Farm Not for Voluntary Assessments 110 FULLER ROAD Property Address -------- RONN FAIOEN Owner owner's Name information is NORTH ANDOVER MA 01845 AUGUST 17, 202 required for every ... .....3 .._.__ _.... page. CatytTown State Zip Cade Date of Inspection _..... _ _......... _____..__ ._____ ___.__ _ __w._ _......,.,_,, _.__ -- _____ � _ . .._....... 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: 71 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, riot leaking and if a.Certificate of Compliance indicating that the tank is less than 20 years old is available.. n Y ❑ N E] ND (Explain below): t5msfrAoc-rev 7k26/201 S Title 5 O f6ciM Inspection Faim Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts M 'Title 5 Official Inspection Form n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 110 FULLER ROAD Property Address RONN FAIGEN Owner Owner's Name inforration is NORTH ANDOVER MA 01845 AUGUST 17, 2023 required for every page, C ity°Town State Zip Code Date of Inspection C. Inspection Summary (cant.) 2) System Conditionally Passes (cant.): mm Pump Chamber pumps/alarms not operational. Systern will pass with Board of Health approval if purnps/alarrns 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): [__,l broken pipe(s) are replaced .. Y 0 N [ ND (Explain below): obstruction is removed �._..� Y El N 0 NCB (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 E� Y N � ] ND (Explain below): obstruction is rernoved El Y N 0 NCB (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 1 .303(1)(b) that the system is not functioning In a manner which will protect public health, safety and the environment: t5irrrp.Uuc-rev '7r261::0 5 Tst,u 5 Offici l fnspzsr¢_Prrr¢^F:arrr SubsV.ul'iao,n ha( mage Dmip rsal System-Page 3 of 18 Commonwealth of Massachusetts l;E Ti'le 5 Offida.l InspecUon Farm Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 110 FULLER. ROAD _ -- Property Address RONN FAIOEN Owner Owner's Name information is NORTH ANDOVER MA 01845 AUGUST 17 2023 squired for everWy page Cetyn-own State Lp Code rate of InspeoVon . . ............ .__...__,........ ............. C. Inspection Summary (cant.) [l Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fall 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. [I The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply, fin ) 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: NEEDS OUTLET TEE AND GAS BAFFLE IN TANK. NEEDS NEW OUTLET COVER 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 1] Ell Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5 mtsa'd or„.rev 7d26fi2Ob 8 1 itie b office a�fovo pectFo^n rut m >fiJt:~;wfaace Sewage r1P alnsaiaf SyMem-Page 4 M 18 Commonwealth of Massachusetts TMe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 FULLER ROAD Property Adc Tess RONN FAIOEN Owner Owner's Name _. regUil'edon us NORTH ANDOVER MA 01845 AUGUST 17, 2023 recNuired for every .. page, CitylTawvn _ ;Mete Zip Cade gate Iof Nnspectian . C. Inspection Summary (cant,) 4) System Failure Criteria Applicable to All Systems; (cant.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool U z Liquid depth in cesspool is less than 6"° below invert or available volume is less than '/�day flow n z Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El z 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. (D z Any portion of a cesspool or privy is within 50 feet of a private water supply well, E] z 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.] El Z The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. The system falls. 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 D ❑ the system is within 400 feet of a surface drinking water supply [__j E] the systern 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 11 of a public water supply well Y!rinsp dx rev 7Y26J'20t8 1 it[e 5 01fcw G°rativecl*yr Form SUbsuwfaace Saw age Chsposaai Systert•6 age 5 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 FULLER ROAD Property Address RONN FAIGEN Owner .. __.. C7wner's Name information is required for every NORTH ANDOVR MA 01845 AUGUST 17, 2023 page, City/Town State Zip Code Date of Inspection _..................... ..__..._.._......_......_ _._..._._._..___ .__ ....._..........._........,......._....__.._.._.__....__..._......._.......... ..._..__.._......_w__......_.......w._.....w..._......._......__..__.____._._.._._._.. C. Inspection Summary (cant.) 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 `Zx ❑ Pumping information was provided by the owner, occupant, or Board of Health 0 Z Were any of the system components pumped out in the previous two weeks? Z El Has the system received normal flows in the previous two week period? 7 Z Have large volumes of water been introduced to the system recently or as part of this inspection? Z ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Z 0 Was the facility or dwelling inspected for signs of sewage back up? Z ❑ Was the site inspected for signs of break out? Z El Were all system components, excluding the SAS, located on site? Z El 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? Z 11 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: Z El Existing information, For example, a plan at the Board of Health. © 0 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)] t5nsp.doc rev.7126/201 S TrUe 5 Offf dad Inspection FormSu7surface Sewage Disposal SyMern.Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form .M Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 FULLED ROAD Property Address RONN FAIGEN Owner Qwner"s Name"' information is NORTH ANDOVER MA 01845 AUGUST 17 2023 required for every page, bity(Town State Zip Code Date of Inspection �__ �_. __.._..v.....___...................._.._.._.,.M._.. .._.._..............._....._,..__._____..._...._..___. __ ..._......._......_..._.....____....___...w._.._.._.__.w_,_..._.w. D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 GPD -_ Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes Z No Does residence have a water treatment unit? ❑ Yes Z No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Z No information in this report.) Laundry system inspected? Z Yes ❑ No Seasonaluse? D Yes Z No Water meter readings, if available last 2 years usage d SEE ATTACHED Detail: Sump purnp? D Yes ® No Last date of occupancy: CURRENT Date t5irisp.doc^rev.7l26/2018 'Title 5 Official Inspecli an Fore,Subsurface+Sewage Disposal System-raga"7 of 18 Commonwealth of Massachusetts (tp Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 110 FULLER ROAD Property Address RONN FAIGEN Owner Owner's Name required for e (NORTH ANDOVER MA 01845 AUGUS. 17 202 ar r cured far every page btyitown State Zip Code Date of Inspection D. System Information (cant.) 2, Commercial/industrial Flaw Conditions: Type of Establishment: _ .. Design flow (based on 310 CMR 15.203): GaBlon_s per day(gpd Basis of design flow (seats/persons/sq.ft,, etc.): Grease trap present? E Yes Ej No Water treatment unit present? 0 Yes E] No If yes, discharges to: Industrial waste holding tank present? ❑ Yes [I No Non-sanitary waste discharged to the Title 5 system? ❑ Yes r] No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3 Pumping Records: Source of information: BATESON ENTERPRISES INC NOVEMBER 2022_. Was system pumped as part of the inspection? 0 Yes Z No If yes„ volume pumped. gallon How was quantity pumped determined? Reason for pumping: fbnnP doc rev.7f2& 0l'f8 'TiOe 5 OfYic,al Inspedion F v m ,auhswrfw a Sewage nfspos:al Systwn•Pnage 8 of 4s Commonwealth of Massachusetts Title 5 t ffi ial Inspection Form 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 FULLER ROAD Property Address RONN FAIGEN Owner Owner's ner's Naire information as NORTH ANDOVER MA G184�a AUGUST 17, 2023 required for every _ page C4y/Town State Zip Code Date of hispectlorr D. System Information (cant.) 4. Type of System: 11 Septic tank, distribution box„ sail absorption system E.) Single cesspool (] overflow cesspool E] Privy Shared system (yes or no) (uf 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. .KK other(describe): Approximate age of all components, date installed (if known) and source of information: 1 YEARS OLD, DESIGN PLAN Were sewage odors detected when arriving at the site? Yes No S. Building Sewer(locate on site plan): Depth below grade: 24 feet Material of construction: E.1 cast iron F, 40 PVC [I other (explain): Distance from private water supply well or suction line: fees Comments (on condition of joints, venting„ evidence of leakage, etc.)' JOINTS AND VENTING OK NO EVIDENCE OF LEAKAGE G.r,'riwwrsp doc•,.ev 7I2&2011'9' 'N A,h y�S CPdfiurrak Vtnr,'grx u°iton["'„arrr aMEr,un'6' a;:s »arwaewq;« Ck xp:a l y4 rtro•P"'ma paa ak r8 5kyt Commonwealth of Massachusetts TMe 5 Offidal Insp►ec coon Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 FULLER ROAD Property Address RONN FAIGEN Owner Owner's Namelnformat _ regUired for Is NORTH ANDOVER MA 01545 AUGUST 17, 2023 rervfaalred Ecar every page city&own_ State _ Zap Cade mete of Inspect ion 1 ........... D. System Information (cant.) 6. Septic Tank (locate on site plan): Depth below grade: 12" feet Material of construction concrete C_. metal fiberglass ❑ polyethylene other(explain) If tank is rnetal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes No Dimensions: 15" 5_ 4" Sludge depth: 4 _ Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness Distance from top of scurrn to top of outlet tee or baffle Distance frorn bottom of scum to bottom of outlet tee or baffle 1 Flow 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.): RECOMMEND PUMPING OLDER SYSTEMS YEARLY INLET BAFFLE OK, OUTLET BAFFLE ROTTED OFF TANK OK NO EVIDENCE OF LEAKAGE LIQUID LEVELS NORMAL I'm mp duc a'ev 7126/2018 Title 5 OthciM Insp7iaM,t6on r cirm So,aknasrYace Sewage e Dfs r'i M System Page 10 of 18 Commonwealth alth of Massachusetts � p Title 5 Official Inspection Form m al Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 FULLER ROAD _ FIroperty Address RONN FAIGEN Owner fJwrpeP"s Narxne required is NOR*rH ANDOVER MA 01845 AUGUST 17, 2028 ree�auired for every _ page. btyrrowr� State Zip Code Cate of Inspection .... _._.._...,,. D. System Information (cant.) 7. Grease Trap (locate on site plan): Depth below grade: er, _ Material of construction: El concrete EJ metal fiberglass 0 polyethylene F� other(explain): ........ _. . Dirensions: 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. Data Comments (on pumping recommendations, unlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tarok (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: _ Material of construction: 0 concrete El metal [I fiberglass F-1 polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: galtlons per day t5nsp^h ak x�fev 826/2`01 kf 6 tia'M1 d''8 C9"tGra�s4 Ir s�pav�"^tue+cf k'rsrrrr.S'ubswferce Sekwag*f Msrvosa, l,Sym em*Pages 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection ction Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 110 FULLER ROAD Property Address RONN FAIGEN Owner bwner's Name requiredfo is NORTH ANDOVER MA 01845 AUGUST 17 2020 required for every _ page, City/down State. Zip Code Mete of Inspection _..__......_, ......_ ___.,_... _ ._......... _ ...,..... ....._._..._.,.____ D. System Information (cant.) 0. Tight or Holding Tarok (cant.) Alarm present: ] Yes No Alarm level: ------ Alarm in working order: 0 Yes 0 No Date of last pumping: CJate -- ------ Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract (required), Is copy attached? Yes �M� No 0 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 IS LEVEL AND DISTRIBUTION IS EQUAL LIGHT EVIDENCE OF SOLIDS CARRYOVER NO EVIDENCE OF LEAKAGE REPLACED D-BOX COVER , in aga efoc�rev 71261201 k riYleu b O frnwr;u€Prolsptrr,ho;iF r'rsrm S4ubsur'C'F.Bce Sewago kD�,Ap sal System.Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w,, Subsurface Sewage Disposal System Form Not for Voluntary Assessments . 110 FULLER ROAD ...__.__ Property Address RONN FAIGEN Owner -- ........ _ C7wner's Name information is NORTH ANDOVER MA 01845 AUGUST 17 2023 required for every _ _ .__f ITowp'__ _ page CI X State Zip Code Cate of Inspection D. System Information (coot.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Noy` 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; 25' X 36' ❑ overflow cesspool number: ❑ Innovative/alternative system Type/name of technology: t5nspa.doc•rev.M&2018 'ri W 5 Offiicwl IrrsprecN)n Fora:Subsurface Sewage Disposal System•Page'13 of 18 Commonwealth of Massachusetts 'title 5 Official Inspection Form -` 6 Subsurface Sewage Disposal System Fora - Not for Voluntary Assessments 110 FULLER ROAD Property Address RONN FAIGEN Owner Owner's Name information Is NORTH ANDOVER MA 01845 AUGUST 17, 2023 required far every ..... page. citylTown State Zip code Date of Inspection _. ...- _......._._..._.__..__ ...._...__.... ..... ....... .. .. ... ... .. _ .. ... ......_. . ... ....._ ..,.,. . _._....._...._....... _... D. System Information (cent.) 11. Soil Absorption System (SAS) (cant.) Comments (note condition of soil, signs of hydraulic failure, level of panding, damp soil, condition of vegetation, etc.): SOIL AND VEGETATION OK NO EVIDENCE OF HYDRAULIC FAILURE OR PONDING 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 panding, condition of vegetation, etc.): (&nsp doc•rev."7/26i2C I e 'ritie 5 Official OnspecUon Form:Subsurface Sewage alsposai Systern-Page 14 of Is " Commonwealth of Massachusetts N C Title 5 Offidal Inspection Form j Subsurface Sewage Disposal System Farm - Not for Voluntary Assesst ents {' 110 FULLER ROAD Property Address RQNN FAIGEN Owner Owner's Dame �nforrredor us e NORTH AND OVER MA 31845 AUGUST 17 3 3 age red for every —City/1-own _� ._ State Zip Code Date of Inspection -------- _ .. ....... _ . .....ww--- _..... D. System Information (cant.) 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,): i."t;,er% ekur.a rev 7126120 18 'rrt6e 15 Offfcwl hspmv:,:mvi FOFM &jbsurfaycev Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts c� Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �r ° 110 FULLER ROAD Fro�s�rky Address R(ONN FAIL N Owner required is NORTH ANDtOV R MA 01845 AUGUST 17, 2023 pageed for even w �,���. Grkyfcawrr fate Zip C crde b aOe of IrmspectNon D. System Information (coat.) 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 w� 15ex) GAO�1 �.w C� ......x,....ww».x......mmw.,w...,.....,.w-r«...mmm.»..mmn uw.m .+rew.u.wxrwr«x,wumYr.wawwwuw xw.rxxxnwnw.wvxx..n.+i.nn,erw,✓..www..... .. ..ter... l 0t it1 ►i f5 nsp,tdDc•rev.70612018 Tut e 5 Offs rW lnsrraac tion Form:'Su b surface S wa go&1mpscai Symeens•Page 16 of 18 Commonwealth of Massachusetts T'tie 5 Official Inspection Form Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 110 FULLER ROAD Property Address RJNN FAIGEN Owner Own er°s harminforma _ required us NORTH ANDOVER MIA 91845 AUGUST 1�, 2g23 page for every .. CryiTown State Zip Cede Gate of Inspection D. System Information (cant.) 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; AUGUST 1992 [late F„ Observed site (abutting property/observation hole within 150 feet of SAS) z Checked with local Board of Health _ explain: DESIGN PLAN ON FILE 0 Checked with local excavators, installers - (attach documentation) [_] Accessed USGS database -explain. ....... You must describe how you established the high ground water elevation: DESIGN PLAN ON FILE Before filing this Inspection Report, please see Report Completeness Checklist on next page. tl,nsp coc easy 76260016 Tire 5 Officfai hnspoct(on Forrn Suhsufface Sewage Vssspos ad Sy^Mern•Page 17 of 18 Commonwealth of Massachusetts �e :IFw Title 5 Official Inspection For ► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 FULLER ROAD Oroperty Address RONN FAIOEN Owner Owner's Name required is NORTH ANDOVER MA 01845 AUGUST 17, 2023 rent€abed for every page Cityrrown state Zip Cade Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Z A, Inspector lnformation: Complete all fields in this section. E. Certification: Signed & Gated and 1, 2, 3, or checked Z C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria( and 5 (Checklist) completed Z D System mformat%on: 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 t5msp'.a.dor-rev 7/M2018 nue q'a Officmi u nsruaruon Form Subsurface Sewage crts os ai System•&Waage t8 0't8 Surcvrwy Record Cart generared on W1012023 A 18,40 PM by Karerrr Hankm Page 1 Town of North Andover Tax Map # 210-065.0-0016-0000.0 Parcel Id 13417 110 FULLER ROAD FAIGEN, RONN 110 FULLER ROAD N. ANDOVER, MA 01845 .............. Class 101 Single Family Property Type I ResidentW Size Total 3.03 Acres IFY 2024 UB Malling Index Name/Address Type Loan Number Active/Inact, From Until FAIGEN,RONN Payor A(I m,', l 10 FULLER ROAD N,ANDOVER, MA 01846 UB Account Maint, Account No Cycle Occupant Name Active/inactive Bldg Id. 17209.0-110 FULLER ROAD Last Billing Date 7/10/2023 3160287 03 Cycle 03 Active UB Services Maint, Account No, 3160287 Service Code Rate Charge MultipNer/Users MISCF EE ADMiN FEE 0.635/8 7,82 11 WTR WATER 01 ALL,METER SIZE 346A1 /1 UB Meter Maintenance Account No. 3160287 Serial No Status Location Brand Type Size YTO Cons 32707566 a Active 00 b Badger w Water 0M5 0.625 579 Date Reading Code Consumption Posted Date Variance 616/2023 4770 aActual 69 7114/2023 126% 3/312023 4701 a Actual 28 4/12/2023 -29% 12/612022 4673 a Actual 41 1116/2023 -62% 9/7/2022 4632 a Actual 115 10/18/2022 150% 6/312022 4517 aActual 44 7/18/2022 89% 313/2022 4473 aActual 22 4/13/2022 -5% 12/6/2021 4451 a Actual 25 1/1712022 -76% 913/2021 4426 aActual 104 10115/2021 '148% 6/3/2021 4322 a Actual 42 7/27/2021 35% 3/3/202'1 4280 aActual :30 4/21/2021 -47% 12/4/2020 4250 a Actual 59 1/13/2021 -61%