HomeMy WebLinkAboutPass - Title V Inspection Report - 252 GRAY STREET 12/18/2023 Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e`
252 GRAY STREET
FProperty Address
MIKE ENSMINt3ER
Owner Owner's Name
information is
NORTH ANDOVER MA 01845 DECEMBER 11, 2023
required for every _
page City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
_ .. _....... ....... _..
Important:when _.__.... . m_..... ._. . ..... ._..... ......... . .._...... _...__..._..
fillingImportant:
When
A. Inspector Information
t forms
on the computer,use only the tab Todd James Bateson
...........
key to move your Name of Inspector
cursor-do not Bateson Enterprises Inc,.
use the return _
key. Company Name
111 Argilla Road
r Company Address
Andover MA 01810
......I City/Tow n State Zip Code
I 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 systern 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 1 have determined
that the system.
1. F] Passes
2. El Conditionally Passes
1 Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
/Ors
` DECEMBER 12„ 2023
Inspat 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.
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M Commonwealth of Massachusetts
Ir Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t kµ
AF . 252 GRAY STREET
Oroperty Address
MIKE ENSMINGER
Owner Owner's Name
information
equired fuurre d for every IS NORTH ANDOVER MA 01845 DECEMBER 11 2023
re __ --
page. Cityfrown State Zap Code gate of Inspection
_. _.......__.,.w__...._._....__....._...� __ ..... ...............
.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:
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,
E'] Y ❑ N ND (Explain below):
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Commonwealth of Massachusetts
4.,
Ta le 5 Official Inspellabon Form
l Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
252 GRAY STREET
Property Address
MIKE ENSMINGER
Owner Owner's Name
information is NORTH ANDOVER MA 01845 DECEMBER 11, 2'023
required for every
page City/To,wn Mate Zip Code Mate of Inspection
........... ._.. ...., ._____... ..._...._.,_._.. _ _ ..__,_. ....... _.......... ...... _..............
C. Inspection Summary (cent.)
2) System Conditionally Passes (cant.):
Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
El 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).
El broken pipe(s) are replaced [-1 Y F� N [I ND (Explain below):
Ej obstruction is removed El Y [l N El ND (Explain below):
F� distribution box is leveled or replaced F� Y N Ej 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 7 Y 7 N El ND (Explain below):
0 obstruction is removed ❑ Y ❑ N [I ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
El 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:
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a� °gin Commonwealth of Massachusetts
Tom, Title 5 ►ftl lnpetirn Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M
ux 252 GRAY STREET
Property Address
MIKE ENSMINGER
Owner Owner's Name
information is NORTH ANDOVER MA 0145 DECEMBER 11, 2023
regUired for every _
page. Clty[Town State Zip Code Date of Inspection
......... .....,_...._. _...._ _.._. .. ._ ............ ...._.� _.......... ......._._..._,_,__... __... _.. _.w_..__w....__
C. Inspection Summary (cant.)
R 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
El clogged
of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
D Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5hsp.clx•rev 7/26/2018 rile 5 Official cial Irtspedio i F orm Subsurface Sewapea Disposal System-Page 4 0 18
Commonwealth of Massachusetts
=� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
fi pew
252 GRAY STREET
Property Address
MIKE ENSMINGER
Owner Owner's Name
informatrequired
is NORTH ANDOVER MA 01845 DECEMBER 11, 2023
required for every _.
page. CetyrTown state Zip Code rate of Inspection
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
11 z Liquid depth in cesspool is less than " below invert or available volume is less
than 1/2 day flow
❑ Z Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: ,W_ .
El E Any portion of the SAS, cesspool or privy is below high ground water elevation.
1:1 z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
E Z Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
[ -1 z Any portion of a cesspool or privy is within 50 feet of a private water supply well,
El 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 S ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
l M The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ M 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 flaw of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the fallowing, in addition to the
questions in Section CA.
Yes No
[� ❑ the system is within 400 feet of a surface drinking water supply
C] C] the system is within 200 feet of a tributary to a surface drinking water supply
El 0 the system is located in a nitrogen sensitive area (lnterim Wellhead Protection
Area— IWWPA) or a mapped Zone II of a public water supply well
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Commonwealth of Massachusetts
I Title Off d l Insp ton Form
1} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
` 252 GRAY STREET
t �
Property Address
MIKE ENSMINUER
Owner Owner's Name
squired fo is NORTH ANDOVER MA 01B45 DECEMBER 11, 2023
grmati
a
p �r every _. _ _ ...
e CltyfTown State Zip Code Cate 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
U Pumping information was provided by the owner, occupant„ or Board of Health
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?
❑ Z Have large volumes of water been introduced to the system recently or as part of
this inspection?
Z 0 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?
El Was the site 'inspected for signs of break out?
Z 1:1 Were all system components, excluding the SAS, located on site?
Z 0 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 El 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 1:1 Existing information. For example„ a plan at the Board of Health.
Z El 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)]
r5insp elr,rr-rev '7f212018 rive 5 offictnl Inspection uosm Suasuxfaur Sewage D spossa Sys¢rsm.Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
52 GRAY STREET
Property Address
MIKE ENSMINGER
Owner Owner's Name
information is NORTH ANDOVER MA 01845 DECEMBER 11, 2023
required for every
page. CityfTown State Zip Code Date of Inspection
D. System Information
1. Residential Flaw Conditions:
Number of bedrooms (design): Number of bedrooms (actual).
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Description:
4
Number of current residents: _
Does residence have a garbage grinder? 0 Yes F] No
Does residence have a water treatment unit? F-1 Yes Z No
If yes, discharges to;
Is laundry on a separate sewage system? (Include laundry system Inspection El Yes Z No
information in this report.)
Laundry system inspected? Z Yes E] No
Seasonal use? El Yes Z No
Water meter readings, if available last 2 ears usage d SEE ATTACHED
g f y g (gp ));
Detail:
Sump pump? E' Yes Z No
Last date of occupancy- CURRENT
p y date_...
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Commonwealth of Massachusetts
Title a Official Inspection Farm
r Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
252 GRAY STREET
Property Address
MIKE ENSMINGER
Owner Owner's Narne
information as regraired for every NORTH ANDOVER MA 01845 DECEMBER 11, 2023
_
page. City[Town State Zip Code Date of Inspection
_...._ _._ .....__.......______.
D.. System Information (cant.)
2. Commercial/industrial Flow Conditions:
Type of Establishment: _
Design flag(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? El Yes E] No
If yes, discharges to: _
Industrial waste holding tank present? ❑ Yes E 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
Was system pumped as part of the inspection? E Yes ❑ No
If yes, volume pumped: 1500 GALLOONS
gallons
How was quantity pumped determined? TRUCK GAUGE
Reason for pumping: MAINTENANCE _
�!wsp do,",•rev '712612018 1 rare 5 Offic al V u3pxtop F'ovm Subs ufface Sewago DmpraaaW System•Page 8 of 18
Commonwealth of Massachusetts
id Title 5 0fficial Inspection Form
; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
252 GRAY STREET
Prraperty Address
MIKE ENSMINGER
Owner Owner's Name
information is NORTH 9 ANDOVER MA 01845 DECEMBER 11, 2023
required for every
page C6tyffown _. .___..Mate Tip Code bate of enspection
D. System Information (cant.)
4. Type of System..
z Septic tank, distribution box, soil absorption system
7 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:
18 YEARS, INSTALLED OCT 2005, AS BUILT PLAN
Were sewage odors detected when arriving at the site? El Yes No
5. Building Sewer(locate on site plan):
1.5"'
Depth below grade: feet
Material of construction:
w._
(, cast iron E 40 PVC [I 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
t5nsp.rlaw•rev."7f2612018 T'Ifle',Offrcwl lnsa scotrcrrr f°oars SUbsurfaacao Sewagaa DisposW system»raage 9 of 18
Commonwealth of Massachusetts
s T"FE
'Ie 5 Official Inspection Form
�IAl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 252 GRAY STREET
Property Address
MIKE ENSMINGER
Owner owns I"Jar^ne
information is NORTH ANDOVER MA 01845 DECEMBER 11, 2023
rep�airedforevery _.
page CityFTown State Zip Code Date of Inspection
D. System Information (cant.)
& Septic Tank (locate on site plan):
8
Depth below grade: teed
Material of construction:
FA concrete metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes No
10' X 5" X 4'
Dimensions:
Sludge depth
Distance from top of sludge to bottom of outlet tee or baffle 3
Scum thickness
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle S'"
How were dimensions determined? SLUDGE JUDGE AND 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.):
RECOMMEND PUMPING YEARLY
PLASTIC INLET AND OUTLET TEES OK
TANK IN GOOD CONDITION
LIQUID LEVELS OK
NO EVIDENCE GE LEAKAGE
TANK 12" DEEP MAN HOLE COVERS ON INLET AND OUTLET 7" DEEP
P9iHmsp dx•rev '7f2.6;2O t 8 Tiflle 5 OdfrrmoM h)sgpecto re F ofrn SUb%xm'@'mam Sewage CJusr'.m)sM f:,ystemmv•Page 10 of 18
Commonwealth of Massachusetts
'Title 5 Offidal Inspe t'on Form
� Subsurface Sewage Disposal System Farm _ Not for Voluntary Assessments
252 GRAY STREET
Property Address
MIKE ENSMINGER
Owner Owner's Nameinfor
required
as NORTH ANDOVER MA 01845 DECEMBER 11, 2023
required for every
page, CityrTown State Lp Code gate of Inspection
............... ..........,,----..-------_._ ._....
D. System Information (coat,)
7. Grease Trap (locate on site plan)
Depth below grade: feet
Material of construction:
El concrete [_I metal [1 fiberglass F-1 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.):
...._.....
& Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete 0 metal [ fiberglass D polyethylene [ ] other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
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Commonwealth of Massachusetts
Tide 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
22 GRAY STREET
Property Address
MIKE ENSMINGER
Owner Owner's Name
required
is NORTH ANDOVER MA 01545 DECEMBER 11, 2Ci23
required for every _ ..
page City/Town Mate Zip Code Date of Inspection
........._ ........ ...._.... .. ._._ _ .. ....... .._...__w..._......... .. .....................
D. System Information (coat.)
5. Tight or Holding Tank (cant.)
Alarm present: ❑ Yes ] No
Alarm level: Akairrr in working raider: P 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):
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.).
D-BOX IS LEVEL AND HAS SPEED LEVELERS
DISTRIBUTION IS EQUAL
LIGHT EVIDENCE OF SOLIDS CARRYOVER
NO EVIDENCE OF LEAKAGE
LIGHT SCALE ON WALLS OF D-BOX
t5in sp dm-rev 7/2612018 fi lea 5 Offrc,4 Inspection i'°crnn Subsurface Sewage Msposal fayslem.Waage 12 of 18
Commonwealth of Massachusetts
" Tide Official Inspection Form
I Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments
�At
252 GRAY STREET
Property Address
MIKE ENSMINCER
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 DECEMBER 11„ 21023
_ _ _
page. CrtyfTown State Zip Code Cate of Inspection
D. System Information (cant.)
10. Pump Chamber (locate on site plan):
Pumps in working order; 0 Yes [l No*
Alarms in working order: 0 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:
z leaching chambers number; 20 _
El leaching galleries number:
El leaching trenches number, length:
leaching fields number„ dimensions:
[� overflow cesspool number.
[� innovative/alternative system
Type/name of technology:
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Commonwealth of Massachusetts
I T"i -le 5 official Inspection Form
Subsurface Sewage Disposal System Farm Not for Voluntary Assessments
r 252 GRAY STREET
Property Address
MIKE ENSMINGER
Owner Owner's Narne
inforrnation is NORTH ANDOVER MA 01845 DECEMBER 11„ 2023
required for every _
page. City/Town State Zip Code Crate of Inspection
D. System Information (cant.)
11. Soil Absorption System (SAS) (cant.)
Comments (note condition of sail, signs of hydraulic failure, level of ponding, 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 ponding, condition of vegetation„
etc.):
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Commonwealth of Massachusetts
p141 Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
252 GRAY STREET
Property Address
MIKE ENSMINGER
Owner Owner's Name
information is NORTH ANDOVER MA 01845 DEC EMBER 11 2023
required for every _
page City/Town State Zip Code [late of Inspection
......
.......
......
�_....._.__ . _ _....._
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.):
t5insp,doc-gev 7/26/2018 "1We 5 officiW Inspection Form,Subsurface Sewage Disposal Systern Page 15 of 18
" Commonwealth of Massachusetts
Wpm Tiff 5 Official Inspection Farm
_- w.... Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
., 252 GRAY STREET
Property Address
MIKE ENSMINGER
Owner t�wner's Name
information is NORTH ANDOVER MA 01845 DECEMBER 11!._2023
required for every _.
page Cftyfrown State Zip Code Date of inspection
D. System information (cant.) µ
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
..
/�._• A
a�p�M
J
D
tsinsp.doc•rev.712612018 Cite 5 OtPiciiaad Inspection Foam:Sutreasrface Sewage Disposal System•Page 16 of 18
° Commonwealth of Massachusetts
Title 5 Official Inspection Form
-. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
252 GRAY STREET
Property Address
MIKE ENSMINGER
Owner Owner's Name
required for
is NORTH ANDOVER MA 01845 DECEMBER 11, 2023
required for every _
page City/Town State Zip wade rate of lnspectlon
_..__�_._.. .__...._ .._ _.. . .......,_..._.,.._.a.. ....
D. System Information (cant.)
15, Site 'Exam:
Check Slope
EXI Surface water
Check cellar
F'� Shallow welis
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: MAY 23„ 2002 _
vase
[❑ Observed site (abutting property/observation We within 150 feet of SAS)
z Checked with local Board of Health -explain:
PLANS ON FILE
❑ Checked with local excavators„ installers - (attach documentation)
El Accessed USES database -explain:
You must describe how you established the high ground water eievation:
DESIGN PLAN ON FILE
Before filing this inspection Report, please see Report Completeness Checklist on next page.
t5insp doc^rev 7/260018 f Ale 5 official Inspectm Form Subsurface Sewage Disposal System•page'1"7 or 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
. . 252 GRAY STREET
Property Address
MIKE ENSN1INGER
Owner Owner's Narne
inforrequired ron
is NORTH ANDOVER MA 01845 DECEMBER 11, 2023
regciired for every
page. City/Town State Zip Code Date of hospection
_....... _.,_m _...._...._.._._�._............. __. .. .... ...... _._ ._ .. ...,.. . ,_.._.._..
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspector information: Complete all fields in this section..
S, Certification: Signed & Gated and 1, 2, 8„ or 4 checked
El C. inspection Summary:
1, 2„ 8, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
Z 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
t5?r%pr.a9oc-vwwm.'712612018 1"me,5 Orfrc,,ak in si:xxt on Foffn.Subsurface Sewage f'YtlnsW„mal SyWem•Pige 18 of 18
Summary Record Card generated on 121412(Y23 8:53:52 AM by Karen Hanlon Page I
Town of North Andover
Tax Map # 210-107.D-0126-0000.0
Parcel Id 22682
262 GRAY STREET
MICHAEL& ELIZABETH ENSMINGER
262 GRAY STREET
NORTH ANDOVER MA 01845
..................
Class 101 Single Family Property Type 1 Residential
Size Total 1.024 Acres
FY 2024
UB Mailing Index
Name/Address Type Loan Number Active/Inact, From Until
MICHAEL&ELIZABETH ENSMINGER Owner Active
252 GRAY STREET
NORTH ANDOVER MA 01845
LITCHFIELD CO. Payor Inactive 10/25J2005
26 RAY AVENUE
BURLINGTON,MA 01803
DAVIDAMENHAUSER Previous Customer lnactive 2/1212009
MELISSA CHATFIELD
252 GRAY STREET
NORTH ANDOVER,MA 01845
ROBERT PRATT Previous Customer Inactive 6/18/2015
252 GRAY STREET
NORTH ANDOVER,MA 01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg to.20725,0-252 GRAY STREET Last Billing Date 11114/2023
1090514 01 Cycle 01 Active
UB Services Maint.
Account No. 1090514
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0,635/8 7,82 1/
WTR WATER 01 ALL METER SIZE 81.55 1/1
UB Meter Maintenance
Account No, 1090514
Serial No Status Location Brand Type Size YTO Cons
32422043 a Active 00 b Badger w Water 0.6250.625 424
Date Reading Code Consumption Posted Date Variance
10/1 9=23 3903 a Actual 21 11/21/2023 -12%
7/20/2023 3882 a Actual 24 8/14/2023 13%
4/19/2023 3858 a Actual 21 5/10/2023 5%
1118/2023 3837 a Actual 20 2/14/2023 -75%
10/19/2022 3817 a Actual 79 11/912022 -9%
7/20/2022 3738 a Actual 88 8/16/2022 373%
4/1912022 3650 a Actual 18 5/12/2022 -19%
1/20/2022 3632 a Actual 23 2/16/2022 -30%
10/2012021 3609 a Actual 32 11/22/2021 -44%
7122/2021 3577 a Actual 58 8/24/2021 187%
4/21/2021 3519 a Actual 20 5/18/2021 1%
1/2012021 3499 a Actual 20 2/23/2021 -35%
10/2012020 3479 a Actual 32 11/12/2020 -78%
7/16/2020 3447 a Actual 126 8/12/2020 547%
4/24/2020 3321 a Actual 23 5/13/2020 7%
1/1712020 3298 a Actual 20 2/10/2020 -66%
10/18/2019 3278 a Actual 57 12118/2019 45%
7/2212019 3221 a Actual 42 8113/2019 142%
4/19/2019 3179 a Actual 17 5/1512019 0%
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