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HomeMy WebLinkAboutPass - Title V Inspection Report - 263 RALEIGH TAVERN LANE 9/17/2024 Commonwealth of Massachusetts A Title 5 Official Inspection Form e4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 263 RALEIGH TAVERN LANE Property Address NATASHA DANDREO OwnerCiwnersName information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 17, 2024 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, 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 Q Company Address Andover MA 01810 City 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. Z Passes 2. R Conditionally Passes 1 F1 Needs Further Evaluation by the Local Approving Authority 4. E] Fails SEPTEMBER 19, 2024 ................lr�s,p'/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. t5iinsp doc-rev.7/2612018 Title 5 Official Inspection Form:Substrface Sewage Disposal Systern-Page I of 18 " Commonwealth of Massachusetts Title 5 official Inspection Form �� fM Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 RAI_EIGH TAVERN LANE Property Address NATASHA DANDREC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 17, 2024 ------ _ page btyfTown State Zip Code date of Inspection _..._„_,......_,a....a,....__..._...................._.... __ _.................. _........ ............... 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. Q Y ❑ N ❑ ND (Explain below): f5inspAcc-rev 712612018 Title 5 Of iciM inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 rvw Commonwealth of Massachusetts q Title 5 Official Inspection Farm . .. r, Subsurface Sewage disposal System Form - Not for Voluntary Assessments 263 RALEIGH TAVERN LANE Property Address NATASHA DANDREO Owner Owner's Name requi required is NORTH ANDOVER MA 01845 SEPTEMBER 17, 2024 requdred for every _ _ page. coy/"town State Zip Cade Date of InspeGfion ..... .. _ ........_..._...____ . _...... C. Inspection Summary (cant.) 2) System Conditionally Passes (cant.): Pump Chamber pumps/alarms riot operational. System will pass with Board of Health approval if pumps/alarms are repaired. 0 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): [y.] broken pipe(s) are replaced 0 Y E] N [ ND (Explain below). E] obstruction is removed E] Y Q N [1 ND (Explain below). distribution box is leveled or replaced Q Y F-1 N ❑ ND (Explain below). El 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 F� N [ ND (Explain below): ❑ obstruction is removed 0 Y F� N NO (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: Nrrsp doc.ouv '712612018 t Ale 5 Offlcwl taospectsa n Farm subsurface Sewage Q'A sposaal."^'°,ypstem,Page 3 of 18 Commonwealth of Massachusetts �t i Title 5 Official Inspection Form iv Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 RALEIGH TAVERN LANE Property Address NATASHA DANDREC7 Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 17, 2024 page. CltyFrown State Zip Code Date of Inspection _ C. Inspection Summary (cant.) ❑ 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 l5msp.doc-rev 7/26/2018 Tittle 5 Off'iciak Inspection Forrn_Subsurlace Sewage Disposal Systern-page 4 of 18 4 ° Commonwealth of Massachusetts �pTitle 5 official Inspection Form "� .. .11 Subsurface Sewage Disposal System Farm Not for Voluntary Assessments 263 RALEIGH TAVERN LANE Property Address NATASHA DANDREO Owner Owner's Name information is NORTH AN OVER MA 01845 SEPTEMBER 17, 2024 required far every -- _ _ _-------._-- _ page. City/Town State Zip Code Date of Inspection __. _......._...v.._..,....___......._______ _..._._.._...__ _..._..._a................... ___..__._......____ _....m.._a._..__.._._.........__.._................ 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 ❑ Z Liquid depth in cesspool is less than 6" below invert or available volume is less than 'f2 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: ❑ 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. ❑ z Any portion of a cesspool or privy is within 50 feet of a private water supply well, ❑ 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 DLP 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. ❑ z 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 — IW'PA) or a mapped Zone II of a public water supply well t5insodoc-rev 7126J2018 Title 5 0115 W Inspection Form Subsurface Sewage 1Tisgasal System-Page 5 of 18 ti Commonwealth of Massachusetts IWT Title 5 Offidal Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` 263 RALEIGH TAVERN LANE Property Address NATASHA DANDREO _ Owner Owner's Name requiredfo is NORTH ANDOVER MA 01645 SEPTEMBER 17, 2024 required for every page. City/Town State .Zip Code Date of Inspection .. ..... ........ ....... G. 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 316 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 j F Pumping information was provided by the owner„ occupant„ or Board of Health Ej E Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not ❑ available note as N/A) El rI Was the facility or dwel@ing inspected for signs of sewage back up? El :1 Was the site inspected for signs of break out? El 0 Were all system components, excluding the SAS, located on site? 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? 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)] t5fr`sp doc iev.7/116;2018 711te 5 Officol Insp:ramr,6on r¢�ion Subsurface s awargo D7 gxa,.al System.Page 6era Is Commonwealth of Massachusetts i, Tide 5 Official Inspection Farm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 263 RALEIGH TAVERN LANE Property Address NATASHA DANDREtJ Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 17, 2024 page. Cltyrrown 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#I`of bedrooms): 6010 GPD Description: -- — ........ Number of current residents: Does residence have a garbage grinder? ❑ Yes ® 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 ® No information in this report.) Laundry system inspected? Z Yes ❑ No Seasonal use? ❑ Yes Z No Water meter readings, if available last 2 ears usage d SEE ATTACHED g ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes Z No CURLast date of occupancy: Date NT__ kainsp doc^rev.7/26/2018 1'ive 5 Official Inspection Farm:Subsurface Sewage Disposal System•Faye 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 RALEIGH TAVERN LANE Property Address _ NATASHA DANDREO Owner Own er"s►Varna informotion is NORTH ANDOVER MA 01845 SEPTEMBER 17, 2024 required for every ....page. Cltyf own State Zip Code Date of Inspection D. System Information (coot.) 2. Commercial/industrial Flow Conditions: Type of Establishment Design flow (based on 310 CMR 15.203): Gallons per day(gpo) Basis of design flow(seats/persons/sq.ft.„ etc.) Grease trap present? E] Yes No Water treatment unit present? 0 Yes [] No If yes, discharges to: _ Industrial waste holding tank present? Yes 0 No Non-sanitary waste discharged to the Title 5 system? 0 Yes E] No Water meter readings, if available: _ Last date of occupancy/use; DIate _ Other(describe below) 3. Pumping records: Source of information: MAY 2024 OWNER Was system pumped as part of the inspection? E] Yes Z No If yes, volume pumped: gallons How was quantity pumped determined? _ Reason for pumping: ttiinsp doo.: oev.712612018 1"rile 5 Official inspection Fom Subsurface Sewage Disposal System«Page 8 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,:- 263 RALEIGH TAVERN LANE Property Address NATASHA DANDREO . Owner Owner's Name information is NORTH ANDOVER MA 01845 SEPTEMBER 17, 2024 required for every - page. City/Town State Zip Code Date of Inspection ----_ ............ D. System Information (cons.) 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: 41 YEARS, INSTALLED 1983, D-BOX/OUTLET TEE REPLACED 2007, PREVIOUS TITLE 5 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 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.); JOINTS AND VENTING OK NO EVIDENCE OF LEAKING t5lnsp.dric-rev,7/261201 H "rime 5 Official Inspection Farm Subsurface Sewage Disposal System Page 9 of 18 " Commonwealth of Massachusetts �l it Tulle 5 Off dal Inspection Form . Subsurface Sewage Disposal System Fora - Not for Voluntary Assessments �* 263 RALEIGH TAVERN LANE'. Property Address NATASHA DANDREO Owner Owner's Name information is NORTH ANDOVER MA 01845 SEPTEMBER 17„ 2024 required for every _ page. City/Town estate Zip Code Date of inspection _.._.__...� _..._.._ ... .._,_........... . . ... .........._ .... ......... . _ .... ._........ .. D. System Information (cent.) 5. Septic Tank(locate on site plan): 12`° Depth below grade: feet Material of construction: Z concrete D 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) F1 Yes Z No Dimensions; 1 Cp" " X 4" Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 3 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 1 l R, 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 AND CLEANING FILTER IN OLDER SYSTEMS YEARLY CONCRETE INLET BAFFLE OK PLASTIC OUTLET TEE OK OUTLET TEE HAS FILTER RECOMMEND RISER TO GRADE ON TANK TO ACCESS FILTER TANK IS GOOD LIQUID LEVELS GOOD NO EVIDENCE OF LEAKAGE t5 rrspr r cw.•rev 7050018 Title 5 Ofticial Inspection F o:rm,Suasurfrarur Srmv age Dislaaaml System•Page'10 of W `'ww4 Commonwealth of Massachusetts N , fficial Inspection Form'i° 1+ 5 o i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 263 RALEIGH TAVERN LANE_ Property Address NATASHA DANDREO Owner Owner's fume information Is NORTH ANDOVER MA 01845 SEPTEMBER 17„ 2024 required for every page. y. _.....�..._....... ..� of Inspection Clt l-rown ......... __w._..... ....... ....._ ._._ ._. State Zip Code CIate ....In D. System Information (coat.) 7. Grease Trap (locate on site plan): Depth below grade: Material of construction: El concrete El metal (_1 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. bate 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 D fiberglass ❑ polyethylene E] other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t"amsp doc-rev 7/26/2018 TMer 5 official Inspection rorin Subsuflrace Sewage C7ixposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Corm n Subsurface Sewage Disposal System Form Not for Voluntary Assessments 263 RALEIGH TAVERN LANE Property Address NATASHA DANDREO Owner Owner's Name information is NORTH ANDOVER MA 01845 SEPTEMBER 17, 2624 required for every City - _. -state-...-.-_.-_ page. CltyiTown State Zip Code Date of Inspection _......... D. System Information (cent.) 8. Tight or Holding Tank (cant.) Alarm present: El Yes M 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 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 D-BOX HAS SPEED LEVELERS LIGHT EVIDENCE OF SOLIDS CARRYOVER NO EVIDENCE OF LEAFAGE i5inspAcx:•rear.7/2612018 'Title 5 Of icIa1 Inspection Form Subsurface Sewage Disposal System-Page 12 of 18 d Commonwealth of Massachusetts Title 5 official Inspection Form �R Subsurface Sewage Disposal System Form Not for Voluntary Assessments 263 RALEIGH TAVERN LANE ^n e Property Address NATASHA DANDREO ------ Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 17, 2024 , .... ---__. page. City/Town State Zip Cade 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: 0 leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: 3, 32` LONG ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t insp doc-rev 7f2612018 Title 5 official inspection Fenn Subsauface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts I 'Title 5 Official Inspection Form arq Subsurface Sewage disposal System Form Not for Voluntary Assessments 23 RALEIGH TAVERN LANE Property Address NATASHA DANDREO Owner bwner's Name regUi edfo is NORTH ANDOVER MA (}184 SEPTEMBEIR 17, 2024 required far every ._. _ _ page. City/Town State Zip Code Date of Inspection _ww... _.......... .._ ..... ................ D. System Information (cont.) 11. Soil Absorption System (SAS) (coat.) Comments (note condition of soil, 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 scurn 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.): 5er+ is •r av '7t d„K11EiP r0o 5 oMua;M Rrw fedv)6°<aam "rra"rsurftice Sewage 4'7mpo"SyMem•Pap 14 of 18 Commonwealth of Massachusetts Tiff 5 Official Inspection Farm Subsurface Sewage disposal System Form -Not for Voluntary Assessments 263 RALEIGH TAVERN LANE Property Address NATAHA DANDREO Owner owners Name regUiredfo is NORTH ANDOVER MA 01845 SEPTEMBER 17, 2024 req�fired for every pave. y P p eft fiTown State ?.i bode Date of Ins ecteon D. System Information (cant.) 13. Privy (locate can 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.): I5fn sp dEoc*rev."X P2'@'at7018 Title 5 Moat Inspection f'e'yrrm.Su bskipfacea Sewage C.T sposal System-Page 15 of 18 Commonwealth of Massachusetts a F Tale 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 263 RALEIGH TAVERN LANE Property Address NATASHA DANDREO Owner Owner's Name Information is NORTH ANDOVER MA 01845 SEPTEMBER 17 2024 requiredfor every _____._......... ............. .w._......_,_. _. .r.......... _..__.._.. ..__.. _.... _........_ .._ ...... ,_.._._. page CltylTown State Zip Code Date of Inspection _._ __._.__.__.._..w...__ D. System Information (cone.) 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 _ t5insp.doc•rev.7/2612018 'title 5 Official Inspection Form Subsurface.Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Farm } iIs Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 263 RALEIGH TAVERN LANE Property Address NATASHA DANDREO Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 17, 2024 page, City/T'own 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: NOVEMBER 1982 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: PLANS ON FILE Checked with local excavators„ installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: DESIGN PLAN Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev 7/26/2018 Titles 5 Official Inspection Form Subsurface Sewage Msposal System•Fags 17 of'18 " Commonwealth of Massachusetts �y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 263 RALEIGH TAVERN LANE Property Address NATASHA DADREQ Owner Owner's Narne information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 17, 2024 _ page. cityfrown State Zip Code Gate of Inspection _._. _... ...... . .. ............. _......._............,._...... _.._w._.._......_. _ ...... ..... _..... E. Report Completeness Checklist Complete all applicable sections of this farm Inclusive of: Z 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 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 t nsp doc,.raw+ 'Tf2knd2018 "I kt e 5 offtcxw Ogispo-ae.ao n r'aar n asbsud ace Sewage Dmposal System•Flage 18 0 18 Summary Rewrd Cmd gemWed on W12/2024 10 39 05 AM by Karen I,iarflon Page I Town of North Andover Tax Map # 210-106.C-0115-0000.0 Parcel ld 17748 263 RALEIGH TAVERN LANE DONATO & NATASHA DANDREO 263 RALEIGH TAVERN LANE NORTH ANDOVER MA 01845 FY 2025 .......... UB Mailing Index Name/Address Type Loan Nurnber Active/Inact. From Until DONATO&NATASHA DANDREO Owner Adive 263 RALEIGH TAVERN LANE NORTH ANDOVER MA 01845 EICHLER,ROBIN PreViOUS CUstorner 1113012009 C/O JOSEPH SAVY, PC 811 TURNPIKE STREET N.ANDOVER,MA 01845 CHRIS'TOPH BALICKHAGE Owner raNlvf", 12/21)2017 263 RALEIGH TAVERN LANE NORTH ANDOVER,MA 01845 CHRISTOPH BAUCKHAGE Previous Custoaier 12130/2019 CHEMIN DE LA ROCHETTE 3 1071 CHEXBRES VD SWlTZERLAND MATTHEW DESAN'ro Owner 12123/2019 CAITLYN SULLIVAN 263 RALEIGH TAVERN LANE NORTH ANDOVER MA 01845 UB Account Maint. Account No Cycle Occupant Nwne ActivelInaefive Mg Id. 14146 0-263 RALEIGH TAVERN LANE Last Billing Date 9/512024 2100130 02 Cycle 02 Active UB Services Maint, Account No. 2100130 Service Codo Rate Charge MulflpRlerlthers MISCFEE ADMIN FEE 0,63 518 782 1/ VVTR WATER 01 At..[.METER SIZE 342,02 11 LIB Meter Maintenance Account No 2100130 SerW No Status Locabon Brand Type SIZO YTD Cons 16944460 a Active ERT HH b Badger w Water 0�625 0.625 719 Data Reading Code Consumption Posted Oate Varianco 811/2024 911 a AcluaR 68 9/12/2024 177% 5/1/2024 843 a Actual 24 6/13/2024 -6% 2/1/2024 819 a Actuat 26 3/1412024 -27% 11/1/2023 793 a Actual 35 12113/2023 -46% 81212023 758 a Actual 65 911812023 '119% 512/2023 693 a Actual 29 6/1412023 10% 21112023 664 a AcAW 27 3/1412023 -55% 11/1/2022 637 a Actual 59 12/19/2022 -22% 81212022 578 a Actual 76 9/20/2022 172%o 5/2/2022 502 a ActuaV 27 6/21/2022 -12% 21212022 475 a Actual 32 3/15/2022 -61% 111`1 P2021 443 a Actual 79 1211312021 -25% 8/312021 364 aActtW 106 912112021 2340/6