HomeMy WebLinkAboutTitle V Inspection Report - 78 VEST WAY 11/18/2015 Commonwealth of Massachuse tts 1, TOA-,
Title ff' ' I Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is North Andover MA 01845 11/18/2015
required for
every page. Cityfrown 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: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key x P `t 0 4
to move your Neil J. Bateson
cursor-do not Name of Inspector
use the return 1i 01111P,G OF P1lt'M 119
key. Bateson Enterprises Inc. [IFA[ I G f P, Y,d4FMIFI
Company Name
VQ 111 Argilla Road
Company Address
Andover MA 01810
re�.n Citylrown State Zip Code
978-475-4786 S115
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Nee s Fu her Evaluation by the Local Approving Authority
r
11/18/2015
Inspecto s Si nature 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 is a shared system or
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 should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection r
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 11/18/2015
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) 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:
B) 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):
(Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 11/18/2015
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
C) 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.
1. 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:
❑ 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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fr
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is North Andover MA 01845 11/18/2015
required for
every page. CityTTown State Zip Code Date of Inspection
B. Certification (cont.)
2. 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.
3. Other:
D-Box needs to be replaced.
D) 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
❑ ® 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 '/day flow
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 11/18/2015
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 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 2000gpd-
10,000gpd.
❑ ® 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.
E) 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 D.
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
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection r
lu- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owners Name
information is
required for North Andover MA 01845 11/18/2015
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): N/A Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 11118/2015
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 4
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): Yes
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 11/18/2015
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Pumped 2013, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank&tees
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):
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection r
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 11/18/2015
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Original, owner. Outlet tee in septic tank was replaced 2004, B.O.H. info
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1e.6
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.):
4"Cast iron through wall, 3" PVC in house, no leaks visible
Septic Tank(locate on site plan):
Depth below grade: 0.6
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'x5'x4'
Sludge depth:
6°
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 11/18/2015
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
7"
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumped septic tank. Inlet tee ok. Outlet tee ok. Inlet cover has riser under patio blocks. Depth of
liquid at outlet invert. No evidence of leakage.
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owners Name
information is North Andover MA 01845 11/18/2015
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.r 78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 11/18/2015
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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 level &distribution equal. Evidence of carryover, pumped d-box to clean. D-box has
corrosion holes, needs to be replaced.
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owners Name
information is North Andover MA 01845 11/18/2015
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 field 15'x 40'
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil Ok. Vegetation ok. No sign of ponding to surface.
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 11/18/2015
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 11/18/2015
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
� l = `i �
� ✓ tit l� W
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection r
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 11/18/2015
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >4
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: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database-explain:
Essex County Soil Map.
You must describe how you established the high ground water elevation:
Essex County Soil Map, Sheet#30, Paxton Soil, Water>6' deep
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection r
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 11/18/2015
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
r V r L- L V I J I L- J V I ". .... v I I I i
srirtvntry Record cud g°ntraled on I W312016 12:40,69 PM W Mawean McAuby PD;a
Town of North Andover
Tax Map # 210-104.0.0170-0000.0
Parcel Id 16492
78 VEST WAY
MILLIKEN, SOPHIA
78 VEST WAY
N.ANDOVER, MA I
__ _01845
Class .---- 101 Single Family Property Type 1 Residential
Zaning2 1 Residential Zoning3 1 Residential
Size Total 1,01 Acres
FY 2016
IJB Mallin_ Index
Name/Addres8 Type Loan Number Activeflnact, From Until
MILLIKEN,SOPHIA Payor
78 VEST WAY f
N.ANDOVER,MA
01845
ltB Ace;otant i1jL
Account No Cycle Occupant Name Activellnmctivo
Bldg Id,17831.0-76 VEST WAY Laet Billing Date 101812W i
3170496 03 Cycle 03 Active
LrvIog9 Maiint.
Account No,3170490
Service Code Rate Charge Multlpller/Users
MISCFEEADMIN FEE 0.63 616 7.82 11
WTR WATER 01 ALL METER SIZE 425.85 /1
UB Meter Maintenance a e ry
Account No.3170496 f t) '1 L G l r O
Sariat No Status Location Drand IM Size YTD Cons
35844525 aActivo ERT HH b Badger w Water 0.63 003 961
Date Roadirig Code Consumption Portad Date Variance
91912015 095 a Actual 83 10/18/2015 62%
611012015 912 aActual 45 7124/2015 221%
3/1212015 867 aAotual 14 4/28/2015 -42%
1211212014 863 a Actual 26 111512015 -73%
911012014 828 aAotual 91 10/15/2014 363%
619/2014 7$7 aActual 19 711612014 45%
3/11/2014 718 aAotual 13 4/11/2014 •58%
12/1212013 705 a Actual 32 111712014 48%
9112!2013 673 aActuai 63 1011=13 55%
6/1112013 610 a Actual 39 7/2412013 210%
3/1412013 571 a Actual 13 4/22(2013 42%
1211212012 558 a Actual 22 119/2013 -77%
0112/2012 536 a Actual 96 10115/2012 94%
6/1212012 440 aActual 49 7M 612012 313%
3113!2012 391 a Actual 12 4/14/2012 -22%
12/1212011 379 aActual 15 1/1712012 -•77%
9/1312011 364 a Actual 70 1011312011 110%
0/7/2011 294 &Actual 30 7120/2011 107%
317/2011 264 a Actual 14 4113/2011 -54°A
121812010 250 a Actual 31 1/12/2011 •72%
9/9/2010 219 a Actual 114 10/1512010 190 11/0
618/2010 105 a Actual 38 7/16/2010 135%
3/1012010 67 aActual 16 4/14/2010 A%
1211112009 51 a Actual 17 U121010 -U%
918/2009 34 a Actual 34 1011512009 09/4
719/2009 0 n Now Motor 0 10//512009 0%
61812009 4714 m Manual estimate 40 7/2012009 32%
3/1612009 4674 m Manual estimate 35 412912009 .7%
MSG
f1
I
:�_L\ Commonwealth of Massachusetts
City/Town of .
System Pumping.Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information,must be substantially the same as that provided here. Before using.this fortn, Fheck with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
I. System Location: Left/Right front of house, Left/Rig rear of house, e /right of hous Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address t•--1�. ��� V"�� �C��� _�
CWrown ' ` State Zip Code
2. System Owner.
Name
Address(if different from location)
City/rown State Zip Code
Telephone Number
i
.B. Pumping JRpcord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition of System;
6. System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
_ S Lowell Waste Water
SignAttle I Heule Date
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