HomeMy WebLinkAboutTitle V Inspection Report - 145 BRADFORD STREET 3/23/2006 i°tYnonweW�d
J-31 Forest's, � l
MIDDLETON, MA 1.t�9 9
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Not for rliArrt � Assessments
Suys urface Sewage Di aCsal Sy teni Forrn
rrstrecfiearr reSiiits i'atlst be submitted or,r thwi s foryra or oil ti°ae official Title 6 Inspection Form dated
1,151 000. Inspection forms may not be altered in any way,
IrB"riT#7I"'$iX tie:
When filling out 1. Property Information:
form ation:
forme on the
r;carrrprrter,USO 145 BRADFORD O w3"'r"., NO. ANDOVER, MA
only the tab key Pr°orrer"$'y F4cr#+iresrx ��� •, ;I , ,r�v;`I
to move yoi.rr MAf JORIE GAUD f T � , ,, i�
cursor-do not --...._... , ,.,..
use the return Owner's Narne
Ivey. 145 BRADFORD ;�:T.
Owner's Address
- _
NCB, ANDOVER A,A 0184.5
-- - -
City/Town — Stag - -
�:ip C;tacic
� Coate of Inspection: '/2310
�i
Date,
2, Inspector:
JAIVIES CURRIER
Marne of raspector
J's SEPTIC & DRAIN
Company Name
'131 F=OIIIM ST;a_.I..
Company Address
MIDDLETON MIA
01 949
ity c>vvra Stafe Zip Cade:
978-774-6685
telephone Numtsear
-..........—------—..... _ ......__..._ . _ ... _.._.
Certification Statement:
I certify that 1 have Personally inspected the sewage dispersal system at this address and that the
information reported below is tree, accurate and conTtplete as of the time of the inspection. The inspection
was perforrned based on my training and experience in the proper function and Maintenance of orr site
sewage disposal systeff is. terror as DEP approved system) inspector pur-st.iarnt to Sectiort 15.340 of
Title 5 (310 CMR 16.000). The systern:
Passes [�_� C' oraditioraa(ly {asses � a fails
C 1 Needs Further Evaluation by the Local Approving Authority
_ _ r 3/23/06
inspz w T r _
utcar's r fir, ,� �ffole- , Date
The s . tern insC ector shaft sribrnit a co py ofthiS inspection report to the Approving Authorit y (Board
of Health or CHEF')within 30 days of completing this inspection. If the systern is a shared systern or
has a design flow of 10,000 gpd or greater-, the inspector and the systern owner-shall submit the
report to the appropriate regional office of the DE P. The original should be sent to the system owner
and copies sent to that beiyer-, if applicable, and the approving auttlorifyr.
°"111",T ris report only describes conditions at the time of inspection and tinder the conditions of use
at that time. This inspection does riot:address heavy the systerri will perform in tlre footsore under
the same or different conditions s of rise.
.'title V.rioc.1112004 Title 5 Official inspection Form: Subsurface Sewage Disposal System
Paa4,1e 1 of 16
Coritirvionwealth of a s husett �J' r �E4wu�r�'fl �;" RAL
13,1 Foresi:Street
Title 5 Official Inspection , 1 01W,`'MD .t� 9
kof i . r r° olunt s rrt
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SUbst.trfr ce Sewage Disposal Systern Forrri
A. Certification (cont.)
145 BRADFORD--- ...... --- -- ------ _..__..
Property Address
NO. ANDOVER MA 01845
citylrown state Gip rode
MA JO IE: GAUC7ETTE :3/23/06
UWr1eI"s Name Date of Inspection
Inspection Summary: Check, A, ,C,D or E d always;complete all of Section D
A) System Passes:
10 1 have not found any information which indicratea that ally Of the failure Gfiteria described
in 310 CMR 15.303 or in 3,10 Cif" R 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) sten'a Coriditionally Passes;
0 one o a"rot's;systerra components as described in the "Condition � ' ass"section need to be
replaced r reptaired. The sy stem, upota completion of tiae;� cernenE or repair, as approved by
the Board o�Eta raltir,'Will pays.
,Answer yes, no or not determined (Y", N, N1-.7) in the,efor the foilowinct staterrierits. If"not
determined," please
The septic tank is rrietal and ov �C� �Ars oldll or the septic tame (whether metal or not) is
structurally unsound, exhibits subsA� 4 infiltration or exfiltration or tank failure is imminent.
ystern will pass inspection if tll °existiri"-"lc s replaced with a complying septic,tank as
approved by the Board of I-Y 6.11.
A rrie,tral septic tank tifl pass inspection if it is tr'rrctt_rral1T�,s tared, riot leaking and if a Certificate
of Gornpliance indip6ting that the tank is less than 20 years ol(t"i availabie.
ND Explain- �
,f
- -------
"title V.duc.11/2004 'Fit to 5 Official Inspection Form:srit;)surface sewage Disposal systern
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A. Certification (cont.)
145 BRAE)FORD ST.
Property Address
Cw( .), ffC)ty/fi;.& li/[fy t `t34�a
cityn-cwrr state Zip Cede
MARJORIE CbAUl; E°1"TE 3/23/06
Owner's Name Date of Inspection
t ) System Conditionally Passes (coat.):
E] Observrafion of sewage backup or break out or high static water level ill the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. Systern will
ass inspection if(with approval of Board of Fieaith):
broken pipe(s5) are replaced
El 60struction is removed
] distf,','ution box is leveled or replaced
ND Explain:
_ ._ - -.--------
...,
._.......... _ __
r
"l`he sy Stern required purnpin p more, than 4•tirrres a year di to broken car obstructed pipe(s). 'The
system will pass inspection if� ith approval of the oar, of Health):
El broken pipe(,) are replach
CW] obstruction is rernoved
ND Explain:
-- ---
G) ftrrther Evaluation
Conditions exist..which erlrri ° :d by the Board of Heat��o
v e,(p re further•evaluation by the l ogi-d of Health in order to determine if
the ,>ystrarrr is fairing to liar fiect prablic health, safety or the ti;rav onrnent.
I. System wilf pass aaiess Board of Health determines in earl; �aratance with 310 GM
�1 .3d3(1)(b)that tfia. system is not frunctioning in a manner wl"rl will protect tarabiio health,
safety acrd.the er iror•rrr•rerat:
[� Gessa of or privy is within J f eet of s surface water,
pl C. pool or privy is within yo fee l: of a bordering vegetated etated wet:la nd\orsalt marsh
Atle V.doc m 11/:2004 `rltie 3 official Inspection r'°Clr`M SUbsrrr ace;sewage Dispo a'System-
Page 3 of 1 CS
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A. Certification (cont.)
'145 BRAI)FORD ST,
r'ropprty Address
NO. ANDOVEFI, MA 01845
Cityrrown State Zip Code
MARJORIE _ _ .._.. -_— --
Owner's Natne Date of Inspection
C) Gmrarti�er Evaluation is Required by the Board of Health (coot.)„
System Wiji tail unless the Board of Health (and Public Water Supplier, ti
detena,rines th t the system is fiarac.t"roning in a manner that protects the p l"rc health,
saatety anLI 'nvih?nme 'tn
L..1 The 'syster�,4jas a septic taank and soil absorption system (A ' and the SAS is within
100 feet of a . ,(face water supply or tributary to a surface, ater supply.
w
w,
r yw SAS 4",° x C" d'",, .a x u
�..�
The system has as sc,l�al�tc tank and ���,�, and the ; rv,within a .ora� 1 ot�a pertalicwat�.r
supply. ``°�
I. 1 The system has a septic tank" Fd SA— arrel thra AS is within 50 feet of as private water
supply welL
I_j The system( hraas a septic to ' aalld SA ,, nd the SAS is lass than 100 Gent but 50 teat or
more from a private wet supply wel;*-
Method used to deter, tine. distance: - -- - -- __._ - -- ---
This system passes if tae well water analysis, perform 0 at a DEP certified lataonatory, for
coliform bacteria and �latilc orgeaniG cornpounds indicates hat the well is free from( pollution�froraa
that facility and the esence of ammonia nitrogen and nitrat., nitrogen is equal to or less than a
ppin, provided the t`no other failure cr`iteriaa are triggered. A col of the analysis must fee attached
to this form. 7
'title Vdoc 1"IJ2004 -nitro 5 0ff`icitat Inspection r=orrw sure surface sawagc),Is prasai System
Page,4 of 1r5
Commonwealth of Massachusetts
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Not for Voluntary Assessuietits
Subsurface Sewage Disposal System Form
--- __._ __.. - -... _.. -- ---
A. Certification (cot-it.)
'145 BRADFORD ST
F'ralaarty,n:e�rrres
NO. ANDOVER MA 01845
city/Town State Lirxcode
1\MA RJORIE C)11tJ[�> ...tT 3/ /06
_ . ------ _ ---
C>wrrer's Name irate of inspection
D) system Failure Criteria Applicable tar All systems.
fora must,indicate "Yes" or"No"to each of the following for all inspections:
Yes No
Backup of sewage into facility or systern component due to overloaded or
clogged SAS or cesspool
C� Discharge or-ponding of effluent to taro surface of the ground of surface waters
clue to all overloaded or clogged SAS of-cesspool
El R Static.liquid level in the distribuliorl box above outlet invert due to all overloaded
or clogged SAS or cesspool
El Ej iA, Liquid depth in cesspool is less than " below invert or-available volume is less
►"
than %.day flow
Required pumping snore than 4 times in the last year N 7'due to clogged or
obstructed pipe(s). Number of tirnes pumped:
CJ /-!ray portion of the SAS, cesspool or privy is below high ground water elevation.
CJ E] lj�. Any portion of cesspool or privy is within 100 feet of a surface water supply or,
tributary to a SUrfr-ace water supply.
Any portion of a cesspool or,privy is within a Zone 1 of a public well
1�i� lyfly portion of a cesspool or privy is within 50 feet of a private water supply
C l El well
Any portion of a cesspool of,privy is less than 100 feet but greater than 50 feet
frorn a private water supply well with no acceptable water quaality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution front that facility and the
presence of ammonia nitrogen,artd nitrate nitrogen is equal to or leas
than 6 pailml, provided that no, other failure criteria are triggered. Att copy of
the analysis must he attached to this form.]
Yes No
0- 0 The system fails.. I have determined that one or rnore of the above failure
criteria exist as described in 310 CIVIR 15.3013,therefore the systern fails. ..I.he
system owner should contact the Board of Health to determine what will be
necessary to correct,the failure.
Title V.doc M 1112004 _title 5 Official Inspection Ford):SUI)Srarface Seweago Di.,fraosai SyStefrr
Page 5 of'16,
tl 7Fw
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Not
e��
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ply
r°Voluntary Ass
Stabsurtace Sewage Disposal al y,trim f oit'r1
--- - — ----- __._
A. Certification (cont.)
'145 BRADI`µ,°ORD ST
_ ............
Property Address
Iw10 AND OVEf R IAA 01845
City/Town State Zip Code
MARJORIE_. GAUDETTE
.............------
Owner's Narne Cate of Inspection
'$ Large tems; To be Considered a large System the system must serve a facitity with to
dosicfrr flew J� ,000 K) try 1 , ttt1 ct d.
r�or,large system s � r must indicate- either"yes" or,"rio"' to each of tl"rep following, in ddii"iort"to the
questions in Section D. "
YES NO M
_l the system is�within feet of a surface ,r11(in g A"water,supply ,
FJ EJ the system is within 200 feet 61 1 tetra�
_. � < �., r�y to a srrri'"ac;e; drinking water Supply
the system is located in a nit�x n s ris"1t+v area (Interim Wellhead Protection
Area - p lr r�) or a rrrap 1 ,,. II of a pu6T ti. !at supply well
It you have answewd "yes"to any questio ,frr Section E tire System is conso. rVC1 a Significant threat,
or answered "yes" in Section D above , large system has failed. The owner o erator of any large
systerri considered a significant thm under Section E or failed under Section D ash alf,upgrade tree
system in accordance with 310�41R 15.304. The system owner should contact the appropriate
regional office of the D(,.,partr .nt.
Title V.doc«11/:1004 "title 5 Official inspection Fortis:Subsurfaces Sewage Disposal System= �
Page,6of16
of Massachusetts
((11 �Jry1 rr�'lri9l YC n ,"�rtrr, MiA 0 941 9:
41'5168F
Inspection
Not ai° la� iiita�y � rii�
t SL.i:aswdace Sewage, Disposal Systern Form
...... .. - -- __.............. --._.-
B. .0 flee
'145 FAD-FOR ST.
f'raperty Address
NO. ANDOVER l"JiIA
01845
_.
City/town ";fare
Owner's Name Date of Inspection
Check if the following have been adore, You must indicate "yes" or,"no" as�tra each of tite following:
YES NO
`1 D Purriping infcrniat.ion was provided by the owner, occupant, or Board of Health
0 � Were any of the systeni cornponerits primped ot.it in the previous two weeks?
Has tite system received non-nal flows in tite previous two week period?
Fiave large volumes of water,been introduced to the system recently of,as pail of
this inspection?
M El Were as Built plans of the sy stern obtained and exarnined? (if they were [tot
available note as N/A)
M El Was tite 'facility or dwelling inspected for'signs of sewage back rip?
H E] Was tire site inspected for signs of break out?
El Cl Were all system components, excludincl the CAS, located oil site?
Were trite septic tank nifinholes 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 tile, facility owner(arid occupants if different front Owner) provided with
information on tare proper maintenance of subsuilace sewage disposal systerrrs?
..p.he sizes avid location of the Soil Absorption System (SAS) on the site has
been determined based oil:
M E-1 Existing infon-nation. For example, a plan at the hoard of Health.
Deterrridned in the field (if any of the failure criteria related to Fart C is at issue
approximation of distance is unacceptable) ( 1 C1 C CAR 15.302(3)(b)]
`title V.doc-11/2004 "title 5 Of NOW Inspection r'onn:Suiasurfaee sewago Disposal Systern 6
Facie 7 of 16
�� i�iwu il9rt daa'r xri 41 i as e ago,
�' mum �������
`� .....�� SUIDSWface Sowage Disposal Syst1T1 Form
'145 BRADFORD -r
Property Address
NO. ANDOVER �� 0'15 5
Clty[Town _..._ . --. --....
,Mate Grp node
-- -- -
oWner's Name .__
Date of Inspection
Residential Flow Conditions:
Nurnbew of bedrooms (design): Number of k7ecfrloorrrrs (aG foal):
/A) CogCf GPD
DESIGN flow based ran 5103 GMR 15.203 (for xanlplea: 44-0 gpd x#o f bedrooms):
Number of current residents: 4
Does reasiden(,e have ra gat-bage grinder? � 'Yes ( < No
Is laundry on a separate sewage systena? [if Yes separate inspection required] `(e's, [X-1 No
Laundry system inspected? / �!]�J Yes 0 I``°to
Seasonal use?
Water rnete;r readings, if available (last.2 years usage (gl)d)): 42/ g5 G-
SUMP purrrp?
El Yes M No
Last date of occr.lpancy: CUI I EN-1_
..................
Bate
Commercial/industrial Flow (:"onditiorls:
"I've of Est )lishrrreant:
r
Design flow(laase�ra 10 C�fV R 15.20 ):
__..
Gallons per day(qp�
Basis of design flow (se;aatt't e>rsons/sq.ft., etc.): ...—.--- -`
Grease trap present? � �,
Industrial waste holding tank present"? ���� ��
[.....] `fps F1 No
Mon-sanitaty waste discharged to the Titles a fs��f�;rr7 � (� Yes No
Water rrleter readings, if available:
Last ate of oc
cupancyluse,
,. -Date
-
Other �4
(describe): ��° --. ---
ritie V.due^11/2004 .l itle 5 Official inspection Form;subwr'farG:sewage(aiSposal Sysfen`r,
Page 8 of 16
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3 J^'m� r III Title Official➢Po7 tlN Inspection
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C. System Information (cont.)
'145 BRADFORD ST.
'reaper°ty Aetdress
--
NO. ANDOVER
MA 01845
-._
City/Town state Zip Gaade
MAR JO I ' C:�AtJC ETT F 3/23/06
Owner's Name Date of Inspection
General Information
Pumping Records.
Source of information: - .........- _
Was system purnped as part of the illSpeGitOn? ❑ Yes 10 No
If yes, volume pumped:
gallons
I..low was quantity pumped determined?-- ----- -
Reason for purnping; - - - - - —
Type of System:
I-Z] peptic tank, distribution box, soil absorption system
El Single cesspool
C� Overflow cesspool
Privy
l Shared system (yes or no) (if yes, attach pfevious inspection records, if arty)
❑ Innovative/AIternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
(..j Tight tank. Attach a copy of the DEP approval.
E-1 Other(describe).,
Approximate age of all corrrporrents, date installed (if known) and source of inforr-nation:
1985 A>T:3UIL.1"
Were sewage odors detected when arriving at the site'? I.� Yes `( No
Title V.doc-11/2004 .l itl¢a 5 Official Inspo.,tion Forr):subsurface Sewac4e Disposal Systr In
Page 9 of 16
c Corrun 6"°vveafth o asses husett s „is�"Gti�l0"')i
Title Official
Inspection Form
Not n r A.ssessr rtt:
Subsurface Sewage Disposal 11.3y st m Form
C. star--Information (cont.)
145 d AE: FOR S..t.
- -1-1-1-1---- _-1-1-1-1_
Property Address - --
Nt . AfwiLJO1/ER MA 01845
-1111._ Y ._f
-1-1-11
CityTrown State Zi p Code
MARJORIE (3At,JDETT 3/23/06
- ---- 1-11-1_--- ----_,_.- .. _ __.
Owner's Name Date of Inspection
Building Sewer (locate on site plan):
4'+ - BELOW CELLAR FLOOR ie atr below grade: -------
feet
Material of construction:
cast iron [X� 4 F'VC 1 other (e)cpleain)= -1-1-1-1_
Distance from private water supply well or suction line: 24' FROM TOWN WATER
ferat
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan): g
4 0" (m,�+t ,g")
Depth below grade:
-
feet
Material of construction:
caracre e E metal F-1 fiberglass E1 polyethylene El other(explain)
If tank is rnetral, list age: ----
years
Is cage confirmed by ea Certificate of Compliance? (attach fr copy of El Yes �_J No
certificate) �f
10' X5' X4' 1500 GAL..
Din'lenSloflS;
Sludge depth: ......... - -- - -
Distance frorn top of sludge to bottom of outlet tee or baffle l 6
Scurn thickness
1°
Distance from top of scurry to top of outlet fee or baffle=
1 F3°
Distance frorn bottom of scram to bottom of outlet toe: or baffle .....-
How were dimensions det.ertr7inecf'?' SLUDGE JUDGE &TAPE
Title V.cloo»11/2004 "rifle 5 Official Inspection Form:Subsrarface Sewage Disposal System
Page 10 of 16
t
Not for-Voluntary sse smetr s
SubS[Arface Sewage Disposal Sy teni Form
G. Systern Information (corit.)
'14� BRADFORD ��s'"f
_ _ ---
-
Property
AcicBreaa
IV a ANDOVE ire 1 1845
_
Grkylr'ow+r� State Zip Gode
ftrlfli" t,O IE GAl.DETTE ;3f23fU�
Owner's Nar�rre Uate crf ins pectic>n
Comments (oil pumping recommendations, inlet:and outlet tee or Baffle;condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
MIDDLE COVER HAS RISER TO WITHIN 14" OF GRADE. PUMPED AS PART OF INSPECTION,
`,Grease Trap (locate on sitc) plan):
t7o th below grade:
sr�et
Mratc r1 1� f construction: ✓
�.1 concrete _
...( rrretral El fiberglass � .( polyethylen ❑ other (explain):
Dimensions:
-.___
SCUM tt'rickraess
Distance o �
�>aararµe� frorra to ot�;�e,urrr tot o utlr�t fee or ta�rffl
Distance from bottom of sr,'um to botton�,f o utleft or baffle
Date:of last purripairig: yy--1--
rJ 4�re
Car'rrme;rlts (ori puirrpirigl recorrrrrrerrdati, s, inlet d outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, avide ncea of I- kage, etc.):
_— -- --
Tight or Bolding TariC�,Tank ,,rust be pumped at time of insp�e;ctioi (locate on site, plan):
Dop�th below g�atd i�: 0 ---_.-- - --
Material of ce ruc;t pon:
l .wl cone- to ❑ metal E1 fiberglass [ , polyethylene
(explain);
Titre v(iec»11I2004 Title;'a Offidar Inspection Farr:Subsurface Sewage Disposal System"
Page 11 of 16
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145 BRADFORD ST.
Property Act clY ess
NO.ANDOVER MA
0184
--- - -
City/Town State Zip code
r�r► h rcar t Ora rTe /23/0
Owner's Name Date of Insr ecthon
Tight &r liolding Tank (corn.)
Dimensions: �`w � � _._
Capacity:
,
Design Flow:
ffe":lIlOYY:ro 1'SC'Y`clay
Alarm present: Yes [._ No
Alarm level:
'. Al_ rrrn in"' rcciaacl ardor: �_� Yogis�a.� No
Date of lass: purnpincg:zn0f a Comments (condt� larm and float switches, etc.):
- _
C,
Distribution tion Box (it present must be opened) (locate on site plan):
Depth of liquid level above outlet invert �
Comments (mote if box is level and distribution to outlets equal, any evidence of solids caanyover, any
evidence of leakage into or out of box, etc.):
30" BELOW GRADE. LIQUID RUNNINGC AT CORRECT ELEVATION, NO EVIDENCE OF
LEAKAGE. ALL PIPES EQUAL.
l°'aurrrp Chamber-(beat.-b a,,j to plan):
Itlrrlpa„ in viotkirars orct€rr: ° l `yes C :.i No
Alarms in workitl -ofaer: ."". �".���,��, " � Yes N o
Title VA)c-11 f2,004 Title 5 Official Inspection Foral:Subsurface Sewacle Nsposal Syst€=rn
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Assessments
SLbsufface Sew - Disposal
Systcarn F" r-rn
.
.
it Information (cont)
—BRADFORD
--
I'rral'7e:rty�,�clress __._ --- ___-
NO. AhtIM1OVE.R 91�a1 0'1845
Gltyrr°ov✓tr — -- �q. - _
Mate
.?1p Code
Owner's Narne _-...-- -- -_.-
Date ref Irrspcc;frr�rr
Comments (note condition of pump chieerift-q,r, condition of purrips and appurtenances, etc.):
�r
Soil Absorption Systein ( A ) (loot€ on site plaari, excavation riot required):
If SAS not located, explain why:
I ype:
C..
leaching pits number.
letach'rrag chaffib i's nut'riber:
Ieaclrillg galleries nuruber-: _
( 60-X 3`X 12"
_.J leaching trenches number, length: --- _.,..__...._
EJ leaching fields number, dirnen sions: ---------__.
C] overflow cesspool number - ----__.__._._............--_-----__.
L-1 innoval:ive/alternaative system)
Type/name of techlaoiocly. -___. -
GOITrments (mote condition of soil, signs of hydraulic failure, level of ponding, d';arrip soil, condition of
Vegetation, etc.):
TRENCHES APPEARTO BE WORKING WELL_, NO EVIDENGE OF HYDRAULIC FMI-t_7 ' .
l"illr \�.rTrac.M1 M1 1 iat7 b Til:le 5 Official InsPecftion Forrrr:Sutrsurfaco aowage Disposal syrst'errr,
Page 13 of V-5
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Sty
Title u Official Inspect"on Form
Not 'f¢ it°Vokintary Assessments
tiMr "�
'U surface Sewage age Dis po s l Systern Form
w SyStem. rI rp r i (cont.)
'145 5 l:af AL3iW=ORD ST.
Property Actdre,.>
NO, ANDOVER
MA 01845
—
t:',itylTawn 8taia — Tip Grdc
Owner's Name Daie of Ins paoiic>r)
Cesspools (cesspool must be purnpod as part of inspection) (locate oil site pj ara):
NurrabC -rand conficgurratioi'a - --- - } -
Depth—tale f liquid to inlet invert
Depth of;solids t�a er _ r'.__.---_
Depth cat Lacuna lrayer
Dimensions of C sst"aool. ...
Materials of Cara 7tructiaarr
Indication Of groundwater inflow C) Yes No
Comments (note condition of soil, signs ath7ydrauii frailure, learel of pondind, condition of vtacdototion,
Privy
(locate or1 site plan):
Materials s of construction: -- ---
Dirnemsions --- _ _ ---
Depth of solids -------- _ - --_ _ _..___. -_.__ _.___.___ -
coinmerits (i to condition of soil, sips of laydri~aulii;failure, level of ponding, cortditioi of vegetation,
etc.): %
11t'le V.doc.w 11/2004, "ritlo a Oft'iriuml Irrspaciiora Farm:Subsurface Sewage Disposal System
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Nr cn Voluntary Asses i .s
C. to (cont.)
145 BRADFORD d�alu�l ORD ST.45raperty Address
NO.ANDOVER X11, 01845
Gityll'eawn St,
te; Zip Code
MARJO IE GA(.) t-;°. ,i° ': 3/23/06
---.__-----__.._ --__.—_-. __—..__.. ......_._
Owners Narne Date of Inspection
k t.ch Of Sewage Disposal S yst rrl. Provide n sketch of the sewage disposal systern including tics
to at least two permanent reference I nrdlrinrks or laench in r&cs. Locate to rill wells within 100 feat..
Locate where public water supply enters the building.
1 �
1
C-1 37
. �
4. a w ro
Title V,doo. 1'I/2004 Title 5 Official Inspection f=orm:Subsaarfac;_,Sewage Disposal System.
Page 15 of 1 F,
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Not,for Voluntmy sanents
Subsurface Sewage Disposal System Form
C. SYStern Information (eont,)
14 RADd'=°Ol"D ST
Property Address
NO. ANDOVER IMA 01845
Stafe Zip cracir-;
MARJORI GAUD f l E ;3/�3/f3
_.- —
_
Owner's Name
D of lils�Jectlral5
Site Exam:
131oPe" /11)r0
SUrfeace water tjo i _e
t heck cellar
Shallow wells r'lo12, ,.
Estimated depth to ground water:
Please indicate tall methods used to detef-Mire the high ground water elevation:
E0 Obtained from system design plans oil rec orrl
If checked, date of desigr r plart reviewed: 1
_ - -
Date
F1 Observed site (abutting property/observation )mole within 150 feet of SAS)
F_.� Checked with local Board of h-letrltlt - explain:
El Checked with local excavators, installers - (attach documentation)
D Accessed USGS database- eacplairt:
You must describe Brow you established the high Around water elevation:
13YSTEM DESIGNED AT 4-'ABO\/E GROUND WATER -A SBUIL"r DATED 1985
.title v.ctcac a 11/2001 "title 5 Official lnq)ectican mare°re:Subsurface Sewage Disposal systel'rl
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p^'wr,.+'8,a0R.Wlb+v*M'°wN h.M,.wyp; .
Cortirrionwealth of Massachusetts
City/Town f NO. ANDOVER
System Purripirig Record
Form , 1 r i 1r �a<
DEP has provided this form for use by local Boards of Health. Other f 'rrns'mAy be' us'e'd',"-but the
information must be substantially the sarne as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The Systerrt Purnping Record n-rust be submitted to
the local Board of Health or other approving authority.
._......._...
----........_._�.... -._.__....__..._._.._ .a...
A. Facility Information
Important:
When filling out 1. Systern Location:
forms on the
computer,use 145 BRADFORD ST.
only the tab key Address
to move your NO. ANDOVER, MA 01 845
cr,u sor-do not — -.._
use the return City/Town State Zip Code
key.
61/11'
. �Systern Owner:
i rad� MARJORIE OAUDEl TE
It__._�._ _ --- - -
Name — — -
�r-;-= Address if different from location)
ion)
State Zip code
-
one Number
B. Pumping Record
3/23/06 '1500
1. Gate of Pumping 1. Quantity Purraped: - - --
Date Gallons
. Type of system: Cesspool(s) &Septic"l"ante I_] Tight Tank
C❑ Other(describe): __
4. Effluent Tee Filter present? [ Yes No If yes, was it cleaned? F] Yes No
5. Condition of System:
-6e""'e C C'1?'���,-r' zr - - --- — .._.......-
C. System Purnped fly:
JAMES CURRIER H79 40
Narrre Vehicle License Number
J's Septic, Drain
Company _
7. Location where contents were disposed:
OLSU
Signature Mauler Bate
t5forrTA.doc-06/03 Systern Pumping Record o rage 1 of 1