HomeMy WebLinkAboutTitle V Inspection Report - 1459 TURNPIKE STREET 6/14/2007 'i,
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use the Fetid°f7
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6114/07
i-teate Of insh7s-'rt.iOn: t7�tc.
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—
Name:of rrmr:,eWo
cwc„nip aYYy r 6sarrrc
131 FOREST
MA
ii117I�1iru1Y1Y�'4iC'r8e<roLS
c ityrfo.” 1
Tt`:ler�llranei i�l�.YYeYi7c:r
I d egii tia�:at I haves�e,rsc7rar: " 0' sewage t' „ l Y .. , s 'And th at thOD
rllr iia°,�k;�,tt��1 tats; "111(i ;c�rrr���le,t ��s cst EG�r�rtsrdrrr-�ic��t1�ae�rrr �t�cr�sca�a. TI,�� rrar;���r;f.1r.>r�
t¢lr rdrsH �t per
iiYlerrirrrserra reported t7aa€�7�r is trerr',;, gar .urr
1.
e 5~.0 r based n m t.raal9' i �a w. �� w�0 �� a ir1���7�r��earar"rCtiC7Y'1 and Tide�lilt��9�8c�f1( �° of(711 'C�OiC;
sewage (Ai"eaFosal s step n . d rar arriiDEF1rappre�aaer�d s�sitr'a t I d
I � `� f
�-� � , d � �y � l �w �.� �"t � Ytarersurarat to sratiezar 15.340 of
..d.,.itle 6 (a'l'it GIVIR 16-0 00). systenf1:
....., l y
Passes El (>G7rlcditiC7ncally Passes I.__.
I.m.l :,atyt Is 1:a.,rs„ther �v�aslu ai:on b fie 1�c�s:9::1,fi`pprc���rir„rci �?+.g.xu.tr�,lkty
lrr�y�� sYC�O Oro
DMe„
s copy Of dlds inspe ctie�rY¢ report tc7ltar� F`ti7lraa7virrtl ��e4ueYrtarlt��� (BoY .,ard
�1��� � 6i �raEarrarr �a swae.,7_ r
lee a,��tkit8 i1r�>�hae"t ttar`shall
of Health or tyt.l�„)within 30 days rat comNetng Ws iii>i7eae trm It the rsyste,rrs is ca shared systeanft Or
licas a cic;r.>r rr din s of 10,000 gpd or r aLc;r, the ¢ra r;a G,.of sand ttre sys,tern r��+,ner�shall �wrat7mit�th.
re;pori to tire, appropHate r rrs i'onal r>ttice of the DER "T'he t figin al should be scant to the systern owner
and ce7oes sor t to the buye q if apdalie aaN% and Um approving a:;arr ority.
., i t71 report only rde sr';Yrbes �” Irr"�rt9Pa�7r"_u a � � �ti _ � tr�4P e"�r& $r„rf;�q.ClGe�e'r e�S` r"r��rt4e9rJ eYd use
it ter arrr'ar� rra
r:rt Umt°t me, i'd�ds hmp ectiora does asset�ar,�dr�drr„ss omi the system will Pei'f r ire th O tr,id:rar„ "nrler"
"rl're° sa rviie 9:)r different d`C"rrrr°Rions of$,rse-
Irt e 5 C�rPu,N me ir�:,ticrrl V�'0rrrY: sr�r4�lrarre�c;�`ya vv�eae',iJr�irY7st�(;yet Y�
I ikler\/.dz « 11%�la04 � � Pago 1 of'1 e4
-qMojjweaj&" ocMassach use I. s
T
( ff i 3 1 Forest Street
vL'on �rorm [A D0L
lF-- 0
-T,- N7 WA 01-94'
Inspeca
T itle 11 i c I"R P-1
9
J�M Not for Voluntary Assessments
Sm Forrc,
!% U bSUrface Sewage Dispersal yste
sal ID
A�Cp_rtjficatlon (oont.)
1459 TURNPIKE ST,
Property Address M A
NO. ANDOVER -S,t-a-t-e Zip Gode
6/14/07
JENNIFER DUBE bate-of inspection
owner's Narne
Inspection Surnmary: Check A,B,C,D or E 1 always complete all Of Section D
A) System Passes:
1 have not found any information which indicates that an,,I of the failure criteria described
in 310 MR1 5.303 Or in 310 CMR '15.304 exist, Arty failure criteria not evaluated 81`0
indicated below.
C;ornrnents:
SYSTENA VVORKING PROPERLY.
Bi Systejn, Conditionally Passes:
❑ o be
ne' or more system components as described In the "Conditional Pass" section need to
replaced or repaired. The system, upon completion of the replacement or_WV-air, as approved by
the Boaf4bf Health, will pass.
11 11-11'
Answer yes no or,l�iot determined (Y, N, ND) in the El for the foil trig statements. if"not
determined:" please �Yplain.
years old' or�We Septic tank (whether metal or not) is
❑ The septic lank Is rnetba',,and over 20 ye�
structurally unsound, exhikits substantial i nfi lt lion or e fii l
ration or tank failure is 1imminent.
System will pass jnSpeGti0nff,the existing s
replaced with a complying septic tank as
approved by the Board of HeAVL
metal Septic tank will pass ins n it it is Structurally sound, riot leaking and it a Certificate
A
indicating tha�
of compfiaanGe- We.
flank is SS than 20 years old is available.
)
ND Explain:
Title 5 official inspection Form:Subsurface Sewage Disposal Sysiell-
Title V,doc-11/2004 Page 2 of 16
[�2
commonweah" Of, Massachusetts
131 F c r
IMIDDMCO[\� i"AY,
Tib Official Inspecti
on Form
e
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Cerfification (cont.)
1459 TURNPIKE ST. _
Property Address MA 01845_______
_ State Zip Code
City/Town
owner's t`lame
JENNIFER DUBE
Date of InspLotiol
B) System Conditionally Passes (coot.):
❑ N of sewage backup or break out or high static water level in the distribution box due
er System will
to brokeR or obstructed pipe(s) or due to a broken, settled or uneven distribution box
pass insp6l_t ion if(with approval of Board of Health):
❑ broke c,,j-e replaced
❑ obstRiCtiOn io, removed
❑ distribution box\ leveled or replaced
�
ND Explain:
z
❑ The systen' required purnping more t.lan 4.times a-gear due to broken or obstructed PiPe(s). ThO
Y
system vjill pass inspection if(,.,v(ith appra-�al of thb Board of Health):
❑ broken pipe(s) are replaced
y.
❑ obstructiol-I is removed
ND Explain:
l 44
f
C) Fuddier Evaluatio
n is Required by the Board of Health.
I- alth in order to determine it
❑ Conditions exist'which require further evaluation by the Board�o
the system i,P"jailing to protect public health, safety or the environle'nL
qg. Sysjeyij wjii pass unless Board of Health determines in accord ice with 310 CMR
wi
,15.303(4)(b)that the system is not functioning in a manner which wi rotect public health,
; -e�p nent:
af W' and the es
cesspool or privy is within 50 feet of a surface water
❑ marsh
Cesspool or privy is within 50 feet of a bordering vegetated wetland eras
Title 5 official inspection Form SLOSWNGe sewage Disposal System-
—itle V.doc, 11/12004 Page 3 of 10
sb
Gorimnonvvewth c r ; assachuse fir,s
IIIDDLETON�, MIA(3
Title 5 0 fildial Inspection Form
ff
Not for Volukitawy Assessirnents
Subsurface Sewage Disposal System Form
A. Dertifiratio (cont.)
1459 TURNPIKE ST.
Property Address MA 01845
NO. ANDOVER
c5it-jif—own -- -__ State Zip Code
JENNIFER DUB_E___ 6/14/07
Date of Inspection
oviner's Name
C) Further Evaluation is Required V)y the Board of Health (cont.):
2. Syste�tkwffl-fail unless the Board of Health (and public water Supplier, if any)
deterrnineslipat the system is functioning in a rnanner that protects the public Dbalth,
safety and e&y'ironnient: z
(SAS) and e SAS is within
❑ The syssteq�i has a septic tank and soil absorption system �A�
001V
-face wat , pply�
100 feet of asujjace water supply or tributary to a sut
❑ The system has a sP, tic tank and SAS and the AS is w jfi a Zone I of a public water
supply.
❑ The system has a septic tan Land SAS and the)M is within 50 feet of a private water
supply well.
❑ The system has a septic tank and S,�Ak and the SAS is less than 100 feet but 50 feet or
more from a private water supplyW611,�",\
Method used to determine dis�Ance:
This system passes if the well'v6ter analysis, pellorn,ed at a DEP certified laboratory, for
coliform bacteria and volatile(79-aniccompounds indicate St at the well is free from pollution from
"
that facility and the pFesellcVlof ammonia nitrogen and n1trat fl1roge'l e qual to or less than 5
pprn, provided that no Oth r failure criteria are triggered. A GOP
f the analysis must be attached
to this form.
3. Other
Title 5 official inspection Form:Subsurface Sewage Disposal System
Title V.doc-111200z' Page 4 of 16
corfinnormewth of massachusefts
F—� 131 Forcjsl, art c
on Form MMOLETON; ivif,01
Title 5
" Offidal Inspecti
Not for Voluntary Assessments
SubSUrface Sewage Disposal System Form
A. Certification (cont.)
1459TURNPIKEST.
_Property AMvess
NO. ANDOVER _MA
Cityfrown State ZipCode
JENNIFER DUBE 6/14/07 -----------
6vimr�s�larne___ Date of inspection
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" ov"No"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
El EXI clogged SAS or cesspool
Discharc e of the ground or surface waters
ge or ponding of effluent to the surface
due to an overloaded or clogged SAS or cesspool overloaded
Static liquid level in the distribution box above outlet invert due to an
El or clogged SAS or cesspool available volume is less
E] EIP Liquid depth in cesspool is less than 6" below invert or m
than 'Y2 day flow
Required pumping more than 4 tinges in the last year NOT due to clogged or
El 01 obstructed pipe(s). Number of times Pumped:
Ej 0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
[j E] III fl, Any portion of cesspool or privy is within 100 feet of a surface water supply Of
tributary to a surface water supply.
C, El 91 Any portion of a cesspool or privy is within a Zone I of a public well.
E] [I A y n portion of a cesspool or privy is within 50 feet of a private water supply
well.
El E] Any pottion 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
systerA 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 from that facility and the
presence of ammonia nitrogen and nitrate a
to nitrogen is equal to Or less
than 5 ppin, provided that no Other failure criteria are triggered. A copy of
the analysis must be attached to this form.]
Yes No
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 GIVIR 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.
Title 5 Official inspection Form:subsurface Sewage Disposal sysiem
Title V.doo- 11/2004 paste 5 of 16
Comm 051weami of Massachusetts 131 F G i-e st S tr e(z,,u
M!IDDLETON, MA
9
Title 5 official Inspection Form 70
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
1459 TURNPIKE ST,
Property Address MA 01845
NO, ANDOVER
-6�ty/Tmvn State Zip Code
JENNIFER DUBE 6114/07
batieo-f Inspection
Owner's Name
E) Large Systenis.--TO be considered a. large system the system mus-st se a facility with a
design flow of 10,00�jRd to 16,000 91)cL
For large systems, you mU"S-,4 th lowing, in addition to the
questions in Section D.
YES NO
0 the system is within 40 �e, f a surf ace drinking water supply
tributary rf
to a suace d er drinking wat supply
the system is witl)44�0 feet 0
El El 1z "�'Xinsitive area (interim Wellhead Protection
❑ ❑ the system i,,,Kocated in a nitrogen
Area- *W PR
A) or a mapped Zone it opubli c water supply well
if you have answered "y 1 -o any question in Section E the sVst considered a significant threat,
P94 operator of any large
or answered "yes" in S66tion D above the large system has failed. T1t1(),zwn.erorope
system conside ve -A/significant threat under Section E or failed Linder SKon D,shall upgrade the
I let the appropriate
system in - - ante with 310 GMR 15,304. The system owner should cont.
regional office the Department.
Tile 5 Official inspection Form):Smsurface Sewage Disposal Systerr,
ills V�dor-11/2004 Page 6 of 16
of Massachusetts -J"IN'd���
=�°'4���� �� �=���������� Inspection ��a������� y�( l3lFom«tS�e« 49
� ���� �� �_�� � ������� 0� m�������������� � Form� � � ""�^'~'~ ''''``--
~ � ~�� Official (9721)774-�t8S
Not for Voluntary Assess00ents
Subsurface Sewage Disposal System Form
B,. Checklist
i458 TURNPIKE ST.
pmp�w Adueum
' ' 01345
NO. ANDOVER | 9�A �-�--�_'�______ -_--_'��_______�_____
� �---�- -��-�--� �--- �--�—�� Zip Code
�-------�---- omg�
ciV�[mwn .
JENNIFER DUBE ��\07 _____�_-_-__'--__�-__________
---------------- D�eofmspn�mn
owne(aName
Check if\he following have been don�. You mnust indicate^yem'' nr~no' entn each of the following:
YES NO
0 Fl Pumping information was provided by the owner` occupant, or Board of Hoe|8h
\N �opupedoutinthepnavinusbwoweoks?
[j- FA- Were nn
N Fl Has the system received normal flows inthe previous two week period?
Have large vn}urneo nf water been introduced tu the oystennrecently oraspa�of
�] �� this inspection?
Were as built plans of the system obtained and examined? (If they were not
[
y� :
�~ ^~ available note as NIX)
EXI Was inspected fo Fl a�thefaoUitynrdwa dwelling r Signs uf sewage back up?
El Fl Was the site inspected for signs of break out?
0
t excluding theSA8 located onnke?
�� VVenea(\ sy��emconnpenens. .
�� Fl VVonethe septic|— manholes uncovered, opened, and the interior of the tank
�� �� inspected for the -condition oi the baffles or fees, material nfconstruction,
dimensions, depth or liquid, depth of sludge and depth ofscunn?
Was the facility owner(and occupants if different from owner) providedwith
�� El information or,the proper maintenance ol subsuilace sewage disposal systems?
The size and location «4 the Soil Absorption Sym8emm (SAS) un the site has
been determined based on:
Fl ��
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part G is at issue
oppnmx\noskion ofdia(anoeisunacceptable) [310 CK0R 15.302(3)(b)]
Title 5 Official Inspection Form:Suuourfm»o Sewage Disposal Svmvm'
Cornirnonwealth 09' � assachusefts &,
J.31 Forest Street
ion M& Frm MIDDLETM, MIA
'J
(9 7 8) 7'1 4; 6 6 8
EMRR- Title 5 Official Inspect o
'
Not for Voluntary Assessments
Subsurface Sewage Disposal Systern Form
C. Systern Information
1459 TURNPIKE ST.
-
Property Address
NO. ANDOVER MA
61-t—yrMr- -1 State Zip Code
JENNIFER DUBE 6114107
_dWne_C -N-a-m-_e Date of Inspection
Residential Flovy Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual):
330 GAD
D-_SIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents'.
Does residence have a garbage grinder? ❑ Yes FXI No
Is laundry on a separate sewage system? [if yes separate inspection required) E] Yes ❑ No
Laundry system inspected? l 16 ❑ Yes ❑ No
Seasonal use? ❑ Yes nX No
83.85 G_
Water meter readings, if available (last 2 years usage (gpd)): PD__ _
Sump pump? ❑ Yess ❑ No
CURRENT
Last date of occupancy: Date
Flow Conditions:
Type of Estab'll "n-tent:
Design flow (based oil 0 ChAR 15.203): Ga-11011st-W
Basis of design flow (seats/per-o s/sq.ft,, etc.):
❑ Yes ❑ No
Grease trap present? jF-1 Yes F1 No
Industrial waste holding tank present?
Yes ❑ No
Non-sanitary waste discharged to the Title 5
\Natey meter readings, if available:
Last date ofoccupancy/us&:_1__1,,1_11'
Other (describe):
df' Title 5 Official inspection Form:Subsuilace Sewage Disposal SYsieff!
I'itle V.doc I 1/2004 Page 8 of 1C
'Corn monwealitth of assachusetts
131 Forest stree-i-
on Form
T'fle c Official Inspect'l
Not for Voluntary Assessments
- F
-face Sewage Disposal Sy,5
tern orm
S ubsui
C, System Information (cont.)
1459 TURNPIKE ST.
Property Addle "
NO. ANDOVER M.A
City/Town State Zip Code
JENNIFER DU BE 6114107
—
Owner's Name Date of Inspection
General Infon-nation
Purnping Records.'
OWNER- LAST PUMPED 2003
Source of information: —------
Was system pumped as part of the inspection? � Yes [I No
if yes, volume pumped: '1000 GAL.
How was quantity pumped determined? LX W XD X 7�5
Reason for pUrnping: -REGULAR MAINTENANCE
Type of System:
❑ Septic tank, distribution box, soil absorption System
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared systern (yes or 110) (If yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and
El maintenance contract (to be obtained from system owner)
1:1 Tight tank. Attach a copy of the DEP approval.
ED Other (describe):
Approximate age of all components, date installed (if known) and source of information:
REPAIR DONE
'Were sewage odors detected when arriving at the site'?, ❑I Y e s _L>_,j No
Title 5 Official Inspection Form:Subsurface sewage Disposal System-
Title V.doc—i 10ND4 Page 9 of 16
eoky�,kTnonwealth 4-3, Arlassadlusefts
133, Fores't
T -le 5 Official Inspection Form MR-Mi-F-TON, AAA oj�r,"
�MEN HE zq,, i t
Not for Voluntary Assessnients
Subsufface Sewage Disposal System Form
C. System Information (cont.)
1459 TURNPIKE ST.
Property Address
NO. ANDOVER MA 01845
City/Town State Zip Code
JENNIFER DUBS 6/14/07
Owner's Name Date of Inspection
Building Sewer(locate on site plari):
Depth below grade: feet
Material ol C011SIRIction:
N, cast Iran El 40 PVC n other(explain):
Distance from private water supply well or suction line: 22' FROM PUBLIC WATER
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
JOiNTS LOOK GOOD
Septic Tank(locate on site plan):
U,
Depth below grade: feet
Material of construction:
N G0nCFftC- El metal 0 flilerglass El polyethylene other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of Yes No
certificate)
Dit-nensions: -B' DIAMETER
Sludge depth: —--------
Distance from top of sludge to bottom of outlet tee or baffle 12"
�curn 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 21
81-UDGE JUDGE &TAPE
I-low were dimensions determined? MEASURE
Title VAoc 11/2004 Tifle 5 Official Inspection corns:Suicvsurface Sewage Disposal System,
Page 10 of 16
IS,L t"i
y ` 13 Forest Stre et
Comnionwealth of Massachusetts
100DI ETON, MiO 0119V
(978-31' 774,'65811--
Title 50, Offidal Inspection Form
Not for Voluntary Assessments
Subsuilace Sewage Disposal System Fol
C. System Information (cont.)
1459TURNPIKEST.
Property Address
NO. ANDOVER MA D18-45
City/Town State Zip Code
JENNIFER DUBE 6/14/07
Owner's Narne Date of Inspection
Comments (oil pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
BOTH BAFFLES PREVIOUSLY REPLACED WITH PVC TEES. OUTLET BAFFLE WAS PLACED
1/2 WAY BETWEEN CENTER COVER AND OUTLET COVER. OUTLET TEE IS A LITTLE LONG.
TANK SHOULD BE PUMPED ONCE PER YEAR.
Grease Trap (locate oil site plan):
�epth below grade:
I feet
Mat6 of construction:
cones` to metal L__I fiberglass polyethylene i ether(explain):
Dirfrensions:
SGUM thickness "IN, -----
Distance from top of scum 1,10 top of outlet tee or baffle
X, /
Distance from bottom of Scum;o\tlottorn of outlet 01•baffle
Date of last pumping: \1. 1/
Comments (oil pumping recommendati S�\Jnlet and outlet tee or baffle condition, Structural integrity,
liquid levels as related to outlet invert"ewlvide'itqe of leakage, etc.):
Tigm or Holdin-ci Tap "(tank must be pumped at time Of insip,tion) (locate an site plan):
Depth below grq
Niateriai of nstruction:
❑ cor�ofete El metal FA fiberglass Ej polyethylene other (explain):
Title V,do, -11/2004 Title 5 Official inspection Form:SLibsurfac&Sewage Disposal System,
Page 11 of 16
Contrnonwealth of Massachusetts --�IkIP'101C & UHW`,'�h"Ni
rot est Street
IV7 I DDLETOM, NIA 011'-3149
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
1458 TURNPIKE S--I-. —-----
Property Address M A 01845
NO. ANDOVER
-C-wyiTo,;,-n----------'- - State Zip Code
JENNIFER DUBE 6114107
ovvn�r�s.—Name Date of Inspection
Tight or Wf-Ad��o, Tank (cont.)
Dimensions: —-----------
Capacity: gallon -1
Design Flow:
gallons per day
Alarm present: �"--' ❑ Yes ❑ No
Alarm level: "I rmii-� working order: ❑ Yes❑ No
Date of last pumping: Date
Comments (condition of alarm and float switcries, etc.)'.
Distribution Box (if present most be opened) (locate on site plan):
Depth of liquid level above outlet Invert -0
comments (note it box is level and distribution 10 outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
AS PART OF TITLE V INSPECTION, VVE REPLACED D--BO-X-----_
pilro
pcharph-er(locate oil
pumps in working order: ❑ Yes ❑ No
Alarms in workirig order: F-I Yes ❑ NO
Title 5 Official inspection Form:Subsurface Se?wae Disposal System,
Title NJAoc-1112004 g Page 12 of 16
I Massachusefts
Gommovlivveal& 'f M
b", X9, I-E,
�
tu, I R I L E,"
�—5M I , LIM, 2 ns 10 P
Not for Voluntary Assessments
n
-ace Sewage Disposal Systern -0!
v
'k, 61 Subsurf
Systern
1459 TURNPIKE ST,
Propeily Address
NANDOVER (dpi
--
5
city/Town State Zip Code
JENNIFER DUBS 6/14/07
Own,eCs Nalyvc� Date o f t nspection
Comments (note condition of pump chat iber p6ndition of purnps and appurtenances, etc.):
oH Absorption System (SAS) (locate on site plan, excavation not required)'.
If SAS !-lot locat-ed, explain-,h1hy:
Type:
0 leaching pits nury-tber:
F-1 leaching chambers number:
❑ teaching galledes n umber: --------
❑ leaching b-lenches number, length:
number, dimensions: (1)
0, leaching fields 90013Q. FT
El overflow cesspool number
❑ innovative/alternative system
Type/narne of technology:
Col-yll-flents (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.,''
ALL VEGETATION' LOOKS NORMAL, SYSTEM WORKING PROPERLY, NO SIGNS OF
HYDRAULIC- FAILURE,
—---------
-title VA oc 11/2004 Title 5 Official Inspection Form-subsurface Seviaga Disposal Sx/slell'
-
- Page 13 of 1
a- .. Inspection Form 131 Forest S s t
eii
�E i�l, i}/E
, Assessments
�� Not for olunta j W8)
J
Subsurface Sewage Disposal y t�rr� Orrrt
G. System Information (cont.)
1459 TURNPIKE ST.
Property Address
NO. ANDOVER �— — MA 01845
City/Town State Zip Code
JENNIFER l DBE _ 6/14/07
Owner's Name Bate of inspection
Sketch Of Sewage Disposal System: Provide a sketch of the sewage dispersal 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.
¢ � -- ---
�n
t
i le�J.t10 1 fiiZGO i ifie 5 Official inspection Fonn:Subsurface Sewage Disposal Sysic;1
Page 15 of 16
EPT11C & BRAD
Title 5 131 Forest Stree+
4i _ - MIDDLETON, MA
— � Not for Voluntary Assessments
{1.478)774-668:
Subs urface Sewage Disposal Systern FOrryi
C. System Information (coot,)
1459 TURNPIKE ST.
Property Address
NO. ANDOVER ESA -----
GitylTown State Zip Gode
JENNIFER DUCE _ 6/14107 -- - -- ---
Owners name date of Inspection
Site Exam:
Slope
Surface Water
Check cellar
Shallow wells
Estimated depth to ground water; 0 F
{Tease indicate all methods used to determine the high ground Water elevation:
® Obtained from system design plans on record
If checked, date of designs plant reviewed: TITLE V
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)
Q Accessed USES database -explain:
You must describe how you established the high ground seater elevation:
DATA FROM EARLIER REPORT DONE BY JOIN SOUCY DATED 5/17/01.
Title V.doc-11/2004 Title 5 Official Inspection f=orm:Subsurface Sewage Disposal System
Page 16 of 16