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HomeMy WebLinkAboutTitle V Inspection Report - 14 PURITAN AVENUE 5/25/2011 �cx at t.rttada:aa° "tfa of Mass ac:irtt.aseft i rare a MIDDLET a,trect .:p 5 a n a,tet3 sMa aO e Sewage Disposal Sya Vem F ornn, - Not for-N/c:rlunim y /t:A tills rtsrrreratf�a PURlT*AN AVE, NO. AND(WER, MA 01845 l. Addn-ss dn- ,JASON VINI NG ✓" Owner Ome s rfalurl inforrnatiora is required for NO, ANDO-VER fly tk I 81451 5/25/11 every page. c ityaa cwra State Zip cc-,aye Date of Inspection inspection results must be saatamiffect on this forma. Inspection forms may not be altered in arty way, lrbapcartaraa: enerr �"��q t1"� w,1tioi��,l When filling out form or)the corrrpuYer,use 1. Ira Spector: only trae tab trey to move your .6f�AA S H. CURRIER II e;ursor-ago not N,rrne of rra,ta.,r.,tor _. u.R.e ttae r�etr.}rn r r r rU W N1 _ ..... Company Name Company A ddres - -� t AID 1.7P. 't-ohl._ ktr"1A 01949 ^dn s - - city/To state Zip Code T'raeptaone Number License rtturnber -- — _- _..... ------ RE . Certification I certify that I have personally inspected the sewage disposal systerrt at this address and that the information reported below is true, accurate arid csorrrl:rle;^te as of Unrea of the inspection.The inspection was performed based on rny training and experience in the proper function and maintenance of on site sewage disposal systerns. I am as DEP approved system inspector pursuant to Section 15.340 of "Fitle 6 (310 C MR 15.000). The sy stt;rrr: ❑� Basses E-1 Conditionally Passes ❑ pails ❑ cards F=urther Evaluation by the Locat Approving Authority 5/25/11 pectorsl Sicmmatr,rr°e Date The systetri inspector"shall submit as copy of thi s inspfaction report to the Approving AUth0l'ity (Board of Health or DEP)within 30 days of completing thus inspection. it the systern is a shared system or has a design flora of 10,000 gpd or greater, the inspector and the systern ommer shall submit the report to the a,ppropriaie regional office of the t EP, °fire Oiighaal sl'aoulda be, seat to the systern owner and copies sent to the bt.ryer, if applicable, anct the approving authority. ""This is report only describes conditions at the time of inspection and under the conditions of use at that tinge, This Inspection does not address how the syst:ena 7,1� " or different conditions of rise, t fUtu�ae under fire sam TIRE V 2008.(9©e 03108 rtlu 5 Official hl."p eLtio"6-0m) stjb,mu m e Sn Vra'p Di-vu sal 2I s#rani.d'a(M'1"f 1 Ts SEPT11C, Z", DRAM Commi anwealth of MassachuseUs [11 131 Forest Street F" ' F1 " — (C:� rf-V U ui�da zz) (U) U U a Li U-"U) MIDDLETON, MA 01949 (978) 774-6685 Al Not for Voluntary Assessments Subsurface Sewage Disposal stem Fory 14 PURITAN AVE., NO. ANDOVER, 1\11A 01845 'Property Address JASON MINING Owner Owner's Name information is required for NO. ANDOVER MA 01845 5/25/11 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E alvmys 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: SYSTEM WORKING PROPERLY. B) Syst in Conditionally Passes: F-1 One r more system components as described in the "Conditional Pass"section need to be reply d or repaired. The System, upon completion of the replacement or repai s approved by the Boa of Health, will pass. Answer yes, no -not determined ff, N, ND) in the ❑ for the following s ements. If"not determined," plea explain. 0'the replacement aremen 0" e a' ❑ for the following owi ng S e e Its The septic tank is etal and over 20 years old" or the septi ank (whether metal or not) is I _ I I structurally unsound, xhibits substantial infiltration ore I tration or tank failure is imminent. _p om System will pass inspe Jon if the existing tank is re ced with a complying septic tank as approved by the Board o ealth. "A metal septic tank will pas inspection if' s structurally Sound, not leaking and if a Certificate of Compliance indicating that th tank is ss than 20 years old is available. ND Explain: ❑ Observation of se age backup or break out or high sta ' water level in the distribution box due to broken or ob ructed pipe(s) or due to a broken, settled uneven distribution box. System will pass inspecti if(with approval of Board of Health)* td ❑ 6ken pipe(s) are replaced ❑ obstruction is removed TITLE V 2008.dac•03106 Title b Oi ic31 InnGxt en F�m7:Sci s lace�cwage Die{ i System•Page Z of 2 -SEPTM & Dk-�Ai IN nj Fcr0s;t,Street Commonweafth of Massachusetts MIDDLETON MA 01949 ;= — e- (978) 7�4-66,5 �U( irflc Dal I., h--1jsp- (i�UuQz�nnj' rf (0)ur u PL - Subsurface Sewage Disposal System Form -NotfOrVOILintar y Assessments 14 PURITAN AVE., NO. ANDOVER, MA 01845 Property Address JASON VINING Owner Owner's Name information is required for NO. ANDOVER MA 01845 5/25/11 every page. CityfTo,,vn State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced N xplain: ❑ The syste , required pumping more than 4 times a year due to brok or obstructed pipe(s). The system will p s inspection if (with approval of the Board of Heal ❑ broken i e(s) are replaced ❑ obstruction 1- removed ND Explain.- C) Further Evaluation is Required b ' e Board of Health: ❑ Conditions exist which require fu 01 �er ev uation by the Board of Health in order to determine if the system is failing to protect public healtNsafety or the environment. '7 1. System will pass unle§8 Board of Health etermines in accordance with 310 CMR 15.303(i)(b)that the syst`4m is not functionin in a manner which will protect public health, safety and the enviro ent: 1* ❑ Cesspool privy is within 50 feet of a surface w -er F-1 Cess of or privy is within 50 feet of a bordering vege fed wetland or a salt marsh 2. Syste will fail unless the Board of Health (and Public ate upplier, if any) determ' es that the system is functioning in a manner that protec the public health, safet and environment: The system has a septic tank and soil absorption system (SAS) and I SAS is within Ces5 'P n a manner surface tj a er 0 bordering na vege a,� S�e will I upp'ier, i' de term' es that tec the public ter I/ fet and environment: syst and I The \AS 100 feet of a surface water supply or tributary to a surface water supply. u blic The system has a septic tank ublic and SAS and the SAS is within a Zone I of water supply. El The system has a septic tank and SAS and the SAS is within 50 feet of a privy water supply well- -Mit 5 Offiial In5pr,3Uon Focni!Subsurface Sewage Disposal Page 3 1 of 3 -"T t�w lJ N309.6m,03�lW 11"S, SEVVIC 8r, DRAOR commanweaft of massachuseUs 181 For(;si Street MIDDLETON, MA 01949 (9783) 774-6685 7 Kfla 5 C)Uch id t Subsurface Sewage Disposal System Eon -Not for Voluntary Assessments 14 PURITAN AVE., NO. ANDOVER, MA 01;345 Property Address JASON VINING Owner - -- - - -- ------------- Owner's Name information is required for NO. ANDOVER MA 01845 5/25/11 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system septic eptic tank and SAS and the SAS is less than 100 feet but 50 feet oi- 1, � a\ more from a privat star supply ywell". Method used to determine X' tance: This system passes if the well water nalysis, perform at a DEP certified laboratory, for Goliform perform' rm nitrogen e a nitrate nitrogen bacteria indicates absent and the presen of ammo " nitrogen and nitrate nitrogen is equal to or I W _ I copy less than 5 ppm, provided that no other fail e crit is are triggered. A copy of the analysis must be attached to this form. 3. Other: ------------- 7� D) System Failure Criteria Applicable to All Systerns: 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 ❑ M Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ El Liquid depth in cesspool is less than W below invert or available volume is less than 1/2 day flow El M 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. E] ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. TITLE V 200&dac•03(08 Title 5 Official InspLaipf)Frmw Subsurface Semage Disposal SyMeni•Pago 4 of 4 Corm-nonweafth of Massachusetts 80TYC, A DRAgM treet j-S MM 131 Fore�D�78) 77 ET6�.i iVIA 01949 ri"Hu n-- n F ul- v 5r-n -6685 Subsurface e Disposal Sysfe� -'13-ewag Form -riot for Voluntary Assessments 14 PURITAN AVE., NO. ANDOVER, MA 01845 45-Foperty Address JASON VINING Owner Owner's Name information i's required for NO.-ANDOVER -MA— 01845 5/25/11 every page. CityfTown State Zip Code Date of Inspection S. Certification (cont.) D) ystern Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ❑ ll�� 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 ❑ ❑ ilk� Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with 110 acceptable water quality analysis. [This system passes if the well water analysis, performed at a D certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprn, 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- 11 0,000gpd. ❑ 0 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 110,000 gp b `15,000qpd. For large systems, You Must in i ate either"yes" or"no"to Bch of the following, in addition to the questions in Section D. Yes No 1:1 ❑ the system is within 0 f et of a surface drinking water supply the system is within 00 fe of a tributary to a surface drinking water supply the system is lo ted in a nitro fn sensitive area (interim Wellhead Protection Area- IWP or a mapped Zone I of a public water supply well If you have answered "yes'to y question in Section E the stem is considered a significant threat, or answered "yes" in Sectio above the large system has fai . The owner or operator of any large system considered a sign' cant threat under Section E or failed un r Section D shall upgrade the system in accordance h 310 CMR 15.304. The system owner shoo contact the appropriate regional office of the epartment. TITLE V 200˙•03106 TAIL 5 011i6al Inspection Form:Subsurface Sewage Disposal System-Page 5 of 5 � &, DRAW d�. �� �� ~~^ '� ������ur����� �����^"����� 13lFmo���o �� ���� �����8 Nl0DLETONjNAOl949 �� ��/� # U��ne�� (97D) 7/4-�uu� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 PUR|TANAVE, � ANDOVER, MA 01845_��_�_�_�__��______ Property Address JA3ONV|N|NG Owner owneFSwame information is m �m NO. ANDOVER MA 01845 5/35/11 required ��= viery page. c|tylTnwn State Zip Code Date o,Inspection C. Checklist Check if the following have been done. You must indicate ^you^ or"no" as to each of the following: Yes No Fl Pumping information was provided by the, owner, occupant, ur Board ofHealth Fl M Were any of the system components punnped out in the previous two weeks? 0 E] Has the yystenn received nurrnm} Uu*vo in the previous two week period? Have large volumes of water been introduced to the system recently oros part of Fl [� this inspection? 0 Were ere us built plans of the system obtained and examined? (if they vveno not �~ available note eyN/A) �� Fl VVoyihe facility or inspected for of back up? | ~~ ^� | � �� Fl VVanthe site inspected for signs nf break out? / 0 El Were all system components, excluding the SAS, located onsite? �� [l Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles ur tees, material ufconstruction, dimensions, depth of liquid, depth nf sludge and depth ofscum? �� Fl Was the feoi>ih/ owner(and occupants if different fronn owner) provided with �~ �� information on the proper maintenance ofsubsudore sewage disposal systems? The size and location nfthe Soil Absorption Sya1enm (S/\S) on the site has been determined based on: N Fl Existing information. For example, a plan at the Board of Health. y� [� Determined in the field (if any of the failure criteria related to Part is at issue �~ ~~ approximation of distance is unacceptable) [310 CK8R 15.302(5)] TITLE vz00v-u=.^oam Title o Official Inspection Form.Subsurface Se-wage Disposal System'Page s"/^ Commonwealth of MassachUsetts n do ��OCgt - 131 Forest Street MIDDLETON,MA 01949 WE 5 (978)774-6685 7 Subsurface Sewage Disposal System Fonn - Not for Voluntary Assessments 14 PURITAN AVE., NO. ANDOVER,-MA 01845 Property;w-dr-8-8s JASON VINING Owner Owner's Name information is required for NO. ANDOVER MA 01845 5/25/11 every page. City/Town State Zip Code Date of Inspection D. System Inforrination Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 GMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GILD ONE Number of current residents: Does residence have a garbage grinder? ❑ Yes rq No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes � No Laundry system inspected? ❑ Yes ❑ No Seasonal use? [:] Yes 0 No Water meter readings, if available (last 2 years usage (gpd)): 166_GPD,__ Sump pump? ❑ Yes F1 No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Est lishment: Design flow (bas on 310 CMR 15.203): Ga Ions per day(gpd) Basis of design flow (s ts/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present ❑ Yes ❑ No Non-sanitary waste discharged the Title ystem? ❑ Yes ❑ No Water meter readings, if ailable: Last date of occupan /use: ------------- ------ to Other(describe . TITLE V 2008Aoc-03106 Tftfe 5 Offiml Inspection Form:Subsurface Sevsou Disposal Svstem•Ratio 7 of 7 J's SEPT19C 8-1 DRAIN Cornmonwealth of Massachusetts 131 Fore st Street MIDDLETON, MA 01949 (978) '774-6685 f IJIU-022- P,W 7'ud�, t d c -a 1R Subsurface Sewage Disposal Systenn Fonir, -Not for Voluntary Assessments 14 PURITAN AVE., NO. ANDOVER, MA 01845 Property Address JASON VINING Owner Owner's Name information is required for NO. ANDOVER MA 01845 5/25/1 every page. Cityri-ovin State Zip Code Date of Inspection D. SySteffl WOMMUM (cont.) General Infon-nation Pumping Records: Source of information: LPD 9/28/2010 Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons How was quantity pumped determined? —--------- Reason for pumping: 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: ASBUILT DATED-5/-21/1998 Were sewage odors detected when arriving at the site? ❑ Yes 2 No TITLE V 200&doc-03108 T41L 5 Official Inspection Fnmv Subsurface SLvvage Disposal System-Pap 3 of 8 Commonweakh of Ftqassac�Dusetts DRANi 131 Forest Street MIDDLETON MA 01949 . Subsurface Sewage Disposai System Fovmm -blot for Voluntarl Assessments (972) 7 74-6685 1�k 14 PURITAN AVE., NO. ANDOVER, MA 01845 - — ------- Property Address JASON VINING Owner Owner's Name information is required for NO. ANDOVER MA 01845 every page. City/Town State Zip Code Date of Inspection D. System Mformation (cont.) Building Sewer(locate on site plan): Depth below grade: ONE POOH Material of construction: ❑ cast iron M 40 PVC ❑ other(explain).- Distance from private water supply well or suction line. N/A feet Comments (on condition of joints, venting, evidence of leakage, etc-): PLUMBING GOOD. Septic Tank (locate on site plan): Depth below grade: feet Material of construction: 0 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' X6'- 1500 PAL-­__ 2" - 3" Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 2" ------- " Scum thickness 0. 1/2 611 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? SLUDGE JUDGE, TAPE MEASURE -rFR E V 2008 doc•03/O3 Title S f)ffictal lospettion Form'Subsurface Sewage Disposal System=Page 9 of D Ts ` EPTPC & DRAIN commonweadth of Massachusetts 131 Favo-_t Street MIDDLETON, MA 01949 r n,t - mo (9-78)774-6685 b Lie-, n��-s in, t, (a)ru F co %sa lace Sewage, Disposag yst ern Frinnn -Not for Voluntary Assessments 14 PURITAN AVE_ NO. ANDOVER, MA 01845 Property Address JASON VINING Owner Owner's Name information is required for N© ANDOVER MA­ 01845 5/25/11 every page. City/Town State Zip Code Date of Inspection D. Systern Information (cont.) Comments (oil pumping recommendations, inlet and outlet tee of-baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): LIQUID LEVEL CORRECT, TEES IN GOOD CONDITION, DOES NOT NEED PUMPING AT THIS TIME. Grea Trap (locate on site plan): Depth be w grade: feet Material of co struction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene other(explain): Dimensions: Scum thickness Distance from top of scum to top of o et tee or baf Distance from bottom of scum to bottorn o et tee or baffle Date of last pumping: Date Comments (on pumping reGomr-nen ations, inlet an outlet tee or baffle condition, structural integrity, liquid levels as related to outlet it ert, evidence of lea ge, etc.): ----------- Tight or Holding dnk (tank must be pumped at time of inspectio (locate on site plan): Depth below gy de: Material construction: ❑ coi, Mete ❑ metal ❑ fiberglass ❑ polyethylene other(explain): TITLE V 2008.doc 03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page ID of 10 Comrtionweafth of P.Piassachuseffs J'�; SEPPIC S, DRAW 131 Forest street 0 MIDDLETON, MA 01949 [I C Q L]A U[n��pza t (ta))in 00 Frm (978)774-6685 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 PURITAN AVE., NO. ANDOVER, MA 01845 Property Address JASON VINING Owner Owner's Name information is required for -NO.-ANDOVER ----------- MA 01845 5/25/11 every page. City/Town State Zip Code Date of Inspection D. System ;nformation (cont.) Tight or [ding Tank (cant.) Dimensions:ns:!ding Tank (GOnt.) Capacity: :low. ._-- gallons Design Flow.- _---------- ons per day Y Alarm present: El Yes 0 No Alarm level: Alarm in working order ❑ Yes ❑ No Date of last pumping: Date Comments (condition of al2r /a�d float switches, etc, _/o, I float switches, Co Attach 0 of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): 0 Depth of liquid level above Outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidel Ice of leak— inf, 1,�uf �f hn-, �f ay° ML� �, � L � — — BOX IS LEVEL AND WORKING PROPERLY, NO EVIDENCE OF CARRYOVER, NO EVIDENCE OF LEAKAGE. BOX 16" BELOW GRADE. t Pump Chamber(lo to Von e plan): Pumps in working ord ❑ Yes ❑ No Alarms in worki/nrder.' ❑ Yes ❑ No TITLE V 2008Aoo•03J08 Title 5 Official finszpcction Form:Subsurface Sewage Disposal Sy-stern-Page 11 of 11 J" SEPTIC RN DRAW 131 Fores�Street Commonweaft h of Massachusetts MIDDLETON, MA 01949 U an-) v-0 (978) 774-6685 { '0 A Subsurface Sexavge Disposal Systenn, Farzff, -Not for Voluntary Assessments 14 PURITAN AVE., NO. ANDOVER, MA 01845 Property Address JASON VHNG Owner Owner's Name information is required for NO. ANDOVER MA 01845 5/25/11 every page. Cityrrown State Zip Code Date of inspection D. System Worg-nation (cont.) Comments (note condition of pump chamber, nditio A/f pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: THREE-20' EA. ❑ leaching fields number, dimensions: ❑ 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.): SOILS DRY, NO SIGNS OF HYDRAULIC FAILURE, VEGETATION NORMAL. TITLE V 2048-doc; OM13 Tile 5✓�fcnial thspLetion Form:Subsurface Smage Disposal%,ctm-Page 12 of 12 J" SEPTUc & DR 1r, ,- " A 131 Forest street Commonwealth of Massachusetts MIDDLETON MA 01949 (978) 7hj-C,6,q5 is v FW",J Subsurface ewage Disposal System Form -Not for Voluntary Assessments 14 PURITAN AVE., NO, ANDOVER, MA 01845 Property Address JASONVINiNG Owner Owner's Name information is required for NO. ANDOVER MA 01845 5/25/11 every page. Cityrrown State Zip Code Date of Inspection D. SySteffi WOFP-naUrM (cont.) Ces ools (cesspool must be pumped as part of inspection) (locate on site plan): Number d configuration ------------------ Depth —top o liquid to inlet invert ----------- —----- Depth of solids la er Depth of scum layer Dimensions of cesspool - ------ Materials of construction Indication of groundwater inflow El Yes ❑ No Comments (note condition of soil, si s of hydrauh/failure, level of ponding, condition of vegetation, etc.): P r iv y (l o c at e on n site it e p la n) : Materials of constructio Dimensions Depth of solid_ C o mments rote condition of soil , signs of hydraulic failure, level of ponds condition of vegetation, etc.) etc.): --------- - TITLE V?2008.doc,0310,S TjHe 5 Official Inspection Form:Subsullace sLwlge L115psal System•Page 1301`13 -E Commonweafth & Massachu MM setts —8, DRAIN 131 FDl l-,t Street MIDDLETON, MA 01949 -no�rfc--hn 11 ki urf 111��o virn -6685 TU`T? (978) 774 Subsufface Sew-age Dispoc-a� System Form -loot for Voluntary Assessments '14 PURITAN AVE., NO, ANDOVER, MA 01845 Property Address JASON VINING Owner Owner's Name information is required for NO. ANDOVER MA 0`1845 5/25111 every page. Cityri-ovrn State Zip Code Date of Inspection D. System InfOrMatiOn (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. TITLE V 2008.dac;-03108 Title 5 Official ltisreLtJon Form,Subsurface Scwage Disposal System-Page 14 of 14 RAW 131 Forest Street MIDDLET"ON, MA 01949 (978)774.6685 i \ DRNW E4SEUVIff kh LOT 13 \ ` , o ° A. \ N rro� ° DA \ FxIsrlNo F°D n� \ T 17®• F. B 168.58 :rAW DRIMEWA) !��sQS EASEME/V NOTE: / ��1�68.25 167.76,- DENOTES INVERT s' OF EXIST. PIPE (TYP.) 168.09 4" PVC 1 168.0Q� ��67.81 167.53 167.54 167.81 4" PyC 167.$1 167.71 167.72 4® PVC ® 167.54 N ny Commonwealth of Massachusetts i's SEPTIC & DRAIN 13 1 Forest Street MIDDLETON, MA 01949 YUCU . ......... U]e S (00) (978) 774-6685 SuL Waco: Sewage DispospM Syst m Foan -Not for Voluntary Assessments 14 PURITAN AVE., NO. ANDOVER, MA 01845 r'r+5perty Address -- - JASON VINING Owner Owner's name Information is required for NO. ANDOVER MA 01845 5/25/11 every page. City/Town State Zip Code Date of Inspection D. System Wormafion (cont.) Site Exam: ❑ Check Slope surface water Check cellar Shallow wells Estimated depth to high ground water: 58" SHWT feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plaris on record If checked, date of design plan reviewed: 9/11/1997 --- ------ Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ —-- ------------------ Checked with focal excavators, installers- (attach documentation) ❑ Accessed USGS database - explain.- You must describe how you established the high ground water elevation: TEST PIT DATA ON FILE WITH BoH. TEST PITS PERFORMED 7/2/1997. Tlfli,5 Offmial lt3specbon Fomi:Subsus au:SmagL Dispos,_15yWm-Pagp 15 of 152