HomeMy WebLinkAboutTitle V Inspection Report - 11 STONECLEAVE ROAD 5/22/2013 ^
Commonwealth of Massachusetts
'
Title 5 Official Inspection F orm
�u
Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments
1 Stonecleave Road
Property Address
Steven Nutter
Owner Owner's Name
information is
required for North Andover MA 01845 5/22/2013
every page. Cityl-Fmwo State Zip Code Date o[Inspection
Inspection results must be submitted on this form. Inspection forms may not bw altered inany
way. Please see completeness checklist mtthe end of the form.
Important: A. �������U U����K���~��n
VVhenM|Y|ngout
^ ~^ -- � =Information
forms on the FMCEIVED
computer, use 1� Inspector:
only the tab � '
�
to move your
cumur'dom� Peter
mmthe m�m '~~'~~ ^~,``~'
130 Andover Street
---- Company Address
Andover MA 01810
Qtyffown State Zip Code
978-375-3750 811855
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 (31MCKAR16'0$0). The system:
E Passes El Conditionally Passes F-1 Fails
Fj Needs Further Evaluation by the Local Approving Authority
5/24/2O13
|o��e�or'o S|Qnatupe Daio
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\Vthe appropriate regional office Vfthe DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
°°°°TMis report only describes conditions mt the time of inspection and under the conditions ofuse
at that time. This inspection does not address how the system will perform in the future under
the same pr different conditions ofuse.
mmo'mm Title 5 Official Inspection Form:o"u""xac^Sewage Disposal System'Page 1mn �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Steven Nutter
Owner Owner's Name
information is North Andover MA 01845 5/22/2013
required for _...._. __.._..... _._........._ _ _._.... -----
every page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E 1 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):
u
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V 15ins•3113 Titio 5 official Inspection Farm:Subsurface Sewage Disposal System•Page 2 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Steven Nutter
Owner Owner's Name
information is North Andover MA 01845 5/22/2013
required for _. __ _.._. _._....
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (coat.):
❑ 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
i Wins•3113 Title 5 Official Inspection Form',Subsurface Sewage Disposal System Page 3 of 17
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`
Commonwealth of Massachusetts
'
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments
118hunecloa e_Romd
Property Address
Steven Nutter
Owner Owner's Name
information is
required for North Andover MA 01845 5/22/2013
every page. City/Town State Zip Code Date mInspection
B. Certification /CODt.\
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:
F-1 The system has a septic tank and soil absorption system (SAS) and the SAS is within
10U feet nfa surface water supply nr tributary tVa surface water supply.
R The system has a septic tank and SAS and the SAS is within a Zone 1 of public water
supply.
R The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
�l
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 nupp|yvve||°°
Method used to determine distance:
^°
This system passes if the well water analysis, performed at DEP certified |abnnah),y, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
tonr less than Gppm. provided that no other failure criteria are triggered. A copy nf the analysis must
bn attached to this form.
3. Other:
CA System Failure Criteria Applicable to All :
You must indimmte"Yes" or"Ncy'bo each pf the following for all inspections:
Yes No
�� �� Backup nf sewage into fan|Kvor system component due hnovedoadedor
�� �� clogged SAS urcesspool
�� �� Discharge orpondingofef uenttothesu� � waters
�� ��
due tuan overloaded or clogged SAS o[cesspool
�� ��
Static Uquidlevel in the diotribuUonbox above uuUotinveddue tomnovednmded
�� �� or clogged SAS orcesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
�� �~
than 1/2day flow
l5ins-3113 THIL 6 Official Inspection Farm�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
11 Stonecleave Road
Property Address
Steven Nutter
Owner owner's Name
information is
required for North Andover MA 01845 5/22/2013
_.... _... ...
every page. CitylTown State Zip Code Gate of Inspection
B. Certification (cons.)
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
9 ❑ ❑ the system is within 400 feet of a surface drinking water supply
i
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El El 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.
i' t5ins•3113 Title 5 Official Inspection Ferm:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 11 Stonecleave Road
Property Address
Steven Nutter
Owner Owner's Name
information is North Andover MA 01845 5/22/2013
required for __.... _.......
every page. City/Town 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 NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® El 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.
❑ El Determined in the field (if any of the failure criteria related to Part Cis at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
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D. System Information
i
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Residential Flow Conditions:
Number of bedrooms (design): 500 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms); 440
15ins•3113 Title 5 Official Inspection Form:Subsurface sewage Disposal system-Page G of 17
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Commonwealth of Massachusetts
~��°��N�� �� ������������N N����������������� ����UpN1�U
Title �� ��y� � ���N�wN 0mm���������N��mm N—�pmmmm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
11 8honecleavgRoao
Property Address
Steven Nutter
Owner Owner's Name
information is
NodhAndover MA 01845 5/22/2013
required for
every page. City/Town State Zip Code Date WInspection
D, System Information
Deoohpt|oni
1,5009allon septic k d-box and one [each fi
Number of current residents: �-----------
Does residence have a garbage grinder? El Yes Z No
Is laundry on a separate sewage system? (include laundry system inspection �� Yes �� No
informahon |nthisropu�j -- --
Laundry system inspected? El Yes E] No
Gemsona| ua*? El Yoe 0 No
Water meter readings, if available (last 2 years usage (gpd)): N/A----------������
Detail:
'
The domestic water system is a private well, located greater than 100' from the closest septic system
|
' com
Sump pump? Yes Z Nn
current
Last date ofoccupancy:
Date
Conmnnen:imNndumtria| F|mxv Conditions:
Type ofEstablishment:
Design flow (based on310CPNR15.2O3): --��������—'-----------�����-------
Gallons per day(gpd)
Basis of design flow (eeets/peronns/sq.ft.. eto.):
Grease trap present? El Yen El No
|nduoh|m| vvmnhaholding tank present? �� Yes �� No
Non-sanitary waste discharged tn the Title 5system? El Yes 0 No
Water meter readings, if available: --------'—��������'------------�����
t5i""'3113 n,*n Official Inspection Form:Subsurface oaw"ge Disposal System'Page/*n
. .
Commonwealth of Massachusetts
"�"°��N�� �� ��`���������N N������������°���� ����UrN7K�
Title �� ��/� � ���N�wN Inspection 0—�rmmmm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1_1 Ohuneoleave'Romu
Property Address
Steven Nutter
Owner Owner's Name
information is
required m North Andover MA 01845 5/22/2013
quiur ���������---------------���������------- ------'---
every page. City/Town State Zip Code Date mInspection
D. System Information (cont.)
Last date nfonoupanuyuau: Date
Other(describe bo|nvv :
General Information
Pumping Records:
last d �/22/2007 rBOHnaoordo
Source ufinformation: ==�=�=��-��—==-������'������
Was system pumped ee part nf the inspection? El Yen 0 No
|f yes, volume pumped: gallons ---------------����������-------------���
How was quantity pumped determined?
Reason for pumping�
Type ofSystem:
Septic tank, distribution bux, soil absorption system
Single cesspool
Overflow cesspool
El Privy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
E-1 Innovative/Alternative technology. Attach a copy of the current operation and
�
maintenance contract(to be obtained from system owner) and a copy nflatest
inspection of the |/4 system by system operator under contract
Tight tank. Attach m copy of the DEPapproval.
F-1 Other(describe):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
. .
x�^ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Diaposa| SymtmmnFomn - NotforVo|untoryAaaaeemente
11Shoneulegye_Road
Property Address
Steven Nutter
Owner Owner's Name
|nf0nn21tmnio
required for North Andover _yWA 01945 5/22/2013
every page. ouyffown Smve Zip Code Date WInspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
The o atem wea installed in 1979 when the house was built.
Were sewage odors detected when arriving mt the site? El Yen H No
'
Building Sewer(locate on site plan):
Depth below gnade� 12^ - 14"
feet
Material of construction:
0 cast iron El4OPVC El other(exp|min):
Distance from well >100
feat
Comments (on condition of joints, venting, evidence of leakage, eto.):
The building harti ht and was hu ctionin _Iqperly.
Septic Tank(locate on site p|an):
12"
Depth below grade:
feet
Material ufconstruction:
0nononab* El metal El fiberglass El polyethylene other(explain)
Rectangular 1.5OOoaUontank
If tank is metal, list age:
years
|e age confirmed by a Certificate of Compliance? (attach acopy of El Yes E] No
' 10'
Dimensions:
1^ 2.'
Sludge depth:
15ins 3113 Title 5 Official Inspection Form Subsurfane SewagL D�sposal System-Page 9 of W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Steven Nutter
Owner Owner's Name
information is North Andover MA 01845 5/22/2013
required for
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 161$
0" - 1"
Scum thickness
6
Distance from top of scum to top of outlet tee or baffle 11-71$
—-----
" "
Distance from bottom of scum to bottom of outlet tee or baffle 15 - 16
How were dimensions determined? measurement
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1,500 - —properly.
_gall0..."n septic tank was watertiqht. Concrete baffles were in place and functioning
.............
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
Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Steven Nutter
Owner Owner's Name
information is
required for North Andover MA 01845 5/22/2013
every page. City/Town 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 [:1 No
Date of last pumping: ........
Date
Comments (condition of alarm and float switches, etc.):
Il
......------- -----------
Attach copy of current pumping contract(required). Is copy attached?
El Yes ❑ No
6ins•M3 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
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Commonwealth of Massachusetts
| "�°�N�� � ��������N N��������~���� �������
/ NN�N�� �� ��'� � ������N Inspection ����mwwm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1i5toneo|eaveRoad
-- ���-_------------_---- _- '___� .......... _--
Property Address
8tawan Nutter
Owner ������������---------------�� --'---- --��� ���----------
Owner's Name
information is
required for North Andover MA 01845 5/22/2013
every page. City /own State Zip Code Date o«Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site p|an):
[/'
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etcj:
Five lines leaving d-box were accepting effluent evenly. The box was watertight and structurally
sound. D-bnx cover was 1O" - 18" below the surface.---
Pump Chamber(locate on site pkan\:
Pumps in working order: Fl Yes El No*
Alarms in working order: El Yes D No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.)-.
°
If pumps or alarms are not in working nn1or, system is n conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not |oosdnd, explain why:
15ins Tille 5 Official Inspeclion Form:Subsutface Sewage Disposal Syslem Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Steven Nutter
Owner Owner's Name
information is
required for North Andover MA 01845 5122/2013
every page. Cityl-rown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
1:1 leaching galleries number:
r-1 leaching trenches number, length: .........
'
® leaching fields number, dimensions: 20 x 45'
❑ 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.):
One large field with 5 lines. Soils look normal, no evidence of breakout or ponding.__,
.......... ........
............ .
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
N o
Indication of groundwater inflow El Yes [:1
15ins-3113 Title 5 Officiat Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
11-Stonecleave Road
Property Address
Steven Nutter
Owner Owner's Name
information is North Andover MA 01845 5122/2013
required for
every page. CitylTown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
., 11 Stonecleave Road
.......-- - --- --- - - ....__._.-
Property Address
Steven Nutter
Owner Owner's Name
requir on is North Andover MA 01845 5/22/2013
required d for
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cant.)
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
t�
,.rte
F
YR RD
t5ins•3113 Title 5 Official Inspection Ferm,Subsurface Sewage D3 sposal System•Page 15 of 17 '..
Commonwealth of Massachusetts
u Title 5 official Inspection Form
n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Steven Nutter
Owner Owner's Name - -._.. ... _._........w......... �_.
information is North Andover MA 01845 5/22/2013
required for �..._.�__ ___.._...........................�.--�-._..--
every page. CityfFown 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: 1"-4' or greater
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: 1979
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:
You must describe how you established the high ground water elevation:
Design plan dated March of 1979 showed no ground water at 4' or greater below bottom of SAS.
Soils, relative elevation of SAS and grade changes show no evidence of groundwater in the SAS.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Msposal System-Page 16 of 17
Commonwealth of Massachusetts
0
Title 5 official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
11 Stonecleave Road
Property Address
Steven Nutter
Owner Own �
Owner's Name
information is
required for North Andover _ MA 01845 5/22/2013
eve a
every page, Cit Y!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
t5ins-3113 Title 5 Officiat Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
i
9
DISCLAIMER
This passing septic inspection under Massachusetts Title V is in no way a guaranty
or warranty of the inspected septic system. The inspection is a "snapshot in time"
and does not constitute a complete assessment of the quality or potential longevity
of the septic system. The pass/fail criteria are specific and outlined in detail in this
report. Under the limited criteria of a Title V inspection, it is impossible to determine
how long any septic system will last. The inspector made a diligent effort to certify
the septic system based on the criteria required under Title V.
Under Massachusetts Title V, soil evaluation is the accepted method of determining
the high groundwater elevation. This inspector is not a certified soil evaluator and is
therefore not qualified under Title V to determine or establish the high groundwater
elevation. The method used to estimate the high groundwater for this inspection was
based on the public records and methods of observation described on the previous
page. Groundwater levels can vary greatly from season to season, year to year and
soil evaluation is considered the most reliable method of groundwater determination
under Title V.
L�
Peter F. Reilly
Inspector
May 22, 2013