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Home My WebLink AboutTitle V Inspection Report - 754 BOXFORD STREET 2/8/2017 Commonwealth of Massachusetts 01 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessment " _ 754 Boxford Street DaveAddress - -- I---.------.------.- � Dave Hart Owner Owner's Name information is North Andover Ma 01845 1/24/17 required far every ... page, City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. --..._.---_— Important:when A. General Information filling out farms on the computer, use only the tab 1. Inspector: key to move your cursor-do not John DlVincenZo use the return key. Name of Inspector J and S Development Corp/Stewarts Septic Service raa Company Name 58 South Kimball St Company Address Bradford MA 01835 City/Town Skate Zip Cade 078-372-7471 s113386 Telephone Number m License Number ---- ---------- ........_...........--_...._..--..-_ B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails E] Needs Further Evaluation by the Local Approving Authority f Inspe tar's Signature Date T system inspector shall submit a copy of this inspection report to the Approving Authority (Board o Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. j ----- ------- I I "This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is North Andover Ma 01845 1124117 required for every -- --..... ----.. ._.-_ page. CltylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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 ex€iltration 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): t5ins.dec-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 a s ` ' Commonwealth of Massachusetts ^�°�N�� 0 0�� NN��* �� '� � N�� Inspection �~��mmmw Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 764Boxford Street _�� _____________�� ______________��_' Property Address Dave Hart Owner Owner's Name information is NurthAndoverMa 01845 1/24/17 requiredfor ��'_-------------��----------'— ------- ------�� page. oity[Town State Zip Code Date mInspection B. Certification (cont.) El Pump Chamber pumps/alarms not operational, System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (oont.): Fl 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 pmpy inspection if(with approval of Board of Hen|th): El broken Aipe(s)are replaced 0 Y F1 N D ND (Explain be|ow): Fl obstruction is removed El Y E7 N Fl N[] (Explain below): � distribution box is leveled or replaced E Y El N F-1 ND (Explain below): Distribution box is coroaded around the d t Invert needs rep]ouin El The system required pumping more than 4times ayear due to broken or obstructed pipe(s). 7he system will pass inspection if(with approval nfthe Board ofHen|th): El broken pipe(s)are replaced El Y �� N Fl ND(Explain below): F1 obstruction is removed F1 Y F1 N F1 ND (Explain below): ' C) Further Evaluation imRequired bythe Board mfHealth: | Fl Conditions exist which require further evaluation by the Board ofHealth inorder to determine if the system is failing to protect public health, safety or the environment. Y' System will pass unless Board ofHealth determines |naccordance with 31OCMR i 18.3O3(1)(b) that the system ia not functioning inamanner which will protect public health, safety and the environment: Fl Cesspool nrprivy iawithin 50feet nfmsurface water Fl Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh mmo.u�',"~*xo nu°oom"a/m,p"w�m�.o.m"m,^*Sewage o/.p�m��rm'ms"�m,r Commonwealth of Massachusetts r u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form » Not for Voluntary Assessments ° 754 Boxford Street v Property Address Dave Hart Owner Owner's Name information is North And__over Ma 01845 1124117 required for every page. Gityffown State Zip Cade Date of Inspection B. Certification (cant.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No El ® 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below inert or available volume is less than 1/2 day flow t5ins.doc•rev.6116 Title 5 Official inspection f=orm:Subsurface Sewage Disposal System•Page 4 of 17 I. I , Commonwealth mfMassachusetts Title 5 Official Inspection Form Subsurface Sem/age Disposal System Form - Not for Voluntary Assessments 7S4Boxford Street PmnrrtyA0drema Dave Hart Owner Owner's Name information is North AndoverMa 01845 1/24/17 required mrnvr� -------_'_ page, c|tyfTmwn State Zip Code Date u/Inspection B. Certification (cont.) Yen No �� Required pumping more than 4Umesinthe last year&��Tduohzclogged or �� ~~ obstructed pipe(a). Number oftimes pumped: _____ AnyporUonof(heOAS. reoapoo| orpr|vy |mbg|owhiQhQroundvvatere|evaUon. �� Any po�ionofcesspool or9rk/yisvvithin 18Ufeet ofonu�oonwater supply or �~ �� tributary to surface water supply. El M Any portion ofacesspool nrprivy ipwithin aZone 1 nfmpublic well. E] M Any portion of a cesspool or privy is within 50 feet of a private water supply well. El M 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 ifthe well water analysis, performed mtmDEP certified laboratory,for fecal coliform bacteria indicates absent and the presence pfammonia nitrogen and nitrate nitrogen |sequal toorless than 5ppm, provided that no other failure criteria are triggered.A copy ofthe analysis and chain mfcustody must beattached 6mthis fornn.] �� The system |oocesspool serving afadUtyvv|thodesign flow of2OOOQpd' ^� �� 10.000gpd. �� system Th�myst� f�|s. | have determined that one ormore ofthe above failure �� =� criteria exist aadescribed in 310 CMR 15.303' therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary tocorrect the failure. E\ Large Systems: To bmconsidered alarge system the system must serve mfacility with m design flow of18,0O00pdto10'Q80gpd. 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 | Fl 1:1 the system iswithin 4O0feet ofmsurface drinking water supply | ' El El the myohann is within 2OOfeet ofo tributary to surface drinking water supply F� �� the oyutenn |mlocated inonitrogen oeno|Uvearea (interim VVe||headProtection �� Area— NVPA)oramapped Zone || ofapublic water supply well / If you have answered "yes" to any question in Section E the system is considered a significant threat, | or answered ^ynn^ in Section D above the large system has failed. The owner oroperator of any large | ` oyohamonnnidenadmaignifivantthnoatunderOectionEorfaUedunderSnctionOnhaUupgnadathe system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office ofthe Department. ' Commonwealth of Massachusetts �N��N�� ~"��N 0��^�� 0�� N�� y� � ��mN �wm�r��*��N��nm 0—��mmmw Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754Boxford Street _________��___________��__________��__----_---��__--_ � pmrerty^uomoz Dave Hart Owner Owner's Name information is North Andover Ma 01845 1/24/17 umuiveumr��ry ----___�� --------_-'�� ------- ��----- page. «»v[Tow» otmn z/pCuuu Date mInspection C. Checklist Check if the following have been done. You must indicate"yee ur"no^ onhneach ufthe following: Yom No Z El Pumping information was provided by the owner, occupant, or Board of Health El 0 Were any nfthe system components pumped out inthe previous two weeks? 0 Fl Has the system received normal flows inthe previous two week period? [� [� Have large volumes ofwater been in�nduoedtothe system recently nroapart of �~ .~ this inspection? [� [� VVereaabuilt �onsnfthe system obtained and examined?(if they were not ~~ �~ available note as N/A) E El Was the facility ordwelling inspected for signs Vfsewage back up? 0 E7 Was the site inspected for signs ofbreak out? � M El Were all system components, excluding the SAS, located unsite? ! E El 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, dinnenuiono, 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 ofthe Soil Absorption System (SAS) onthe site has been determined based on: E Fl Existing information. For example, o plan at the Board of Health. Determined in the field Uf any ofthe failure criteria related to Part C is at issue �� ` �� approximation ofdistance ieunacceptable) [310CMR 1S.3O2(5)] D. System Information Residential Flow Conditions: 44 Number ufbedrooms(denign): Number ofbedrooms(octua|): 600 --------�� DES|GNfl yN nwbonedon31OCR15.2O3(forexmmp|e: 11Ogpdx #ofbedrnoms). "c�----' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Ownerowner's Name information is North Andover Ma 01845 1/24/17 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: ....... -------- Number of current residents: 3 Does residence have a garbage grinder? El Yes 0 No Is laundry on a separate sewage system?(Include laundry system inspection El Yes N No information in this report.) Laundry system inspected? El Yes El No Seasonal use? El Yes Z No Water meter readings, if available(last 2 years usage(gpd)): Detail: ---- ------- Sump pump? El Yes N No Last date of occuancoccupied py: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons a11ons per day(gpd) Basis of design flow(seats/persons/sq,ft., etc.): ------ -- Grease -------- Grease trap present? El Yes El No Industrial waste holding tank present? E] Yes [—] No Non-sanitary waste discharged to the Title 5 system? El Yes E] No Water meter readings, if available: Mns.cloc•rev.6116 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form W Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is North Andover Ma 01845 1124117 required for every _ ___ W.._ ------- .... page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: bate Other(describe below): General Information Pumping Records: Source of information: Stewart's Septic Service Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Site guage on truck In Reason forpumping: spect tank _-s __.. Type of System: ® Septic tank, distribution box, soil absorption system ElSingle 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 IIA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ElOther(describe): t5ins.doc•rev.6I16 Title 5 Official Inspection Form:Subsurface Sewage Olsposal System•Page B of 17 I: i. ( Commonwealth of Massachusetts Title 5 Official Inspection Form ® 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is North Andover Ma 01845 1124117 required for eery __......__ ___._-.......... ----....-- page. CltylT"own State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 38 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: - feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1011 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: � years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: - Sludge depth: _.........._. _ t5ins.doc•rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1�) Subsurface Sewage Disposal System Form Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is North Andover Ma 01845 1124/17 required for every ...... -- --.......--------- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 30" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness ---------- Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 15.1 How were dimensions determined? Tape measure sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both baffles are good. No leakage and the liquid level is good_.,.-----....-r1. ...... .... ----------- - Grease Trap(locate on site plan): Depth below grade: feet Material of construction: El concrete El metal 0 fiberglass El polyethylene El 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 ......... tbins,doc•rev.6116 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 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is North Andover Ma 01845 1124117 required for every — �... _ _-- -......_ _. page. Cltyffown 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: .._Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level' — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Da to- .... ..... Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins.doc-rev.8116 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I'. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 754 Boxford Street ------- ipi-operty Address Dave Hart Owner Owner's Name information is required for every North Andover Ma 01845 1/24/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 ....... Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box needs replacing..Very little solids carryover. Leakage around outlet inverts. ............... .......... ........... ................. -------------- Pump Chamber(locate on site plan): Pumps in working order: El Yes El No* Alarms in working order: El Yes F1 No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): --------------- If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: 15irs.dDc-rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is North Andover Ma 01845 1124117 required for every ---...,- page. C1tyfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: El leaching chambers number: ...... ❑ leaching galleries number: ❑ leaching trenches number, length: --- 1-20x45 ® 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.): No hydraulic failure, no ponding and there are no damp soils. V Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer —..._ ___... Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ Na is y'. F5ins.doc•rev.8116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is North Andover Ma 01845 1/24/17 required for every I- ---I........... page. Cityffown 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.doc-rev.606 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts _ v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is North Andover Ma 01845 1124/17 required for every ................_......_-_ -------- page. City own State zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins.doc•rev.6116 Title 5 Official inspection Form:Subsurface Sewage Olsposal System•Page 15 of 17 &ISHEA CONCRETE PRODUCTS New England's Premier Precaster! ... ........ ........... ........... T7� t; ........... ..................................... .......... ........... ........... .......... ........... ............i-.1- . .. ...P C J il F .......... .......... ............ .......... J........... .......... ............. .......... . .......... Lo ... ........ .......... . ........ .......... i T .......... .......... .......... . ..............�1111 .......... ...... ........... .......... .. ........ ..... .......... .......... ........... .......... ........... .......... ........... . ...... .. ....... . Wilmington Plant Amesbury Plant Rochester Plant Nottingham Plant 773 Salem St. 87 Haverhill Rd 153 Cranberry Hwy 160 Old Turnpike Rd Wilmington,MA Amesbury,MA Rochester,MA Nottingham,NH 01887 01913 02770 03290 (978) 658-2645 (978) 388-1509 (508) 291-1314 (603) 942-5668 Commonwealth of Massachusetts w --Y Title 5 official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner pwner's Name information is North Andover Ma 01845 1124117 required for every -_..._..-- ----................ --........_.. page. City/Town 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: 3'-6" 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: 3-26-77 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Pulled file ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Taken from design plans on record. S.H.W.T at elevation 93.5 Bottom of the bed 97.5 System 4' above the water table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15tns.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is North Andover Ma 01845 1/24/17 required for every page. CityrFown 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 Mns.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ! r , PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of. 2-7-2017 This is to certify that the individual. subsurface disposal. system received a SATISFACTORY INSPCCTION of the: Repair of . -box and 2 Pipes By: John DiVincenzo At: 4 Boxford Street Map 105.A Lot 0018 :... Orth Andover, MA 01845 Tno,1.8sufaace of this fi all not be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.4540 Fax 978.688.8476 Web www.townofnorthandover.cora