HomeMy WebLinkAboutTitle V Inspection Report - 10 WOODCHUCK LANE 11/16/2017 Commonwealth of Massachusetts RECEIVED
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
10 Woodchuck Lane
Carol Strout
Owner 7-W-7 —bwn �sNMe
Information is
required for every North Andover Ma. 01846 11/15/17
...........
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
filling out forms A. General Information
the computer,
use only the tab I Inspector:
key to move your
cursor-do not Ron Jenkins
use the return
key. Name of Inspector
R. Jenkins&Sons
VQ Comp'any —---------
58 Pleasant St.
——-----------
Company Address
Ma.
01969
Cityfrown State Zip Code
-978-314-0503 S14268
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 16.340 of
Title 5(310 CMR 16-000).The system:
ED Passes n Conditionally Passes El Fails
F] Needs Further Evaluation by the Local Approving Authority
11/15/17
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 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.
****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.
15ins-3113 Tige 5 Official Inspection Form:Subsurface Sewage Disposal System-page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
10 Woodchuck Lane
Property Address
Carol Strout
Owner Owner's Name
Information is North Andover
required for every Ma. 01845 11/15/17
page. Cltylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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:
Distribution Box was replaced and Outlet Tee was installed on 11/9/17,
All work was performed by Jim Borachek who is a licensed Installer in the town of North Andover
All work and materials used are in compliance to Title 5 regulations
Septic Tank was also pumped
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):
A
9
9
P
R
15ins-3113 Title 5 Official Inspection Form:Subsurface Sewago Disposal system•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
10 Woodchuck Lane
Property Address
Carol Strout
Owner Owner's Name _
information is
required for every North Andover Ma. 01845 11/15/17
page. Cityrrown state Zip Code Date of inspection
B. Certification (cont.)
❑ Pump Chamber Pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ 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 ❑ NO(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(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 ❑ NO(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 390 CMR
15.303(9)(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
15ins•3113
Title 5 4ffwjnl Inspection form;Subsurface Sewage Disposal System•Page 3 of 17