Loading...
HomeMy WebLinkAboutTitle V Inspection Report - 410 SUMMER STREET 11/8/2017 Commonwn,sith of MassachJisotts RECEIVED Title 5 Official 4 spection Form �w Subsurface Sewage[disposal SyMem Form-NQt for Volurtary Assessments I A,N t 'dCl'4 . 4t0 Summer Street � . .... �I. C9( r.t'AiTIdiE� .. Ferland r L}mar4a Nau�rsw irfTrrtlGPn Is required lo,. Wr h Andower "'�A. .__ .lune A,2015 every gage. Cl VfT own � SWIQ lip Ccde Crate of In Mon inspection results most be submitted ort this form.Inspection forms may not ba altered In any way.Plealse see completeness checklist at the pend of the farm. ri2pt�ctlrt�nt. __ V..._ When filling out A. General Information fb mes on the I wmputwa use 1, Inspector nn+y the tab key P� °G rne~vs Yaw Dearl:,t tuscorr b li cwureaor-der not IV____, ,,w lnsc� r _.... u"this return s�n�of k�,r. Dean G. Luswrrib It P3v Sons GGnttra�ilyrdam� ' l.O, Box 135 r rnary AddTess — Mr.0 d:F+iCtn MA6A � 01° 49 tyit�l t IMIn State e 978-774-4065 S1843 _ o,lapi- r,e hurrblae L sage NUM bet i B. Certification I certify that I have perscnally Inspected the sewage disposal system attbits ad€iross and that the Information reported below is true,accurste-inti complete as of the tune of tile,Inspec.di3n. The inspection was perlbrrred based on my training artcl experienoe in the proper function and maintenance of oti site sewage d spossl systems,i ant a DEP aporoved system Inspector pursuant to Suction%348 of Title 5(310 OMR 15.000).The system: ; f Z Passes U Conditionally Passes ® Fa•1l$ M Needy Farther Evaluation cry tile local Approving Authority i a eine$, {!1& (resp ori w9gnatane Date. Tile systern in.sspectoi shiall'subr�st e copy of this Inspection report to the Approving Autlsorlty(Board of Hw4lth ar DEP),Nithirx 30 bays of coitnpleting Mia,Nuri adonn,If the synth+Is a shared system or has a design fiovi of 10,000 Od or rester, ,the inspector and tyre system:owner shall submit the report to the appropriate regional o sMe of the DEP.The original should be sent to the system owner and poples gent to the buyer,If,applicable,and tb4s approving authority. *"'Tbis report only describes condMons at the time of Inspection and sunder the conditions of use at that time.This Inspection does'not address how the system will perfutm in the future under th,a same or different conditions of use. i 1�'nu.5Pt3 I &i�ru�t3tEl,m.J Ir�P,"Si�.fCmr Suaouiew,�eHa�e IJlYhfiriil9Y�urn'Pr+ya+4�17 FILE# -And d '- fpy, m TITLE V INSPECTION .ra DeanG. Luscomb H & Sons P.O. Bax 135 Middleton, MA 01949 978-774-4065 Licensed Plumber # 20285 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNERS NAME �� r ) a r) PROPERTY ADDRESS 14 1 0 U M M E r N , A v(-- DATE OF INSPECTION NAME OF INSPECTOR ' ., QUALITY IS NUMBER ONE TO US Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M •'v 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18 2014 required for every page. Cityrrown 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 A. General Information forms on the ' computer, use 1. Inspector: 's only the tab key to move your Dean G. Luscomb I) cursor-do not Name of Inspector use the return key. Dean G. Luscomb II &Sons Company Name P.O. Box 135 Company Address Middleton MA 01949 x°07 City/Town State Zip Code 978-774-4065 S1848 Telephone Number License Number B. Certification 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 ❑ Needs Further Evaluation by the Local Approving Authority Ins ectoes Signature Date 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts J Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is required for North Andover MA August 18, 2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A&D or E 1 always complete all of Section D A) System Passes: r-1 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: 13) System Conditionally Passes: Z 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. 2 Y M N n ND (Explain below): Tank is precast concrete but is structurally unsound. Baffles are missing and tank is leaking approximately 6" below the outlet invert at this time. t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 410 Summer St, Property Address Ferland Owner Owner's Name information is North Andover MA August 18, 2014 required for ---- every page, Cityrrown State Zip Code Date of Inspection B. Certification (cant.) ❑ 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 ❑ 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18, 2014 required for � eery page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 ❑ ® 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 ❑ ® 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 invert or available volume is less than %day flow t5ins•3113 Title 5 Official Inspection Form: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 410 Summer St. Property Address Ferland Owner Owner's Name information is required for North Andover MA August 18, 2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El El Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: EJ Z 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. A El ® Any portion of a cesspool or privy is within a Zone 1 of a public well. V F1 E 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) Lar Systems: To be considered a large system the system must serve a facility with a design of 10,000 gpd to 16,000 gpd. For large systems, u must indicate either"yes"or"no"to each of the followin in addition to the questions in Section D. Yes No R El the system is within 0 feet of a su a drinking water supply El El the system is within 200 f o tributary to a surface drinking water supply the system is loc in a nitrogen sen i i e area (Interim Wellhead Protection Area—IWP r a mapped Zone 11 of a pu. i water supply well If you have answered "yes' any question in Section E the system is co i ered a significant threat, or answered "yes" in S ion D above the large system has failed. The owner erator of an large system considere significant threat under Section E or failed under Section D s pgrade the system in acco nce with 310 CMR 15.304. The system owner should contact the appir date regional off' of the Department. "I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts u - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18, 2014 required for q _^ every page, Cityrrown 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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, ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18, 2014 required for w...,_ every page. City/Town State Zip Code Date of Inspection D. System Information Description: owner Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes E No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail Q& - D"S 414,1 pow Sump pump? ® Yes ❑ No Last date of occupancy: current Date C mmercial/Industrial Flow Conditions: Type of Esta ' ent: Design flow(based on 310 15.203). Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., — ---- --- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste dischar o the Title 5 system? Yes ❑ No Water meter re i gs, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18, 2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Laate of occupancy/use: Date �..,-,._-.--r-.-._--•.- Other(describe below❑ General Information Pumping Records: Source of information: Last pumped in 2013. On average every 2 yrs- owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: / No need at this time 7�-,;k cw, (Z�pure � r-c�ola c�rl 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): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Z Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18, 2014 required far '� __...,.,_. every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): 5 Depth below grade: 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.): Main line and joints are in very good condition. Septic Tank(locate on site plan): 7 Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast round- 1000 gallons If tank is metal, Is years Is y a Certificate of Compliance? (attach a copy of certificate) o Dimensions: 5'x U diam- 1000 gallons Sludge depth: 1" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is required for North Andover MA August 18, 2014 every page. Cityrrown 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 3411 Scum thickness Distance from top of scum to top of outlet tee or baffle 13-1 Distance from bottom of scum to bottom of outlet tee or baffle 3" How were dimensions determined? sticks and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank is in very poor condition, it is leaking at approx 14" below the cover. The liquid is leaking out 6" below the outlet invert. The tank shows a lot of deterioration at this heigth. The liquid in the tank is not running at ifs correct working heigth. G ase Trap (locate on site plan): Depth bell rade: feet r 'Oas Trap p "Ocae on site 0 Depth bel rade Material of constructi n concrete F] metal En fiberglass F] polyethylene El of explain): Dimensions: Scum thickness Distance from top of scum to top of outl e or baffle — Distance from bottom of scu ottom of outlet tee or baffle Date of last pumpin Date t5ins-3/13 Tide 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 410 Summer St. Property Address Ferland Owner Owner's Name information is required or North Andover MA August 18, 2014 every page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Cl6ittm Em_ts (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels lated to outlet invert, evidence of leakage, etc.): Ti ht or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Holding Dept elow grade: pt O Material o onstruction: concrete r-1 metal El fiberglass ❑F-1 polyethylene her ❑ (explain): Dimensions: Capacity: gallons Design Flow: gallons per y Alarm present: D s 0 No Alarm level: larm in working order: D Yes ❑ No Date of last pumping. ate Comments (condition of alarm and float itches, etc.): Attach copy of current pumping contract(required). Is copy attached? FIS n No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is required for g North Andover MA August 1$, 2014 _ _.. every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): r Depth of liquid level above outlet invert Zero / 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.): The d-box is in good general condition. The liquid in the d-box is actually low as it does not get a normal flow from the tank because it is leaking. The d-box shows no signs of having any problems. This would indicate that the leaching field is in good shape. 27 ","zj Chamber(locate on site plan}: Pumps in workin er. ❑ Yes O Alarms in working order: Yes ❑ No* Comments (note condition of pump chamber, c n ' 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: 4ID-AUje k level c�� o4 �- t5ins•3/13 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 �M 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18, 2014 required far _. every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 20'x 40' ❑ 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.): The SAS was located from d-box to level area of.yard. There are no signs of ponding or breakout in the yard to be noted. The yard is covered with well maintained green grass. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number an figuration - --- -- Depth–top of liquid to i t invert Depth of solids layer Depth of scum layer - — Dimensions of cesspool Materials of con ction Ind' i of groundwater inflow ❑ Ye ❑ No. t5ins•3113 Title 5 Official 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 M 410 Summer St. Property Address Ferland Owner Owner's Name information is 9 required for North Andover MA August 18, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Commen (note condition of sol, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Priv (locate on site plan): Materials of co uction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic e, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 1 Commonwealth of Massachusetts r . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments .' 410 Summer St. Property Address c~ Ferland Owner Owner's Name information is required for North Andover MA August 18, 2014 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal Syst m: Provide a view of the sewage disposal system, including ties to at least two perma ent reference andmarks or benchmarks. Locate all wells within 100 feet. Locate where public water upply enters he building. Check one of the boxes below: ® hand-sketch in the area belo ❑ drawing attach d separately �rG►��O� �L 9p1�SQ� Y � cf n P I © -M.k-c cGa 13 b-@ox 10 93b� � '2 60 X t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 410 Summer St. Property Address Ferland Owner Owner's Name information is required for North Andover MA August 1$ 2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Site Exam: / ® Check Slope &11,6/ 9,"[, ® Surface water /Woe ® Check cellar TtRmp j'(Al"4P ® Shallow wells "O fNiC- Estimated depth to high ground water: approx 4' 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: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Pumping records only ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: The basement is 4' below grad e with a sump pump in it. There was no other information available. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts u . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 410 Summer St. Property Address Ferland Owner Owner's Name informsfo over r q is required for North AndMA August 1$, 2014 every page. Cityrrown 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 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 'F of`t T Commonwealth of Massachusetts ' City/Town of System Pumping Record Facility Information: System Location: �La, I � L Address LhC,�� City/Town State Zip Code System Owner: Name: Adress (if different from location of pump) City/Town State Zip Code 6- Telephone Number Pumping Record Date of Pumping ' Quantity Pumped C gallons Type of System Septic Tank Grease Trap Other (what) System Pumped by: l Company: ROOTER-MAN 46 Portland Street Lawrence, MA 01843 Location where contentwefEosed: �� Signature of Hauler 1' Date