HomeMy WebLinkAboutTitle V Inspection Report - 169 GRAY STREET 1/12/2018 Commonwealth) of Massachusetts
= Title 5 Officiall Inspections Form
4y
w� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
169 Gra Street
S ____ -------
Properly Address
Francis & Ellen Murp
Owner Owner's Name
information is
required for every North Andover MA 01845 12/12/17
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:WhenQ. enerai Information
filling out forms
on the computer, 1i'„
use only the tab 1. Inspector:
key to move your 70M ll iP CgOR 1 i MCC:t IrJR.
cursor-do not Robert Herrick
use the return -- - - -
key, Name of Inspector
--- Wind River Environmental
raG Company Name --
163 Western Avenue
Company Address
reran Gloucester MA 01930
City/Town State Lip Code
978 282-7315 5113759
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
El Needs Further Evaluation by the Local Approving Authority
12/12/17
1 Spector"s 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 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.doc•rev.6116 "rifle 5 Official Inspection Form SUbSurfaCe Sewage Disposal System�Page 1 of 17
Commonwealth of Massachusetts
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Subsurface Sewage Disposal SyotmmForm '' Not for Voluntary Assessments
10QGro Street
Property Address
Francis & Ellen Murphy ------
Owner Owner's Name
information is
required for every North Andover MA _ 01845 12/12/17
page. City/Town State Zip Code Date ufInspection
B. Certification (cont.)
Inspection Summary: Check A.B.C},DorE/always complete all nfSection D
AJ System Passes:
[l I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303orin 310 CMR 15.804 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
Z One or more system componentsas 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
dobynnined," please explain.
The septic tank is metal and over 20 yoena 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.
°Ametal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is |e«o than 20 years old is available.
El y N El ND(Explain be|ovv �
15ins.doc-rev.6116 1 itle 5 Official inspection Form:SUbSUrface Sewage Disposal System-Page 2 of 17
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Commonwealth of [0assachWsett$
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Title �� %��� � ������� Inspection Form
Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments
169 Gray Street
Property Address
Fnanoia & B|unk4u�
»w»^/ OwonreNmmn
information is
required for every North Andnver MA 01845 12/ 2�17
Q
page. ty�^wn Smte Zip Code o*�eof|nnpeuion
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 (cunt]:
|| 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 ofBoard ofHeokh):
0 broken pipe(s) are replaced El Y F1 N F-1 NQ (Explain be|»w)�
R obstruction isremoved Fl Y El N F-1 ND (Explain below):
Z distribution box isleveled orreplaced El Y F-1 N [l NO (Explain bm|uvv �
The distribution box is rotted and needs toboreplaced.
-- ----
|l 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):
R broken pipe(s) are,replaced EJ Y FIN R ND (Explain below):
Fl obstruction inremoved El Y R N F1 ND (Explain be|ow):
C1 Further Evaluation hsRequired bythe Board ofHealth:
E] Conditions exist which require further evaluation by the Board of Health in order to determine if
the system iofailing hoprotect public health, safety orthe environment.
1. System will pass unless Board mfHealth determines inaccordance with 31DCMR
15.803(1)(b)that the system isnot functioning |nmmanner which will protect public health,
safety and the environment:
Fl
Cesspool orprivy imwithin 50feet ofasurface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Commonwealth of Massachusetts
Title 5 official Inspection Form
n Subsurface Sewage Disposal Systte n Form Not for Voluntary Assessments
169 Gray Street
Property Address
Francis & Ellen Murphy
Owner Owner's Name
information is
required for every North Andover MA 01845 12/12/17
page, City/TownState Zip Code Date of Inspection 1
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
Backup of sewage into facility or system component due to overloaded or
El M 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
El ® liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/a day flow
t5ins.doc•rev.6/16 f"itle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
G Commonwealth of Massachusetts
- u Title CJf *inial Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
169 Gray Street
Property Address
Francis & Ellen Murphy
Owner Owner's Name
information is Horth Andover MA 01845 12/12/17
required far every ....._ ._........... .m...____. _. ....— ._.._....
page. City/Town State Zip Code Date of Inspection
B. Certification (cant.)
Yes No
E❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ E 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 DEI' 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 fair;. 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) targe 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
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ 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.
t5ins.doc•rev.6116 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of MassachWsett.,;
^����� � �������U ������������� �������
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Subsurface Sewage Disposal System Form '' Not for Voluntary Assessments
169G�a S�naex ___ -----------
Property Address
_-PmpenyAddmss
Francis & Ellen Murphy
Owner Owner's Name
info/maUon|o
required for every
North Andover MA 01845 12/12/17
__�w_
Pogo� Ci��^ n State Zip Code Date wInspection
C. Checklist
ChnokifthefoUom/inghavebeendong. Younmustindioobm^yen" or"no" amtoeachOfthahoUowing:
Yen No
�� Fl
Pumping information was provided bythe owner, occupant, orBoard ofHealth
Fl E Were any ofthe system components pumped out inthe previous two weeks?
Has the system received normal flows inthe previous two week period?
[l B�
Have large volumes ofm/aterbeen introduced tothe system rwoenUyorampart of
�� ��
this inspection?
Were mobuilt plans ofthe system obtained and examined? (If they were not
available note aeN/A\
M Fl Was the facility ordwelling inspected for signs ofsewage back up?
E El Was the site inspected for signs ofbreak out?
• El Were all system components, excluding the SAS, located onsite?
• 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,
dimensions, depth nfliquid, depth ofsludge and depth ofscum?
�� F� Was the facility nwner(endoccupants ifdifferent from owner) provided vvith
�� �� information onthe proper maintenance ofsubsurface sewage disposal systems?
The size and location mfthe Soil Absorption System (SAS) onthe site has
been determined based on:
E El Existing information. For example, m plan edthe Board of Health.
Determined inthe field /fany ofthe foUurecriteria related tmPart<� ioedissue
`
opprnximationofdistance iounacceptable) [31OCK4R1��30�(5>] |
' . �
|
D. System Information
Residential Flow Conditions:
�
Number ofbedrooms (desi3(design): ���----- Number nfbedrooms (aotuo):
DESIGN flow based on31OCK4R15.203 (for example: 110gpdx#nfbndroVmo): "ocq----
|
t5ins.doc rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
q_7). ..... Title 5 Officiall Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
169 Gray Street
Property Address
Francis & Ellen Murphy
Owner Owner's Name
information is
North Andover MA 01845 12/12/17
required for every
page. City/TownState Zip Code Date of Inspection
D. System Information
Description:
This system is madeup of tank, distribution box and soil absorption
system.
3
Number of current residents:
Does residence have a garbage grinder? El Yes 0 No
Is laundry on a separate sewage systern? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? El Yes No
Seasonal use? El Yes E No
Water meter readings, if available (last 2 years usage (gpd)): N/A
Detail:
Sump pump? ❑ Yes No
Last date of occupancy: Occup i edDate
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/pe rsons/sq ft, etc,):
Grease trap present? El Yes n No
Industrial waste holding tank present? El Yes n No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes n No
Water meter readings, if available: ------___
t6ins.doc:•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
N:- w Title 5 official Inspection Form
m
Subsurface Sewage Disposal Systelr Form •• Not for Voluntary Assessments
- ,- 169 GW Street
Property Address
Francis & Ellen Mur h
Owner Owner's Name
information is
required for every North Andover MA 01$45 12/12/17
page City/Town State Zip Code Date of Inspection
D. System Information (cont.) j
i
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Wind Enver Environmental and the Board of Health
Was system pumped as part of the inspection? ❑ Yes M 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):
t5ins.doc•rev.6116 rifle 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
❑ Title 5 Of iciM inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
a
°w 169 Gray Street
Property Address
Francis & Ellen Murphy.. _..
Owner Owner's Name
information is North Andover MA 01845 12/12/17
required for every -..._..____ _.._--- _ _ ._._ _ _._...___. -- _._
page. City/Town StateZip Code Date of Inspection
I
D. System Information (cant.) _.__-__._--
Approximate age of all components, date installed (if known) and source of information:
27 years; Plans on File
Were sewage odors detected when arriving at:the site? ❑ Yes ® No
Building Sewer(locate on site plan):
21"
Depth below grade: Leet
Material of construction:
Z cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town Water feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
All aoints look to bEy solid. There are no signs of leakage and ventin is through the building's sewer.
Septic Tank (locate on site plan):
12"
Depth below grade: feet.
Material of construction:
M concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain)
i
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
10'x 5'x
Dimensions: __........ ...__ _.....___..._.�_
4"
Sludge depth: _
t5lns.doc•rev.6!'16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
=w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
169 Grav Street — --
......._._�_
Property Address
Francis & Ellen Murphy
Owner Owner's Name
information is
required for every North Andover MA 01845 12/12/17
page, City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 32" -
1"
Scum thickness
6
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? Tape Measure & Sludge Jle —
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Recommend pingyearly. The inlet and outlet baffles are solid. There are no suns of leakage or
carryover and the liquid level is OK in relation to the inverts.
Crease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal [] -fiberglass n polyethylene ❑ other (explain):
Dimensions: _._..... _._ ........._
1
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 -
1 Date of last pumping: Date
I,
15ins.doc-rev.6/'16 Tillie 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
169 Gray Street
Property Address
Francis & Ellen Murphy
Owner Owner's Name
information is
required for every North Andover MA 01845 12/12/17
pageC I I I tyfTown 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:
El concrete El metal D fiberglass El polyethylene El other(explain):
............
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: El Yes El No
Alarm level: Alarm in working order: El Yes El No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach COPY Of Current pumping contract (required). Is copy attached? El Yes Ej No
t5ins.doc-rev,6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Officiall Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
169 Gray Street
Property Address
Francis & Ellen Murphy—..
Owner Owner's Name
information is
North Andover MA 01845 12/12/17
required for every
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.):
The distribution box is showings. ions of rot and leakaqf c
e but has no sicins oarr
over in or out of the
_"
box.
Pump Chamber(locate on site plan):
Pumps in working order: F] Yes El No*
Alarms in working order: M Yes El No*
Comments (note condition of purnp 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:
15ins.cloc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title����0� � �������U N�������°��� �������
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Submu�ocmSexvo0e []|sposa| Sys��nmForm
~ NotforVo(untmryAmseoym�ntm
Property Address
Francis & Ellen Murohv
Owner Owner Owno/aWmma
information is
NodhAndover MA 01845 12Y12Y17
m�ui��turevary
�� State Zip Code Dawormspecmun
page. City/Towna
D. System Information (cont.)
Type:
R leaching pits number:
0 leaching chambers number: -----������---
[l
leaching galleries number: ----------���
F-1 leaching trenches number, length: ------------���-
1; 10' x50'
Pq leaching fields number, dimensions: -
Fl overflow cesspool number ---���--------
F� innovaUve/a|\ernmtiveayetem
Type/name Vftechnology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The soil is dry and there are no�,jqns of hydraulic failure or ponding. The veqetation is normal for
the area.
Cesspools (cesspool must bapumped aapart ofinspection) (locate onsite p|on):
Number and configuration
Depth-top of liquid to inlet invert ---���-- -
-
Qepihofoo|ido |aygr -------
Depthofanum |eyer ---' ----��
|
Dimensions ofcesspool --------- �
| �
Materials ofconstruction
Indication ofgroundwater inflow Yes [l No
s Commonwealth of Massachusetts
M - Title 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
169 Gray Street..... _._.- — .......... -- _ — .....,.— _.—..._..
Property Address
Francis & Ellen Murphy
Owner Owner's Name
information is North Andover MA 01845 12/12/17
required far every -- ..,_..-- _..__. ... _-_ ....... _...-- _. ......_._-._ — j
page City/Town State Zip Code Date of Inspection
D. System Information (cont.) r
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.):
i'
II
t5ins,doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposai System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Systern Form Not for Voluntary Assessments
169 Gray Street
...........
Property Address
Francis & Ellen Murphy__
Owner Owner's Name
information is
required for every North Andover MA 01845 12/12/17
page. CityiTown 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:
El hand-sketch in the area below
Z drawing attached separately
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Page 10 of 1]
OFFICIA.I.,INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
i
Property Address: 169 G YSTREET
NO. TyeR.MA 0is
Owner:MURPHY,FRANCIS
SKETCH OF SEWAGE I§1L 0SCM a
Provide a sketch of the se ge dis s zi including ties to at least two permanent reference landmarks or
benchmarks.Locate all we s withi �t.Locate where public water supply enters the building.
No.rne
A 4,D '71 z5 .2.5 ' ►
Commonwealth of Massachusetts
mm_ Title 5 Of iaciall Inspection Form
Subsurface Sewage Disposal Systerrr FormNot for Voluntary Assessments
169 Gray Street,.,,............._..—
Property Address
Francis & Ellen Murphy
Owner Owner's Name
information is North Andover MA_— 01845 12/12/17
required for every — — ----__...__._— _ _ . _....__ ...... I
...........
page. CltylTown _ State Zip Code Date of Inspection 1
D. System Information (cont.) _.
Site (Exam:
Z Check Slope
] Surface water
Z Check cellar
Z Shallow wells
Estimated depth to high ground water: 8Y
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)
z Checked with local Board of Health - explain:
Previous Title V Pei-formed in 2005
[] Chucked with local excavators, installers -(attach documentation)
[] Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
I obtained the estimated ground water information from the previous Title V Inspection that was
performed in 2005. 1 also excavated a hole near the soil absorption system to a depth of about 5 feet
and found no signs of water. The basement was dry and the layout of the land shows no indication
that the ground water would be an issue with this system.
I
s
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t51ns.doc•rev.6116 'Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Paye 16 of 17
Commonwealth of Massachusetts
� ...: Title 5 Of��iMall Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
n; 169 Gra_Street
Property Address
Francis & Ellen Murphy
Owner Owner's Name
information is North Andover MA 01845 12/12117
required for every _—
page. Cltyrrown _ State Zip Code Date of Inspection
E. Report ICompletene:se• Cheekllist
• 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
15ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Mage 17 of 17