HomeMy WebLinkAboutMiscellaneous - 120 LACONIA CIRCLE 4/30/2018 (2) Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c,M 120 Laconia Circle
Property Address
Karen Crawford
Owner Owner's Name
information is North Andover
required for every MA 01845 August 2, 2013
page. City/Town 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 ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
Distribution box must be repaired to bring within 9"of finish grade, presently over 6'of cover over d-
box. Pipe between septic tank and d-box is crushed (less than 1" of clearance) approximately 15'
fromt tank. This pipe is also not level and must be replaced and backfilled with clean fill (no large
stones).
❑ 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):
II
CI er Evaluation is Required by the Board of Health:
❑ Conditions exist equire further evaluation by the Board of Health in order to determine if
the system is failing to pro blic health, safety or the environment.
1. System will pass unless Board o determines in accordance with 310 CMR
15.303(1)(b)that the system is not functionin anner 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 ora saltmarsh
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