HomeMy WebLinkAboutMiscellaneous - 120 LACONIA CIRCLE 4/30/2018 (3) Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 120 Laconia Circle
Property Address
Karen Crawford
Owner Owner's Name
information is North Andover MA 01845 August 2 2013
required for every g ,
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,
s ty and environment:
❑ The tem has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of urface water supply or tributary to a surface water supply.
❑ The system s a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a tic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply II**.
Method used to determine distance:
** This system passes if the well water analysis, pe med at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of monia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria a triggered. A copy of the analysis must
be attached to this form.
3. Other:
i
t
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
N/A ❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
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