HomeMy WebLinkAboutMiscellaneous - 120 LACONIA CIRCLE 4/30/2018 (4) Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Laconia Circle
Property Address
Karen Crawford
Owner Owner's Name
information is North Andover MA 01845 August 2
required for every g , 2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
N/A ❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
N/A ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
N/A ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A ❑ ❑ 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) rge Systems: To be considered a large system the system must serve a facility with a
des flow of 10,000 gpd to 15,000 gpd.
For large systems, 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 eet of a surface drinking water supply
❑ ❑ the system is within 200 feet of i utary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sense area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a publi ter supply well
If you have answered "yes" to any question in Section E the system is const ed a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or rator of any large
j system considered a significant threat under Section E or failed under Section D shal rade the
system in accordance with 310 CMR 15.304. The system owner should contact the approp
regional office of the Department.
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