HomeMy WebLinkAboutMiscellaneous - 164 MILL ROAD 4/30/2018 (4) _ —�
� '
— t
�: s
k,:.
1 I
FILE#
, y
k ,: � ID
TITLE V INSPECTIONG�
.w° Dean G. Luscomb II & Sons 01
�o 1
g *;� P.O. Box 135 Ka :,Allo
Middleton, MA 01949
978-774-4065
Licensed Plumber # 20285
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
,.
PROPERTY OWNERS NAME L a h .S i o n
PROPERTY ADDRESS 6
N. Andover MX
DATE OF INSPECTION LC 7
- NAME OF INSPECTOR n L C,C j'C Q P'n p
QUALITY IS NUMBER ONE TO US
RECEIVED
Commonwealth of Massachusetts
- Title 5 Official Inspection Form AUG o ? 2017
Inspection -Ma OF NORTH ANDOVER
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments pEpARTMENT
IgALTH7M
164 Mill Road
Property Address
Langston
Owner Owner's Name
information is North Andover MA 01845 Jul 29, 2017
required for y
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may notbe a er i any
way. Please see completeness checklist at the end of the form.
Important:
When filling out A. General Information ����"""`'"'���'
forms on the D Lo L
computer, use 1. Inspector: I /
i only the tab key VVV
to move your Dean G. Luscomb II
cursor-do not
use Name of Inspector nn
Com'
key the return. Dean G. Luscomb II &Sons j` i_/.
Company Name
288 Maple Street /
Company Address V
Middleton MA 01949
Pop Cityh'own State Zip Code
978-774-4065 S1848
Telephone Number License Number
B. Certification
1 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
• July 29, 2017
Inspector'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 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M
164 Mill Road
Property Address
Langston
Owner Owners Name
information is North Andover MA 01845 Jul 29, 2017
required for Y
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check AJB,C,D or E/always complete all of Section D
A) System Passes:
® 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:
B) System Conditionally Passes:
❑ 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.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 164 Mill Road
Property Address
Langston
Owner Owner's Name
information is North Andover MA 01845 Jul 29 2017
required for Y
every 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):
❑ 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 164 Mill Road
Property Address
Langston
Owner Owner's Name
information is North Andover MA 01845 Jul 29, 2017
required for Y
every 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
El ® 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
El
® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
t5ins•3/13 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
wM 164 Mill Road
Property Address
Langston
Owner Owner's Name
information is North Andover MA 01845 Jul 29, 2017
required for Y
every 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.
An portion of cesspool or privy is within 100 feet of a surface water supply r
❑ ® YP P P Y PPYo
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 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 custodymust 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) -Ur
ge Systems: To be considered a large system the system must serve a facility with a
desi flow of 10,000 gpd to 15,000 gpd.
For large syste , ou must indicate either"yes" or"no"to each of the follo in addition to the
questions in Section
Yes No
4 ❑ ❑ the system is with 400 fee a surface drinking water supply
❑ ❑ the system is wit ' 00 fee a tributary to a surface drinking water supply
❑ ❑ the syste s located in a nitrogen sitive area (Interim Wellhead Protection
Are: WPA) or a mapped Zone II of a blic water supply well
If you have ans d "yes"to any question in Section E the system I onsidered a significant threat,
or answere ` es" in Section D above the large system has failed. The o r or operator of any large
system nsidered a significant threat under Section E or failed under Section hall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the ropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
w . Title "5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 164 Mill Road
M
Property Address
Langston
Owner Owner's Name
information is North Andover MA 01845 July 29, 2017
required for
every page. Citylrown 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?
ns of break out?®
for si❑ Was the site inspected o g
® ❑ 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,
it
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.
® ElDetermined 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): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Mill Road
Property Address
Langston.
Owner Owner's Name
information is North Andover MA 01845 Jul 29, 2017
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
owner and town
Number of current residents: 3
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 ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): hQ �
Detail:
7o75-27Z = '73Clod,
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
C mercial/Industrial Flow Conditions:
Type of Esta i ment:
Design flow(based on 3 MR 15.203): --
Gallons per day �--'
Basis of design flow(seats/persons etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank ent? ❑ Yes ❑ No
Non-sanitary a discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 164 Mill Road
Property Address
Langston
Owner Owner's Name
information is North Andover MA 01845 Jul 29, 2017
required for y
every page. Cityrrown State Zip Code Date of Inspection
D. Sys nformation (cont.)
Last date of occupancy/us Date
Other(describe.below):
General Information
Pumping Records:
Source of information: Last pumped March 2017 and pumped every yr.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: Zero
gallons
How was quantity pumped determined?
Reason for pumping: No need at this time
Type of System:
® Septic tank, distribution box, soil absorption system W/f uMfi S 5cj; i6)
❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
164 Mill Road
Property Address
Langston
Owner Owner's Name
information is North Andover MA 01845 July 29 2017
required for ,
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Asbuilt is from 8/9/1985-32 years old.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 4
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 good condition.
Septic Tank (locate on site plan):
p, Depth below grade: 3feet
v` Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
Precast rectangular concrete- 1500 gallons
it an Is metal, list age:
Is o ompliance? (attach a copy of certificate)
Dimensions:
5'x 5' x 10' - 1500 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
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164.Mill Road
Property Address
Langston
Owner Owner's Name
information is North Andover MA 01845 Jul 29, 2017
required for Y
every page. City/Town 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 34"
e Scum thickness 1
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 15"
How were dimensions determined?
by measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic tank and baffle are in very good shape. The solids are light and do not require pumping at this
time. The liquid is running at it's correct working heigth.
ease ra
p (locate on site plan):
Depth belo rade: feet
Material of construct)
❑ concrete ❑ metal ❑ fiberglass ❑ po ylene TEI other(explain):
Dimensions:
Scum thickness
Distance from t f scum to top of outlet tee or baffle
Dist a from bottom of scum to bottom of outlet tee or baffle
i
Date of last pumping: Date
t5ins-3)13 Title 5 Official Inspection Four: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
w 164 Mill Road
Property Address
Langston
Owner Owner's Name
information is
required for North Andover MA 01845 July 29, 2017
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
C ments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid e s related to outlet invert, evidence of leakage, etc.):
Ti t or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth b w grade:
,.
Material of con uction:
❑ concrete metal ❑fiberglass ❑ polyethyle ❑ other(explain):
Dimensions:
Capacity:
g
allons
Design Flow:
Alarm present: o
I
Alarm level: '� der: ❑ Yes ❑ No
i
Date of last pum ' Date
Com mer (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
164 Mill Road
Property Address
Langston
Owner Owner's Name
information is North Andover MA 01845 Jul 29, 2017
required for Y
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 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 20"x 30" and is 11" below grade. The d-box is in very good shape.
Pump Chamber(locate on site plan):
Pumps in working order: ® Yes ❑ No*
Alarms in working order: ® Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
The cover is 9" below grade and measure 3'3"x 3'3". Pump and alarms all in good working order.
* 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:
SAS was located by asbuilt drawings.
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
164 Mill Road
Property Address
Langston
Owner Owner's Name
information is North Andover MA 01845 July 29, 2017
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 5-61' long l�eh
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology.-
Comments
echnology:Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.).-
The
tc.):The SAS is in good condition. There are no signs of ponding or breakout.
ools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and co ration
Depth—top of liquid to inlet i
Depth of solids layer �,r
Depth of scum layer
Dimensions sspool
�a erials of construction
Indication of groundwater inflow ❑ Yes No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page f 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 164 Mill Road
Property Address
Langston
Owner Owner's Name
information is North Andover MA 01845 July 29, 2017
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Commen e condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
ivy(locate on site plan):
Materials o struction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of by, Hure, level of ponding, condition of vegetation,
etc.)
6�
rr..•
J
/
4
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
. Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 164 Mill Road
Property Address /
Langston t
Owner Owner's Name
information is
required for North Andover MA 01845 July 29, 2017
every page. CitylTown State Zip Code Date of Inspection
D. System Information cont.
Sketch Of Sewage Disposal System: Provide a view of tie sews a disposal system, including ties to
atleast
I t two permanent reference landmarks or benchmirks."Loc ite all wells within 100 feet. Locate
where public water supply enters the building. Check on a of the I oxes below:
® hand-sketch in the area below
❑ drawing attached separately
�3
FA
� Entry Sa`c�y[,
� N
e NIT m ill Rd,
IV, AndoH-r- A-
$t1,P � 7sS
t c►
AhD � GZ3N
q714
L' D "
D
_SO
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.° 164 Mill Road
Property Address
Langston
Owner Owner's Name
information is North AndMA 01845 Jul 29, 2017
required for July
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar bc-1
® Shallow wells ';,� CJr Q
Estimated depth to high ground water: 5
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: 6/8/83
Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Permit, proposed, asbuilt and previous title v (11/7/03) on file.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Test hole# 1 -5'to ground water. Test hole#2 -6'to ground water. By Richard F. Kaminski 6/8/83.
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M
164 Mill Road
Property Address
Langston
Owner Owner's Name
information is
required for North Andover MA 01845 July 29, 2017
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
I
I
I
I�
1
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
A Of NORT:Sq. 7973
O
0,
_. 9
Town of North Andover
HEALTH DEPARTMENT
,SSACMU`+tt
CHECK#: q( DAT,
LOCATION:
H/O NAME:
CONTRACTOR NAME: D WD
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
13Title 5 Report - jJO-3 5 $— 41
❑ Other. (Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
Form 8 i
DEOE File No. 242_ 258
(To be provided by DECE)
Commonwealth City/Town North Andover
_ of Massachusetts Applicant_Stephen Leone
Lot 7B Mill Road (4164)
Certificate of Compliance
Massachusetts Wetlands Protection Act, G.L. c. 131 , §40
and under the Town of North Andover Bylaw, Chapter 3, Section 3.5 A&B
From North Andover Conservation Commission Issuing Authority
To Stephen.. Leone 164 Mill Road, North Andover, MA 01845
(Name) (Address)
Date of Issuance November 9, 1988
This Certificate is issued for work regulated by an Order of Conditions issued to Stephen Leone
dated March 26,1985 and issued by the NACC
1 . ❑ It is hereby certified that the work regulated by the above-referenced Order of Conditions has
been satisfactorily completed.
2. ❑ It is hereby certified that only the following portions of the work regulated by the above-refer-
enced Order of Conditions have been satisfactorily completed: (If the Certificate of Compliance
does not include the entire project,specify what portions are included.)
3. ❑ It is hereby certified that the work regulated by the above-referenced Order of Conditions was
never commenced.The Order of Conditions has lapsed and is therefore no longer valid. No future
work subject to.regulation under the Act may be commenced without filing a new Notice of Intent
and receiving a new Order of Conditions.
. .......................................................................................................................................................................................
(Leave Space Blank)
8-1
Effective 11/1/87