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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
284 Bradford street
Property Address
Oualter
Owner's Name
North Andover
City/Town
MA 01886 September 22,2015
State Zip Code Date of Inspection
it
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.
A. General Information
1. Inspector:
John DiVincenzo
RECEIVED
OCT 2 0 2015
Name of Inspector HEALTH lil�li RTMENT rM
Stewarts Septic Serive
Company Name
58 South Kimball street
Company Address
Bradford
Cityrrown
978-372-7471
Telephone Number
B. Certification
M
State
S113386
License Number
01835
Zip Code
I 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:
E Passes El Conditionally Passes F� Fails
El Needs Further Evaluation by the Local Approving Authority
Inspector',6 Signature
Date
q /�,� � A T
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of He6lth 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 DER 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
<C\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
284 Bradford street
Property Address
Oualter
Owner Owner's Name
information i's
required for every North Andover MA 01886 September 22,2015
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,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:
13) System Conditionally Passes:
El 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.
El Y r-1 N El ND (Explain below):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
4*N
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
284 Bradford street
Property Address
Oualter
Owner Owner's Name
information is
required for every North Andover MA 01886 September 22,2015
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
[:1 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):
El broken pipe(s) are replaced
obstruction is removed
El Y El N El ND (Explain below):
El Y El N F-1 ND (Explain below):
El distribution box is leveled or replaced F-1 Y El N F1 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 F1 Y El N El ND (Explain below):
obstruction is removed El Y El N El 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(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
El Cesspool or privy is within 50 feet of a surface water
El 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
284 Bradford street
Property Address
Oualter
Dwner Owner's Name
nformation is
equired for every North Andover MA 01886 September 22,2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall 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:
El 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.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
El 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
E]
0
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El
0
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El
0
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
11
i
r
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins - 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
** 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
E]
0
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El
0
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El
0
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
11
z
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins - 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
<r
Commonwealth of Massachusetts
Title 5
Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
284 Bradford street
Property Address
Oualter
Owner
information is
Owner's Name
required for every
North Andover
MA 01886 September 22,2015
page.
City/Town
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
E]
z Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: _.
Ej
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.
El
E Any portion of a cesspool or privy is within a Zone 1 of a public well.
E]
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 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) Large 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
0 0 the system is within 400 feet of a surface drinking water supply
El El the system is within 200 feet of a tributary to a surface drinking water supply
M M the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
i :1-0 glum
4;
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
284 Bradford street
C. Checklist
MA 01886 September 22,2015
State Zip Code Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Z El
Property Address
E] 0
Civalter
Owner
Owner's Name
information is
required for every
North Andover
page.
City[Town
C. Checklist
MA 01886 September 22,2015
State Zip Code Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Z El
Pumping information was provided by the owner, occupant, or Board of Health
E] 0
Were any of the system components pumped out in the previous two weeks?
E 1:1
Has the system received normal flows in the previous two week period?
El E
Have large volumes of water been introduced to the system recently or as part of
this inspection?
Z El
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z 1:1
Was the facility or dwelling inspected for signs of sewage back up?
Z 1:1
Was the site inspected for signs of break out?
Z El
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,
dimensions, depth of liquid, depth of sludge and depth of scum?
E]
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.
Z El
Determined 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:
1? 3
Number of bedrooms (design): Number of bedrooms (actual).
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ril. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
_� : �X, c �' 284 Bradford street
Property Address
Oualter
Owner Owner's Name
information is
required for every North Andover MA 01886 September 22,2015
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
2
Does residence have a garbage grinder?
EJ
Yes
Z
No
Is laundry on a separate sewage system? (Include laundry system inspection
El
Yes
Z
No
information in this report.)
Laundry system inspected?
El
Yes
[_1
No
Seasonaluse?
El
Yes
Z
No
Water meter readings, if available (last 2 years usage (gpd)):
73 GPD
Detail:
Water meter readings
Sump pump?
Z
Yes
FI
No
Last date of occupancy:
Occupied
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
El
Yes
[_1
No
Industrial waste holding tank present?
El
Yes
[I
No
Non -sanitary waste discharged to the Title 5 system?
El
Yes
El
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
284 Bradford street
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
MA 01886 September 22,2015
State Zip Code Date of Inspection
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Date
2011 last pump Andover septic
1000
gallons
Site quaqe on truck
tank
Property Address
Oualter
Owner
Owner's Name
information is
required for every
North Andover
page.
City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
MA 01886 September 22,2015
State Zip Code Date of Inspection
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Date
2011 last pump Andover septic
1000
gallons
Site quaqe on truck
tank
Z Yes [—] No
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
El Innovative/Alternative technoloay. Attach a cor)v of the current oneration 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
Septic tank, distribution box, soil absorption system
Single cesspool
El
Overflow cesspool
D
Privy
Z Yes [—] No
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
El Innovative/Alternative technoloay. Attach a cor)v of the current oneration 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
<f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
284 Bradford street
Property Address
Oualter
Owner Owner's Name
information i's
required for every North Andover MA 01886 September 22,2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
30 vears +
Were sewage odors detected when arriving at the site?
El Yes Z No
Building Sewer (locate on site plan):
Depth below grade: 26"
feet
Material of construction:
Z cast iron El 40 PVC other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
0 concrete D metal
1411
feet
El fiberglass n polyethylene [:1 other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions:
Sludge depth:
El Yes El No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Aj� � Mimi ga
L ELLAl
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
284 Bradford street
Property Address
Clualter
Owner Owner's Name
information is
required for every North Andover
page. City1rown
D. System Information (cont.)
Septic Tank (cont.)
MA 01886
State Zip Code
Distance from top of sludge to bottom of outlet tee or baffle
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
29"
0
911
18"
September 22,2015
Date of Inspection
How were dimensions determined? TApe measure & sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both baffles good no leakage liquid level good
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
0 concrete El metal
Dimensions:
Scum thickness
feet
El fiberglass El polyethylene r-1 other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
t5ins - 3/13
Date
Title 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
284 Bradford street
Property Address
Oualter
Owner Owner's Name
information is
required for every North Andover MA 01886 September 22,2015
page. City[Town 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:
0 concrete El metal 0 fiberglass El polyethylene El other (explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: 0 Yes No
Alarm level: Alarm in working order: El Yes R 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 El No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
284 Bradford street
Property Address
Oualter
Owner Owner's Name
information is
required for every North Andover MA 01886 September 22,2015
page. CityfTown 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.):
-Equal dist no solids carryover no leakage
Pump Chamber (locate on site plan):
Pumps in working order: El Yes EJ No*
Alarms in working order: El Yes 0 No*
Comments (note condition of pump 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:
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
284 Bradford street
Property Address
Clualter
Owner Owner's Name
information is
required for every North Andover
page. CityfTown
D. System Information (cont.)
MA 01886 September 22,2015
State Zip Code Date of Inspection
Type:
El
leaching pits
number:
E]
leaching chambers
number:
El
leaching galleries
number:
El
leaching trenches
number, length:
N
leaching fields
number, dimensions:
E]
overflow cesspool
number:
E]
innovative/alternative system
1-1 5X40
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
-no hydraulic failure no ponding no damp soils.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes [:1 N o
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
284 Bradford street
Property Address
Clualter
Owner Owner's Name
information i's
required for every North Andover
page. Cityrrown
D. System Information (cont.)
RAA nippa
September 22,2015
Date of Inspection
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.):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
11
Commonwealth of massa6husetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
284 Bradford street
Property Address
Oualter
Owner Owner's Name
information is
required for every North Andover MA 01886 September 22,2015
page. CityrFown 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
7r public water supply enters the building. Check one of the boxes below:
hand_sketch in the area below
El drawing attached separately
E
L L
,L. u-Aj
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
284 Bradford street
Property Address
Oualter
Owner Owner's Name
information is
required for every North Andover
page. CityfTown
D. System Information (cont.)
Site Exam:
Z
Check Slope
Surface water
Check cellar
El
Shallow wells
Estimated depth to high ground water:
MA 01886
State Zip Code
4'
feet
September 22,2015
Date of Inspection
Please indicate all methods used to determine the high ground water elevation:
014
Obtained from system design plans on record
If checked, date of design plan reviewed: Date
Observed site (abutting p rope rty/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Pulled files
Checked with local excavators, installers - (attach documentation)
El Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
USG indicates water 76.0' system aprox 2'above 2.5 below grade bottom of system above ground
water
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
<L�\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
284 Bradford street
Property Address
Clualter
Owner Owner's Name
information is
required for every North Andover
page. Cityfrown
MA 01886 September 22,2015
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
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Commonwealth of Ma,-�sachusetts
Ci ty/Town of North Andover RECEIVED
System Pumping Record
Form 4 OCT 2 0 2015
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other forrhWUyDWAfffWNlPut the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
T;lephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) C�/Septic Tank Ej Tight Tank [I Grease Trap
El Other (describe):
4. Effluent Tee Filter present? 0 Yes E] No
5. Condition of System:
_S,1em Pumped By:
If yes, was it cleaned? Fj Yes F'� No
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
i�g
EF7
__V CFft�
Signature of Recei Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
A. Facility Information
Important: When
filling out forms
on the computer,
1 System Location -
use only the tab
fcj
key to move your
Address
cursor - do not
North Andover
use the return
key.
------- --
City/Town State
Zip Code
2. System Owner:
Name
Address (if different from TFOC�t_io4__
CityfTown State
Zip Code
T;lephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) C�/Septic Tank Ej Tight Tank [I Grease Trap
El Other (describe):
4. Effluent Tee Filter present? 0 Yes E] No
5. Condition of System:
_S,1em Pumped By:
If yes, was it cleaned? Fj Yes F'� No
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
i�g
EF7
__V CFft�
Signature of Recei Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
NEW ENGLAND ENGINEERING SERVICES
INC
-66iL if/
Tq
June 18, 2004
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 0 1845
RE: TITLE V REPORT: RE: 284 Bradford Street, North Andover, MA
Dear Sir or Madam:
Enclosed is a copy of the Title V report for the above referenced property. The system PASSED
our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
0 "
Benjamin C. Osgooyr.
Certified Title 5 inspector
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
COMMONWEALTH OF MMSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRs
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OF NORTH ANDU 7R/
BOARD OF HEALTH
1 2
TITLE 5 1
'OFFICIAL INSPECTION FORM — NOT FOR VOAUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.FORM- J
PART A
CERTIFICATION
Property Address: 28 4 9Ri+ic> i-o%zD
0 0 P_ --11-f P, " -D C>0 0 (z
Owner's Name: jpc> to pv�__c> S -r 3 C -W
Ownees Address: 2aq 04ZPrD fbac) S -P
__M- A,,j Dc>.) ol _,4 ix,
Date of Inspection: 0,q1c>(4
Name of Inspector: (please print) -Ben-i amin C. Osgood, Jr.
CompanyName:New England Engineering Services Inc.
bUiling Address: 60 Beechwood Drive,
ljorth Andover, MA 01845
Telephone Number: 978-686-1768
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurateand 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 1530 of Title 5 (310 CMR 15.000� The system:.
ZPasses
Conditionally Passes
_Needs Further Evaluation by the Local Approving Authority
Faids
Inspector's Signature: tl Date: .6
I 2L(5
The system inspector shall submit a copy of this inspection to the Approving Authority 03oard 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.
Notes and Comments
****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.
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 284 BRADFORD STREET
Owner: NORTH ANDOVER, MA
Date of Inspection: DONALD ST. JEANE
6/9/04
Inspection Summary: Check ABCD or E ALWAYS complete all of Section D
A. . System Passes:
I have not found any information -which indicates that any of the fidlure criteria described in 3 10 CMR
15.303 or in 3 10 CMR 1.5.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
AID one or more system components as described in the -conditional passr sedlon need to be replaced I or
repaired- 1"he system. upon completion of the replacement or repair. as approved by the Board of Health, will pass.
Answer yes, no or not determined (YNND) in tile for- the following statements. If -not determined7 please
explain -
The septic tank is metal and over 20 years old* or the septic tank (whoher metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltrahon or tank failure is imm * inent, System will pass mspection if idle
existitig 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.
ND explain:
Observation of sewage backup or break out or high static water level in idie distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution bm System will paw inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more tim 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
obstruction is removed
ND explain:
Pagel of 11
OFFICIAL INSPECTION FORM - NOT FOR -VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
284 BRADFORD STREET
NORTH ANDOVER, MA
DONALD ST. JEANE
6/9/04
C_ Further Evaluation is Required by the Board of Health:
Conditions exist which require fin-ffier evaluation by the Board of Health in order to determine if the system
is failing to protect public he" safety or the environment
L System Will pow unless Board of Health determines in accordance with 310 CMR 15.303(l)(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 fed of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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 I (SAS) and I e SAS is wi 100 feet of a
Sys em h dim
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 I of a public water supply.
1he system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.,
VThe systemhas a septictank and SAS andthe SAS is lessthan 100 fed but 50 feet ormore from a
nvaie water supply well** - Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that fitcility and,
the presence of ammonia nitrogen and nitrate nitrogen is equal toor less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
I Other:
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address; 284 BRADFORD STREET
NORTH ANDOVER, MA
Owner: DONALD ST. JEANE
Date of Inspection- 6/9/04
D. System Failure Criteria applicable to all systems:
You must indicate -yes" or -no!' to each of the following for jU inspections:
Yes No
Badcup 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 cesslml
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_!!L- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/, day flow
-i::f Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
-1Z Any Portion Of the SAS, cesspool or privy is below high ground water elevation.
-.Ef�-AAY POrtiOn Of cesspool of privy is within 100 fed of a surface water supply or tributary to a surface
water supply.
Any portion of a emspool or privy is within a Zone I 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 am 100 feet but greater than 50 fed from a private water
supply well with no acceptable water quality analysis. rMis system passes if the well water analysis,
performed at a DEP certified laboratory, for colfform bacteria and volatile organic compounds
indicates that the Well is free from Pollution from that facility 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 fornq
(YOSINO) The system kL& I have dde - rmined that one or more of the above failure criteria exist as
described in 3 10 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. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to V�000
gpd.
You m dicate either "yes" or "noP to each of the following:
( . The followin -teria =apply to large systems in addition to the crit ve)
yes no.
the system is within 400 offf a surface
ce g =water supply
the system is within 200 feed o b
in t 0 u surfacme drinking water supply
the system is locat i a nitrogen sensitive area (Int thead Protection Area - IWPA) or a mapped
Zonellofa ic water supply well itive area (In
If You have answered "yes" to any question in Section E the system is considered a significant threat, or answered
4cyes7? 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 3 10 CUR
15-304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _
Owner:
Date of Inspection:
284 BRADFORD STREET
NORTH ANDOVER, MA
DONALD ST. JEANE
6/9/04
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
V"' Has the system received normal flows in the pr evious two week period ?
—iZHave large volumes of water been introduced to the system recently or as part of this inspection 7
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 9
Was the site inspected for signs of break out ?
z— Were all system components, excluding the SAS, located on site 7
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 of liquid, depth of sludge and depth of scum 7
. Z� Was the factlity 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 tile site has been determined based on:
Yes no
xisting information. For example, a plan at the Board of Health.
etermined 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(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'Property Address: 284 BRADFORD STREET
NORTH ANDOVER, MA
Owner: DONALD ST. JEANE
Date of Inspection: 6/9/04
FLOWCONDITIONS
RESEDFIf MAL
Number of bedrooms (design): — Nunber of bedrooms (actual): �
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd. x #of bedrooms): 4�
Number of current residents: ;-2—'
Does residence have a garbage grinder (yes or no): A/0
Is laundry on a separate sewage system (yes or no): AIL? [if yes separate inspection requiredl
Laundry system ins�ected (yes or no): —
Seasonal use: (yes or no)+ Al 0
Water meter readings, if a��diable (last 2 years usage (gpd)):
Sump pump Cyes or no):
IAA_4kte d1[occWanW.__.L-
COMN[ERCL&IJINDUSTRUL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): ____gpd
Basis of design flow (seats/persons1sqketc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTIIER (describe):
Pumping Records GENERAL INFORMATION
Source of information: Pj11vjf-C-,,9
Was system pumped as part of the inspection (yes or no): Aj 0
If yes, volume pumped: ----Pllons — How was quantity pumped deternkined?
Reason for pumping:
TYP
.,E OF SYS17EM
Septic tanL distribution box, soil absorption system
Si�gle 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)
—Tighttank Attach a copy of the DEP approval
— Other (describe):
Approximate age of all components, date installed (if known) and source of information:
V ju ji, tj
Were sewage odors detected when arriving at the site (yes or no): So
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 284 BRADFORD STREET
NORTH ANDOVER, MA
O"er: DONALD ST. JEANE
Date of Impection: 6/9/04
11UHMING SEWER Gocate on site plan)
Depth below grade: 07 6)
Macrials of construction: ic%st iron 40 PVC other (explain)-.
Distance from private water supply well or suction line
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
--,/2, R,17- 4-0 D 6- -C-� 6 0 7 /,.j 13A:sl�
SEMC TANIQ _ (locate on site plan)
Depth below grade:
Material of construction: -<m-crete metal __fiberglass
- other(explain)_
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions: 67 a 0 &-A4" )v
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How were dimensions determined:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
AJ X &J &Z?<;� !-
co 0 D 4 r r,,
/ /U 5,d,�FC T� 6 Aw
GRFASF TRAP: Ayl�ocate on site plan)
Depth below grade:
Material of construction: —concrete metal __Aberglass
(explain): __polyethylene __other
Dimensions:
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:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _
Owner:
Date of Inspectiow.,
284 BRADFORD STREET
NORTH ANDOVER, MA
DONALD ST. JEANE
6/9/04
TIGUr or RoLmNG TANK.. Lbank must be Pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction. concrete metal —fiberglass -polyethylene —_qffier(explain):
Dimensions:
CaPach), --J�allons
Design Flow-.
Alarm present (yes or no):
Alarm level: Alum in working order (yes or no):
Date of last pumping: _
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: _ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert e—)
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.):
PUM CRAMER: Vl� (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances , etc
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 284 BRADFORD STREET
NORTH ANDOVER, MA
Owner: DONALD ST. JEANE
Date of Inspection.: 6/9/04
SOIL ABSORMON SYSTEM (SAS): _ (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:
leaching ies, number:
leaching trenches, number, length:
—='-leaching fields, number, dimensions: p--) IS' "' 'y 40
overflow cesspool, number:
innovativetalternative system Typetname of technologr.
t�=-ents (note condition of soil, signs of hydraulic failure, level Of p0nding, damp soil, condition of vegetation,
etc.):
Al2
15- 65 /Z VAJuL,AC, V70 Aj-,
CLWOOIS: 0' (cesSP001 must be Pumped as Part of inspectionkocate, on site plan)
Number and configuration:
Depth - top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic fitilure, level of ponding, condition of vegetation, etc.):
PRIVY:Aj(locateonsite plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
P-2 ge 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address -
Owner:
Date of Inspection
284 BRADFORD STREET
NORTH ANDOVER, MA
DONALD ST. JEANE
6/9/04
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage, disposal systeni including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells wiffiin 100 feet. Locate where public water supply enters the building.
Page It of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 284 BRADFORD STREET
NORTH ANDovER, mA
Owner: DONALD ST. JEANE
Date of Inspection: ____�/9/Q4
SMEXAM
Slope q 79
Surfitce water A10 A.157
Checkcellar
Shallow wells
Estimated depth to ground water H feet
Please indicate (check) all mediods used to determine the high ground water elevation:
Obtained from system design plans on record - If chocked, date of design plan reviewed:
y Observed site (ahitting property/obswitation hole within 150 fed of SAS)
- Chocked with local Board of 11calth-explain:
- Checked with local excavators, installers- (aftch documentation)
—*—Accessed USGS database -explain: '
You must describe how you established the high ground water elevation:
V51" 1 - S> % C 1�7 G. C-11,
Ae ow %�- 1= . L)2
(L
L-,
5; STC
COMMONWEALTH OF MASSACHUSETTS
ExEcunvE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONME�47t—AV`!�� "
St?,JIMUCTION
1�1 Ay 2 1
L, -
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 2e� GeAc>y:�,aa ��
A), A�upn6o/z "/9-
Owner'sName: r?aAqa"-�,
Owner's Address: ;Z p q tZ-, R Ay i:i�:, rz t5m,
Date of Inspection: 4ig-1 o
Name of Inspector: (please print) e PA� C C—C. r�
Company Name: NC --vi Q4 C, L4,- t� G--�, r -2F r. -,m C,
Mailing Address: --& e> J&C--e C j -e w oo j> 1> 17.
A ) - A-tj E> t), -, M A4,q 6i -q q -S' -
Telephone Number: T7k- 686—/-268
CERTIFICATION STATEMENT
I 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 fimction and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15-W of Tide 5 (310 CMR 15.000� 1he system:
V-lPasses.
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
ne system inspector shall submit a copy of this Os�ection 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
DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****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 w perform in the future der the me or erent
conditions of use. ill un sa diff
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Z24
A (L
Owner: 0-/U4L-0
Date of Inspection: )?-IQ I
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
_ZI have not found any information which indicates that any of the failure criteria described in 3 10 CMR
15.303 or in 3 10 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 repla
--77 d7d:
repairb� 1he system, upon completion of the replacement or repair, as approved by the Board of Heal V �pass.
Answer yes, no' not determined (YNND) in the for the following statements. If "not d ed" please
explain. %
jj1he septic tank is etal and over 20 years old* or the septic tank (whether m or not) is structurally
unsound, exhibits substantia * filtration or exfiltration or tank failure is immin . System will pass inspection if the
L Z
39a d(
existing tank is replaced with a plying septic tank as approved by the B of Health.
*A metal septic tank will pass mi ion if it is structurally sound, not I g and if a Certificate of Compliance
z
indicating that the tank is less tffitwn 20 s old ii available.
ND explain:
Observation of sewage backup or break o gh static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uP distribution box. System will pass inspection if (with
approval of Board of Health):
0 pipe(s) are r cod
,ard o ction is removed
g
d,h static'
'str*buti'
:e.a e(s) are ep ced
0 pip r
ct n 0 v
d strib on s e eled
i ut�
'ffi)X
distribution box is leveled replaced
ND explain:
The vyste% uired pumping more �than 4 times a due to brok or obstructed pipe(s). The system will
I ft f year
t
pass inspection with approval of the Board of Heal h
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Z84
A) o izn-e A -^j c> o og�7� -m
Owner: De, A3 At -r'> e- T- Aj
Date of ection: 612-1 .1
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require ftuther evaluation by the Board of Health in order to determine if the system
is failm to protect public health, safety or the environment.
1. Syste will pass unless Board of Health determines in accordance with 310 CMR 15.3 , 03(l)(b) that the
system not functioning in a manner which will protect public health, safety and the enylironment:
Cesspoo r privy is within 50 feet of a surface water
Cesspool o is within 50 feet of a bordering vegetated wetland or a salfmarsh
2. System will fail unless the B d of Health (and Pabl.ic WaterSupplier, if any) determines that the
system is functioning in a mann Ir t t protects the public hea�tl�, safety and environment:
The system has aseptic tank and il absorption system (SAS) and the SAS is within 100 feet of a
i�Race water supply or tributary to a sur water supply.
The system has a septic tank and SAS an / e/SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS
/rAd the S"�kS is within 50 feet of a private water supply well.
The system has a septic tank andXAS and the SAS is\lqss than 100 feet but 50 feet or more from a
private water supply well". Meth/o&used to determine disw*
"This system passes if the well water analysis, performed at a D certified laboratory, for coliform
is Ij
bacteria and volatile organ compounds indicates that the we Nfreeom pollution from that fiLcifity sad
the presence of anmumnon' itrogen and nitrate nitrogen is equal to or less 5 ppm, provided that no other
rm
failure criteria are tri ered. A copy of the analysis must be attached to this
3.
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: -Z S 4 G (z f�s> f �6 9- p s; -F,
Al Q A-) P C> 0 (F fZ- M A
Owner: 0 0 ^-) L -D -CI-7- J-0
Date of Inspection: c;-))Zj01
i U
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
V- Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of cffluent 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
V' Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
— _U/ Any portion of the SAS, cesspool or privy is below high ground water elevation.
— V Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
I/ Any portion of a cesspool or privy is within a Zone I of a public well.
V Any portion of a cesspool or privy is within 50 feet of a private water supply well.
v ' 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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.]
AID (Yes/No) The system fails. I have determ'ined that one or more of the above failure criteria exist as
described in 3 10 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. arge Systems:
To be c ered a large system the system must serve a facility with a design flow of I 000-6d to 15,000
c
ered a lar e system th system mus 0
gpd.
0�� " to
You must indicate ei es" or "no" to ea�d�iof tthe following:
(The following cniteria app e systems in addition to7the criteria a
:M
yes no.
j
the system is within 400 feet of a s dri i water supply
the system is within 200 7feet of a t,,*bdfiLry to a ce drinking water supply
the system is located in -a nitrogen sensitive area (Interim 1head Protection Area - IWPA) or a mapped
Zone 11 of a pubtic-ikm'ter supply well
If you have answef�d "yes" to any question in Section E the system is considered ai'kigi�ificant threat or answered
"yes" in Sec(ion D above the large system has failed. The owner or operator of any large's3��t considered a
significant threat under Section E or failed under Section D shall upgrade the system in accwtance with 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: eZA tj Oefts�' r--0 go
- /'J' A") PQ
Owner: -ST- 3-6711.1v
Date of Inspection:
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 ?
Was the site inspected for signs of break out ?
-Z — 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
;f—thJ�-ffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
—Z— Was the facility owner (and occupant� if different from owner) provided with information on the proper
maintenance of subsurfitee sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no
— �;� Existing information. For example, a plan at the Board of Health.
— V"' Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2 9 1-1 J�, a4p r -b V -r-> Sm
Aj. Atr>ep��otz
Owner: .120 AIAL-1) t-, 7- J -&7-,4,y
Date of pection: �->j 1-2 1.1-1
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms):
Number of current residents: Z
Does residence have a garbage grinder (yes or no): A)o
Is laundry on a separate sewage system (yes or no): A � u
A ) [if yes separate inspection req ired]
Laundry system inspected (yes or no): -
Seasonal use: (yes or no): No
Water meter readings, if available Oast 2 years usage (gpd)):
Sump pump (yes or no): Cc -
Last date of occupancy: 71 -
COAIMERCIAL/INDUSTRUL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gpd
Basis of design flow (seats/persons/sqf4etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (ves or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: f --A- k-�
Was system pumped as part of the inspection (yes or no): ALO
If yes, volume pumped: _____gallons - How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
?Q 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)
InnovativetAlternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
— Tight tank _ Attach a copy of the DEP approval
— Other (describe):
Approximate age of all components, date installed (if known) and source of information:
0 " 14- 1'et -f I
Were sewage odors detected when arriving at the site (yes or no):.AZO
4
sums
Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 0B 4 r- a r -ID a -D 57n
" - p 0')kF'9- AAA
Owner: yc>,-4t-9
Date of Inspection:
BUELDING SEWER (locate on site plan)
Depth below grade:
Materials of construction: —cast iron v/'40 PVC other (explain):
Distance from private water supply well or suction line: 121,4
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
.F -i PE 'Looldc-5 c, I J- (&j e. 19S C-- '-.14 C- ^j —)
SEPTIC TANK: _ (locate on site plan)
Depth below grade: 12""
Material of construction: v -concrete _jnetal _fiberglass __polyethylene
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions: /c, inoc�
Sludge depth: / I d
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 41 "
Distance from top of scum to top of outlet tee or baffle: 8 4E
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: 44Epsofec.- .577c K
Comments (on pumping recommendations, inlet- and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, efc.):
11+x) is, 1^J nA 0 0 NC fz r- =j- 911'�r-r--Lex 1,0 T-'IC-7� iz t�-C-
i �- ', r-PrL-L-ATN0^, &Cee k 0 ?Ile '7&L— 6 ^ n --r LL --r- P , "'> C�-
GREASE TRAP: AAocate on site plan)
Depth below grade: _
Material of construction: —concrete ___!netal fiberglass other
(explain): ___.polyethylene
Dimensions:
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:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
I
Page8 ofll
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
4;
Property Address: 2,F?H 9gA1?j:::0gQ 5-:-11
/J - /N A4 04
Owner: -C-T
Date of Inspection:
TIGHT or HOLDING TANK: N)+ (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: —concrete —metal fiberglass ____polyethylene other(explain):
Dimensions:
Capacity: ---____gallons
Design Flow: __gallonstday
Alarm present (yes or no):'_
Alarm level: Alarm in working order Cyes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: _ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 11�) c
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.):
13 Z, 2, Olk CZ) e-4 P. Atz Eo) p
0 'A 11 Al 6 C- -(tk 3 y4t-
PUMP CHAAMER.-AA (locate on site plan)
Pumps in working order Cyes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ZE?L-t e2 ao-c> r-6.1 g -j-)
/Ij- Ar tJ > e-4- —
Owner: Oo,�jA-,�c> A/
Date of Inspection: g;jItlo,
SOEL ABSORPTION SYSTEM (SAS): _ (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
:Zleaching fields, number, dimensions: ;30 x ItIo
overflow cesspool, number:
innovativelaltcmative system Typetname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
A'n� a r= AI L:F-1-0 L-00 K 5. Q
CESSPOOLS:Q- (cesspool must be pumped as part of inspectionXIocate on site plan)
Number and configuration:
Depth - top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY./]M- (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.):
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ZSLA r--ppq>
/V. Ao D o,)ae
Owner: 4(, P 5iTJ-6-AAJ
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
- 4
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: zt-3!j
?-,jLaj> r-bizo 5:-,7
--AA
40 Pc> J6 f7 -
Owner: 'VO A.) A a- 9
5,T0-6'AAJ
Date of pection: �g�-j I-& 1 0
SITE EXAM
Slope q 04
Surface water POA�e
Check cellar 5 "S' rh r
Shallow wells ^1C, " e
Estimated depth to ground water 9 feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high grorA water elevation:
loz>44ib,
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I h by make application for a permit for a sewage disposal installation at
ve .
0� &JR- 1 will install this system in ac-
cordance with all the laiks of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. 1 will install a con-
crete septic tank of / J�� in size. A manhole (s) permitting easy cleaning
will be provided with� removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of /I &� d lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel, or crushed stone ranging
in size fro ' m 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/81, to 1/41, (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be.Maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
Ifurther agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE &' - / 4-/- -7 /
I hereby issue the above permit for
Andover, Massachusetts.
DATE 7
ure off/ADrlicant
Board of Health of the Town of North
6;��L Agent
I have inspe ted the uncovered system indicated above and find everything done
as described
/7
DAT 1171
ILS�
V e-ze
'nignature of Inlic tiiig Officer
Percolation Test
Garbage Grinder
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BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
..........
Ct4 L TA' sJ
lel
1 6- t (
41
�5-01 / ? I
1.
NAME ;q RC o
R -P -
DATE.
2.
ADDRESS L f
PAj) r 0 p-
's LOT NO. TEL.
3.
NO. OF BEDROOMS,
DEN YES NO
4.
GARBAGE GRINDER
YES
NO Z--
5. SHOW DIMENSIONS OF HOUSE /-
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 4—
?. SHOW DIMENSIONS OF LOT c--
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOLZ--
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM IV -n rx,,4//
j
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. lValue
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
�n
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE
NAME OF APPLICANT Raron Corporatinn
LOCATION Lgt #1 Bradford St.
Address of lot no.
BUILDING: Dwelling X -Other
SYSTEM: New X- Repair
GENERAL DESCRIPTION OF LAND_ laigh
SUBSOIL: Clay -
&, Gravel Sand
PERCOLATION TEST 12 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK.1,000 -gallon capacity.
LEACH FIELD 18Q -lineal feet of drain pipe.
aililiam J. D 1, Engineer
Board of Heal
SEPTIC SYSTEM INSPECTION FORM
--Z <K4
ADDRESS
DATE INSPECTED.
PROPERLY FUNCTIONING? N
WEATHER CONDITIONS
COMMENTS:
WATiEk OVALITY TESTE-b'Z- lZe!&0L-TS-?
'DYE TEST PERFORMED? Y V
DATE?
SKETCH:
Insurance Adjustment Service** Inc.
435 K�ng Street - Second Floor
bittleton, MA 01460
978-952-6966 - Fax 978-952-2459
Email: iashtfleton@netlplus.com
Date: -
Board of Health: 4,4,4&4,t
Building Inspector:
Fire Department:
Re,: Insured: Sf
Location:
Claim Number: 2e
Policy Number:
Our File Number:
Cause of Loss:—i,)e,-&,
Date of Loss:
Dear Sir/Madam:
A claim has been made involving loss, damage or destruction of the above
captioned property which may either exceed $1,000 or cause Massachusetts
General Laws, Chapter 143, Section 6 to be applied.
If any notice under Massachusetts I General Laws, Chapter 139, Section 3B is
appropriate, please direct that information to my attention and include a
reference to the captioned insured, location, date of loss and file number.
Thank you for your cooperation.
Very truly yours,
Scott O'Neil
Adjuster
Al C)T-
ow
Ext. 129
a-1
DEC 2 7 2ool
EO
WATERSHED RESIDENTS QUESTIONNAIRE
1. Nam
2. StreetAddress
3. How many members are in your household?
4.
What type of sewage disposal system do you have?
F-1 cesspool
septic tank and leaching area
connection to municipal sewer
El other (describe)
El do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health?
E yes E no E3 do not know
6. How old is your sewage disposal system? El 0-5 years El 6-10 years Er 11-20 years
El over 20 years F-1 do not know
7. Has your se e disposal system been rebuilt or repaired?
0 yes W; no F� do not know
If yes, approximately how long ago?
years. What was done?
8. How frequently is your sewage disposal system pumped out? El annually
Y every 2-4 years 0 every 5-10 years El over 10 years El never
9. Have you had any problems with your sewage disposal system? El yes F� no
If yes, what problems?
El repeated pump -outs needed
El system clogs, backs up, or drains slowly
7 odors
El sewage surfaces through ground
10. How many of each appliance are connected to your sewage disposal system?
washing machine V dishwasher garbage disposal
dehumidifier drain — sump pump toilet
roof/pavement drains — shower/bathtub
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher '�I) � ', -' - j) 1�
clotheswasher U,) )
12. Does your property have a lawn? yes no
If yes, approximately what size?
El less than 1/4 acre El 1/4 acre 1/2 acre El 3/4 acre 0 1 acre
F-1 more than 1 acre (Specify) — acres
13. How often do you fertilize your lawn?
No. of applications per year
Season(s) of the year
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
Check here if your lawn is maintained by a professional landscape contractor.
6
�Nh
Town of Nort]j Andover, KA,
watershed SsRtic syste
servicinq ReRort
Date: i2
Homeowner: ��Y? 4�2d/o 6.(4
Street :,QC0_0
Phone Oo Ando veA
Pumper : Stewart's Septic Tank Svc.
Address: 47 Railroad St., Bradford
Phone 508-372-7471
Nature of Service: Routine knme 6ale-
Emergency
Observations: Good Condition aLjph�
Full to Cover 06 rm..Ize
Baffles in Place It7*1C4
Leachfield Runback ob�."O"Pkz"I, 140
Excessive Solids—
Heavy Grease
Roots
Other (Explain)
15jze_ j000 oalleya
Description 6f -Work:
Ptmp septic tank a. -A 6VI 0 on e
Comments:
This is not a septic certification-.Shouid not be used to provide at closings.
That is an additional fee.
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