HomeMy WebLinkAboutMiscellaneous - 285 RALEIGH TAVERN LANE 4/30/2018.1. . I I \--,
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North Andover Board of Assessors Public Access
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'romm of Moyth AnAdk>ver
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Pagib I of*"
lawX Property
14 Record Card
Parcel ID: 210/106.C-0118-0000.0 Community: North Andover
SKETCH PHOTO
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285 RALEIGH TAVERN LANE
Location: 285 RALEIGH TAVERN LANE
Owner Name: POLVERARI, PAUL G
BETTY C POLVERARI
Owner Address: 285 RALEIGH TAVERN LANE
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 7 - 7 Land Area: 1.01 acres
Use Code: 101 - SNGL-FAM-RES Total Finished Area: 3171 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 569,800 595,000
Building Value: 345,000 358,400
Land Value: 224,800 236,600
Market Land Value: 224,800
Chapter Land Value: I
LATESTSALE
Sale Price: 305,000 Sale Date: 08/04/1992
Arms Length Sale Code: Y -YES -VALID Grantor: HOWARD, JAMES
Cert Doc: Book:03518 Page: 0161
http://csc-ma.usNandoverPubAcc/jsp/Homejsp?Page=3&LinkId=1 181617 5/l/2008
as"N Commonwealth of Massachusetts
City/Town of NORTH ANDOVE
R, MASSACHUSLETT
System Pu 'ping Record
m
Form 4
Important:
When filling out
forms on the
.computer, use
only the tab key
to move your
cursor - do not
use the return
key.
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
1 - System Location:
Address
City[Town
2. System Owner:
Name
muuress kiT airrer klffUIVED
City/Town
An
MAY 11 2006
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
ping Record
1. Date of Pumping
Type of system: 11
El Other (describe):
I,/)"- -
State Yip Code
— 54�e_
L
State Zip Code
g F 7-?- � �� /- -7- --
Telephone Number
2. Quantity Pumped
Cesspool(s) xSeptic Tank
. X < 'e-1, -)
t;allons
El Tight Tank
4. Effluent Tee Filter present? D Yes 56NO If yes, was it cleaned? [I Yes F-1 No
5. Condition of System:
mped B
6.,Sys ;�mPu
Name Vehicle License Number
(3). /"- .. 4y
Company
7. Location where contents were disposed:
er Date
f
ppro
hftp://www.mass.gov/dep/water 7avals/t5for
t5form4.doc- 06/03
System Pumping Record - Page 1 of I
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
6 1 ,
2 /, I
xf/46
SYSTEM LOCATION
(example: left front of house)
P c /-1
DATE OF PUMPING: QUANTITY PUMPED GALLONS
CESSPOOL: NO YES
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
SEPTIC TANK: NO YES
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
Commonwealth of Massachusetts
Title 5 Official Inspection Form -14
Form Not for Voluntary Assessments
Subsurface Sewage Disposal System
285 RaIeiqh Tavern Lane
i5mpe�Address
Paul Polverari
Owner ov;ners_Name
information is Nla. 01845 3-29-08
required for North Andover
State Zip Code Date of Inspection
every page.
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out
forms on the
computer, use I Inspector:
only the tab key
t,o move your N. Timothv White-.-, ........ -------- - -----
a
of 1��
s 'i��
cursor - do not or
use the return
key. HomePro Northshore
Company Name
75 Glen Street
Company Address MA 01969
Rowl
-t- __ ____ - __ .1 - Z,ip Code
Cityrrown f, ate
(��8 __g48-8428 S12015
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate arid 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:
�Pass�es Cond tionally Passes Fails
Needs Further Evaluation by the Local Aipproving Authority
At - —, - __.- -
A-\
3729-08
inspector's Signature Date
The system inspector shall submit a copy of Lhis inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completilIg 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 applic.3bie, 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 add ress how the system will perform in the future under
the same or different conditions of use�
Title V Form - 1 ?J07 litin 5 offifial hvectlon rami: sljbsurla� Sewige lfill)Osal SYMM - R-1110 I Of i!�
I -d di't,:ao 60 Ba jolu
FEA
. ----E!P�ZLEECFE�j
VED��
HEALTH
MENT
VtORT" 3247
0
Town of North Andover
HEALTH DEPARTMENT
emu
CHECK#: DATE:
LOCATION:
H/O NAME:.
CONTRACTOR NAME:
Type
of Permit or License: (Check box)
•
Animal
$
•
Body Art Establishment
$
•
Body Art Practitioner
$
0
Dumpster
$
•
Food Service - Type.
$
•
Funeral Directors
$
•
Massage Establishment
$
0
Massage Practice
$
•
Offal (Septic) Hauler
$
•
Recreational Camp
$
0
Sun tanning
$
0
Swimming Pool
$
11
Tobacco
$
0
Trash/Solid Waste Hauler
$_
0
Well Construction
$
SEP77C Systems
•
Septic - Soil Testing
$
•
Septic -Design Approval
$_
0
Septic Disposal Works Construction (DWC)
$
0 Septic Disposal Works Installers (DW[) $
0 Title,5 Inspector $
R",�
Title 5 Report
0 Other. (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer I
2 6 4
Town of North Andover
HEALTH DEPARTMENT
4CHU
CHECK DATE:
LOCATION:
H/O NAME;
CONTRACTOR
Type
of Permit or License: (Check box)
•
Animal
$
•
Body Art Establishment
$
•
Body Art Practitioner
$
0
Dumpster
$
•
Food Service - Type.-
$
•
Funeral Directors
$
•
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
-'$
1i
Recreational Camp
$
•
Sun tanning
$
•
Swimming Pool
$
•
Tobacco
$
•
TrashlSolid Waste Hauler
$-
•
Well Construction
$
SEPTIC Sustems:
• Septic - Soil Testing $
• Septic - Design Approva I
0 Septic Disposal Works Construction (DWC) $
0 Septic Disposal Works Installers (DM) $
0 Title 5 Inspector $
3--T�itle 5 Report $1 Iola
07
5e
0 Other (Indicate)
Health Agent Initials
White - Applicant . Yellow - Health Pink - Treasurer
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
A/2
Commonwealth of Massachusetts
Title 5 Official Inspection ONWEIVED
Subsurface Sewage Disposal System Form - Not for Volu tary Assessments
285 Raleiah Tavern Lane r APR 0 7 2008
Property Address
TOWN OF NORTH ANDOVER
Paul Polverari I HEALTH DEPARTMENT I
Owners Name
North Andover
Cityrrown
Ma. 01845
State Zip Code
3-29-08
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information
1. Inspector:
N. Timothy White
Name of Inspector
HomePro Northshore
Company Name
75 Glen Street
Company Address
Rowley
Cityrrown
(978) 948-8428
Telephone Number
B. Certification
MA
State
S12015
License Number
01969
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 6 (310 CMR 15.000). The system:
0 Passes El Conditionally Passes M Fails
F� Needs Further Evaluation by the Local Approving Authority
Inspectors Signature
3-29-08
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 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.
Title V Form - 12107 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 15
Commonwealth of M.assa6husetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Paul Polverad
Owner Owners Name
information is North Andover Ma. 01845
required for
every page. Cityrrown State Zip Code
B. Certification (cont.)
3-29-08
Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
Z 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:
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.
Answer yes, no or not determined (Y, N, ND) in the n for the following statements. If "not
determined," please explain.
F] 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.
ND Explain:
na
F1 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
R obstruction is removed
Tale V Form - 12/07 Trde 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 15
Owner
information is
required for
every page.
Commonwealth of M.assa6husetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Paul Polverari
Owner's Name
North Andover
Cityrrown
B. Certification (cont.)
B) System Conditionally Passes (cont.):
Ma. 01845 3-29-08
State Zip Code Date of Inspection
n distribution box is leveled or replaced
ND Explain:
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):
El broken pipe(s) are replaced
F1 obstruction is removed
ND Explain:
na
C) Further Evaluation is Required by the Board of Health:
El 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(i)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
Ej 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
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:
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.
[:1 The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
Title V Form - 12107 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Paul Polverari
Owner Owner's Name
information is
required for North Andover Ma. 01845
every page. Cityrrown State Zip Code
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
3-29-08
Date of Inspection
F1 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 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:
na
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
0
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
E]
0
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
E]
M
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El
0
Liquid depth in cesspool is less than 6" below invert or available volume is less
than % day flow
El
0
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
E]
0
Any portion of the SAS, cesspool or privy is below high ground water elevation.
EJ
0
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Title V Form - 12/07
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 15
I <Ll\ Commo�wealth of Massachusetts
Q Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
P.qtjl PnIverari
Owner Owners Name
information is
required for North Andover Ma. 01845
every page. Cityfrown State Zip Code
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
3-29-08
Date of Inspection
E] 0 Any portion of a cesspool or privy is within a Zone 1 of a public well.
E] Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El 0 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 6 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
El Z The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000gpd.
El E The system falls. 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
El n the system is within 400 feet of a surface drinking water supply
El 1:1 the system is within 200 feet of a tributary to a surface drinking water supply
El 1:1 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.
Title V Form - 12107 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Paul Polverari
Owners Name
North Andover
Cityrrown
C. Checklist
RA -
01845 3-29-08
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 F1 Pumping information was provided by the owner, occupant, or Board of Health
[:1 Z Were any of the system components pumped out in the previous two weeks?
Z Ej 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?
El Z Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
ED El Was the facility or dwelling inspected for signs of sewage back up?
Z E] Was the site inspected for signs of break out?
0 Were all system components, excluding the SAS, located on site?
Z El 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?
Z El 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:
E] Z 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)]
Title V Form - 12107 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 15
Owner
information is
required for
every page.
Commonwealth of Malssachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Prop" Address
Paul Polverari
Owners Name
North Andover
CityrFown
D. System Information
State
01845
Zip Code
3-29-08
Date of Inspection
Residential Flow Conditions:
Number of bedrooms (design): na Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? [if yes separate inspection required]
Laundry system inspected?
Seasonaluse?
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump?
Last date of occupancy:
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use:
Other (describe):
Gallons per day (gpd)
Date
na
2
D Yes
E
No
El Yes
E
No
El Yes
E
No
El Yes
E
No
06 & 07 52500
gal =71gpd
El Yes
0
No
still occupied
Date
El
Yes
E]
No
El
Yes
Ej
No
El
Yes
[:)
No
Title V Form - 12/07 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 15
Commo6wealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Paul Polverari
Owner
Owners Name
information is
North Andover Ma.
required for
every page.
Cityrrown State
D. System Information (cont.)
Pumping Records:
Source of information:
01845 3-29-08
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
gallons
Date of Inspection
7019��
Type of System:
z Septic tank, distribution box, soil absorption system
El Single cesspool
11 Overflow cesspool
El Privy
El 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)
Tight tank. Attach a copy of the DEP approval.
El Other (describe):
Approximate age of all components, date installed (if known) and source of information:
20 vears old Information from owner
Were sewage odors detected when arriving at the site?
F1 Yes 0 No
Title V Form - 12107 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 15
Commo6wealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Paul Polverari
Owner Owner's Name
information is North Andover Ma. 01845 3-29-08
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.)
Building Sewer (locate on site plan):
20in
Depth below grade: feet
Material of construction:
E cast iron El 40 PVC E] other (explain):
Distance from private water supply well or suction line: town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
joints & venting good condition no evidence of leakage
Septic Tank (locate on site plan):
14in
Depth below grade: feet
Material of construction:
E concrete E] metal El fiberglass El polyethylene other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No
---------------------------------------------------------------------------------------------------------------------------
Dimensions: 1 Oft long - 60in deep 60in wide
1500 gal
Sludge depth: 4in
Distance from top of sludge to bottom of outlet tee or baffle 36in
Scum thickness 2in
Distance from top of scum to top of outlet tee or baffle 7in
Distance from bottom of scum to bottom of outlet tee or baffle 1 Oin
How were dimensions determined? measuring rod & tape measure
Title V Form - 12107 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 15
Owner
information is
required for
every page.
Commonwealth of Massa6husetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Paul Polverari
Owners Name
North Andover Ma. 01845 3-29-08
Cityrrown 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.):
Tank does not need to be pumped - inlet tee - outlet tee good condition - liquid at bottom of outlet
invert - no sign of leakage in or out of tank
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
El concrete EJ metal
Dimensions:
Scum thickness
feet
El fiberglass El polyethylene E] 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: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
na
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal El fiberglass
El polyethylene E] other (explain):
Title V Form - 12/07 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 15
<L"., Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Paul Polverari
Owner
information is
required for
every page.
Owners Name
North Andover Ma. 01845
Cityrrown State Zip Code
D. System Information (cont.)
3-29-08
Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
dry rockey gravel - no hydraulic failure - no ponding - system was under back lawn - leach pit was 26
in below grade 8ft long 29in deep 5ft wide 1 in liquid a little sludge 2in
Tide V Form - 12107 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 15
Soil Absorption
System (SAS) (locate on site plan, excavation not required):
If SAS not
located, explain why:
Type:
z
leaching pits
number: 1 leach pit
El
leaching chambers
number:
El
leaching galleries
number:
leaching trenches
number, length:
leaching fields
number, dimensions:
overflow cesspool
number:
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
dry rockey gravel - no hydraulic failure - no ponding - system was under back lawn - leach pit was 26
in below grade 8ft long 29in deep 5ft wide 1 in liquid a little sludge 2in
Tide V Form - 12107 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Paul Polverari
Owner Owners Name
information is North Andover Ma. 01845 3-29-08
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.)
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 E] No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
na
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.):
Title V Form - 12107 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 15
Commonwealth of Massachusetts
'Y"itle 5 Official Inspection Form
71 Not for Voluntary Assessments
Subsurface Sewage Disposal System Fonn
VII. ')Or, D�Iexinh Tnuckm I nnp
01845 3-29-08
Zip Code Date of Inspection
D. System Information (cont.)
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
J
'43 3
T - Page 14 of 15
Title V Form - 12107 Itle 5 Official Impectim Fow. Sowrtace Sewage Disposal System
i-ropervy tAuwubb
Paul Polverari
Owner
Owner's Name
information is
North Andover Ma.
required for
State
every page-
Cityrrown
01845 3-29-08
Zip Code Date of Inspection
D. System Information (cont.)
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
J
'43 3
T - Page 14 of 15
Title V Form - 12107 Itle 5 Official Impectim Fow. Sowrtace Sewage Disposal System
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Paul Polverari
Owner Owners Name
information is
required for North Andover Ma. 01845
every page. City/Town State Zip Code
D. System Information (cont.)
Site Exam:
F1
Check Slope
Surface water
Check cellar
Shallow wells
3-29-08
Date of Inspection
Estimated depth to high ground water: 8ft
feet
Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record
I
if checked, date of design plan reviewed: Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
n Checked with local excavators, installers - (attach documentation)
F1 Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
from closest house at same elevation 99 Raleigh Tavern Lane groundwater at 100 in eshgw at 94in
Title V Form - 12/07 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 15