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Home My WebLink AboutMiscellaneous - 693 JOHNSON STREET 4/30/2018 I i A J I 1 r I, i i 1 i 1 i 1 t �i i - '1S Plosrq tio-c q b I n MORTq 6813 ~:•:. + `•• LID Town of North Andover ' '•�;,;;:: HEALTH DEPARTMENT ,SSACHU`�tt CHECK#: J499 DATE-SwIld LOCATION: b 0?-)J�h H/O NAME: j;6Pb U CONTRACTOR NAME: Jhlymb Type of Permit or License: (Check box) 0 Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $� ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer FILE# NA n d 5.2 ( 14 REC -6 MAY 19 2014 TITLE V INSPECTION TOWN HEALTH Mt�t� 19�r€� HE,QLTH t��ijF/jam Dean G. Luscomb H & Sons P.O. Box 135 Middleton, MA 01949 978-774-4065 Licensed Plumber # 20285 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNERS NAME PROPERTY ADDRESS 9 N) N111 DATE OF INSPECTION V cX �, C) 14 NAME OF INSPECTOR -u- QUALITY IS NUMBER ONE TO US • N. Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 693 Johnson St. Property Address Gaffn Owner Owner's Name information is North Andover MA 01845 May 26, 2014 required for State Zip Code Date of Inspection every page. City/Town 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. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Dean G. Luscomb 11 cursor-do not Name of Inspector use the return key. Dean G. Luscomb 11 &Sons Company Name P.O. Box 135 Company Address Middleton MA 01949 nen Cityrrown State Zip Code 978-774-4065 S1848 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 and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority May 26, 2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of!use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 693 Johnson St. Property Address Gaffny Owner Owner's Name information is North Andover MA 01845 May 26, 2014 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Checl 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 Sindicated below. Comments: B) System Conditionally Passes: ElOne 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 indicating that the tank is!less than 20 ears old is available. Compliance d g Y ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 693 Johnson St. Property Address Gaffny Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): D ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection If(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipeks). The system will pass inspection if(with approval of the Board of Health): D ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required'by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 693 Johnson St. Property Address Gaffny Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has aseptic 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 �} ❑ ® Backup of sewage into facility or system component due to overloaded or 9/ clogged SAS or.cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 693 Johnson St. Property Address Gaffny Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a'cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes'if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of 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 des' flow of 10,000 gpd to 15,000 gpd. For large Sys s, you must indicate either"yes"or"no"to each oft lowing, in addition to the Oquestions in Secti D. Yes No ❑ ❑ the system is in 400 of a surface drinking water supply ❑ ❑ the system is n20 t of a tributary to a surface drinking water supply ❑ ❑ the sys is located in a nitrog ensitive area (Interim Wellhead Protection Ar —IWPA)ora mapped Zone II o ublic water supply well If you have answ d.,yes"to any question in Section E the system onsidered a significant threat, or answered" es" in Section D above the large system has failed. The o r or operator of any large system sidered a significant threat under Section E or failed under Sectio shall upgrade the system in accordance with 310 CMR h5.304. The system owner should contact th ppropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i 9890 '°N MWS tiI06 Z unr auaii pania0a� Dean G. Lu�comb II &Sons P.OJ fox 135 Mid&eto* MA 01949 978-':774-4065 June 2,2014 North Andover Board of Health North Andover, MA I am sending you a corrected copy of a Tit16 V report done at 693 Johnson St.North Andover,MA. This corrected copy shows'] mnber of bedrooms as being 4. We went by the available information at the time, whicli was a previous Title V done,which was done on 6-19-02. The house has 4 small bedrooms in main part of house on second floor. The field card from the assessors office shows 4 bedrooms (enclosed). Please call if you have any questions. I Thank you Dean Luscomb P.O.Box 135 Middleton, MA 01949 978-774-4065 i is i i' II • 9890 "N MWS �IOZ Z unp anvil paniaOa� Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurrace Sewage Disposal System Form-Not for Voluntary Assessments 693 Johnson St_ Property Address Gaffny Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every page. City/Town j state Zip Code Date of Inspedion C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system recelved 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 plan's of the system obtained and examined?(If they were not available note as;N/A) ® ❑ Was the facility o 'dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system bbmponents,excluding the SAS, located on site? ® ❑ Were the septic t, nk manholes uncovered,opened, and the interior of the tank inspected for the�onditlon of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility ovlrner(and occupants if different from owner)provided with information on the,proper maintenance of subsurface sewage disposal systems? The size and loc4tion of the Boll Absorption System(SAS)on the site has been determined,based on: ® ❑ Existing information. For example, a plan at the Board of Health. ; ® ❑ Determined in thdifield(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(5)1 j. D. System Information Residential Flow Conditions: Number of bedrooms(design): :i Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd'x#of bedrooms): 440 gpd tfiina•9l73 Me 5 otlldal tnepeetion Form$uha dace Sewage Disposal SWUM Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 693 Johnson St. Property Address Gaffny Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information Description: owner and town Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date mmercial/Industrial Flow Conditions: Type of Esta ' ent: Design flow(based on 310 R 15.203): Gallons per day(gpd U Basis of design flow(seats/persons/s etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank pres ❑ Yes ❑ No Non-sanitary waste arged to the Title 5 system? ❑ Yes ❑ No Water me readings, if available: t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17 I I Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 693 Johnson St. Property Address Gaffny - Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupa y +fie, Date Other(describe below): General Information Pumping Records: Source of information: Pumped every year. Last pumped 4-30-14. -owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: O gallons How was quantity pumped determined? No need at this time Reason for pumping: Type of System: ® 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 693 Johnson St. Property Address Gaffny Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every 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: Previous title v stated the system is from the 1970-approx 40 yrs old. Were sewage odors detected when arriving at the site? ❑ Yes ® No SBuilding Sewer(locate on site plan): / Depth below grade: eet Material of construction: ®cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Main line and joints are in very good condition. Septic Tank(locate on site plan): Depth below grade: feet Wl&anbe Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast rectangular- 1000 gallons If tank is metal, list age: Is a y a Certificate of Compliance? (attach a cop�of !rtificate�) E�] Yes�� Dimensions: 5'x 5'x 8'- 1000 gallons 1 Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 693 Johnson St. Property Address Gaffny Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom,of outlet tee or baffle 34" / Scum thickness 1" 61' Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? sticks and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,;evidence of leakage, etc.): The septic tank and baffles are in very good condition. The liquid in the tank is running at it's correct working heigth. The solids in the tank are light and do not require pumping at this time. Gr se Trap(locate on site plan): Depth below de: feet Material of construction. ❑ concrete ❑ metal ❑ fiberglass El po Wylene ❑ other(explain): Dimensions: Scum thickness Distance from top um to top of outlet tee or baffle Distancef om bottom of scum to bottom of outlet tee or baffle r Date of last pumping: Date t5ins•3/13 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 M 693 Johnson St. Property Address Gaffny Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Com is(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid leve s 7cited to outlet invert, evidence of leakage, etc.): ------ Ti ht or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth elow grade: U Material of c struction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ther(explain): Dimensions: Capacity: gallons Design Flow: g ns per day Alarm present: ❑ Yes ❑ No Alarm level: A in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of ala and float switches, etc.): f *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 • Commonwealth of Massachusetts Title 5Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 693 Johnson St. Property Address Gaffny Owner Owner's Name information is North Andover MA 01845 May 26, 2014 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): / Depth of liquid level above outlet invert Zero Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box is 3' below grade and is 13"x 33". The d-box is level and in good general condition. The liquid in the d-box is running at its correct working heigth. The soil in this area is clean and dry with no signs of any problems P Chamber(locate on site plan): V Pumps in working ❑ � " Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber itio umps 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): e I If SAS not located, explain why: The SAS was located by previous title v. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 693 Johnson St. Property Address Gaffny Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ej ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 -20'x30' ❑ 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.): The SAS is in good general condition with no signs of any problems. The soil in this area is clean and dry with no signs of ponding or breakout. C spools (cesspool must be pumped as part of inspection) (locate on site plan): Number an nfiguration /r Depth—top of liquid to t invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of constructi Indication o- undwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 . J Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 693 Johnson St. Property Address Gaffny Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 27ents(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, P ' (locate on site plan): Materials o nstruction: Dimensions Depth of solids Comments(note condition of soil, signs o raulic f ' e, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 693 Johnson St. Property Address Gaffn Owner Owner's Name information is North Andover MA 01845 May 26 2014 required for State Zip Code Date of Inspection every page. Cityfrown 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 where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately E 40-�a 3 33 �X zs�7ti IL 133 , 7" os e I� t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 JdAm SQ'►1 J4remell. • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 693 Johnson St. Property Address Gaffny Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells depth to high round water: approx 5' below grade. Estimated de P 9 9 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design'plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Previous title v. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Johnson St. sits approx 5' below the grade of the yard where the d-box is located with no signs of any water breakout. The basement is 7' below grade with no sump pump. On 6-19-02 during previous title v, a hole was dug to 4' below grade with no signs of water to be noted. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "r 693 Johnson St. Property Address Gaffny Owner Owner's Name information is required for North Andover MA 01845 May 26, 2014 every page. City/Town 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 Residential Property Record Card PARCEL—ID:2101038.0-0075-0000.0 MAR038.0 BLOCK:0075 LOT.,0000.0 PARCEL ADDRESS:693 JOHNSON STREET FY:2014 Far _.JeV -P.,n3w,.M._1 r www— [0-2- P Weas M; -64 F PARCEL INFORMATION Owner. I fla, ffSae RaRei T4 `—M-45 LOAN U510-101-2 at Land Area: 1 9- ---'Sale alid: T Water: I • L GAFF NY,SUSAN Z AWAF4 W�4� r Address: .WO k n Trl M,IFT V_- Collect SGC z-4 W, 011"9,111—N. jig 693 JOHNSON STREET P.0 1 NORTH ANDOVER MA 01845 rE_xempt-B&% I Resid-B/L% I00I100 Comm-BILK Indust-B/L% I Open Sp-EVL1/6 I RESIDENCE INFORMATION LAND INFORMATION -.75 NBHD CODE:T N8HD CLASS: 7 ZONE: R2 -mgk ISO! 1200 1191 r. !P7 P 101 ---�S �4W60 1.000 22 ,713 Story Height: Bedrooms: 4 U Fn Area: 59 BSMt 0: - _`. - _n " - M ft 2 R 101 A 0 0.050 380 Ext Wall. Bat s I U Area: Bsnit Grade: A DETACHED STRUCTURE INFORMATION Fo*nda�d C_ Bath 21. 1771-54 WON RM" 3 OWN: A No 4�- 8 ype: t: 9 ound a ue: 9 S " R8 W8_ M-A4_ TW10/#4"3 _ 206 1 PV 3 800 0.00 1988 A F 1501142 12,400 1 VALUATION INFORMATION Current Total- 414,300 Bldg: 190,200 Land: 224,100 MktLnd: 224,100 Prior Total: 489,100 Bldg: 253,500 Land: 235,600 MktLnd: 235,600 Porch Type Porch Area Porch Grade Factor 52 E 144 SKETCH PHOTO ----- 1z144- qft -- i - IFM B G R)IFNA 36 i'SgXt- 7 650 S4Ft It 2 5-Si*Ft it. 26 26 25 25 693 JOHNSON STREET Parcel ID:2101030.0-0675-0000.0 as of EV30/14 Page 1 of 1 RECEIVED Dean G. Luscomb II & Sons JUN 0 4 2014 P.O. Box 135 Middleton, MA 01949 TOWN OF NORTH ANDOVER 978-774-4065 'HEALTH DEPARTMENT June 2, 2014 North Andover Board of Health North Andover, MA I am sending you a corrected copy of a Title V report done at 693 Johnson St.North Andover, MA. This corrected copy shows number of bedrooms as being 4. We went by the available information at the time, which was a previous Title V done, which was done on 6-19-02. The house has 4 small bedrooms in main part of house on second floor. The field card from the assessors office shows 4 bedrooms (enclosed). Please call if you have any questions. Thank you Dean Luscomb P.O. Box 135 Middleton, MA 01949 978-774-4065 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 693 Johnson St. Property Address Gaffny Owner Owner's Name information is required for NorthY Andover MA 01845 May 26, 2014 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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? ® ❑ 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 pian at the Board of Health. ® ❑ 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: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Residential Property Record Card PARCEL ID:210/038.0-0075-0000.0 MAP:038.0 BLOCK:0075 LOT:0000.0 PARCEL ADDRESS:693 JOHNSON STREET FY:2014 PARCEL INFORMATION Use-Code: 101 Sale Price: 420,000 Book: 07019 Road Type. T Inspect Date: 04/17/201!3' Tax Class: T Sale Date: 08/19/02 Page: 0345 Rd Condition: P Meas Date: 04/17/2013 Owner: Tot Fin'Area: 2049 Sale Type: PCert/Doc.. Traffic:, M Entrance: C GAFFNY,SUSAN Z Tot Land Area: 1.05 Sale Valid: Y Water: Collect Id: SGC Address: Granter. GOLANXENtN#THE � � Sewer- Inspect Real: M 693 JOHNSON STREET _. _ _ _. _. NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / RESIDENCE INFORMATION LAND INFORMATION Style: CL,R Tot Rooms: "' 0 Main Fn Area: 1191 " Attic' NBHD CODE: 7 NBHD CLASS: 7 ZONE: R2 Story Height: 2.00 Bedrooms: 4 Up Fn Area: 858 Bsmt Area: 1191 Seg , Typa' Code Method Sq-Ft ' Acres Inf ti YIN_`' Value Class Roof: G Full maths: 1_ AddFn Ai ea: Fig BsmtArew', 1 P 101 S 43560 1.000 223,713 Ext Wall: AV Half Baths: " 1 Unfn"Area " Bsmt Grade: "A 2 R 101 A 0 0.050 380 Masonry Trim Ext Bath Fix '0 Tot Fin Area:" 2049 ION Foundation: CN "Bath Qual... . T RCNLD: 177554 Str Unit srA: AAs 2DETA°E Y=81tCHED TG Grade Gond%GRUCTURE ood P FTEIR Cost` """ GIaSs' Kitch Qual: T Eff Yr Built 1+979 Mid Adl .. Heat Type: HW Ext Kitch Year Built 1965 Sound"Value: SE S 100 0.00 1988 A A _. /50//43 200 1 - PV S 800 0.00 1988 A F /50//42 12,400 1 Fuel Type:__ aG Grade: ACost Bldg: 177,600, Fireplace: 1 Bsmt Gar Cap: Condition: A Att Str Val 1: VALUATION INFORMATION Central AC " N Bsmt Gar SF.' PCt Gam'lete:' Att Str V612: Current Total: 414,300 Bldg: 190,200 Land: 224,100 MktLnd: 224,100 Att"Gar SF 650%Good P/F/E/R: /100/100/78 Prior Total: 489,100 Bldg: 253,500 Land: 235,600 MktLnd: 235,600 Porch Tyne Porch Area Porch Grade Factor P 52 E 144 SKETCH PHOTO 12 E k # �" f� , � x �K 12144 Oft 31 12 2c; a = FMB Ga FU/FM/B 366 Sq.Ft. Z2 650 Sq.Ft 825 Sq.Ft is 26 26 25 25 11 FR 1 53 q•rt ; 693 JOHNSON STREET ' Parcel ID:210/038.0-0075-0000.0 as of 5/30/14 Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS ` EXECUTIVE OFFICE OF ENVIRONMENTAL,AFFAIRS / DEPARTMENT OF ENVIRONMEN -AL_RROTECTION Vt�i�l TOOF NORTH ANDO;. :R BOARD OF HEALTH JUL G 0 2002 TITLE 5 j - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A // CERTIFICATION Property Address: (03 M .,15 a Owner's Name: Owner's Address: Date of Inspection: G — q d Z Name of Inspector: 1 e Tint) Company Name: ,[ � Mailing Address: LAIZI)InIle OL- Telephone Number:.j -7 t-1 4-) & d (o CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information repotted 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 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatur ` Date: -6 -2-6 '62_ The system inspector shall submit a copy of this pection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. 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. Title 5 Inspection Form 6/152000 page I :k Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Addriss• 6 7 /V Owner: Cj w Date of Inspection: Inspection Summary: Cbeek A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: —U— I have not found any information which indicates that anv of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Anv failure criteria not evaluated are indicated below. Com n etiN. g fi� t` NI �. B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please . explain. The septic tank is metal and over 20 yean old*or the septic tank(whetber metal or not)is structurally unsound, exhibits substantial infiltration or exfiltradon or tank failure is immb=L 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: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed 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): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART A CERTIFICATION(continued) Property Address: p e .�77 Owner: L Date of Inspection: tA — r C. Further Evaluation is Required by the Board of Health: Coto ns exist which require further evaluation by the Board of Health in order to termine if the system is failing to Prot ct public health,safety or the environment. 1. System wi pass unless Board of Health determines in accordancew 310 CMR 1S_W3(lxb)that the system is no functioning in a manner which will protect public b th,safety and the environment: Cesspool or 'vy is within 50 feet of a surface water _ Cesspool or pn is within 50 feet of a bordering veg d wetland or a salt marsh 2. System will fail unless the Board Healt and Public Water Supplier,if any)determines that the system is functioning in a manner that t ts the public health,safety and environment: _ The system has a septic tank;and it sorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to surfac water supply. The system has a septic and SAS and a SAS is within a Zone 1 of a public water supply. _ The system has a s tank and SAS and the is within 50 feet of a private water supply well. _ The system has a c tank and SAS and the SAS ' less than 100 feet but 50 feet or more from a private water supply ell .Method used to determine de "This system es if the well water analysis,performed at DEP certified laboratory, for coliform bacteria and vo the organic compounds indicates that the well free from pollution from that facility and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crite ' are triggered.A copy of the analysis must be attached to this form. 3. Othe . 3 Page 4 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �( �6�a e 4v� Owner: ColO( a Date of Inspection: -p.-,L— D. LD. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No t kup of sewage into facility or system component due to overloaded or clogged SAS or cesspool charge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ._ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/:day flow Required pumping more than 4 times in the last year _Udue to clogged or obstructed pipe(s).Number of times pumped 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. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes it 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 S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma (Yes/No)The system fa�li , 1 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 thBoard of Health to determine what will be necessary to correct the failure. e 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. You must indicate either'Ives"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone Il 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. d Page S of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:� ...ZS Owner: 66 1 A-k j Q Date of Inspection: ��-f Check if the following have been done. You must indicate"ves"or`fro"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? D-� 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? _ 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 a baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ 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: Yes � po Existing information. For example, a plan at the Board of Health. 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)J S Page 6 of 11 . S OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: r.[ Owner: p Date of Inspection: Z RESIDENTIAL FLOW CONDITIONS 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: (311 _ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): �[if yes separate inspection required] Laundry system inspected(ycj or no): J_�J Seasonal use:(yes or no) Water meter readings, if avai le(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: COMMERCIAIANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft etc•): 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: OTHER(describe): _ Pumping Records GENERAL INFORMATION _ _ J ekyL� Source of information�4N G&�: ►�--C Was system pumped as part of the inspection(yes or o): If yes, volume pumped: ¢allons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy /f 2(,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 _Other(describe): Approximate age of all components,date installed(if known)and source of information: 7 l S o e.v-.'_ Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of l 1 OFFICIAL INSPECTION FORINT—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Lee d Owner: 601 v%..w Date of Inspection:_v z-- BUILDING BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:L(locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene _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: Sludge depth: C Distance from top of sludge to bottom of outlet tee or baffle: 4� Scum thickness /n ej Distance from top of scum to top of outlet tee or baffle: Z Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:Zi44g2:&_ Comments(on pumping recommendations,Net and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evi4ence o leakage,etc.): 7 t ATA C ' 41 A-S r9 4E!`' AV-PI I GREASE TRAP:_(locate on site plan Depth below grade:,_ Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): 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.): 7 Page E of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �-+ SYSTEM INFORMATION(continued) Property Address: 7' -6A,%5ry-, Owner: Gd lid Date of Inspection: —d TIGHT or HOLDING TANK: (tank must be pumped at time of inspectionxlocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_Polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches.etc.): DISTRIBUTION BOX:r1L(if present must be openedxlocate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of akage into or out of v PUMP CHAMBER: (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.): R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. <l S? A-^ 1�-�- Owner: Date of Inspection: —o Z SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not 19cated explain why: Type leaching pits,number._ leaching chambers,number. leaching galleries,number. leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number- innovative/alternative umberinnovativeialternative system Type!name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids laver: 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: (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.): 9 i Mage 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 3 Owner. �i o Date of Inspection: b—YJ—a Z SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pernmertt ference landmarks or benchm .Locate all wells within 100 feet. Locate where public water supply enters a building. J V �J i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C --�- SYSTEM INFORMATION(continued) Property Address: u o Ay Owner: Date of Inspection: Zn— —Q 2-- SITE SITE EXAM Slope Surface water Check cellar c S Shallow wells Estimated depth to ground water 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 propertyiobservation hole within 150 feet of SAS) Checked with local Board of Heald"xplain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: Y st describe hovj you establish the high ground water elevation: 8 s c rLAA S eke V1GL�.b so l V C!n-Lk N :5r-VO Lk I 'yjrJ�� 1jSe�l.V'C� �� [ nJ�C 4e' 2CI 75 Srn LIC ! sb l i 3A S 3 4 II