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HomeMy WebLinkAboutTitle V Inspection Report - 700 MIDDLETON ROAD 7/30/2018%Irj ...........j %; /f FILE # P TITLE V INSPECTION RECEIVED DEAN C. LuscOMB 11 & SONS 2$$ MAPLE STREET MIDDLETON MA 01949 owl() f wf ANOMR, NMI/ 978-774-4065 NPL;,UMBER-#a02$5 LICENSED TITLE V INSPECTOR- $1848 ',,,UCSURFACED SEWAGE DISPOSAL SYSTEM INSPECTION FORM OWNERS ADDRESS. 2� l' DATE OF INSPECTION; , . Q. .) NAME OF INSPECTOR' �� �.. i/ t 1, t QUALITY IS NUMBER ONE TO US ...,, . ^ ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal SysternFmrnm - NotforVo|unturyAssessmentu 70OMiddleton Road Property Address Fisher Owner Owner's Name information is required for North Andover MA 01845 Julv 23 2018 ------------- everynmge City/Town State Zip Code Date o{Inspection Inspection results must be submitted onthis form. Inspection forms may not be altered inany way. Please see completeness checklist mtthe end ofthe form. RECEIVED Important: A. ���������U U���������^��� VVhunUNngou� ^ ~^ General Information ~^ forms onthe JML 3O2018 computer, use 1 only�mm � by � Inspector. TOWN OFNOR THANDOVER t»move your Dean G. LGgcnmb || HEA01iOEMRJMEN1' *vmvr do not --- Name nf|nsAo�ur unu,xu'o�um key. Dean G. Luoconob || & Sone Company Name 2O8Maple Street ___ ------ Company Address Middleton MA 01949 City/Town State Zip Code G1848 Telephone Number License Number B. Certification | certify that| 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 16.34Qof Title 5 (310 CMR 15'000). The system: E Passes [] Conditionally Passes Fl Fails 0 Needs Further Evaluation bythe Local Approving Authority JuIv 23 2018 Inspe or' nature Date Thes6�*=minspector shall submit mcopy ofthis inspection report tothe 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 b}the buyer, |fapplicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use mtthat time.This inspection does not address how the system will perform in the future under the same mrdifferent conditions wfuse. Commonwealth of Massachusetts Title f i i l Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 700 Middleton Road Property Address Fisher Owner Owner's Name information is North Andover MA 01845 July 23, 2018 required for _ - — ----- . . _� — -- every page. Cityrrown ---- state Zip Code Date of Inspection B. Certification (cant.) Inspection Summary: CheB,C,D or E I always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: ------------- B) System Conditionally Passes: 0 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 p� determined," please explain. JU The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): tains-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern•Page 2 of 17 Commonwealth of Massachusetts - Title ffi i I Inspection Form p 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M � 700 Middleton Road Property Address Fisher Owner Owner's Name information is North Andover MA 01845 July 23, 2018 required for __. _._ _ every page. City'Town State Zip Code Date of Inspection B. Certification (cant) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below).- ----------- C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. Il 1. System will pass unless Board of Health determines in accordance with 310 CMR (J 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•3113 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts x= Title ficial Inspection Form -- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 700 Middleton Road M1�. 4yb Property Address Fisher Owner Owners Name information is North Andover MA 01845 Jul 23 201$ requiredfor _ _...._....___..__ __. _. _..._. _.._..__... __._....._.__..._. __._.___�__. IV_... every page. CityfTown State Zip Code Date of Inspection B. Certification (cant.) _ 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other; / ------------- --- _ _..._. ....... _..__.._ _ _._..__.-.-- D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ M Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow 151ns•3113 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts ��"��0�� �� ��`��'"��~��� 0������������"���� ����R°N�� � ��N �� Official� � �0��wm N—��mmmm �� �� �m mm�������� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7OOMiddleton Road -`�- Property Address Fisher Owner �wnpr'aName information i's required for North Andover MA 01845 JuIV 23 2018 every page. City/Town State Zip Code Date ufInspection B. Certification (cont.) Yea No Required pumping more than 4times inthe last year NOT due hoclogged or obstructed pipe(s). Number oftimes pumped: El H Any portion of the SAS, cesspool orprivy iabelow high ground water elevation. � l �� Any pu�ionofcesspool orprivy ioxvithin1UOfeet ofasu�ocexvaharsupply or ^~ �� tributary toosurface water supply. [l E Any portion ofacesspool nrprivy iswithin oZone 1Ofapublic well. \ El M Any portion of a cesspool or privy is within 50 feet of a private water supply well. El R Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from m private water supply well with noacceptable water quality analysis. [This system passes |fthe well water analysis, performed atmDEP 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 nmother failure criteria are triggered.4`copy ofthe analysis and chain ofcustody must beattached iwthis Yw,mn'] Fl �� Theayatemieeceeopnn[ seminQafaoi|ityvvithademiOnUowof2UUOgpd- ^~ ~~ 18.800gpd� �� �� The systemmfaMs. ihave determined that one ornnorenfthe above failure �� �� criteria exist as described in 310 CMR 15.303. therefore the system fei|e, The system owner should contact the Board ofHealth todetermine what will be necessary tocorrect the failure. E\ Large Systems: To he considered u large system the system must serve mfacility with a de 'n flow of 10,000 gpd to 15,000 gpd. For large s tems, you must indicate either"yes" or"no" to each of t"elo��ing, in addition to the le in S questions�in 'ekion D. Yes No El the system, is within 400 feet'6f a surface drinking water supply the system is wlihi"n'2 00 feet of a tributary to a surface drinking water supply the systpm'is located in*a.nitrogen sensitive area (Interim Wellhead Protection El 0 Area-L"'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"veg" in Section D above the large system has failed. The owner or operator of any large system cgrisilaered a significant threat under Section E or failed under Section D shall upgrade the systern1h accordance with 310 CMR 15.304. The system owner shou'ld,c,ontact the appropriate regional office of the Department. mms'a`3 '="~^~~^~p~~'~''~~ ``~`^~~—`~°'--,��System '-~--- �7 Commonwealth of Massachusetts y -v Title 5 Official Inspection Farm a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ..''4 700 Middleton Road Property Address Fisher Owner Owner's Name information is North Andover MA 01845 Jul 23 2018 required for �____�-----_._—_--- - — �...._� every page. Cityrfown State Zip Code pate 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? p❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El 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? 0 ❑ 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 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) [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.3113 Title 5 official Inspection Form:Subsurface Sewage Disposal Systern-Page 6 of 17 it\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 700 Middleton Road Property Address Fisher Owner Owner's Name information is North Andover MA 01845 required for 231_2018 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? F-1 Yes No Is laundry on a separate sewage system? (include laundry system inspection El Yes [A No information in this report) Laundry system inspected? El Yes M No Seasonaluse? F1 Yes M No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? El Yes M No current Last date of occupancy: Date Go,mmercial/Industrial Flow Conditions: Type of Estabh'5hment: Design flow(based on 310 5.203): ...... Gallons-p er-da y"(6 p d) Basis of design flow(seats/persons/sq.ft., e Grease trap present? n Yes El No d 0 n 3 10 1 5.20 3): )w(seats/persons/sq ft., present? Industrial waste holdjrigAarhk present? R Yes El No Non- sanitary waste discharged to the Title 5 system? Yes E] 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 7O8Middle(nnRoad Property p�dmoa Fisher _ '_------- --����_ Owner Owner's Name information i's required for North Andover MA 01845 JuIv 23 2018 every page. CityrFown Stat* Zip Code Date ofInspection D' System Information (cont.) Last date--of-oapy.R�ncy/use: Date Other(describe below): General Information Pumping Records: Source ofinformation: No records VVooeymtempnmpadaapartoftheinspevion? Yes [l No = gallons If yes, volume pumped: gallons =�=- ts How was quantity pumped determined? - h solids ReamonfnrpumpinA: -heavy Type of : z Septic tank, distribution box, mni| absorption system [� Single cesspool |l Overflow cesspool [] Privy Fl Shared system (yes or no) (if yes, attach previous inspection records, if any) [l |nnovetive/A|ternativetechno|oQy, Attach ecopy ofthe current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection ofthe |A\system bysystem operator under contract [l Tight tank Attach ocopy nfthe DEP approval. �� Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 700 Middleton Road Property Address Fisher Owner Owner's Name information is North Andover MA 01845 J"l _232 2018 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: -System is from 2016-2 years old. ---------------- Were sewage odors detected when arriving at the site? n Yes No Building Sewer(locate on site plan): 30" Depth below grade: ---------—-----------­-------- feet Material of construction: El 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 pointsarein good condition. Septic Tank (locate on site plan): 2011 Depth below grade: feet—-­ Material of construction: Rtv"evOe [] metal ❑ fiberglass polyethylene El other(explain) -Plastic- 1500 gallons - If tank k=s metal t;al, list s t a�ge: _`mss Is age confirmed by a Certificate of Compliance? (attach a copy of certificate�) ❑Y - }–f� Dimensions: 5' x 4,25' x 14' Ion 2" Sludge depth: t5ins 3/13 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 700 Middleton Road Property Address Fisher Owner Owner's Name information is required for North Andover MA 01845 July 23, 2018 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 .22" 21' Scum thickness 5" Distance from top of scum to top of outlet tee or baffle Distance from bottom Of Scum to bottom of outlet tee or baffle _�y measurements- 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.): Septic tank and baffle are in very good shape. The solids are heavy and do require pumping at this time. The liquid is running at it's correct working heigth. The inlet and outlet covers are built to gmde..... ....... ...... hal e a s eTrap lo ca e on site plan): Depth w grade: feet ........... ....... Material of cons tion: Lconcrete DmEfiberglass polyethyl ene Eother(explain): Dimensions: Scum t`hickne s - Dstafice 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: t5jns-3113 Title 5 Official inspection Form:Subsurface Sewage Disposal Systern•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form Not for Voluntary Assessments 700 Middleton Road Property Address Fisher Owner Owner's Name information is required for North Andover MA 01845 July 23, 2018 every page. C.ityfTown State ^ Zip Code Date of Inspection D. System Information (cont.) ments, (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid lev 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 elow grade: n Material of struction: El concrete \E] metal El fiberglass D polyetliylene E] other(explain): Dimensions: ........ Capacity: g.a.Ilons Design Flow: ------- - gallons per day Alarm present: F-1 Yes E] No Alarm level: in working order: R Yes El No Date of last pumpili Date Comm e nt$,(6ond ition of alarm and float switches, etc.): a. 7z- Attach copy of current pumping contract (required). Is copy attached? El Yes No t5ins-3113 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 700 Middleton Road Property Address Fisher Owner Owner's Name information is required for North Andover MA 01845 Jul 23, �018 ------------- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Zero Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box is 16"x 16" and is 26" below grade.. The d-box is in good shape. ---------------- ----------- ......................... -------- -P.R!TChamber(locate on site plan): Pumps in w6-rking,qrder: El Yes 0 No* Alarms in working order: E] Yes E-1 No* Comments (note condition of pump ch ambbr�-co.nditlion..of-pLTfti-p,s 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: SAS was located by asbuilt drawings. ------------ t5ms 3113 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 700 Middleton Road Property Address Fisher Owner Owner's Name information is required for North -------- 01845 'July 23, 2018 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type.- 0 leaching pits number: - ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ------ innovative/alternative system Type/name of technology: 12 Cul Tec chambers. 4 rows of 3 each. Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS is in good cono.ition. There are no signs of ponding or breakouth. , 6ove_r W/ ct,e, Ce 'ools (cesspool must be pumped as part of inspection) (locate on site plan): P Number u:er and uration top of I le r ........... U Depth—top of liquid to inle rt I U ........ Depth of solids layer ................ Depth of scum layer Dimensions of cesspool Materials of c9 pstriTction Indig,at6n of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subswface Sewage Disposal System•Page 13 of 17 c Commonwealth of Massachusetts Tine 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 700 Middleton Road Property Address Fisher Owner Owner's Name information is North Andover MA 01845 Jul 23 2018 required for .__............. ...._._.-- _._._�.._.._. every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): vy (locate on site plan): Materials o s#ruction: (`} Dimensions ___ _...._.. . . __..._.....__ Depthof solids ---- _ .m.......... .....___ __ _ ...._._.... ..__._._.._.......__.. Comments (nate condition of soil, signs of hydraulic "ure, IeyelAaf ponding, condition of vegetation, etc.): -- t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W&A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Fisher Owner er's Name _--_---_ information is required for North Andover MA 01845 July 23, 2018 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal s tem, incl ding ties to at least two permanent reference landmarks or benchmarks. Locate all wells ithin 100 eet. Locate where public water supply enters the building. Check one of the boxes below. E hand-sketch in the area below El drawing attached separately k 6 Uile T 7- X At,X y p ka D (tc /()Z' t5ins- 113 Title 5 Qffi6al inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 700 Middleton Road Property Address rW --------- Fisher Owner __._,._ _ _. ___ --._..__._ __._. ,.... _....._� ._,._,.._ __.__ _. _....__ _._,._ Owner's Name information is required for North Andover MA01845 JuIv 23, 2018 every page, Cit !Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water bc)e-h tla-4el afe-et 41,vA Check cellar 'DPV Ajo -';ztMP PLAwl Y) Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 5/21/15 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: Permit, proposed and asbuilt on file. El Checked with local excavators, installers- (attach documentation) El Accessed USGS database-explain: You must describe how you established the high ground water elevation: Deep hole# 1 showed ESHGT at 48" and Deep hole#2 showed ESHGT at 84". By James Morin R.S. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form X Subsurface Sewage Disposal System Form Not for Voluntary Assessments 700 Middleton Road _Vrc�er_ty_A,_dd_ress ...... Fisher Owner Owner's information is required for North Andover MA 01845 -July 23, 2018 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 l5ins-3/13 Title 5 Offidal inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 T Town of North Andover HEALTH DEPARTMENT $Ac"O �' I CHECK #: / 2 DATE: LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) 0 Animal 0 Body Art Establishment 0 Body Art Practitioner 0 Dumpster 0 Food Service- 0 Funeral Directors 0 Massage Establishment 13 Massage Practice 0 Offal(Septic)Hauler 0 Recreational Camp El Sun tanning 0 Swimming Pool 0 Tobacco 0 Trash/Solid Waste Hauler 0 Well Construction SEPTIC Systems: 0 Septic-Soil Testing 0 Septic-Desigu Approval 0 Septic Disposal Works Cotistnictiou(DWQ 0 Septic Disposal Works Installers(DW[) 0 Title 5 Inspector A Title 5 Report $ 13 Other. (Indicate)--__- Health Agent Initials White-Applicant Yellow-Health Pink- Treasurer