Loading...
HomeMy WebLinkAboutTitle V Inspection Report - 143 LIBERTY STREET 7/30/2018 FILE# 10 r" C.,. l 1) a TITLE V INSPECTION CLEAN G. LUSCOMB 11 & SONS 288 MAPLE: STREET NMIDDL,ETON, MA 01949 v 978.774,4065 t . J%c � ""LUMBER2U85 LICENSED TITLE VINSPECTOR-# 1848 SUBSURF'ACEL1'SEWAGE DISPOSAL SYSTEM INSPECTION FORM " / iii/i , "FERTY OWNERS NAME: �w.� e v e c) , EI T"Y OWNERS ADDRESS: l i ? L' e r DATE OF INSPECTION: . NAME OF INSPECT . ECIT) r JL QUALITY IS NUMBER. ONE TO US ` Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments � 143_Liberty St. De Owner - --- 'nfomnu\ionio required for North Andover K8A01845 July 1S 2O18 � � every page. City/Town moto Zip Code om�«r|nopomion Inspection results must be submitted qmthis form. Inspection forms may not bealtered inany way. Please see completeness checklist atthe end mfthe form. .~` ' /mponWm: �� � When filling A. =~`~""~~"=" """"~°""°"=~"~°"" forms on the � computer, use 1 ~ only the�b�y � Inspector: ��- tomoveynm 11 oumor-dono( - -- G. ----�- ' usememmm '~~'~~ ^~p^~~' key. Dean G. Luscomb 11 & Sons Company Name VQ ..288_Map le StreetCo pany Address � Middleton MA 01949 City/Town State Zip Code V/u-// Q1848 Telephone Number License Number -------------------- B. Certification | certify that| have personally inspected the sewage disposal system atthis address and that the information reported below is trum, accurate and complete as of the time of the inspection. The inspection � was performed based unmytraining and experience inthe proper function and maintenance ofonsite sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 6(310CMR 15.00Q).The system: 0 Passes F� Conditionally Passes Fails E1 Needs Further Evaluation bythe Local Approving Authority _d-- ,October 21, 2016 In ed6/ms|gnmmm / Dote The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 38 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 tothe appropriate regional office ofthe DER The original should be sent tothe system owner and copies sent b)the buyer, if applicable, and the approving authority, � °~^^Thisreport only describes conditions atthe time mfinspection and under the conditions oYuse . mtthat time.This inspection does not address how the system will perform )nthe future under the same mrdifferent conditions of use. ,5i"°'3113 Title sOfficial mopectwnForm:Subsurface Sewage Disposal System'Page 1w17 � Commonwealth of Massachusetts -w Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 143 Liberty St. q Property Address Deyeso Owner Owner's Name information is North Andover MA 01845 Jul 19 201$ required for � � every page. Cityrrown State Zip Code Date of Inspection .............. ----------- — —- -.... _ - ...— -------------- B. Certification (cont.) Inspection Summary: ChecN gA ,C,D or E/ always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not lJ/ determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 . Commonwealth of Massachusetts ` Title 5 Official Inspection nspecNonF orm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143 Liberty St Property Address D _ Owner Owner's Name information is required for NorthAndnver MA 01845 July 19 2018 every page, Cihfrnwn State Zip Code Date ofInspection 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 (oonL): F] 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 ofBoard ofHoa|th): [l broken pipo(s) are replaced [l Y Fl N F1 ND (Explain be|ow): �� obstruction is removed �l Y [l N Fl NO (Explain below): / �� ^� ^~ ^� � F1 distribution box iuleveled orreplaced Fl Y 0 N El ND (Explain be|ow): ------------------ [] Thueyshemnaquiredpumpingmorethan4bmeamyearduetnbrokenorobshuobedpipe(o). The system will pass inspection if(with approval nfthe Board ofHea|th): � broken pire(s) �are [l� Y �] N � ND (Explain be|ow): obstruction ioremoved Fl Y N 0 ND (Explain below>: C\ Further Evaluation is Required by the Board of Health: [l Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public heo|th, safety or the environment. [� 1. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, ~° safety and the environment: // Fl Cesspool orprivy iswithin 5Ofeet ofasurface water �� Cesspool or privy is within 50 feet ofa bordering vegetated wetland oro salt marsh Commonwealth of Massachusetts Titre 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °¢ 143 Liberty St. -- — Property Address Deyeso ._.____..._......__ ..____..__.._._._..__ Owner Owner's Name information is North Andover MA 01845 Jul 19, 2018 required for n_._.....w_. _.....__.._.._..�.._.____...__...._ every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No F1 ® 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 '/day flow t5ins-3113 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts --W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Liberty St. Property Address Deyeso Owner Owner's Name information is North Andover MA 01845 Jul 19 2018 required far _ -- --- --- _....._ Y ,._........_.................... _— — every page. City/Town State Zip Code Date of Inspection B. Certificati©n (cont.)��.�_______m.________ Yes No ❑ M 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. ❑ E 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. ❑ M 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.] ® N The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a "design flow of 10,000 gpd to 15,000 gpd. For large 9ystems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Sed n D. Yes Nof•~' Q [] the system is in 400 fee surface drinking water supply ❑ ❑ the system iihln200 of a tributary to a surface drinking water supply ❑ [� �thy"y tem is located in a nitrogen nsitive area (Interim Wellhead Protection .. Area—IWPA) ora mapped Zone II of a lic water supply well If you have answered "yes" to any question in Section E the system is sidered a significant threat, or'answered "yes" in Section D above the large system has failed. The own r operator of any large system considered a significant threat under Section E or failed under Section D all upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3113 'ritie 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Liberty St. Property Address D�eso Owner Owner's Name —_..... information is required for North Andover - 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? N ❑ 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. M El Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 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): Q-gid -- t5ins-3113 rifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �,u• 143 Liber St. _.._ _ .______r.._.__w._..._.____.. Property Address Deyeso Owner Owner's Name required fo is North Andover MA 01845 Jul 19, 2018 required far .__._..___.._. _-- Y every page. City/Town State Zip Code Date of Inspection —__-------- ._.___a_ D. System Information Description: owner and town Number of current residents: 2 Does residence have a garbage grinder? Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes M No Water meter readings, if available(last 2 years usage (gpd)): -- - Detail: ! ` Sump pump? ❑ Yes ® No Last date of occupancy: current Commerciallindustrial Flow Conditions: Type of lishment: __._.............._....___...__._..._.._____.___.....__ Design flow(based on MR 15.203): Gallons er- ay-(gpd} Basis of design flow(seats/persons/sq. tc.): Grease trap present? -- ' ❑ Yes ❑ No Industrial waste.-holding tank present? way� 1" "� ., ❑ Yes ❑ No N6'6 sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - — -- tains-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 143 Liberty St, Property Address Deyeso Owner Owner's Name ................................. information is North Andover MA 01845 required for ------ July 19, 2018 every page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of Date ------ Other(describe below): .......... General Information Pumping Records: Source of information: Pumps every 1-2 yrs..-_Lastpmped 9/3/03 & 7/15/17._ Was /3/ 3 & 7!15/17.— Was system pumped as part of the inspection? Yes No If yes, volume pumped: Zero —---------------------------------- gallons How was quantity pumped determined? Reason for pumping: No need at this time ----------------- Type of System: M Septic tank, distribution box, soil absorption system El Single cesspool ❑ Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) E] 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ------ ------- Property Address Deyeso OwnerOwner's Name information is required for North Andover MA 01845 J u 11 19, 2018 every page. 6ty[Town 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 1991 -27 years old. Were sewage odors detected when arriving at the site? Yes No Building Sewer(locate on site plan): L Depth below grade: feet Material of construction: M cast iron El 40 PVC El other(explain): Distance from private water supply well or suction line: ........... feet Comments (on condition of joints, venting, evidence of leakage, etc.): Main line and joints are in good condition. 4"cast iron pipe is in slab of basement. ......------------------ ---------------------- Septic Tank (locate on site plan): Depth below grade: feet Material of construction: M concrete El metal El fiberglass n polyethylene other(explain) Precast rectangular concrete- 1500 gallons ---------- ---------- e e �Yes No �(8�ittach a�copy of fEif�icate) If I meta Ist a 'rt Is age confirmed by Certificate Compliance? Dimensions: 5' x 5' x 10'- 1500 gallons 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 . " 143 Liberty St. _......_....._.___ Property Address De eso Owner __.._�.________ ....__.._.._.__ _..�._...__�_ _..........__. .._..._._ Owner's Name information is required for North Andover NIA 01845 July 19, 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 33 1" Scum thickness ❑ Distance from top of scum to tap of outlet tee or baffle6' -------------.-...........___ _.__.. Distance from bottom of scum to bottom of outlet tee or baffle 15 Haw were dimensions determined? by measurements�� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank and baffle are in very good shape. The solids are light and do not require pumping at this time. The liquid is running at it's correct working helgth Grease Trap (locate on site plan): Depth befow.grade: --- --- -__.....__....._........___.._. feet Material of constructio-ri- " ❑ concrete ❑ metal ❑ fiberglass ❑ polyp hyWnie ❑ other(explain).- Dimensions: explain):Dimensions: Scum thickness w. Distance-fr6m top of scum to tap of outlet tee or baffle ......... Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: _..- - --- - --..-....._.__............_._........_ Date t5ins•3113 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 143 Liberty St. Property Address D .. eI.eso - �- --.--1------1-.1- -------....... Owner Owner's Name information is required for North Andover MA 01845 198 , every page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as relatiedAp outlet invert, evidence of leakage, etc.): ------------- Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Dept b e lo w grade: Material o onstruc tion: `Vl ❑E metalncrete Efiberglass Epolyethyon!6IEother(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: Yes ❑ No Alarm level: rM rm in working order: F] Yes El No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): -z...... ------------- Attach copy of current pumping contract(required). Is copy attached? n Yes E] 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 143 Liberty St. Property Address _Deyes_q --------------- Owner Owner's Name information is required for North Andover---------------------- -------_-- MA 01845 u 19, 2018 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Zero ❑ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box is 20" x 20" and is 30" below grade. The d-box is in _good shape _ -------_--------_--_---- . _- I?ump Chamber(locate on site plan): Pumps i�nirng order: 0 Yes El No* Alarms in working orde EI-Yes __ E] No* Comments (note condition of�rpumpp c Mber, condition of p"amps 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. ..........­------------ ---------- t5ins•3113 Titte 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 143 Liberty St. Property Address Owner Owner's s Name information is required for -North Andover MA 01845 1%_2018 every page. CltyiTown State Zip Code Date of Inspection D. System Information (cont.) Type: El leaching pits number: El leaching chambers number: El leaching galleries number: El leaching trenches number, length: 1 -30' x40' leaching fields number, dimensions: ---- El overflow cesspool number: El 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 condition. There are no sins of Ponding or breakout, S- cvssp ools (cesspool must be pumped as part of inspection) (locate on site plan): Number an i uration Depth —top of liquid to inle rt n p of liquid i u d r t a 0 on inle rt _01 a r Depth of solids layer scum m y r Depth of scum layer Dimensions of cesspool Materials of c9,nsffuction Indication of groundwater inflow F] Yes ❑ No t5ins-3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 13 of 17 Commonwealth of Massachusetts _ w Title Official Inspection For Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 143 Libertv St. Property Address Deyeso Owner Owner's Name information is North Andover MA 01845 Jul 19, 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.). Privy (locate on site plan): Materialgf construction: Dimensions _.__........._. ___...._._.._. �_.._... Depth of solids Comments (note condition of soil, signs of by lic fail.urel,16el/of ponding, condition of vegetation, etc.): r� �- 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 °Q* 143 Liberty St. Property Address Deyeso _ Owner Owner's Name _ information is North Andover MA 01845 Jul 19 2018 required for �_.._ .__ ....___. ." every page, CityTTown State Zip Code Crate of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately ty o . t a�t�y,! f\d �j eZkl vt -n /1/3 LiAeee' `J 5 x A4 AndWer" 7q 52Te-414- A 1A 7- f3 � r 3 7- �� 3r ' b 7- 127 , 1 I Sins-3113 Title 5(Official Inspection Form:Subsurface Sewage Disposal System•Pape 15 of 17 Commonwealth of Massachusetts -------- -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 143 Liberty St. -Property Addre--ss - Dey s2 OwnerOwner's Name information is required for North Andover MA 01845 July 19, 2018 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: M Check Slope Z Surface water Z Check cellar Z Shallow wells Estimated depth to high ground water: 71+ -,r-...------.1-------1-- feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 10/4/9 If checked, date of design plan reviewed: Date 1 z Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Permit and asbuilt on file. ----—----- 0 Checked with local excavators, installers-(attach documentation) El Accessed USGS database -explain: ............. —---------- You must describe how you established the high ground water elevation: X 9 TO- -—-------- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 143 Liberty St. ----------- ....... ------------- Property Address qeYes9---- ---—------------------ Owner Owner's Name information is required for North Andover MA 01845 July 19, 2018 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E 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-3113 Title 5 Official Inspection FormSubsurface Sewage Disposal System-Page 17 of 17 Town of North Andover HEALTH DEPARTMENT CHECK 4: 2 6,;-/-2 DATE: LOCATION: IL-4 HBO NAME: CONTRACTOR NAME: )15c, Type of Permit or License: (Check box) • Animal • Body Art Establishment $ • Body Art Practitioner $ 0 Dumpster $ 0 Food Service- $ El Funeral Directors • Massage Establishment $ • Massage Practice $ • Offal(Septic)Hauler $-- • Recreational Camp $ • Sun tanning • Swimming Pool • Tobacco $ • Trash/Solid Waste Hauler $ • Well Construction $ SEPTIC Systems: * Septic-Soil Testing $ * Septic-Design Approval $ * Septic Disposal Works Coustructioti(DW0 $ * Septic Disposal Works histallers(DWI) $ * Title 5 Inspector $ Title 5 Report s-,5 r 0 Other. (Indicate)--- $ I He-a'hh-Agent Initials White-Applicant Yellow-Health Pink-Treasurer