HomeMy WebLinkAboutTitle V Inspection Report - 230 GRAY STREET 8/15/2018 Commonwealth of Massachusetts
s
tr r1z
Title 5 Official Inspection Form C
NED
7_ 4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
NN
230 Gray Street 4t,1novER
Property Address
Dat Le
Owner Owner's Name
iion is
requirenformatd for every North Andover MA 01845 8-10-2018
page. City/Town State Zip Code Date of Inspection
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:When
filling out forms A. Inspector Information
on the computer,
use only the tab -Neil James Bateson
key to move your Name of Inspector
cursor-do not Bateson Enterprises Inc.
use the return Company Name ----------
key. 111 Arqilla Road
Company Address
Andover MA 01810
State Zip Code
rswn 978-4754786 S1_15
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.006); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. R Passes
2. Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. El Fail
B67- 8-10-2018
-in--- e r'j Fail
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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5msp.doc-rev,7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
Property Address
Dat Le
Owner Owners Name
information is
required for every North Andover —-----------— MA 01845 8-10-2018
page. C.ity/Town State Zip Code Dateof—Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ 1 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:
—---------------
2) 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
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y 0 N ❑ ND (Explain below):
t5insp.doo-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray treet —-----
Property Address
Dat Le
Owner Owner's Name
information is
required for every NorthAndoverMA 01845 8-10-2018
page. CityrFown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
El Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
El broken pipe(s)are replaced ❑ Y N n ND (Explain below):
F1 obstruction is removed ❑ Y N F] ND (Explain below):
❑ distribution box is leveled or replaced n Y E N El 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):
El broken pipe(s)are replaced 0 Y ED N n ND (Explain below):
El obstruction is removed 0 Y E N El ND (Explain below):
—------------ -.
3)
---------
3) Further Evaluation is Required by the Board of Health:
F] 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.
a. 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:
t5insp.doc,•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
-_. Title 5 Official Inspection Form
mm i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
Property Address
Dat Le
Owner Owner's Name
information is
required for every North Andover ---------- -MA---- 01845 8-10-2018
page. d7ty-[Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
F] Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fall unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
[I 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.
E] The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
E] The system has a septic tank and SAS and the SAS is within 60 feet of a private water
supply well.
F1 The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for 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.
c. Other:
Remove trees around d-box& leach area
4) 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
EJ clogged SAS or cesspool
F] E Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/2612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
Property Address
Dat Le
Owner Owner's Name
information Is
required for every North Andover MA 01845 8-10-2018
page. City Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems, (cont.)
Yes No
F1 0 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
El 0 than "/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
D 0 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
El 0 tributary to a surface water supply.
El El Any portion of a cesspool or privy is within a Zone I of a public water supply
well.
El 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
El 0 The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
El 0 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,
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section C.4.
Yes No
0 D 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
R EJ the system is located in a nitrogen sensitive area(interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
15IMp.doc,•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street --------
Property Address
Dat Le
Owner Owners Name
information is
required for every North Andover MA 01845 8-10-2018
page. .City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304, The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
0 r-1 Pumping information was provided by the owner, occupant, or Board of Health
E] 0 Were any of the system components pumped out in the previous two weeks?
E F1 Has the system received normal flows in the previous two week period?
El 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
1Z EJ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
E El Was the facility or dwelling inspected for signs of sewage back up?
0 n Was the site inspected for signs of break out?
[A El Were all system components, excluding the SAS, located on site?
• El Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
• El Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
• El 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)]
15!nsp.doc-rev.712612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
Property Address
Dat Le
Owner Owners Name
information is
required for every North Andover MA 01845 8-10-2018
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 555
50
Description:
3
Number of current residents:
Does residence have a garbage grinder? El Yes 9 No
Does residence have a water treatment unit? El Yes N No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection El Yes N No
information in this report.)
Laundry system inspected? ❑ Yes R No
Seasonal use? D Yes E No
Water meter readings, if available(last 2 years usage (gpd)): Yes
Detail:
Sump pump? El Yes 0 No
Last date of occupancy: Current
Date
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
Property Address
Dat Le
Owner Owners Name
information is MA 01845 8-10-2018
required for every North Andover
page. Cilyfrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 16.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? n Yes El No
Water treatment unit present? El Yes F1 No
If yes, discharges to:
Industrial waste holding tank present? El Yes Ej No
Non-sanitary waste discharged to the Title 5 system? 0 Yes El No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
--------------
3. Pumping Records:
Source of information: Pumped 2016, owner
Was system pumped as part of the inspection? Z Yes M No
If yes, volume pumped: 1500 -------
gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank&tees
(51nsp.doe-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
Property Address
Dat Le
Owner Owner's Name
information is North Andover MA 01845 8-10-2018
every
required for eve
page. City/Town--` State Zip Code Date of Inspection
D. System Information (cont.)
4. 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)
El 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 UA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
13_years q1q, 11-16-2005, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes No
5. Building Sewer(locate on site plan):
1.3
Depth below grade: feet
Material of construction:
El cast iron El 40 PVC F other(explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" PVC through wall, 3" PVC in house, no leaks visible
-—-------------------
t5insp.doo-rev.7126/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
�j ❑( Title 5 Official Inspection Form
fT Form Not for Voluntary Assessments
Subsurface Sewage Disposal System
230 Gray Street
Property Address
Dat Le
Owner Owner's Name
information is North Andover MA 01845 8-10-2018
required for every
page. di-t-yfTown -State -Zip Code Date of Inspection-
D. System Information (cont.)
6. Septic Tank(locate on site plan):
0.3
Depth below grade:
Material of construction:
Z concrete El metal ❑ fiberglass F1 polyethylene ❑ other(explain)
-----------
------------
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) M Yes El No
10'x 5'x 4'
Dimensions:
Sludge depth: 211
---
3111
Distance from top of sludge to bottom of outlet tee or baffle ------------
1 IX
Scum thickness
811
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 1411
How were dimensions determined? 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.):
Inlet tee ok. Outlet tee Ok. Depth of liquid at outlet invert. No evidence of leakage. Inlet&outlet cover
has riser 2" deep.Pumped septic tank.
15insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
Dat Le
Owner Owner's Name
information is
required for every North Andover MA 01845 8-10-2018
Zip Date of
page. Cityrrown State Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: �e—et---
Material of construction:
F-1 concrete El metal ❑fiberglass ❑ polyethylene E] 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.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
R concrete F1 metal El fiberglass El polyethylene ❑ other(explain):
.......... ...........
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
-Property Address
Dat Le
Owner Owner's Name
information is
required for every North Andover MA 01845 8-10-2018
page. CityfTow IT State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: 0 Yes El No
Alarm level: Alarm in working order: El Yes [I No
Date of last pumping: -Ua-te ------
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? El Yes El No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0 -1-------------
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.):
D-box level &distribution equal. No evidence of leakage. No evidence of carryover. Evidence of tree
roots in d-box. Trees growing around d-box & [each area needs to be cut down.
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
--..--
Property-Address
Dat Le
Owner Owners Name
information is North Andover MA 01845 8-10-2018
required for every
page. C5jt-yrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: E Yes El No*
Alarms in working order: E Yes R No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber ok. Pump ok. Alarm ok,Alarm has both audible &visual.
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
E-1 leaching pits number:
leaching chambers number: 18
❑ leaching galleries number:
El leaching trenches number, length:
❑ leaching fields number, dimensions:
D overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doo-rev,712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
—------------------
Property Address
Dat Le
Owner Owner's Name
information Is
required for every North Andover MA 01845 8-10-2018
page. dii�y—/To—wn -§—tate Zip Code Date of Inspection
D. System Information (cont.)
11, Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface. Three rows of infiltrator chambers, six
chambers per row
------- ---
---------- ---------------- ------
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth–top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
-—---------—--------
-----------
t6insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
�ir—operj-A—ddre-s—s ---
Dat Le
Owner Owners Name
information is North Andover MA 01845 8-10-2018
required for every
page. C5t—yffown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
............
—-------------
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
.
�_p Title 5 Official Inspection .Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street ---------
Property Address
Dat Le
Owner Owners Name
information is
required for every North Andover MA 01845 8-10-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
Ar
} a5oa �' -- 3a `
(-OUJ
co
t5insp,doo-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
Property Address
Dat Le
Owner Owner's Name
information Is
required for every North Andover MA 01845 8-10-2018
-67
page. Itiftown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Z Check Slope
Surface water
Check cellar
Shallow wells
4
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
z Obtained from system design plans on record
If checked, date of design plan reviewed: 8-16-2004Date
El Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Design plan ---------------—
El Checked with local excavators, installers-(attach documentation)
F-1 Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
As per design plan test pit data
---—------ -—----------
------—-------
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15insp.doe-rev.712812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Gray Street
Property Address
Dat Le
Owner Owners Name
information is
required for every North Andover MA 01845 8-10-2018
page. Gityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspector Information: Complete all fields in this section.
B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
C. inspection summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6 (Checklist) completed
D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
ow"m"vRecord Card generated on 81712018 1:27:52 pwbyKaren Hanlon Page
Town mfNorth Andover �
Tax Map # 210~107~D-0128-0000~0
Parcel Id 22684
'
230 GRAY STREET
DAT &AMANDA LE
230 GRAY STREET
NORTH ANDOVER MA 01845
Class 101 Single Family Property Type 1 Residential
Size Total 1.31 Acres
FY 2019
UB Mailing Index
Type Loan Number xctivoOnaot. From Vnd|
DAT&AMANDA Ls Owner Amive
23UGRAY STREET
NORTH ANDOVER M801045
STELLA, MARY A Previous Customer Inactive 10/1/2005
C/O JANET M, KL|SKA.TR
1OOGRAY STREET
NORTH ANDOVER, mA
o1o^5
L|TCMP|ELDCO. Previous Customer Inactive 12/712005
2ORAY AVENUE
BURLINGTON, MAO18U3
TONGH8N Previous Customer Inactive 7/29/2811
34HARWICH ROAD
CHESTNUT HILL,MAOz4G7
CYNTH|AUU Previous Customer Inactive 8/17/2012
S4HARWICH ROAD
CHESTNUT HILL, M88u40r
gANDRAH8N Previous Customer Inactive 2129/2016
34HARWICH ROAD
CHESTNUT HILL MAV24d7
UB Account Maint.
Account No Cycle Occupant Name xotivel|nacUvm
Bldg |g. 177O8.O'23DGRAY STREET Last Billing Date 5/7/2018
1090515 81 Cycle 01 Active
UB Services Maint.
Account No. 1O$0515
Service Code Rate Charge Mu|dp|imrlUmem
M|SCFsEADMIN FEE 0.635/8 7.02 1/1
VVTRVVATER n1ALL METER SIZE 41.80 1/1
U13 Meter Maintenance
AnoountNo. 189ns15
Serial No Status Location Brand Type Size YTD Cons
32421970 aActive 00 bBadgm wVVater 0.680.03 1793
Date Reading Code Consumption Posted Date Variance
7/19Y2018 2140 aAcma| 8 '20%
4/18/2018 2139 aAutua| 11 5/17/2018 0796
1/102018 2128 oActua| 6 2/20/2018 48%
10102017 2122 oActma| 4 11/13/2017 -35%
7/19/2017 2118 oAutua| 6 8n5/2017 98%
4/1912017 2112 aAotum| 8 5/17/2017 -20.N
1/19/2017 210$ aActuu| * 2/16/2017 '3%
1019/2016 2105 aAmuo| 4 11/16/2016 -49%
7/22/2816 2101 aAumm| 8 8/16/2016 rO%
Commonwealth of Massachusetts
CWTown of
Syitem Pumping. co
Fcprrn 4
DEp hn provided,his fornf for um by fowl Scmrds of Health. Other formb may bows , but the
inform adon-mint he sub Dint provided here. Before usinp.this form,amok with your
iocil Board of Health to determine ft IWh they use.TheSystom Pumping Record must he subrnitted
the local Board of Health or
A. FaCIMYInfo � tIon
3. System Location, Left i Right front of ho l Righ f�y'i L9 f right side of mouse, i_.e /
fo Flight kis ng, L / i of building, Left! g�"i ` b , Under deck
AddMa
Ir zip 6
2'. System Ownw.
f
.
Pqmping Kpcord
1, Date of Pumping Pumped:
3. Type ofsysternl [3 , °T k Tight Tank
(J- Other(d ): �Nco
, Effluent Too f^ pray t? Ej `r~ if yes, was it cleaned? Yes NQ
6, Condition of.
& System Pumped W.
NW-B 1
Nam VON*LkWM MMW
B E In c
7. Location wtiers content&vwere disposed:
ow
W 'VV
WormCdoo,OWS rd P 9 Of 7
wo RY
Town of North Andover
HEALTH DEPARTMENT
�SSAC
CHECK #:
DATE: .
Y'
LOCATION: ry L
7--
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License.: (Check box)
0 Anitnal $
• Body Arte Establishment
• Body Ail Practitioner
0 Dunipster
0 Food Service-
0 Funeral Directors
• Massage Establishment
• Massage Practice
• Offal(Septic)Hauler $
• Recreational Camp
• Sun tanning
• Swimming Pool
0 Tobacco
0 Trash/Solid Waste Hauler
[J Well Construction
SEPUCEystems.
0 Septic-SoilTesting
0 Septic-Design Approval
0 Septic Disposal Works Construction(DWG)
0 Septic Disposal Works Installers(DVVI)
j �/)
0 Title 5 Inspector � c f
Title 5 Report $
0 Other:(Indicate),—.—,----
Flea„
Ith'Agent Initials
White®Applicant Yellow-Health Pink- Treasurer