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HomeMy WebLinkAbout- Title V Inspection Report - 265 HAY MEADOW ROAD 8/23/2018 Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection Form NJ(1 13 2 0 1[3 Subsurface Sewage Disposal System Form Not for Voluntary Assessments TOWN Or- MC)OVER jjF-A�jj�l[U-AMWEN'T 265 HavmeadowRd ---—---------- Property Address Serrano, Renee —----------- Owner Owner's Name information is required for every No. Andover MA 01845 07-18-2018 ---- . — ------......... 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 Immo out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not John DiVincenzo use the return key. Name of Inspector -------------- J and S Development Stewarts SepticService VQ Company Name 58 South Kimball St Company Address BradfordMA 01835 City/Town State Zip Code 978-372-7471 S113386 ............... 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 16.000). The system: El Passes Conditionally Passes ❑ Fails F-1 d F r Ev luation by the Local Approving Authority d Fj 1211 6,7) In ctor's Signature Date T" e Psystem inspector sUalat)bmit 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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doo rev.5116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts ` T0^tN 5 Official Inspection F om Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 265 Haymeadow Rd Property Address Serrano, Renee Owner Owner's Name information i's mqui�d�/ave� Nu� Andov�r MA 01845 0718-20 page. City/Town State Zip Code Date ufInspection B' Certification /coDf.\ | Inspection Summary: Check A.B.C.D or E/always complete all of Section D A) System Passes: r-1 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303orin 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 eyotem, upon completion of the replacement or napeir, as approved by the Board ofHealth, will pass. Check the box for"yeS''. "no" or"not determined" (Y. N. ND)for the following statements. |f"not determined," please eXp|g|n. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound' exhibits substantial infiltration orexfi|tnatiun ortank failure is imminent. System will pass inspection ifthe existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection ifitie structurally sound, not leaking and if Certificate of Compliance indicating that the tank is less than 2Oyears old is available. 0 y [l N F] ND (Explain be|nw): Commonwealth of Massachusetts ' Title 5 Official Inspection nspe= t=onF o0m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 265 Haymeadow Rd ------------ Property Address Serrano, Renee Omma/ Owner's Name information is required for every No. AndoverMA 01845 07-18-2018 pogo. City/Town State Zip Code Date ofInspection B. Certification (Conf.) E] Pump Chamber pumps/alarms not operational. System will pass with Board Of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (ount]: F] Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) ordue to e bnmkan, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): F] broken p|pe(e) are replaced [l Y [l N F-1 ND (Explain be|0w): n obstruction ieremoved [l Y |l N [l ND (Explain be|ovv : M distribution box is leveled or nap|ecad Z Y F� N F-1 NO (Explain below): Distribution box needs | d built F1 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 nfthe Board 0fNea|th): F1 broken pipe(s) are replaced El Y F� N F-1 ND (Explain below): [7 obstruction iaremoved F-1 Y [l N [I ND (Explain be|ovv): 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 hea|th, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.3O3(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: F Cesspool orprivy iawithin 5Ofeet mfasurface water Fl Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 265 Haymeadow Rd ----------- Property Address Serrano, Renee ...............- Owner Owner's Name information is - required for every No. Andover MA 01845 07-18-2018 -.1--- ,---------- —------ 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. F-1 The system has a septic tank and SAS and the SAS is within a Zone I 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 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 El E Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2day flow t5ins.doe-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title icil Inspection Form M Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 265..._Ha_y_ Meadow Rd s __ Property Address Serrano, Renee _ Owner __..._.... _..__.....w Owner's game information is No. Andover MA 01845 07-18-2.018 required for 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 forma ❑ 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 systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. 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 II 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts _T mmxTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,❑ 265 Haymeadow Rd Property Address Serrano, Renee Owner n-- ,-m6wer"s Nae information is required for every No. Andover MA 01845 07-18-2018 page. City/Town State Zip Code Date of Inspection Co 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? 0 El Has the system received normal flows in the previous two week period? 11 Z Have large volumes of water been introduced to the system recently or as part of this inspection? Z 1:1 Were as built plans of the system obtained and examined? (if they were not available note as N/A) Z F-1 Was the facility or dwelling inspected for signs of sewage back up? M F-1 Was the site inspected for signs of break out? • F-1 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? Z El Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: M F1 Existing information. For example, a plan at the Board of Health. Z 0 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): 4-5 DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x#of bedrooms): 440 t6ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 0 icial nspect on ❑orm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 265 Haymeadow Rd -------------------------------- Property Address Serrano, Renee Owner Owner's Name information is required for every No. Andover MA 01845 07-18-2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: ----------- -------------- ...... --------- ---------------------- Number of current residents: 2 Does residence have a garbage grinder? El Yes E No Is laundry on a separate sewage system? (include laundry system inspection El Yes N No information in this report.) Laundry system inspected? El Yes 0 No Seasonal use? ❑ Yes N No Water meter readings, if available (last 2 years usage (gpd)): Detail: ----- ...................... Sump pump? El Yes Z No Last date of occupancy: Occupied Date Commercial/industrial Flow Conditions: Typeof Establishment: _..._...._. ._.m._..._..._.. ........................................................... Design flow(based on 310 CMR 15.203): ----------------------------------------—---- Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes M No Industrial waste holding tank present? El Yes E] No Non-sanitary waste discharged to the Title 5 system? El Yes M No Water meter readings, if available: --------------- ..w...._-....___._ t5ins.doc-rev.6M6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 OfficialIn a i r _-- a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °a 265 Haymeadow Rd Property Address e Serrano, Rene -- - ..._... _ _.. ......_------------ — - - ---- —.... _ -- - __--------_-.w.w_..v... Owner Owner's Name information is No Andover MA 01845 07-18-2018 required for every _----.__........_. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: _ ___......w_....._. ___.._.._._._-._..-.._.._ Date Other(describe below): General Information Pumping Records: Source of information: ---- Was system pumped as part of the inspection? ® Yes © No If yes, volume pumped: 1500 ........._._-------------------------------.__ gallons How was quantity pumped determined? site gauge on truck Reason for pumping: inspect tank Type of System: z 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.doc-rev.6/16 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 5 265 Haymeadow Rd Property Address Serrano, Renee OwnerOwner's Name information is required for every No. Andover MA 01845 07-18-2018 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: 31 Were sewage odors detected when arriving at the site? Yes No Building Sewer(locate on site plan): Depth below grade: 4611 ------------- feet Material of construction: Z cast iron ❑40 PVC ❑ other(explain): _._..__...w.__...__._._._..._-----....._. Distance from private water supply well or suction line: fee-t --------------- ---------- Comments (on condition of joints, venting, evidence of leakage, etc.): ----------------------------------------------- .......... Septic Tank (locate on site plan): Depth below grade: B.T.G. feet Material of construction: Z concrete ❑ metal fiberglass ❑ polyethylene El other(explain) ----------------- ----------- If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No Dimensions: Sludge depth: —.__w........_..._._._ t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection or Subsurface Sewage Disposal System Form Not for Voluntary Assessments 265 Haymeadow Rd Property Address Serrano, Renee OwnerOwner's Name information is required for every No "A,n,dover MA 01845 07-18-2018 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 2711 Scum thickness Distance from top of scum to top of outlet tee or baffle 711 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? sludge judge/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.): Both baffles are in good shape -------------------- Grease Trap (locate on site plan): Depth below grade: feet Material of construction: M concrete El metal El fiberglass F-1 polyethylene F-1 other(explain): ----------- ............................. ....... Dimensions: ------------------------..----............ -----------1-1-------------................. 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: Date t5hs.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 &� Commonwealth of Massachusetts ........... .... W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 265-Haymeadow Rd ................... Property Address Serrano, Renee OwnerOwner's Name information is required for every No. Andover -------- MA 01845 07-18-2018 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 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 below grade: Material of construction: R concrete El metal ❑ fiberglass El polyethylene ❑ other(explain): ---------------------------- ................ Dimensions: Capacity: gallons Design Flow: -.1--....... gallons per day Alarm present: R Yes El No Alarm level: Alarm in working order: El Yes ❑ No Date of last pumping: ..Date Comments (condition of alarm and float switches, etc.): .............. ----------- --------------- Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc;-rev,6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth 0fMassachusetts ` Title 5 Official Inspection nsec = n F orm Subsurface Sewage Disposal SVstennFonn - Nuth)rVb|untaryAsseaannante 265 Haymeadow Rd Property Address Serrano, Renee Owner Owner's Name information is required for every No. Andover MA 01845 07-18-2018 page. City/Town State Zip Code Date o[Inspection D. System Information (cont.) Distribution Box (if present must baopened) (locate unsite p|mn\: Depth ofliquid level above outlet invert 8 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence ofleakage into orout Ofbox, ebc.): Box needs to be replaced. Leakage around outlet inverts .............. Pump Chamber(locate on site plan): Pumps inworking order: [l Yee El No* Alarms inworking order: El Yea Fl No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ° |fpumps uralarms are not inworking order, system iaaconditional pass. Soil Absorption System (SAS) (locate onsite plan, excavation not required): If SAS not |ocmted, explain why: Commonwealth of Massachusetts --- Tffle 5 Offidal Inspection Far Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 265 Haymeadow Rd Property Address Serrano, Renee Owner Owner's Name information is No Andover MA 01845 07-18-2018 required far every page. City/Town State Zip Code Date of Inspection Ido System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: -- - ❑ leaching galleries number; ® leaching trenches number, length: 4 - 32' ❑ leaching fields number, dimensions: -. ............------------ ❑ overflow cesspool number: _._._m...._._.._a._.__................ ❑ innovative/alternative system Type/name of technology; --......_..._....._.._.a..._,,,_.._.-____......___._.....--------------__ ---------------- Comments - --. Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure, no ponding, no damp soils 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 _._.m..._.._..........._...__.._._._..._a,,,....__.....-.._----_-----. Materials of construction — - Indication of groundwater inflow ❑ Yes ❑ No 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Pane 13 of 17 Co mirrionwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 265 H meadow Rd Property Address Serrano, Renee Owner Owner's Name information is No. AndoverMA 01845 07-18-2018 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): Materials of construction: ................................... Dimensions Depthof solids ._...._..—__----__.__-----------_---------------------- Comments -------------------------------------- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ..................... ........... t5ins.doc-rev.6116 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 265 Haymeadow Rd ........................... Property Address Serrano, Renee Owner Owner's Name information is No. Andover MA 01845 07-18-2018 required for every -------------------------------- page. CityfTown State Zip Code Date 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: EJ hand-sketch in the area below drawing attached separately 15ins,doc-rev,6116 Title 5 Official 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 265 Haymeadow Rd Property Address Serrano, Renee Owner Owner's Name information is required for every No. Andover MA-- 01845 07-18-2018 ................ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Z Check Slope R Surface water Z Check cellar F-1 Shallow wells Estimated depth to high ground water: 81 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: 04-02-2018 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) z Checked with local Board of Health - explain: Pulled file Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: —----------- You must describe how you established the high ground water elevation: Taken from design plans on file ---------- ............ .......... -------——------------ ---------------- -—---------- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts uTitle 5 OfficialInspection r .* Subsurface Sewage Disposal system Form - Not for Voluntary Assessments - a 265Haymeadaw Rd _.---___------ _.____........ Property Address Serrano, Renee Owner Owner's Name information is No Andover MA 01845 07-18-2018 required for 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 an page 15 or attached in separate file l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 + •f��+gyty✓i.tt•N�•'!'tDr� '��� tCi�'�t> g.14� �$+`� $`J � ,, � Gt�^ftCit'�-.1'tlOt�f I:+rsYC-IN tf9€•4i2 �. '� <��� 19t'�'€'t�iii•(-z1G1`I tic-ot.1T .IFjI•Z� N' 0 514P -I= pipe 4 3 €47.73 91AV's€•71lr T A® P!./4i { LAND LOCATION L-c;c ' _ '� % Nc7t2'Cti ,t+.t�1G+f3�lEi21 iviA. PREPARED FOR Mto►-.r--L t4&szltd® .��^ •o SCALE t``�'1 HATE�-*ir3aE YANKEE ENGINEERS IIO JACKSON ST. INEYtIUENp MA.01844 �sv�eswrw+7�+i,AyP.eguL-.X7�t�ar.gga a' °Y+4"DF. ..... .. . ,.r•. . i cr-:c:+'.':.t7-+�E:s ...�.u,:.-....n.:�o'Ev--•..r.•.«ws.ar.n: Page 10 of l I c d OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE iNSFOSAL SYSTEM INSPECTION FORM PART C SYSTEMMOORMATION(continued) PropertyAdaref°5 � 1 quer: - Date of Iaspectiont SKETCH OF SEWAGE DISPOSAL SYSTEM � Provide a sketch of the sewage disposal system including ties to at least two permanent reference laudmarks or Locate all wells within 100 feet Locate where public water supply enters the building. - ,,jj(( � r ��^� S, fJ 4� t t•4 � ` � [ :}- t: {1 � t - r 10 4 '1 0 Z Town o f North Andover v ysA HEALTH DEPARTMENT C CHECK##: DATE: LOCATION: H/0 NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) 0 Animal $ • Body Art Establishment • Body Art Practitioner 0 Dumpster $ • Food Service-Type:-, • Funeral Director,,; • Massage Establishment $ • Massage Practice • Offal(Septic)Hauler • Recreational Camp • Sun tanning • Swimming Pool 11 Tobacco 0 Trash/Solid Waste Hauler $ 0 Well Construction SEPTIC Systems: EJ Septic-Soil Testing $ * Septic-Design Approval $ * Septic Disposal Works Construction(DW0 * Septic Disposal Works Installers(DWI) * Title 5 Inspector , )(I( $ (" I i"I" I on, T ( 'Title 5 Report $ 0 Other. (Indicate),-- 0'.L 0, He lth,Agent Initials White Applicant Yellow-Health Pink-Treasurer