HomeMy WebLinkAbout- Title V Inspection Report - 246 CANDLESTICK ROAD 10/11/2018 Commonwealth of Massachusetts RECEIVED
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Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments TQVVNCFNORTHANDOVER
HEALTHO&RARTMENT
24S Candlestick Road
Property Address
Tom Young
Owner Owner's Name
information is
required for every NorthA MA 01845 09/1
page. City/Town State Zip Code Date m|nopem|�n
Inspection results must be submitted mn this form. Inspection forms may not be altered |nany
way. Please see completeness checklist mt the end of the form.
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Company Name
key.
46 Lizntby Drive
Company Address
Q Marl Marlborou h MA 01752
City/Town State Zip Code
S| 1375A
^--~~--~ Telephone Number License Number
B. Certification
| certify that: yammmD2Papproved system inspector |n full compliance with Section 1G34Opf Title S
(310 CK8R 15.000); | 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 | have determined
that the system:
1. Peosun
2. Conditionally Passes
3. Needs Further Evaluation by the Local Approving Authority
4. Fl Fails
0A/17/2O18
|r?9poum,'aa/gnatun, 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 ut the time mf inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
/n the future under the same or different conditions of use.
»r� Commonwealth of Massachusetts
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Title �� Official� Inspection �-��wmmn
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Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments
24O Candlestick Road
� Property Address
TomYoun
Owner Owner's Name
information is
North Andover MA 01845 09/17/2018
required for every
page. 6t7yifown State Zip Code Date of Inspection
C. Inspection Summary
inspection Summary: Complete 1' 2, 3. or5 and all of4 and 8.
1\ System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310CK8F< 15.303nr|n 310CK8R 15.304exist. Any failure criteria not evaluated are
indicated below.
Comments:
Q\ System Conditionally Passes:
Fj 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
debermined^" please explain.
The septic tank io metal and over 2O years old*o[the septic tank metal nr not) ksstructurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank |a replaced with e complying nnptiubanhanappnovedbyth* 8nerdof
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 io less than 2O years old iaavailable.
n Y F-1 N ND(Explain below):
Commonwealth of Massachusetts
Title 5 Official Inspectionto Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
246 Candlestick Road
Property Address
Tom Young
Owner Owner's Name
information is
required for every North Andover MA 01845 09/17/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
E] 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 El Y 0 N El ND (Explain below):
F-1 obstruction is removed R Y 0 N F1 ND (Explain below):
M distribution box is leveled or replaced 0 Y n N F-1 ND (Explain below):
Distribution box is rotted and needs to be replaced.
❑ 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):
F1 broken pipe(s) are replaced El Y F] N ❑ ND (Explain below):
F-1 obstruction is removed El Y El N 0 ND (Explain below):
..........----
..........
3) Further Evaluation is Required by the Board of Health:
F1 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System-Page 3 of 18
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Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments
240 Candlestick Road
Property Address
Tom Youn
Owner Owner's Name
information is North Andover MA 01845 09V17/2018
required for every ---- �------
page. �itynovn State Zip Code Date nfInspection
C. Inspection Summary (cont.)
R Cesspool or privy im within 5U feet ofe surface water
n Cesspool or privy ia within 5O feet ofa bordering vegetated wetland Vra salt marsh
b. System will tm|| unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in m manner that protects the public hea|th,
safety and environment:
F-1 The system has a septic tank and soil absorption system (SA8)and the SAS |swithin
18O feet ofa surface water supply or tributary toa surface water supply.
F-1 The system has a septic tank and SAS and the SAS is within a Zone ofa public water
aupp|y�
F-1 The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
Fj The system has a septic tank and SAS and the SAS ie less than 1O0 feet but 5Ofeet or
more from a private water supply vve||*°.
Method used to determine distance:
^°This ayobam passes if the well water analysis, performed at a DEPoertifimd |abonatory, for fecal
on|ifnrm 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.
o. Other:
4\ System Failure Criteria Applicable bmAll :
You must indicate "Yee" or"No°to each ofthe following for all inspections:
Yen No
[�[�
Backup ofaevvage into faoU|tynr system component due to overloaded or
�� �� clogged SAS orcesspool
�� �� d
Dixohmrgeorpond|ngof��|ugntto �hneuaneVfthogroumdorau�ecewahare
�� �� due toan overloaded or clogged SAS nrcesspool '
c "y Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ry
246 Candlestick Road
Property Address
1
Tom Young
Owner Owner's Name
information is North Andover MA 01845 09/17/2018
required for every �_....._—_..... ___ _ State Zip Code Date of Inspection
page. City/Town ... p p
C. Inspection Summary (cunt.)
4) System Failure Criteria Applicable to All Systems: (cunt.)
Yes No
❑ ® 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 Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ H 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.
❑ E Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system falls. 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 CA.
Yes No
® El 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
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
..... Title 5 Official Inspection Form
- n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,:, ❑ 246 Candlestick Road
Property Address
Tom Young
Owner Owner's Name
-
information is North Andover MA 01845 09/17/2018
required for every �.._.._ _....._
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cant.)
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 foray inspections:
Yes No
0 ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
® ❑ information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
----------
F Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
246 Candlestick Road
Property Address
Tom Young
Owner Owners Name
information is
required for every North Andover MA 01845 09/17/2018
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
4 Number of bedrooms (design): Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD
Description:
The system is made u of a septic tank, distribution box and soil absorption system.
Number of current residents:
Does residence have a garbage grinder? El Yes 0 No
Does residence have a water treatment unit? ❑ Yes No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection Yes No
information in this report.)
Laundry system inspected? El Yes E No
Seasonal use? El Yes H No
46 GPD
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Usage: 336 x 100 = 33,600 gallons 730 days =46 GPD
............
Sump pump? ❑ Yes No
Last date of occupancy: Current
Date
t5insp.doc.-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Summary Record Card generated on 9012M 9:12:40 AM by Karen Hanlon Page I
Town of North Andover
Tax Map # 210-106.A-0201-0000.0
Parcel ld 17345
246 CANDLESTICK ROAD
YOUNG JR, THOMAS C
246 CANDLESTICK ROAD
N. ANDOVER, MA
01845
-------------
Class 101 Single Family Property Type I Residential
Zonlng2 I Residential ZonIng3 1 Residential
Size Total i Acres
FY 2019 —-----
UB Mailing Index
Name/Address Type Loan Number AGtive/Inact, From Until
YOUNG JR,THOMAS C Payor Actiw�
246 CANDLESTICK ROAD
N.ANDOVER,MA
01845
r
UB Account Maint.
Account No Cycle Occupant Name Activefinaotive
Bldg Id. 17682,0-246 CANDLESTICK ROAD Last Billing Date 7/18/2018
3170362 03 Cycle 03 Active
UB Services Maint.
Account No.3170352
Service Code Rate Charge Multiplier/Users
MISCFEEADMIN FEE 0.63 518 7.82 1/
WTR WATER 01 ALL METER SIZE 76.00
UB Meter Maintenance
Account No,3170352 Size YTD Cons
Serial No Status Location Brand Type 2096
36388073 a Active ERT HH b Badger w Water 0.630.63 Varince
Date Reading Code Consumption Posted Date a
6/11/2018 2085 aActual 20 7/23/2018 440/(
3/712018 2065 a Actual 13 4/2312018 -44%
1217/2017 2052 a Actual 22 1/2512018 -68%
9/12/2017 2030 a Actual 77 10/18/2017 184%
6/8/2017 1953 a Actual 26 7/2512017 93%
3/8/2017 1927 a Actual 13 4/1212017 -51 OX
12/9/2016 1914 a Actual 27 1/23/2017 -73/')
91912016 1887 a Actual 95 10124/2016 141%
6113/2016 1792 a Actual 43 8/2/2016 1880/r
319/2016 1749 a Actual 14 4/2212016 -85%
12/10/2015 1735 a Actual 98 1/20/2016 -11%
9/9/2015 1637 a Actual 98 10/16/2016 61%
6/1012015 1539 a Actual 61 7/24/2015 72%
3/11/2015 1478 a Actual 35 4/28/2015 -21%
12111/2014 1443 a Actual 45 111512015 -56%
9111/2014 1398 a Actual 101 10115/2014 153%
6/11/2014 1297 a Actual 40 7/16/2014 41%
3111/2014 1257 a Actual 28 4/1112014 1%
12110/2013 1229 a Actuai 27 1117/2014 -79%
9/12/2013 1202 a Actual 135 10115/2013 105%
6112/2013 1067 a Actual 65 7/24/2013 73% 1
3/1312013 1002 a Actual 38 4/2212013
12/11112012 964 a Actual 39 1/9/2013 4/6
9/13/2012 925 a Actual 114 1011512012 151%
6/1212012 811 a Actual 44 7/1612012 34%
3/1412012 767 a Actual 34 4/14/2012 -28%
1211212011 733 a Actual 46 1/1712012 -71%
9/1212011 687 a Actual 170 10/13/2011 39%
6/712011 517 a Actual 115 7/2012011 16%
^
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Subsurface SemoageDisposal SVmtmnnFormn ~ NotforVo|un�mryAaaeasmentg
240 Candlestick Road
Property Address
T mYnun
Owner Owner's Name
information is North Andover MA 01845 09/17/2018
required for every ------ �-------
page. City/Town State Zip Code Date nfInspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type ofEstablishment:
Design flow(based on31OCMR162O3): Gallons per day(gpd)
Basis of design flow(mea\a/pgreons/eq.ft.. etc.):
Grease trap present? El Yee El No
Water treatment unit present? El Yes El No
If yes, discharges to:
Industrial waste holding tank present? El Yes El No
Non-sanitary waste discharged to the Title 5system? Yee [_1 No
Water meter readings, if available:
Leatdoteofonoupanuy/uoa: Da�e
Other(describe bn|um/):
3. Pumping Records:
Source ofinformation: VVindRiverEnvironmenha| -Seeottaohedrecord.
Was system pumped ou part uf the inspection? Yen 0 No
1500
If yes, volume' ' ga|ions
Thetit measured by tho t k
Hnvvvvmsquantdypumped determined?
To check h — | i to i of the septictank.
Reason for pumping: '— -
Work Order# 0207099357 Cust# 1044715 Customer Since: 2 0 0 0 Tax: 6 . 2500
0
Job Comments Tech Comments
09/17/2018 WRE to pull plans - Title 5 inspection SVC 1500 Cover(s) secured. 20183701596.
cover in front yard ,consent form in George, water usage 5/20/16 Replaced cover with a new 18" Poly cover. (RH)ds
sent to Kerri- cc on file (dg) 5/16/16 Serviced tank. Removed top solids & heavy
bottom sludge. Cover has cracks in it. (ARV)ds
I
System Owner System Location
Tom Young [North
mary Home
246 Candlestick Road Candlestick Road
North Andover, MA 01845 Andover, MA 01845
(978) 273-6363 ng Tom : (978) 273-6363
Service Date: MON 09/17/2018 01:30 FM Frequency: Call to Confirm:
Service Type: Standard Previous Service: 09/10/2018
Approx. Gals: 1500 COLS: 1.2/13/2002 Location Details:
Depth Below Grade:0 Custom Clean:
Cust Home: YEs Filter:
Township: Inspection/T5:
County: Essex Build Up:
Description >' ,,,,,,`f fJfr7 fce " �! �t Wrd+
Inspection Title 5 (not including pumping) 1,op $ 535,0000, $ 535.00
Inspection (Labor/Exposure Fees)per' hr, ' 1.q0 ' $ 1849990 $ 185.OQ
Inspection Title 5 BOH Fees 1,,00 $ 50.0000 , $ $0.00
Pumping 1001 - 1500 _ 1.00 $ 310.6030 '$- 310.60, .
Environmental Compliance - Residential. 1.00 $ 3.0000 $ 3.00
Fuel / Energy Recovery 1100 $ 88.7880 $ 88.79,
Subtotal; $ 1172.39 we suggest these 3 keys steps to keep your system heatthy:
Tax $ 0.00 d Regular servicing
Use CCLS bacteria additive
Totat $ 1172.39 . Use a filter
Disposal Site: Disposal Volume: Payment Detail:
Waste Code ; 0.0000
Visa xxxxxxxxxx6796 07/2023
Sales Rep : CSR : Dawn Grenier Due on Receipt
Truck : Technician : Robert Herrick On Site : 01:46 PM P 0 Number
Tech Notes :
System Operating Fine. Normal water level. Light top solids. Moderate bottom
sludge. Both baffles are intact. Main line Clear. No filter is present on the
tank; current tank is not designed to be used with a filter. Recommended Boost
additive, COLS additive. Cover(s) secured. Repairs needed: Distribution box
needs replacement. X
Customer Signature
ENVIRONMENTAL
Remit payment to 46 Lizotte Dr Suite 1000,Marlborough,MA 01752
^
Commonwealth of Massachusetts
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Title �� ���� � �����w� �� ����p��������um Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
248 Candlestick Road
— Property Address
Tom Young
Owner Owner's Name
information is NorthAndover
K8A 01845 09/17/2018
equi�dfor evn� "'
���—� ��oe Zip Code Date of|nnpo�mo
* Q��owm
D. System Information (cont.)
page. '
4. Type pfSystem:
0 Septic tank, distribution box, soil absorption system
El Single cesspool
[l Overflow cesspool
E] Privy
El 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 |/4 system by system operator under contract
Tight tank. Attach a copy nf the DEP approval.
0 Other(describe):
Approximate age of all components, date installed (if known)and source of information:
Unknown
Were sewage odors detected when arriving at the site? Fl Yes No
5. Building Sewer(locate on site p|an):
20"
Depth below grade: heo{
Material of construction:
N cast iron El4OPVC F1 other(exp|a|n):
Distance from private water supply well ' Town��WaterWater. feet
Comments (on condition of joints, venting, evidence of leakage, mb:]:
.All thejoints�,look to be solid.There are no signs of leakage. nted through building
�
. .
Commonwealth of Massachusetts
Title=�'°��N�� �� ��`���°�����N 0����������������� ����0��*� �
�� �=�� � �����m� �wm������������mm N-��m � mm �
Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments
246 Candlestick Road
Property Address
Tom.,Y
----
Owner Owner's Name
information is North Andover MA01@4b OS/1�/�018
mqoie�hmrevo�
page. City/Town State Zip
Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site p|an):
13"
Depth below grade: feet
Material of construction:
concrete metal F-lfiberg|asa Fl polyethylene [l other/exp|o|n\
If tank is metal, list ago'' yemm
|aagnconfionedbyaOerifioabeofCw0p|iance7 (athanhaoOpyofnerUfcaba) El Yes El No
11'x0' x5'
Dimensions:
0"
Sludge depth:
1910
Distance from top of sludge h> bottom of outlet toe or baffle
1"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum ho bottom of outlet tee orbaffle 31"
T yW d SludgeJudge,.-
How�eradimene|oned��ermin�d? -
�
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels am related to outlet invert, evidence of leakage, gtc]:
Recommend pumping as needed. The inlet and outlet are solid. There are no signs of leakage. The
U |d |eve| is OK in relation to the inverts.
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
.. n
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
246 Candlestick Road _..
Property Address
Tom Young
Owner owners Name
information is North Andover MA 01845 09/17/2018
required for every ___—__._...._. _...._ _.._ _..... __.__ — _
page. Clty/Town State Zip Code date of Inspection
D. System information (cont.)
7. Grease Trap (locate on site plan);
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain):
Dimensions:
Scum thickness _.....__._. __.............
Distance from top of scum to top of outlet tee or baffle _._....._. _................-
Distance from bottom of scum to bottom of outlet tee or baffle -- - _........_....
Date of last pumping: Data.....__..
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:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: _._............._..,_,._.____ _..ww_..........._
Capacity: _ .. .,.._.. -
gallons
Design Flow; gallons per day
15insp.doc•rev,7126/201 B Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Form Not for Voluntary Assessments
Subsurface Sewage Disposal System
246 Candlestick Road
Property Address
Tom Yoqng__,
Owner Owner's Name
information is North Andover MA 01845 09/17/2018
required for every --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: El Yes 0 No
Alarm level: Alarm in working order: El Yes El No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? 0 Yes R No
9. Distribution Box(if present must be opened) (locate on site plan):
0..
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The distribution box is rotted and needs to be replaced.
.............
...............
t5insp.doc rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
<4f."N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
246 Candlestick Road
Property Address
Tom Youna
Owner Owner's Name
information is North Andover MA 01845 09/17/2018
required for every --- —--- ---- - i
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: 0 Yes El No*
Alarms in working order: R Yes R No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
............
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:
El leaching pits number: -----------
❑ leaching chambers number:
❑ leaching galleries number:
leaching trenches number, length: 2 x 50'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
El innovative/alternative system
Type/name of technology: -......
t9insp,doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
/
Commonwealth of Massachusetts
Title��°����� �� �~������=��N N����������������� ����Nr���
�� ��y� � ������� �mm=����p���N��mm N-��� mmm
Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments
248 Candlestick Road
Property Address
Tom Youn
Owner Owner's Name
information is North Andover MA 01845 0A/17Y�O18 |
required�orav*ry -State- ----�--- �
Q�� ��m{o Zip�vdo Date ov|nmpoonnn
page. '^~'
D. System Information (cont.)
11. Soil Absorption System /SAS\(conL)
Comment (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The soil io dry. There are no signs nf hydraulic failure. Noponding. The vegetation isnormal for the
area.
12. Cesspools (cesspool must bo pumped oa part Vf inspection) (locate on site o|an>:
Number and configuration
Depth-top of liquid to inlet invert
Depth uf solids layer
Depth of scum layer
Dimensions ofcesspool
Materials of construction
Indication of groundwater inflow R Yee El No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
mm"^mm'~.7/26m0/8 Title n Official Inspection Form:Subsurface Sewage Disposal System'Page/4m10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
f, 246 Candlestick Road
Property Address
Tom Youn _._. _...
Owner Owner's Name
information is North Andover MA 01845 09/17/2018
required far every _ _—..._ _...__. _ �__.... _....... .._..., __
page. City/Town 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.):
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
246 Candlestick Road
Property-Address
Tam Yaung
Owner Owner's Name
information is North Andover MA 01845 09/17/2018
page. -----------
required for every Cityrrown ------- 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
D
tsinsp.doo-rev 71'e612018
T"fle 5 Official hspedon Form;$Ubsjrtace Sewage disposal system.page 18 of 18
Commonwealth of Massachusetts
qA .m _._ _ Title Official Inspection Form
_p_77- n
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
246 Candlestick Road
Property Address
Tom Young
Owner Owner's Name
information is North Andover MA 01845 09/17/2018
required for every .. _.... —......_ _ _ ._ —...
page. Cltyifown State Zip Code Date of Inspection
D. System Information (cant.)
15. Site Exam:
® 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:
Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
The Title V for 240 Candlestick Road shows ground water at 124". Noted 4'+ above due to the fact
that this information is from a neighboring property. Cannot be certain of the exact depth on this
rp operty. Propertydoes oes slope off and there is an in round pool in the backyard.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.//26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
c Commonwealth of Massachusetts
xr= Title 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
246 Candlestick Road --
Property Address
Tom dun
_._ ._ ._...._ .....,..._ _ ..._. ........_.
Owner
Owner's Name
information is North Andover _ _ MA 01845 09/17/2018 1
required for every -- _................. .._--
page. CltylTown State Zip Code Date of Inspection
E. Report Completeness Checklist 1
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.7/26/2018 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System Page 18 of 18
tkORTH
Town of North Andover
HEALTH DEPARTMENT
CH
CHECK#: 15 DATE:
2
LOCATION:.
H/O NAME:-
CONTRACTOR NAME: _
Type of Permit or License: (Check box)
0 Animal
• Body Art Establishment
• Body Art Practitioner
IJ Dumpster $
0 Food Service-Type:
0 Funeral Directors
0 Massage Establishment $
0 Massage Practice $
0 Offal(Septic)Hauler $
0 Recreational Camp $
0 Sun tanning $
0 Swimming Pool $
• Tobacco $
• Trash/Solid Waste Hauler $
• Well Construction $
SEPTIC Systems:
El Septic-Soil Testing $
0 Septic-Design Approval $-
0 Septic Disposal Works Construction(DW0 $
0 Septic Disposal Works Installers(DWI) $
0 Title 5 Inspector $
Title 5 Report $
0 Other. (Indicate)
He th--A- kent Initialsl
White-Applicant Yellow-Health Pink-Treasurer