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HomeMy WebLinkAbout- Title V Inspection Report - 65 SUGARCANE LANE 10/31/2018 Commonwealth of Massachusetts „m E IVED _-= Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Sugarcane Lane TEOi OETi.lt100VFP Property Address Thomas Lyons Owner Owner's Name information is North Andover MA 01845 10-29-2018 required for every .. _ _...___..__ .._ —..._ page. Ctty/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 . Inspector Information T._._...___ filling out forms 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 _ __..__.....___ _... __..._ _...... _,._....._ -... key. Company Nape 111 Argilla Road Q Company Address ----- �� � Andover MA 01810 City/Town State Zip Code renrn 978-4754786 S115 _._....._...__ _._------....__.__a._ 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 15.000); 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. Passes 2. ® Conditionally Passes 3. F] Needs Further Evaluation by the Local Approving Authority 4. ❑ Fail 10-29-2018 __.___.._..._..._ __..._.....__..--- __.._._..............._. _ In pe tor s Signs#u 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 j 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. 15insp.doc-rev.712 512 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 1 of 18 '...., ^ Commonwealth olf Massachusetts °�����N �� Official N Inspection �� NN��� � ��N � N�N�� �������N��� ����� ^ Title __ ������ mm������ ���m � Form Subsurface Sewage Disposal System Form - Not for Voluntary AsseSsm8Ot$ 05 Sugarcane L Property Address Thomas L Owner 0w*e/oNome information is required for every North Andover MA 01845 10-29-2018 page. C|tyfTvwn State Zip Code Date of C. Inspection Summary Inspection Summary: Complete 1. 2. 3. or5 and all of4 and M. 1\ System Passes: [l | have not found any information which indicates that any of the failure criteria described in 310CW1R 15.303 or in 310 C[NR 15.304emist. Any failure criteria not evaluated are indicated below, Comments: 3) System Conditionally Passes: �O 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." p|nmoe 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 im less than 2U years old is available. El y 0 N Fl ND (Explain below): ' Commonwealth of Massachusetts ��°��N�� �� ��`��|���°��0 N������������°���� ����R���� � ��� �� Official Inspection �-�~� mwm �� �m ���� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Sugarcane Lane Property Address ThVnn sL Owner Owner's Name information is North Andover MA 01845 10-29-20 18 required for every page. �� te-- Zip Code Date ofInspection C. Unspect^on Summary (cont.) 2) System Conditionally Passes (conL): E] Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. Fl Observation of sewage backup or break out or high static water level in the distribution box due to Unokno or obstructed pipe(s) or due boa broknn, settled or uneven distribution box. System will pass inspection if(with approval nf Board ofHea|th): F-1 broken pipo(s) are replaced F| Y M N [l ND (Explain be|ow): 0 obstruction iSremoved Y 0 N [l ND (Explain be|nw): distribution box is leveled orreplaced Fl Y Z N El ND (Explain below): Fl 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 uf the Board ofHea|th): n broken pipe(a) are replaced El Y M N ND (Explain below): F1 obstruction is removed El Y E N Fl ND (Explain below): 3) Further Evaluation is Required by the Board of Health: Fl 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. a. System will pass unless Board of Health determines in accordance with 31UCK8R 15'303(1)(b)that the system |s not functioning ioa manner which will protect public health, safety and the environment: t5i";p.*,"'=`7o6o018 Title n Official Inspection Form:Subsurface Sewage Disposal System',"o.nm,v Commonwealth of Massachusetts =�"���N �� Official N Inspection �� Title N��0�� ���������� ����� ��0��k� � ���* �� ��y� � �� � � �� � Form m m m m ' m m m�m mm �~���� m��mm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 65 Sugarcane Lane Property Address Thomas Lyons Owner Owner's Name information is required for every North Andover MA 01845 10-29-2018 page. CityfTown !Statv��' Zip Code Date of Inspection C. Inspection Summary (cont.) �] Cesspool or privy is within 50 feet ofo surface water [l Cesspool or privy is within 5O feet nfa bordering vegetated wetland or salt marsh h. System will fail unless the Board of Health (mmd Public Water Supplier, if any) determines that the system is functioning ina manner that protects the public health, safety and environment: Fl The system has a septic tank and soil absorption system (SAS) and the SAS iawithin 1O0 feet ofa surface water supply or tributary too surface water supply. [� The system has a septic tank and SAS and the SAS is within a Zone 1nf a public water mopply� El The system has a septic tank and SAS and the SAD is within 5D feet ofa private water supply well. F-1 The system has a septic tank and SAS and the GAS is less than 100 h»e1 but5O feet or more from g private water supply we||°^ Method used to determine distance: This system passes if the well water ana|yein, performed at DEP certified laboratory, for fecal co|ifnrm bacteria indicates absent and the presence ofammonia 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 10 this form. o. Other: Outlet tee in septic tank&d-box needs tnbereplaced, 4\ System Failure Criteria Applicable tm All Systems: You must indicate°Yes° mr"No" to each #f the following for all inspections: Yen No BGckupofSgvV8ge into faoi|itv0[system C0rnpoOROtdue tO overloaded or ' clogged SAS or cesspool �� �� Discharge orpondingof effluent ho the uu�aceof the ground orsu�acevvohers �� �� due toan overloaded or clogged SAS orcesspool m/mp.o""'toy.nc6/2010 Title v Official inspection Form:Subsurface Sewage Disposal system'Page*m,a Commonwealth of Massachusetts Title 5 Official Inspection Form = }} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Sugarcane Lane Property Address Thomas Lyons _...._..._...._.._ ..............__ __.._.......... Owner Owner's Name information is required for every North Andover _ MA 01845 10-29-201 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cant.) _ 4) System Failure Criteria Applicable to All Systems: (cant.) 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 %day flow ❑ ® 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E 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 2000 gpd- 10,000 gpd. �❑ ® 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 CA. 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 El 1:1 Area—IWPA) or a mapped Zone II of a public water supply well 15insp.doc-rev.7126/2018 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 6 of IS I Commonwealth of Massachusetts a _ :; Title 5 Official Inspection Form n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e , 65 Sugarcane Lane Property Address Thomas Lyons Owner Owner's Name information is North Andover MA 01845 10-29-2018 required for every _____._ _._....a_ .,_ _---_.. ..__ __.......___,._. _ ._._ page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cant.) j 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 ❑ ❑ 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? M ❑ 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? 0 ❑ 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: Z ® 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.7/2 012 01 8 Title 5 Official hspection Form:Subsurface Sewage Disposal System•Pape 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 65 Sugarcane Lane Property Address Thomas Lyons ------- Owner Owner's Name information is required for every North Andover MA 01845 10-29-2018 — .......... page. 6—ty�o-w--n--- State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4----..— Number of bedrooms (actual): ----- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660-1-- Description: .............. Number of current residents: Does residence have a garbage grinder? F] Yes 0 No Does residence have a water treatment unit? ❑ Yes 2 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection r] Yes 0 No information in this report.) Laundry system inspected? El Yes n No Seasonal use? El Yes 0 No Water meter readings, if available(last 2 years usage (gpd)): Yes Detail: -11------------ --------- ......... Sump pump? ❑ Yes Na Current Last date of occupancy: t5hsp.doc•roe.7/2612018 Title 5 official Inspection Form:Subsurface sewage Disposal System-Page 7 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form . .... .......... Subsurface Sewage Disposal System Form Not for Voluntary Assessments 65 Sugarcane Lane Property Address Thomas Lyons ............ ----------- Owner Owner's Name information is required for every North Andover MA 01845 10-29-2018 page. Cityrrown State Zip Code b—ate—of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: ---------- Design flow(based on 310 CMR 15.203): GaBiansper day Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? n Yes El No Water treatment unit present? F-1 Yes n No If yes, discharges to: ----------- ------- Industrial waste holding tank present? D Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: ..._.a._.-.._.___._ Last date of occupancy/use: Other(describe below): 3. Pumping Records: Source of information: Pumped 2017, owner Was system pumped as part of the inspection? El Yes 0 Na If yes, volume pumped: gallons How was quantity pumped determined? .......... Reason for pumping: t5insp,doo•rev,7126/2018 Title 5 Official Inspection Form!Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts =0=���0�� �� m����������� 0��������=~�°���� ������Y�} Title �� �°�� � ���N��@ Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments O5 Sugarcane LaDg ThomasProperty Address Owner Owner's Name information is North Andover MA 01845 10-29-2018 required for every _ page. ~^»''`` �� ~' --Code Date of'Inspection D. System Information (coOt.) 4, Type mfSystem: E Septic tank, distribution box, soil absorption ayetem El Single cesspool [l Overflow cesspool E1 privy El Shared system (yes or no) (if yes, attach previous inspection records, if any) F1 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 uf the |6A system by system operator under contract Tight tank, Attach a copy nf the DEPapproval. [l Other(describe): Approximate age cf all components, date installed (if known) and source ofinformation: 26 vears old, 127 18S2 as built plan VVere sewage odors detected when arriving ai the site? El Yes E No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: 0 cast iron E4QPVC F] other(exp|ain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc1 Unable to see piping leaving foundation, finished cellar, 3" PVC in house, no leaks visible. Commonwealth of Massachusetts Title 5 Official Inspection For } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Sugarcane Lane Property Address Thomas Lyons Owner Owner's Name information is North Andover MA 01845 10-29-2018 required for every -_. ..,__ _._._. _.___ .___— __ _---_-� ___....a,_ _ __._. _.__._.._.__ page. CltyfTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 5 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: ------ -. _..------_- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 10' x5' x4' Dimensions: —_..-. --------- _.._— Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle NIA 1 Scum thickness _._._--.— _._ ___.----__. ---- Distance from top of scum to top of outlet tee or baffle NSA- Outlet tee corroded off. Distance from bottom of scum to bottom of outlet tee or baffle N/A Tape Measure _.- How were dimensions determined? -- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert„ evidence of leakage, etc.): Inlet tee ok, Outlet tee corroded off, needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. Center cover has riser 3" deep. tuinsp.doc-rev.7/26/2016 Title 5 Official inspection Farm:Subsurface Sewage Disposal System-Page 10 of 18 '........, Commonwealth of Massachusetts x - Tide 5 Official Inspection Form r _ a subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Sugarcane Lane Property Address Thomas Lyons Owner Owner` Name information is North Andover — MA — 01845 __— 10-29-2018 required for every _ _..__...-- page ..Yn State Zip Code Date of Inspection I D. _..System Information (cunt.) 7. Grease Trap (locate on site plan): Depth below grade: feet. — _.........._� 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: 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: of ❑ her concrete metal fiberglass polyethylene ❑ (explain): Dimensions: I gallan :Ca acit .._.—_..�. ..--... i p y s Design Flaw: g gallons per day t5inspAoe•rev.7126/2018 Titlo 5 o tiiciai Inspection Form:Subsurface Sewage Disposal System•Pape 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Sugarcane Lane ........... ------------------- Property Address Thomas Lyons Owner Owner's Name information is North Andover MA 01845 10-29-2018 required for every —------ page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: n Yes El No Alarm level: ------ Alarm in working order: F] 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? f-1 Yes n No 9. Distribution Box (if present must be opened) (locate on site plan): 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.): D-box cover broken, replaced it. D-box level & distribution equal. Evidence of leakage, has corrosion holes in box. Light carryover. ------------ t5imp.doc-rev.712 612 01 8 Title 5 Official Inspection Form Subsurface Sewage Disposal Sy I stein Page 12 of 18 Commonwealth of Massachusetts -_ Title 5 fficial Inspection Form n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Sugarcane Lane Property Address Thomas Lyons Owner Owner's Name information is North Andover MA 01845 10-29-2018 required for every ___._.._. ---------- page. page Clty[Town State Zip Code Date of Inspection D. System Information (cant.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ 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: 3 ® leaching pits number: ❑ leaching chambers number: -- [l leaching galleries number: ----- leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — ----- l5insp.doc•rev.7/26/2018 Tille 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 65 Sugarcane Lane -Property Address Thomas Lyons ........ Owner Owner's Name information is North Andover MA 01845 10-29-2018 required for every ---------- page. CityrTown State 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. Camera inside of leach pits, no liquid to inverts ............ 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 F-1 Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t6insp.doo-rev,712 612 01 8 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 65 Sugarcane Lane Property Address Thomas L 0 s ------ ........ Owner owner's-Name information is North Andover MA 01845 10-29-2018 required for 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,doo-rev.7/26MiS Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 15 of 19 Commonwealth of Massachusetts i a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Suqarcane Lane Property Address Thomas Lyons Owner CDwner's Name information is North Andover MA 01845 10-29-2018 required for every �-......_..._....___-- _.. — ---_—._._ ------ page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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 ry wa _ l L4 5 01 l5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts ,Y - =-► Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments " ❑ %! 65 Sugarcane Lane Property Address Thomas Lyons Owner Owner's Name information is North Andover MA 01845 10-29-2018 required for every .._. � .........__ _.._.,._ ._ —._........__�_._._ _._._..�_._... page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 6-17-1992 If checked, date of design plan reviewed: bate _.._....— __ �.. _.....-- ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: uDesi n_plan ❑ Checked with local excavators, installers -(attach documentation) El Accessed USGS database-explain; You must describe how you established the high ground water elevation;. Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc•rev.'712Bf2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 <10"\ Commonwealth of Massachusetts - ---------- -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 65 Sugarcane Lane Property Address Thomas Lyons Owner Owner's Name information is required for every North Andover MA 01845 10-29-2018 .._..--_--.-- page. City/Town 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 Z 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 15insp.doo-rev.7126/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Town of North Andover Tax Map # 210-106.A-0240-0000.0 Parcel Id 17385 65 SUGARCANE LANE LYONS, THOMAS 65 SUGARCANE LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zonin93 1 Residential Size Total 1 Acres FY 2019 UB Mailing Index Name[Address Type Loan Number Active/Inact. From Until LYONS,THOMAS Payor Activc, 65 SUGARCANE LANE N.ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Activelinactive Bldg Id. 17651,0-65 SUGARCANE LANE Last Billing Date 10/4/2018 3170321 03 Cycle 03 Active UB Services Maint. Account No.3170321 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 441.53 /1 UB Meter Maintenance Account No. 3170321 Serial No Status Location Brand Type Size YTD Cons 41900060 a Active ERT HH b Badger w Water 0.63 0.63 1015 Date Reading Code Consumption Posted Date Variance 9/12/2018 1054 a Actual 86 10/15/2018 2859% 6/11/2018 968 a Actual 3 7/23/2018 -65% 3/7/2018 965 a Actual 8 4/23/2018 -60% 12/7/2017 957 a Actual 19 1/25/2018 -72% 9/1212017 938 a Actual 76 10/18/2017 2328% 6/8/2017 862 a Actual 3 7/25/2017 -42% 3/812017 859 a Actual 5 4/12/2017 -74% 12/9/2016 854 a Actual 20 1/23/2017 -86% 9/9/2016 834 a Actual 134 10/24/2016 240% 6/13/2016 700 a Actual 43 8/2/2016 236% 3/9/2016 657 a Actual 12 4122120% -55% 12110/2015 645 a Actual 27 1/20/2016 -72% 9/9/2015 618 a Actual 97 10/16/2015 142% 6/10/2015 521 a Actual 40 7/24/2015 296% 3/11/2015 481 a Actual 10 4128/2015 -58% 12/11/2014 471 a Actual 24 1/15/2015 -75% 9/11/2014 447 a Actual 99 10/15/2014 350% 6/11/2014 348 a Actual 22 7/16/2014 98% 3/11/2014 326 a Actual 11 4/11/2014 -43% 12/10/2013 315 a Actual 19 1/17/2014 -71% 9/12/2013 296 a Actual 67 10/15/2013 107% 6112/2013 229 a Actual 32 7/24/2013 170% 3/13/2013 197 a Actual 12 4/22/2013 -23% 12/11/2012 185 a Actual 15 1/9/2013 -82% 9/13/2012 170 a Actual 86 10/1512012 540% 6112/2012 84 a Actual 13 7/16/2012 -4% 3/14/2012 71 a Actual 14 4/1412012 -24% 12/12/2011 57 a Actual 18 1/17/2012 -72% 9/12/2011 39 a Actual 39 10/13/2011 -100% 8 4 '( Town of North Andover HEALTH DEPARTMENT C Hi U CHECK DATE:A,'.'.": 3 LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) 0 Animal • Body Art Establishment $ • Body Art Practitioner 0 Dumpster • Food Service-Type.--,,,---- $ • Funeral Directors • Massage Establishment • Massage Practice • Offal(Septic)Hauler • Recreational Camp $ • Sun tanning • Swimming Pool 0 Tobacco $ • Trash/Solid Waste Hauler • Well Construction SEPTIC Systems: • Septic-Soil Testing $ • Septic-Design Approval $- • Septic Disposal Works Construction(DW0 $ 0 Septic Disposal Works Installers(DWI) 0 Title 5 Inspector Title 5 Report $ 0 Other. (Indicate) Heath Agent initials White-Applicant Yellow-Health Pink-Treasurer