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Home My WebLink About- Title V Inspection Report - 79 ROCKY BROOK ROAD 10/31/2018 C�KN��nweaUSh of Massachusetts ��'��U�� ~��.�� Title 5 Ommmcwam Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments TOWN OF NORTHAMDOVER 79 Rocky Brook Property Address Pau| Kbuhanski Owner Owner's Name information is North Andover MA Q1845 1�-15'2U18 nqu|�d�remw �� page. State -- Code --' of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist atthe end mf the form. Important;Whenfilling oqt forms A. Unspecto Information on the computer,use only the tab Todd James Bateson key to move your Name mInspector cursor'monot Babeaon Enterprises Inc. use the return key. `~''~~'' '`~^~ | �� | 111 A iU Road CompanyAddress Q Andover MA 0181O n State Zip Code 878-475 S115 ^--~^--~ Telephone Number License Number � B. Certification | certify that: | amnoDEPapproved system inspector|n full compliance with Section 15'340ofTitle 5 (81OCKOR15.0O0); | have personally inspected the sewage disposal system aJ 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. 0 Poameu 2 F1 Conditionally Passes 3. [] Needs Further Evaluation by the Local Approving Authority 4. [] Fails 1O-15-2U18 Irispectilirs Signature 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 1O.0OOgpdor 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 md 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. t5i""p.w"^m.�7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'Page 1o/1^ xr� Commonwealth of Massachusetts °�~��0�� °��~��0 0�� N"NM�� Title �� ~�0 � ��rQ�mN N� m��=��N�~" m Form wmm ' Subsurface Sewage DispmsaoSystemnForrm-NctforVn|untaryAsmessrnenta 79R k Brook Property Address PaV| Knckanoki Owner Owner's Name information is North Andover MA 01845 10-15-2018 ,nquivedfmrewery ~' yoga. ,''.—^ State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2. 3, mr5and all uf4 and 6. 1\ System Passes: 1 have not found any information which indicates that any of the failure criteria described —� im31OCMFl15.3O3orin81OCN1R15,3O4 exist, Any failure criteria not evaluated are indicated below. Comments: � 2) System Conditionally Passes: Fl one or more system components ao described in the"Conditional Pass" section need tobe 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 ia replaced with a complying septic tank ms 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 |sless than 2O years old iaavailable, El Y F1 N [:1 NO (Explain be|ow>: Commonwealth of Massachusetts is== Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Rocky Brook Property Address Paul Kochanski Owner owners game information is North Andover MA 01845 10-15-2018 required for every _..._ ------ _....._..._.-__ _ .. _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cant.) 2) System Conditionally Passes (cunt.): [l Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): distribution box is leveled or replaced ❑ Y ❑ N ❑ 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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 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: 15insp.doc•rev.7/26/2010 'ride s official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title~�"�� `��°��N 0��=�� U��N �� yN � ��0 �wm��0��m � Form ' Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 79 Rocky Brook Property Address PaU| Knnhanshi Owner Owner's Name information is North Andover MA 01845 10-15-2018 required for every _ pogo. City/Town State Zip Code Date of Inspection | —. ..._x-____'' __-'—''_'y `-_n—' � El Cesspool orprivy in within 5O feet ofa surface water F-1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b' System will fail unless the Board ofHealth (and Public Water Supplier, |fany) determines that the system is functioning in a manner that protects the public health, safety and environment: F-1 The system has a septic tank and soil absorption system (8AS) and the SAS iswithin 1OO feet ofa surface water supply or tributary toe surface water supply. Fl The system has o septic tank and SAS and the SAS in within a Zone 1 ofe public water supply. Fl The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. El The system has a septic tank and SAS and the SAS im less than 1OO feet but 5Ofeet or more from o private water supply vve||". Method used bm determine distance: °+This system passes |f the well water analysis, performed at aDEP 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 must be attached to this form. o. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" mx°No"tn each nfthe following for all inspections: Yes No [l �� Backup Of sewage into fanUityor system onOnpOnentdue tooveduededor �� clogged SAS orcesspool �l �� Discharge orpondinQn[effluent to the su�aceof the ground ursV�ace waters ' �� due hoan overloaded or clogged SAS orcesspool mmwzun"^rev.rmomv1u Title 5 Official Inspection Form:Subsurface Sewage Disposal System'Page 4mm Commonwealth of Massachusetts Ix ==: = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Rock Brook Property Address Paul Kochanski Owner Owner's Name information is North And MA 01845 10-15-2018 required for every _.over _,... ..—__ _.e__..,,.... ___..._.._..__ _ _.._._.. —. .........__ page. CltylTown State Zip Code Date of Inspection C. Inspection Summary (coat.) 4) System Failure Criteria Applicable to All Systems: (cont.) 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: El ® 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 Zane 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 fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 16,000 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 Area—IWPA)or a mapped Zone 11 of a public water supply well t5insp.doc-rev.7/2 612 0 1 8 'ritle 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 z�^ Commonwealth of Massachusetts ��~��0�� ^��~��=��0 N��*�� Form N ��N �� Official N Inspection �-��0NN0 �� m wm��~�� ' Subsu�aceSexvnge ��impmsm| SymternForrn -No�forVo|untaryAsuo�ummntm 79 !Roc4q k Property Address Pau| KuChaDahi Owner Owne/oNome information is North Andover &1A 01845 10-15-2018 mquimdfor mm� ��-- �on(�� m page. `'`r^~`~' 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 esignificant threat under Section C.5orfailed under Section CA shall upgrade the system in accordance with 310 CM R 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yom'' mr°no'"for each ofthe following for all inspections: Yes No E El Pumping information was provided by the owner, occupant, or Board of Health El E Were any of the system components pumped out in the previous two weeks? E R Has the system received normal flows |n the previous two week period? �l �� Have large vo|urnesofvvater been introduced to the mymtennreoenUyoraapa�of �� this inspection? �� l VVereaa built plans of the system obtained and examined? (If they were not �� available note as N/A) • El Was the facility mr dwelling inspected for signs of sewage back up? E D Was the site inspected for signs 0f break out? M Fl Were all system components, excluding the SAS. located on site? �� Fl 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 ofscum? �� l VVesthe facility ovvner(and occupants if different hnmovvnehprovided vvith �� 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 boPart Cinatissue �� approximation 0f distance ia unacceptable) [31UCKUR15.302(5)l Commonwealth of Massachusetts x Title 5 Official Inspection Form ' = — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Racky Brook Property Address Paul Kochanski Owner dwners Name information is North Andover MA 01845 10-15-2018 required for every _..._.........._�_w_.._ _.__._.._._ _._.._ _......_._....___._ page C1ty/Tawn State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 - Number of bedrooms (actual): 4 -- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 - - Description: 4 Number of current residents: Does residence have a garbage grinder? PA Yes ❑ 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? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d Yes g ( Y g {gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date 15insp.doc-rev.7120f2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts m = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Rock Brook _........ �.� tea,• ` _.__-__ .. Property Address Paul Kochanski Owner Owner's C�tame information is North Andover MA 01845 10-15-2018 required for every page` Clt y ---- /Town State Zip Cade Date of Inspection D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment; __._ _. ........ __.....__.._.._.� 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 ® No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? 0 Yes ❑ No Water meter readings, if available: — _...._.,....._._ Last date of occupancy/use: baWte___..,_..._,,....w._.._..._-..._............... Other(describe below): 3. Pumping Records: Source of information: Pumped 2018, owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons _ How was quantity pumped determined? ---------_.._.__---_..._____,.__._._.._......__...__.__ Reason for pumping: _..____ ___- _..............._._....._.,.. 15insp.doe•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts 1= 19 Title 5 Official Inspection (Form _- =:_ n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Rocky Brook Property Address Paul Kochanski Owner Owner's Name _ information is North Andover MA 01845 10-15-2018 required far every �._._.. __._._. ... ._.._.__�_.. _..__ ._._ _.._ ._..__ _. .....__—._-- page Clty/'rown State Zip Code Date of Inspection D. System Information (cont.) 1 4. Type of System: 0 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): Approximate age of all components, date installed (if known) and source of information: 23 years old tank& leach area, 10 20-1995, as built plan D-box replaced 10-15-2018. Were sewage odors detected when arriving at the site? El Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): - ---_______. Distance from private water supply well or suction line: feet -- - Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall, 3" PVC in house , no leaks visible. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form Not for Voluntary Assessment 79 Roc k ----------cocky 0'r-operty Address Paul Kochanski Owner Owner's Game information is North Andover MA 01845 10-15-2018 required for every —----- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 3 Depth below grade: Material of construction: ❑ concrete EJ metal El fiberglass El 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 E-1 No 10'x 5' x 4' Dimensions: Ito Sludge depth: -- " Distance from top of sludge to bottom of outlet tee or baffle 32 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. Outlet cover has riser 6" deep. --------------- t5insp.doc rev.7126/2018 TiVe 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 79 Rocky Brook —-—----------- Property Address Paul Kochanski Owner Owner's Name information is North Andover MA 01845 10-15-2018 required for every ----------- ------ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: Material of construction: El concrete El metal El fiberglass El polyethylene El 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: Date 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: El concrete El metal F1 fiberglass R polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day --------------- t5hisp.doc-rev.7126/2018 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 B1 79 Rocky Brook Property Address Paul Kochanski j Owner Owner's Name information is North Andover MA 01845 10-15 2018 required for every .-- ___...... page City["own State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: --- — Alarm in working order: ❑ Yes ❑ No Date of last pumping: date _..._.._ .._---- _...__..._ __...._..._.._ �.m. Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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, has flow levelers. No evidence of leakage. No evidence of carryover. Risers on top of d-box has cover 10"deep. jtbinsp.doc-rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Farm a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Rock Brook Property Address Paul Kochanski Owner Owner'smmNarne information is North Andover MA 01845 10-15-2018 required for every .: _.... .._...a__ _._ .� _...__� _ _.__....,._. _.._ page CltyFrown 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: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: _.__..,._......_.....___-. ® leaching trenches number, length: 2 trenches 35' long ❑ leaching fields number, dimensions: - - ----- — ❑ overflow cesspool number: [l innovative/alternative system Type/name of technology: ---._______..._.._-__,.___. _..... _... _.__..._� _._.___......_._. t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 ,� Commonwealth of Massachusetts Y ITm Title 5 Official Inspection Farm 1" 5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Rocky Property Address Paul Kochanski Owner Owner's Name information is North Andover MA 01845 10-15-2018 required for every - _...__., �_..._.._._._... �_... __...___ . .. ....__-- page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 11. Soil Absorption System (SAS) (cunt.) 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. 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.): l5insp.doc rev.7126/2018 Title 5 Official inspection Form;Subsurface Sewage Disposal System-page 14 of 18 Commonwealth of Massachusetts �.. ._ == Title 5 Official Inspection Form r - Subsurface Sewage Disposal System Form Not for Voluntary Assessments 79 Rocky Brook Property Address Paul Kochanski Owner Owner's Name information is North Andover MA 01845 10-15-2018 required for every __._.._.. _. page. CItyATown State Zip Code Date of Inspection D. System Information (cant.) 13. Privy (locate on site plan): Materials of construction: Dimensions _..w._.__..... __ ___...___ _........._._ _......_-_-- Depth of solids —.._-. ... __ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): u l5insp.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 79 Rocky Brook_........ Property Address Paul Kochanski Owner Owner's Name information is required for every North Andover MA 01845 10-15-2018 page. 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: E hand-sketch in the area below ❑ drawing attached separately Z7 'r, 3 4 L4 L�'Ell C)Wqvr A \J0 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 79 Rocky Brook a ti Property Address Paul Kochanski _..............�- -_.— Owner Owner's Name information is North Andover MA 01$45 10-15-201$ required for every _- ._ _--- page Cltyfrown State Zip Code Date of Inspection i 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: 5-20-1993 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design plan EJ Checked with local excavators, installers -(attach documentation) ❑ 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.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Pape 17 of 18 I Commonwealth of Massachusetts r m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments m_ 79 Rocky Brook Property Address Paul Kochanski Owner Owner's Name information is required for every _.North Andover MA 01845 1 D-15 2018 :,. _ _.a. _ ...._._ _._._.,_- -�......_...._._.... page CItyfTown State Zip Code Date of Inspection E. Deport 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.7126f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 of 18 i Of 8 4 Town of North Andover HEALTH DEPARTMENT U 1, CHECK#: DA,rE:Z 21 LOCATION: H/O NAME: CONTRACTOR NAME: Ll"12, "" 1',156/ Type of Permit or License:(Check box) • Animal $ • Body Art Establishment $ • Body Art Practitioner $ 0 Dumpster $ 13 Food Service-Type.- $ • Funeral Directors $— • Massage Establishment $ 0 Massage Practice $—, • Offal(Septic)Hauler $ • Recreational Camp $ • Suit tanning $--.— • Swimming Pool $ • Tobacco $ • Trash/Solid Waste Hauler $ • Well Construction $ SEPTIC Systents: • Septic-Soil Testing $ • Septic-Design Approval $ [3 Septic Disposal Works Construction(DWQ $ [J Septic Disposal Works Installers(DWI) $ 0 Title 5 Inspector $ Title 5 Report $ [I Other. (Indicate) $ .......... Health-Agent Initials White-Applicant Yellow-Health Pink-Treasurer