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Home My WebLink About- Title V Inspection Report - 7 CARLTON LANE 11/5/2018 Commonwealth of Massachusetts RECEIVEM 6P Title 5 Official Inspection Form NOV Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7 Carl 'T TH A OWN OF N ORNDOVER Carl' ton L.pne Propert�Address HEALTH-DEPARTMEfqT O'Brien, Diane Owner Owner's Name information is No. Andover MA 01845 10-02-18 required for every .......... 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 A filling out forms Inspector Information on the computer, use only the tab John..DiVincenzo . .............. ............. key to move your Name of Inspector cursor-do not J & S Development/Stewart's Septic Service use the return . ..... ke . Company Name Y. 58 So. Kimball St. . .. .............. ............. Q .......... Company Address V Bradford MA 01835 .............. City/Town State Zip Code raran 978-372-7471 S113386 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. Z Passes 2. El Conditionally Passes 3, F-1 Needs Further E a uation by the Local Approving Authority 4. ❑ F' Is /0 In t,p is Scgnatu w. Date he system inspector shall submit a py of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days o,2ompleting this inspection. If the system has a design flow of 10,000 gpd or greater, the (nsp 'or and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 7 Carleton Lane Property Address O'Brien_Dian.e,,.._..m. Owner Owner's Name information is No Andover MA 01845 10-02-18 required for every ......... ............... _....u_— _..._._ page, City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15,304 exist. Any failure criteria not evaluated are indicated below. Comments: Distribution box was replaced. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available, D Y ❑ N ❑ ND (Explain below): t5lnsp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title1RECEIVED Subsurface Sewage Disposal System Form - Not for Voluntary Assessments NOV01 k 01 7 Carleton Lane _.. —. Property Address ..._ __._._ " NO i TH . O'Brien, Diane HC AJH OE:PP T ENT Owner Owner's Name information is { required for every No. Andover MA 01845 10-02 18 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 A filling out forms . Inspector Information on the computer, use only the tab John DlVincenzo ..,_.......... .... __._ key to move your Name of Inspector cursor-do not J &S Develop, Septic Service use the return - .. _.... -- ..__ _. ..... - key. Company Name 58 So. Kimball St. Q Company Address Bradford MA 01835 City/Town State Zip Code re ao 978-372-7471 S113386 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. ❑ Needs Furth r!*valuation by the Local Approving Authority i 4. /Ea i r'sSignatu re Date stem ins ector shall s mit a co of this ins ection re ort to the A rovin Authority (Board p copy p p Approving of Health or DEP)within 3 days of completing this inspection. If the system has a design flow of 10,000 gpd or grea(er j e Inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 � � Commonwealth of Massachusetts ~��=��N�� N=�d��"��0 U�� K�8�� =�� Inspection N—�.mmwm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7Carleton Property Address O'Brien Diana Owner Owner's Name information is required N MA O�45 10-02-18 page. City/Town State Zip Code Date ofInspection C. Inspection Summary Inspection Summary: Complete 1, 2. 3. or 5 and all of and O. 1) System Passes: Fl | have not found any information which indicates that any of the failure criteria described in 310CK8R 15.303orin 310 CK4R 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: Z one or more system components as described in the"Conditional Pass" section need to be replaced ocrepaired. The system, upon completion of the replacement or repair, gV 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 determ|nwd,'' please explain. The septic tank is metal and over2O years n|dw 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. *Anoeta| septic tank will pass inspection if it is structurally sound, not leaking and if Certificate of Compliance indicating that the tank is less than 20 years old is available. El y F-1 N ND (Explain be|ow): mmsp.dn 'rev./a6eo8 Title 5 Official lirispecoon Form:Subsurface Sewage Disposal System'Page omm � | Commonwealth of Massachusetts Title 5 Official Inspection F o m Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7 Carleton Lane Property Address O'Brien, Diane Owner Owner's Name information is ��ui�d�rov*� M �A O�84� 10-O2-18 page. Citw7nwn State Zip Code Date ofInspection C. Inspection Summary (cont.) 2) System Conditionally Passes (oonL): F] 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 broken nr obstructed pipe(e) ordue toe broken, settled or uneven distribution box. System will pass inspection if(with approval of Board ofHoo|th): El broken pipm(a) are replaced [l Y F1 N [l ND (Explain be|nw): F-1 obstruction isremoved [l Y F N El ND (Explain he|ovv): | Z distribution box|s leveled orreplaced Z Y Fl N El N0 (Explain be|ow): Distribution box needsreplacing. There's leakage around outlet a�a F� Theeyetemrequiradpumpingmorethan4timosayemrduetobrnkenorobst/uohadpipe(a). Thu system will pass inspection |f(with approval of the Board ofHem|th}: 0 broken pipe(e) are replaced El Y 0 N [l ND (Explain below): U obstruction is removed D Y F-1 N U ND (Explain below): 3) Further Evaluation is Required by the Board of Health: F-1 Conditions exist which require further evaluation by the Board of Health in order to determine if the system im failing to protect public health, safety orthe environment. a. System will pass unless Board of Health determines in accordance with 310CYNR 15.303(1)/b\that the system is not functioning ina manner which will protect public health, safety and the environment: nmsp.u='rev./n6/2m,o Title n Official Inspection Form:Subsurface Sewage Disposal System'Page o°,`o � y Commonwealth of Massachusetts Title1 A r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments W 7 Carleton Lane ___ _............. Property Address O'Brien, Diane Owner ._._._.........._ __ ___ _ ..._._.. .. ......_ Owner's Name Information i e No. Andover MA 01845 10-02-18 required for every _ _ .... ..._..._... _ -__.... ....._.. page, City/Town State Zip Code Date of Inspection C. Inspection Summary {cons.} ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. 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. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or 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 l5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts z�\ =�"��D�� 6��%�=��"��N ��=�� V��M� 0 ��U �� Official U Inspection �-��ommo �� wm�� Subsu�acmSexxmNeDisposal SystmnmFmrrn -NotforVo|untery/\so�aamun\e 7 Carleton Lane Property Address O'Brien Diana Owner Owner's Name infomnahonie No Andover MA O1845 1D-O2-18 �qui��r�� ---- ------ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable boAll Systems: (cont.) Yee No El �� G�ticliquid level in the diathbut|onbox above outlet inveddue bzanoverloaded �� or clogged SAS orcesspool Fl Liquid depth in cesspool is less than 8^ below invert or available volume is |eoe �� than }6 day flow [� y� Required pumping more than 4times in the last yoarOTdue to clogged ur �� obnt,uobadpipe(a). Number of times pumped: _____. [l �� 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 toa surface water supply. �l �� Any podiunufa cesspool or privy isvvithina Zone 1 ofa public water supply �� = well. Fl E Any portion ofa cesspool nr privy is within 5O feet ofaprivate water supply well. El M Any portion ofa cesspool or privy io less than 1UD feet but greater than 5Ofeet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed atmO2Pcertified laboratory,for fecal oo\ifmnm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppmn' provided that no other failure criteria are triggered. &copy of the analysis and chain of custody must beattached tm this Yormn'] F| �� Thesyatemisaoesopon| aen/inQahaci|i(yvvithodesiqnf|owof2OOQgpd- �� 10,000gpd. E-1 �� The system fails. | have determined that one or more of the above failure �� criteria exist osdescribed in31OCK8R 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. S\ Large ��nns� To be � large �y�t�rnth��y��mmn must � facility with m � ' � design flow nf1O,0O0 gpd to 15,000 Apd. For large gyntems, you must indicate either"yes" or"no"to each of the foUowinQ, in addition to the questions in Section CA. Yes No 0 El the system ia within 48O feet ofa surface drinking water supply El 0 the system is within 20O feet ofe tributary to a surface drinking water supply �l El the system is located ina nitrogen sensitive area (|nterinnVVe||headProtection �� Area- |VVPA) ura mapped Zone || ofa public water supply well m""n.o""'rev.numomo Title o Official Inspection Form:Subsurface Sewage Disposal System'Page nmIv | � � � Commonwealth of Massachusetts =�'=�� N��'��=��H �� 0 @ �� q��@ � � � O Inspection �-�~nuuu �� w mm��~�* Subsurface SmxvageDisposal SysbmnnFmrmm - NotforVo|unt�ryAsaea�mento 7 Carleton Lane Property Address O'Brien Diane Owner Owner's Name information is N" A MA 01845 �- -- 1 requi�dforove� --___ page. City/Town State Zip Code Date ofInspection C. Inspection Summary (cont.) |f 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. O. You must indicate "yes" or"no"for each of the following for all inspections: Yes No E [l Pumping information was provided by the owner, occupant, or Board of Health El E Were any ofthe system components pumped out in the previous two weeks? E F-1 Has the system received normal flows in the previous two week period? [l Have large volumes ofvvuter been introduced to the system ruoendyoraope�of �� this inspection? Were as built plans of the system obtained and examined? (If they were not available note aaN/A) * 0 Was the facility or dwelling inspected for signs of sewage back up? * [l Was the site inspected for signs nf break out? F� n Were all system components, excluding the SAS, located on site? E 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 nf liquid, depth of sludge and depth ofscum? [l VVaethe facility ovvner(and occupants if different hnmovvner) provided with �� information on the proper maintenance of subsurface sewage disposal systems? The size and location mfthe Soil Absorption System (SAS) on the site has been determined based on: E El Existing information, For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Par(C is at issue �� approximation of distance in unacceptable) [31OCMR15.302(5)] Commonwealth of Massachusetts Titleill Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Carleton Lane Property Address O'Brien, Diane ....._... ..._............._ _.__....... _.... ......._____......_...-- Owner Owner's Name information is No Andover MA 01845 10 02-18 required for every —...... .-_...---_ . .,..._........ _ �_.... page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): — Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): --- Description: Number of current residents: Does residence have a garbage grinder? ® 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 years usage (gpd)): — Detail: Sump pump? M Yes ❑ No Last date of occupancy: Occupied — Date t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts r. Title 5 Officialr } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a1 7 Carleton Lane Property Address O'Brien, Diane Owner Owner's Name ....__ ........ ..._......__...._.._ information is No Andover MA 01845 10-02-18 required for every ___w ........ ��.. ......._ ....._. .... page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial 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? ❑ Yes ❑ No Water meter readings, if available; Last date of occupancy/use: D ate ...... _..., Other(describe below): 3. Pumping Records: Source of information; Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: _ - ....gallons ........._...__ How was quantity pumped determined? _....._ __ Reason for pumping: t5insp.doc-rev.7126/2018 Title 5 Official Prtspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Ix 1 � Official IInspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Carleton lane _ _............ __. __-- Property Address O'Brien, Diane Owner ..__._ ... ........ .. ._ ; Owner's Name information is required for every No. Andover MA 01845 10-02.-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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): > 50 years Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 22" De _ p feet t Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): 1 Distance from private water supply well or suction line: feet_ Comments (on condition of joints, venting, evidence of leakage, etc.): 1 t5insp.doo•rev.7/2812 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 ` r Commonwealth of Massachusetts 1Ue 5 Official Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �r 7 Carleton Lane Property Address Diane Owner O Brien Owner ©ie... ......__ - ............... ..,,.._ ._........ _ information is No. Andover MA.._._... 01845 10-02-18 required for every _..—._ . —. _ .....__. page, City/Town State Zip Code Date of Inspection D. System Information (cant.) 6. Septic Tank(locate on site plan): 10" Depth below grade: feet _._........ Material of construction: 0 concrete ❑ metal ❑ fiberglass ❑ polyethylene 0 other(explain) If tank is metal, list age: _..........._ ......... years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ 'Yes ❑ No Dimensions: 5' 5" X 8' X 49" 8" Sludge depth: ....... 12" Distance from top of sludge to bottom of outlet tee or baffle - .. _ Scum thickness 0 " Distance from top of scum to top of outlet tee or baffle 6 ---- -- --- — 18" Distance from bottom of scum to bottom of outlet tee or baffle _ 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, there's no leakage and liquid levels are good. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7 Carleton Lane Property Address O'Brien, Diane Owner Owner's Name information is required for every No, Andover MA 01845 10-02-18 ............. page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 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: 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: D concrete F] metal E] fiberglass El polyethylene E] other(explain): .......... ....... ----------- Dimensions: Capacity: gallons .... ... Design Flow: gallons per day t5insp.doo-rev,7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts OfficialTitle 5 mm r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ..4. 7 Carleton Lane Property Address O'Brien, Diane Owner Owner's Name information is No Andover MA 01845 10-02 18 required for every _. _ _,..,,.. - .. ._....... page. CltylTown State ,Zip Code Date of Inspection i D. System Information (coat.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: _.. ._.__ Alarm in working order: ❑ 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 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.): No solids carryover. Box needs re lacin due to leakage around inverts. „ t5insp.doe-rev.7/26/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts .......... Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7 Carleton Lane Property Address O'Brien, Diane ...... Owner Owner's Name information is No. Andover MA 01845 10-02-18 required for every .......... --- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10, Pump Chamber(locate on site plan): Pumps in working order: E] Yes ❑ No* Alarms in working order: El Yes El 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: E-1 leaching pits number: El leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: 1(a-20 ppfox)_X 40 ., D overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15insp.doe rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 170 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7 Carleton Lane Property Address O'Brien, Diane Owner Owner's Name information is required for every No. Andover ---------- _MA---- 01845 1. 01 -912-18 page. City[Town 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.): No hydraulic failure, no ponding, no damp soils ......... —---------- 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.): t5insp,doc rev,7126/2.016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts lye it ki ' Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Carleton Lane ._....... .._....._ Property Address O'Brien, Diane _ _ Owner _._..._ ....__...... Owners Name information is No Andover MA 01845 10-02-18 required for every — ... .......... t page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 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.): tbinsp.doe-rev.V26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts 5 icial Inspection Form 1--p Title UTY Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7 Carleton Lane Property Address Owner O'Brien, Diane Owner's Name information is No. Andover MA 01845 10-02-18 required for every ---------- ----__ page. CityfTown 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 ------------ ------------ t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7 Carleton Lane Property Address O'Brien, Diane Owner Owner's Name information is required for every NO. Andover MA 01845 10-02-18 ............. page. City/Town State Zip Code Date of In ----------- D. System Information (cont.) 15. Site Exam: Check Slope ❑ Surface water Check cellar ❑ Shallow wells Estimated depth to high ground water: 61 ��feet ..... i - -- 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 0 Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: Pulled file ❑ Checked with local excavators, installers -(attach documentation) El Accessed USGS database -explain: ................. ..................... You must describe how you established the high ground water elevation: Taken from the Title V done on 07/2011998. USGS maps show water 76.0 feet. System is only 12" in .ground, ................................. --- .......... Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.712812018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 OfficialInspection Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7 Carleton Lane........._.__...__ Property Address O'Brien, Diane _.... —_... Owner Owner's Name information is No. Andover MA _ 01845 10-02 18 required for every —....._ —..... page. City/Town State Zip Cade Date of Inspection E. Report Completeness Checklist j 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 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 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Wage 18 of 18 fr7 C - - - I 0 Town of North Andover HEALTH DEPARTMENT ACIAU CHECK#: DATE: LOCATION: H/O NAME. e fi, CONTRACTORNAME: �Za Type of Permit"or License: (Check box) 0 Animal • Body Art Establishment • Body Art Practitioner • Dumpster • Food Service-Type: 0 Funeral Directors • Massage Establishment • Massage Practice • Offal(Septic)Hauler • Recreational Camp • Sun tanning • Swimming Pool 0 Tobacco 0 Trash/Solid Waste Hauler 0 Well Construction SEPTIC Systems: El Septic-Soil Testing * Septic-Design Approval * Septic Disposal Works Construction(DW0 * Septic Disposal Works Installers(DWI) * Title 5 Inspector $ Title 5 Report $ [3 Other:(Indicate) Health AgentInitials White Applicant Yellow-Health Pink Treasurer