HomeMy WebLinkAbout- Title V Inspection Report - 247 FOREST STREET 12/3/2018 Commonwealifh of Massachusetts
RECEIVED
m m
� " r
03 NI
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0,F
247 Forest St TOWN a)i°'No'jj'F f,NDO Vt"l
f4i
Property Address _
. �b "" "1L ..,........_._..._
Storch, Pam i
Owner
Owner's Name
information is No Andover 01845 10-30 2018
required for every __MA----__. __ w _ ..... .. ..... ........w ....
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. Inspector Information
filling out forms
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 ....._.._._..._ .....-.._ .... _
key, Company Name
58 So. Kimball St.
r Company Address
f
Bradford - MA 01835
City/Town State Zip Code
n 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. F-1 Lasses
2. ® Conditionally Passes
3. 0 Needs Further Evaluation by the Local Approving Authority
4. PF
, 7
ignature / Date
m inspector s dal submit a copy of this inspection report to the Approving Authority (Board
or DEP) wit ri' 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DER The original 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 J
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
Mile 5 Off"Icial Inspection Form
- K? Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments
e`
247 Forest St
Property Address
m
Owner's Na.... ..._.... .._.-- —. _. . .. .........___. � ......._ ,_.,._ _ J
tarn
Owner me
information is
required for every No. Andover MA 01$45 10-30-201$
page, City/Town State Zip Code Date of Inspection
G. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ I 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:
2) Systems 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.
EJ Y ❑ N El ND (Explain below):
t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Sutaswface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
°��"��N�� �� Official
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Title �� q��� � � � � Inspection �-��mmmm"� ^� *� @�'�"�
Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments
247 Forest St
Property Address
Stnnuh Porn
Owner 0wner'aNum�
in�rmationio
mquimdforeva� N A MA 01845 3O-�
page, Cit"y/T^w» State Zip Code Date ofInspection
C, Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
Fl Pump Chamber pumps/alarms not operational, System will pass with Board of Health approval if
pumpa/a|arms are repaired.
[l Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(a) or due to m broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board ofHeg|th):
El broken pipe(n) are replaced [:1 Y F-1 N n ND (Explain be|ovv :
Fl obstruction is removed 0 Y E7 N [l NO (Explain be|ow):
M distribution box is leveled orreplaced n Y El N F-1 NO (Explain below):
Distribution box is d d aroundthe outlet inverts. The t ic tank is |eakin
�l The myob+m 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):
0 broken pipe(a) are replaced Fl Y R N E7 ND (Explain below):
El obstruction is removed Y [l N ND (Explain below):
__ __-_
3) Further Evaluation isRequired by the Board nfHealth:
El Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public heaKh, safety nr 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:
Commonwealth of Massachusetts
m - �
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
247 Forest St
Property Address
Starch, F-Iam 1
Owner Owner's Name
information is No Andover MA 01845 10-30-2018
required for every _
page, City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
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:
F1 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.
D The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
LZ 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: Tape measure 85' to distribution box
* 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:
i
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
t5insp.tloc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c ' Commonwealth of Massachusetts
T"de 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
- ,� 247 Forest St ..............__
Property Address
Storch, Parrl .......—. _._.. _ _ _.._.- __.
Owner Owner's Name
information is No. Andover [VIA 01845 10-30-2018
required for every - _ _ _.._...... ........
page. City/Town State Zip Code Date of inspection
....__-----------------_ ------ _ ___
. �r yfl n Summary (cont.)
4) Systom IWatiure Criteria Applicable to All Systems: (coat.)
Yes No
I� 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 G" below invert or available volume is less
than '/2 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 Z Any portion or the SAS, cesspool or privy is below high ground water elevation.
El z 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.
0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El LZ 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 CAR 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 systern is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
The system fails. I have deterrrrined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. Vile
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 systerrt the system must serve a facility with a
design flow of 10,000 gpd to '15,000 god.
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
❑ F-1 the systern is, within 400 feet of a Surface drinking water supply
❑ El the system is within 200 feet of a tributary to a surface drinking water supply
C the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area-- IWI='A) or a mapped Lone II of a public water supply well
t5insp.doc-rev.7/26/2018 'r otla 5 oflicial Inspection Form Subsurface Sewage Disposal System•Page 5 of 18
- Commonwealth of Massachusetts
InspectionTitle 5 Official
- Subsurface Sewage Disposal Systenn Form - Not for Voluntary Assessments
247 Forest St
Property Address
Storch, Flaw
_ .. . ....... ._— _ .__ ........ ____...._.
Owner
Owner's Name
information is
required for every No. Andover MA 01$45 10W30 2018
page, City[Town State Zip Code bate of 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 a significant threat under Section C.5 or failed
under Section GA shall Upgrade the system in accordance with 310 MIR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "fifes" or"no"for each of the following for ay inspection's:
Yes No
1 El Pumping information was provided by the owner, occupant, or, Board of Health
D R Were any of the system components pumped out in the previous two weeks?
LA El Has the system received normal flows in the previous two week period?
El F1 Have large volumes of water been introduced to the system recently or as pail of
this inspection?
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z El Was the facility or dwelling inspected for signs of sewage back up?
1 Was the site inspected for signs of break out?
Were all systern 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 frorn owner) provided with f
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soim Absorption Systort"n (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 t.inacceptable) [310 CIVIP 15.302(5)]
t5insp.doc•rev.7/26/2018 'ripe 5 official Inspection Form:Subsurface Sewage Disposal Sysdern•Page 6 of 18
Commonwealth of M use assachtts
Title 5 Officlal Inspection Form
i� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
247 Forest St
Property Address
Stogy h, Parn
Owner Owner's Name
information is No. Andover MA 01845 10-30-2018
required for every
page. Cityrrown State Zip Code Date of Inspection
---------- ------
D. System �nformaflon
I Residemtial Flow Conditions:
N 3 umber of bedrooms (design): Nuinber of bedrooms (actual); 3
DESIGN flow based on 310 CIAR 15.203 (for,example: 110 gpd x4 of bedrooms): 330
Description:
... .......
.............
3
Number of current residents:
Doec residence have a garbage grinder? Yes No
Does residence have a water treatment unit? n Yes E] No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection Yes i No
information in this report.)
Laundry system inspected? D Yes F-1 No
Seasonal use? El Yes M No
Water meter readings, if available (last 2 years usage (gpcl)):
Detail:
.... ............
Sump pump? ❑ Yes 0 No
Occupie,, -,,
Last date of occupancy: Date d
t5insp.dcic-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern-Page 7 of 18
Commonwealth of Massachusetts
-- Subsurface Sewage Disposal System Fortin -Not for Voluntary Assessments
247 parent St ..._. _ ........_ ......___ ...,.... ......._..
Property Address
Storch, Parn
Owner Owner's Name
information is Na Andover MA 01345 10-30 2018
required for every .__�.. _ - _
page. City/Town State Zip Code Date of Inspection ;
A Systern 4if f" ti n (cont.)
2. 0;,ommerciallIndusfrial flow Conditions:
Type of Establishment: _ ....
Design flow (based on 310 CIVIR 15.203): _.. -
Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Crease 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: Date -
Other(describe below):
3. Pumping records:
Source of information: Last r�ump..2014
Was system pumped as part of the inspection? ❑ Yes F1 No
If yes, volume pumped: 9allons _ .
How was quantity pumped determined? ___ ........
Reason for pumping: _..... _.. _
I
t5insp.doc•rev.7/26120 1 8 Title 5 Official inspection corm:Subsurface,Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusefts
-�-------------
TRIe 5 Off Hdal
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
tiw
!� 247 Forest St
Property Address
Scorch, Pam
—._....„ .............--
Owner Owner's Name
information is No Andover MA 01845 10-30-2018
required for every ., _
page, Cltyfrown State Zip Code Date of Inspection
D. System Information (cone.)
4. `tTypz• of System:
Septic tank, distribution box, soil absorption system
�.� Single cesspool
Ll 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:
196?
Were sewage odors detected when arriving at the site? F-1 Yes R No
5. Builcling Sewer(locate on site; plan):
16"
Depth below grade: fees
Material of construction:
El cast iron 0 40 PVC ❑ other(explain): —
Distance from private water supply well or suction line: --
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
i
i
t5insp.doc-rev.7726f2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
InspectionT"tie 5 Official
r� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
247 wrest St..
Property Address
Storc:h 'arn
Owner Owner's Name
information is No. Andover MA 01845 10-30-2018
required for every .__ .. ---- -
I
page. Cltyn'own State Zip Code Date of Inspection
D. Sys stern Information (cont.)
i
6. Septic Tank (locate on site plan).-
Depth below grade: feet
Material of construction:
`fI concrete ❑ metal ❑ fiberglass F-1 polyethylene ❑ other (explain)
Tank i71< needs to be replaced_ Leakage towards bottom of tank.
If tank is metal, list age: _
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dirriensions: .... .._
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
SCUrn 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 _-- _.
1--low were dirnensions determined"?
Cori mrsnts (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence; of leakage, etc.):
t5insp.doe•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Selvage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
n-,r✓ 247 Forest St
Property Address
Storch, P=am ...
Owner Owner's Name
information is 2018
required for every Clt /Town __... _ _ ..... .. State Zip Code Date of"..-.- _No Andover MA 01845 -
page. Y Inspection
D. System Information (cont.)
7. jrease Trap (locate on site plan):
Dep9:h below grade: feet
Material of construction:
concrete ❑1 metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions: _........
Scum thickness
Distance frorTl 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
Carnments (on pulrtping reCOmlTlendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. r Ig;,kt or �-eomin "rank (truln@< must be pumped at time of inspection) (locate on site plan):
Depth below grade: -
Material of construction:
�._ concrete El metal
[ fiberglass ❑ polyethylene El other (explain):
E)imensions: .......--
(:rapacity: gallons
Flow:
i Desgn ow:
j gallons per day
I
t5lnsp.doc-rev.712612018 Title 5 Official Inspection Foun:Subsurface Sewage Disposal Systern•Page 11 of 18
�.-,d e�u� monw lth �f Massachusetts
x mTI-He 5 Official Inspection Form
tilP
l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�c f
v
247 I crest St _.... . ..
Property Address
S'torch. Parr,
Owner Owner's Dame
information is _ 2018
required for every No. Andover _ ..... State..... 0 Zip
5.. 10-80....--
page City/Tode Date of Inspection
Da Sy Awryn Information (coat.)
i
8. °t"igh.or i-lolding Tank (cont.)
Alorrn present: n `Yes ❑ No
Alrarrn level: — Alarm in working order: [ Yes ❑ No
Date of last pumping: Dat
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract (required). Is copy attached? Yes ❑ No
9. l isixibuutiorr Box (if present roust be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
C;ornmerits (racte if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
30,e r,ccds re laG I g Leakage around outlet inverts
I
15insp.doc•rev.7/2 612 01 8 Tithe 5 Official Inspection Farm:Subsurface Sewage Djsposai Systern•Page 12 of 18
Commonwealth of Massachusetts
m(yTwItle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!/ 247 Forest St
Property Address
Storch Pam
Owner owner's Name
information is No Andover MA 01848 10-30-2018
required for every :.. _. _ _
page. city/Town State - Zip Code Date of Inspection
_----
D. ystem Information (cont.)
M PUM 13 Chamber(locate on site plan):
!-'tarps in working order: ❑ Yes No*
Aiarrns in working order: ❑ Yes [l No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
__._ .... - - _
i
i
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 riot located, explain why:
Type:
J leaching pits number: -----
leaching chambers number: _
Ll leaching galleries number:
� I leaching trenches number, length: 4 . 50
Ej leaching fields number, dimensions:
I_ overflow cesspool number:
innovative/alternative system
Type/name of technology: - -
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern•Page 13 of 18
Commonwealth nwealth of Massachusetts
r� Title 5 Official
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
_.
w.
x ,f 247 forest St
Property Address
Storch, Pam ..
Owner Owner's Name
information is No. Andover NIA 01845 10-30-2018
required for every __-- _
page. City/Town State Zip Code Date of Inspection
D. Systom Information (cone.)
11. 11161 Absorption Systerrt (SAS) (cant.)
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. Field has not seen any effluent because tank is
leak in
12. f c spools (cesspool must be pumped as part:of inspection) (locate on site plan):
N Urnber and configuratioir
E)ep1b -_.top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool - .....
Materials of construction -
Indication of groundwater inflow [1 Yes ❑ No
Corrcrric nts (note c;oridition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
t5lnsp,doc•rev.7/2612016 title 5 Official Inspection Foam Subsurface Sewage Disposal Systern-Page 14 of 18
Conunormeafth of Massachusetts
ells 5 Off lc"W Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
2,14.7.'Forrest St------ - -- ----------------
Property Address
Stoic, Pam . ..... ------
r,
Owner Owners Name
information is required for every No. Andover MA 01845 10-30-2018
page. City/Town State Zip Code Date of Inspection
---------------
D. I'Systern Information (cont.)
13, Privy (locate on site plan):
..........
Materials of construction: .
Dimensions --------
...........
Depth of solids
Corriments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
--------------------
........... .. .. ......
.......... ........... - --_--
t6insp,doc-rev,7126/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 15 of 18
4e"- fts,Commonvylecifth of P sachusetts
.............
TRI e 5 Offlc,'al Insped'on Form
Subsurface Sewage Disposai System Forme - Not for Voluntary Assessments
247 Forest St
Property Address
Owner Owner's Marne
information is
required for every No. Andover MA 01845 10-09 2018
. ...........
page. City/Town State Tip Code Date of Inspection
14. Of Disposal systwli,
Provick)a vi(-",Vv ofi.'he disposal syster:t, ;rtdUding a s to at least 1AVC, perrn�-nnent refere rice
lrinlrnarks of,bend irriatks. Locate ail wells wilhir, '100 fet.,[. Locate wherry pkVC VV�-ItC.YSLlpply enters
r1rX OUIILI,iq, c,cic U, LKI %)elov
j hL-ind-01,tcl iii b0ovy
....................
ii
3F
30' so/ 10
----------------
t5inap.doo•rev,712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16
Commonwealth of Massachusetts
-------------------
° ' eW Mspection Form
._
::15
Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments
* ,147 Forr-,stt
Property Address
Stor0 larft
Owner Owner's name
information is No. Andover MA 01345 10-30-2018
required for every -- __.._ ......... _ .. _.... i
1
page. Cityl-rown State Lip Code Date of Inspection
W z;,yLu,cer In-Vor matio (Cont.)
15. wii: 4::xatra:
F0 Check Slope
[. Surface water
Check cellar
_ Shallow wells
Estimated depth to high ground water: 7
feet
Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record
If checked, date of design plan reviewed: - - --
Date
El Observed site (abutting property/observation hole within 150 feet of SAS)
( I Checked with local Board of Health -explain:
_Puiled file
„J Checked with local excavators, installers- (attach documentation)
6 Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
No sump puri)p M cellar. at bottom of system. Greater than 4' above basement floor.
-. ---
Before filing this Inspection Deport, please see Report Completeness Checklist on next pane.
t6insp.doc•rev.7126/2018 Title 5 Official Inspection Forav Subsurface Sewage Disposal System-Page 17 of 18
Commonweal th of fflassachl[Aseffs
.. ..........
cle 5 Off'MW �nspecfion Form
0 Tow
Subsairface Sewage Disposal Systern Form - foot for Voluntary Assessments
247 IW orest, P ..........
Property Address
Sbrcn larn
Owner Owner's Mame
information is No. Andover MA 01845 10-30-2018
required for every --------
page. CityrTown State Zip Code Date of Inspection
Checklist
�.dlp vlppl;r'ablv -,Ocflons, of this fog'm inclusive of:
r;7\1 A, Inspector Information: Complete ali fields in this section.
`-.signed & Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
1, 2, 3, or 5 completed as al.-)propriate
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 doe-rev.712612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
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Town of North Andover
HEALTH DEPARTMENT
A'�^SACHU�+ES
CHECK..#: "1 ,� ' DATE:
LOCATION
H/0 NAME ".a
T NAME:
CONTRACTOR ✓
Type of Permit car I..icense: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dunipster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $---
❑ Massage Practice $
❑ Offal(Septic) Hauler $ —
❑ Recreational Camp $ ---
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
Septic-Soil Testing $
0 Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $ �—
❑ Title 5 Inspector
Title 5 Reports $ <
❑ Other:(Indicate) -- $
de0th°Agent Initial
White Applicant Yellow Health .!Lk.-Treasurer