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HomeMy WebLinkAbout- Title V Inspection Report - 36 BEAVER BROOK ROAD 12/5/2018 /7y Commonwealth of Massachusetts SEC Title 5 Official Inspection Form m -< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t4opO 36 Beaver Brook Road Property Address Andrew and Shannon Parisotto Owner Owner's Name information is required for every North Andover MA 01845 11/07/201$_ _ _ ....... ..... page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:forms When filling out fo A. Inspector Information fi on the computer, use only the tab Robert Herrick key to move your Name of Inspector cursor-do not _Wind River Environmental use the return Company Name key. 46 Lizotte Drive Company Address MarlborouggW�„ MA 01752 CityCrown State Zip Code 978 833-7924 SB 13759 - Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority I 1 4. ❑ Fails 11/07/201$ e r pector's 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 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions 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. I t5insp.doc^rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 10 r Commonwealth of Massachusetts Y Titlef i i i Inspection ^- V Subsurface Sewage Disposal System Form Not for Voluntary Assessments 36 Beaver Brook Road Property Address Andrew and Shannon Parisotto Owner Owner's Name information is required for every North Andover MA 01846 11/07/2018 �_.�._... w ._ 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: 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. ❑ Y ❑ N ❑ ND (Explain below): l5insp.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18 Commonwealth of Massachusetts w : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 36 Beaver Brook Road Property Address -- —._ Andrew and Shannon Parlsotto Owner Owner's Name information is North Andover _MA _01846 11/07/2018 required for every _.._. ._._ �. _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cons.) 2) System Conditionally Passes (cont.): ❑ 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): i 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspedion Form;Subsurface Sewage Disposal System.Pape 3 of 18 � li Commonwealth of Massachusetts v2 Title Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;v 36 Beaver Brook Road __ __.._.._ Property Address Andrew and Shannon Parisotto Owner Owner's Name information is North Andover MA 01845 11/07/201$ required for every _..-.-_.__ - __.. .. page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cant.) ❑ 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"Edo"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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 4 of 18 '.. Commonwealth of Massachusetts x (� Title 5 OfficialInspection a 5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - � 36 Beaver Brook Road Property Address - Andrew and Shannon Parlsotto ©caner _...m_..._.--._-- Owner's Name information is North Andover MA 01845 11/07/2018 required for every �._.---......___. �. _._ ---. - page, City[Town State Zip Code Date of Inspection C. Inspection Summary (cons.) 4) System Failure Criteria Applicable to All Systems: (cont,) Yes No El ® 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 1/z 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, ❑ 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 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 0.4. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply I i ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection ❑ Area-- IWPA) or a mapped Zone II of a public water supply well t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts OfficialTitle 5 1 _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M !� 36 Beaver Brook Road Property Address Andrew and Shannon Parisotto Owner Owner's Name information is required for every North Andover MA 01845 11/07/2018 ---- ---- -- ---- �` page. - ty/Town State Zip Code Date of Inspection C. Inspection Summary (coat.) 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 i ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® information on the proper maintenance of subsurface sewage disposal systems, The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] i t5insp.doc rev.7/2812018 Title 5 Official Inspedon Form.Subsurface Sewage Disposal System Page 6 of 18 � | Commonwealth of Massachusetts Title��=��U�� �� ��4�����=��U 0��������u��"���� ����0"M�� �� V��NUQ��U��U U" "�����°���H��� m Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Beaver Brook Road AndrewProperty Address d Shannon P h ott Owner Owners Name information is required for every North page. ~'''''``''' State —'Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 Number ofbedrooms (design): —4------ Number ofbedrooms (actual): ---------- 44O{3PD DESIGN flow based mn310CKAR15.2O3 (for example: 11Ogpdx#ufbed000mo): --------- OeauripUnn: __�asystern is made up of_��Aqptj Number of current residents: — -------- Ooeonoeidenno have garbage grinder? Yes No Does residence have o water treatment unit? [l Yen 0 No (fyae. dimchergeuhm: Is laundry ona separate sewage system? (Include laundry system inspection Fl yes �� No i�mnnat|oninthianepo�� -- � Laundry system inspected? [l Yes No Seaeone| une? Yee No Water meter readings, if available(last 2 years usage (gpd)): Detail: G75OO U /730da Q24 {�PQ Sump pump? Fl Yes No Last date nfoccupancy: Current Date t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Surninary Record Card gonatalad on 111112018 11:12:D7 AM by Karon Hanlon Page I Town of North Andover Tax Map # 210-106.B-0231-0000.0 Parcel ld 17626 36 BEAVER BROOK ROAD ANDREW& SHANNON PARISOTTO 36 BEAVER BROOK ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential ZonIng3 1 Residential Size Total 1.47 Acres FY 2019 US Mailing Index Name/Address Type Loan Number Active/Inact, From Until ANDREW&SHANNON PARISOTTO, Owner Adjw� 36 BEAVER BROOK ROAD NORTH ANDOVER,MA 01845 MAHALATI,SIAVASH Previous Customer Inactive 8/1/2008 36 BEAVER BROOK ROAD NORTH ANDOVER,MA 01845 JEFFREY MELLEN Previous Customer Inactive 712912011 36 BEAVER BROOK ROAD NORTH ANDOVER,MA 01845 UB Account Maint. Account No cycle Occupant Name Active/Inactive Bldg Id. 17882.0-36 BEAVER BROOK ROAD Last Billing Date 10/4/2018 3170547 03 Cycle 03 Active UB Services Maint. Account No. 3170647 Service Code Rate Charge Multi plier/Users MISCFEE ADMIN FEE 0,635/8 7.82 11 WTR WATER 01 ALL METER SIZE 1,156.71 US Meter Maintenance Account No.3170547 Serial No Status Location Brand Type Size YTD Cons 99885656 a Active ERT HH METE METE w Water 0.630.63 2642 Date Reading Code Consumption Posted Date Variance 9/11/2018 3432 a Actual 216 10/116/2018 526% 6/812018 3217 a Actual 34 7/23/2018 65% 3/6/2018 3183 a Actual 21 4/2312018 -31% 12/6/2017 3162 a Actual 29 1/2512018 -63% 9/11/2017 3133 a Actual 88 10/18/2017 185% 6/6/2017 3045 a Actual 29 7/2512017 -11% 3/7/2017 3016 a Actual 32 4/1212017 6% 1218/2016 2984 a Actual 31 1/23/2017 -84% 9/8/2016 2953 a Actual 193 10/24/2016 218% 6/7/2016 2760 a Actual 60 8/2/2016 76% 3/7/2016 2700 a Actual 33 412212016 -30% 12/912015 2667 a Actual 49 1/20/2016 -72% 9/8/2015 2618 a Actual 178 10/16/2015 189% 6/812015 2440 a Actual 61 7/24/2015 132% 3/9/2015 2379 a Actual 26 4/2812015 -35% 12/912014 2353 a Actual 40 1f1512015 -70% 9/10/2014 2313 a Actual 138 10/15/2014 527% 6110/2014 2176 a Actual 22 7/16/2014 -5% 3f1 0/2014 2153 a Actual 23 4/11/2014 14% 12/9/2013 2130 a Actual 20 1/17/2014 -89% 911012013 2110 a Actual 181 10/15/2013 524% 6111/2013 1929 a Actual 29 7/2412013 27% Commonwealth of Massachusetts R Title 5 OfficialInspection Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Beaver Brook Road Property Address Andrew and Shannon Parisotto Owner Owner's Name information Is v North Andover required for every -_-..-. MA 01845 11/07/2018 s__._._..._. �.....__..__. _ �.._..._.__ page. Cityfrown State Zip Code Date of Inspection l D. System Information (cant.) 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: Date Other(describe below): I 3. Pumping Records: Source of information: Wind River Environmental-See attached record. Was system pumped as part of the inspection? ® Yes ❑ No 1,500 If yes, volume pumped: gallons --.._..- How was quantity pumped determined? The quantity was measured by the pump truck. Reason for pumping: To check the structural integrity of the septic tank, i 15insp,doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Work Order# 0207101299 Cust# 1982603 Customer Since: 2 017 Tax: 6 .2 5 0 0 0 Job Comments Tech Comments 11/7/2018 AM Title V inspection, SVC 1500 gallons, consent/ Marked dig safe #20184406931. plans sent to Kelly / water usage on file cc on file (dg) I i System Owner System Location 1 Andrew & Shannon Pari.sotto Primary Home 36 Heaver Brook Road 36 Beaver Brook Road North Andover, MA 01.845 North Andover, MA 0184S (77.5) 636-0162 Parisotto Andrew & Shannon (775) 636-0162 Service Date: WED 11/07/2018 01.00 aM Frequency: Call to Confirm: Service Type: Standard Previous Service: 10/31/2018 Approx. Gals: 1500 CCLS: Location Details: Depth Below Grade: Custom Clean: dig, green, right, off pleasant brook. Cust Home: NO Filter: 1500x i Township: Inspection/T5: County: Essex Build Up: Description Qty. Unit Price Ext Price' Inspection Title 5 (not including pumping) 1.00 $� 535.0000 $ 535.00 Inspection Title 5 13011 Fees 1.00 $ 50.0000 $ 50.00 Pumping 1001 - 1500 1.00 $ 310.6030 $ 310.60 Environmental Compliance - Residential 1.00 $ 3.0000 $ 3.00 Fuel / Energy Recovery 1.00 $ 93.0160 $ 93.02 Subtotal: $ 991.62 We suggest these 3 keys steps to keep your system healthy: Tax : $ 0.00 - Regular servicing O Use CCLS bacteria additive Total $ 991.62 ® Use a fitter Disposal Site: Disposal Volume: Payment Detail: Waste Code : 0.0000 Master xxxxxxxxxx2884 06/2023 Sales Rep : NE_Repairs Installs CSR : Dawn Grenier Due on Receipt Truck : Technician : Robert. Herrick On Site : 12:38 PM P O Number ; i Tech Notes : System Operating Fine. Normal water level, Moderate top solids. Moderate bottom sludge. Both baffles are intact. Main line Clear. No filter is present on the tank; current tank is not designed to be used with a filter. Recommended Boost �,/ /� additive, CCLS additive. Cover(s) secured. System is in good working condition. f Customer Signature ENVIRONMENTAL Remit payment to 46 Lizotte Dr Suite 1000,Marlborough,MA 01752 Commonwealth of Massachusetts Title fill Inspection '— Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Beaver Brook Road Property Address Andrew and Shannon Parisotto Owner Owner's Name information is North Andover MA 01845 11/07/2018 required for every — — - _— ------� page City/Town 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 l/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: 1999 Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): 24" Depth below grade: feet --------- i Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): — --- Town Water Distance from private water supply well or suction line: et - -- � Comments (on condition of joints, venting, evidence of leakage, etc.): All joints look to be solid, There are no signs of leakage. Vented through buildingsewer. ' 1 t5lnsp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts OfficialTitle 5 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 36 Beaver Brook Road Property Address Andrew and Shannon Parisotto Owner Owner's Name r information is North Andover MA 01845 11/07/2018 required for every —__ ----- ---- page CltylTown State Zip Code Date of Inspection f D. System Information (cunt.) & Septic'tank (locate on site plan): 1211 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 10'6"x 5"8"x 5'8'" Dimensions: _�.._.._ _.__-.._.. 3" Sludge depth: - 21" Distance from top of sludge to bottom of outlet tee or baffle -- 1'" Scum thickness ---- __ 6" Distance from top of scum to top of outlet tee or baffle - - - 14" Distance from bottom of scum to bottom of outlet tee or baffle - How were dimensions determined? jape Measure and Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend pumping as needed.The inlet and outlet are solid with no signs of leakage. The liquid level is OK in relation to the inverts. i i i i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts i it i lInspection Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 1 36 Beaver Brook Road Property Address Andrew and Shannon Parisotto Owner Owner's Name information Is required for every North Andover MA 01845 11/07/2018 ._ - _------ ---- --- -- page. Cityfrown 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): i Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: _. __.............__ __.. __.....___--- _... I Capacity: gallons — — Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Tide 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts TitlefN i Inspection r i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Beaver Brook Road _ — -- Property Address Andrew and Shannon Parisotto Owner Owners Name information is required for every North Andover _MA 01845 11/07/2018 --- ____._ --- - -- — page, City/Town State Zip Code Date of Inspection D. System Information (cunt.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: - Alarm in working order; ❑ Yes ❑ No Date of last pumping: Date _ i Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes 0 No 9. Distribution Box (if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert --- — Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The distribution box is solid with no signs of leakage and no carryover. The liquid level is OK in relation to the inverts. i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Fo=Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts =- Title 5 Official Inspection Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Beaver Brook Road - ti_ Property Address Andrew and Shannon Parisotto Owner Owner's Name informat on equedlfor levery North Andover _.._ — M State- 018ip ode 45 11/0Date f 018 Inspection page. D. System Information (cons.) I i 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: I ❑ leaching chambers number: ® leaching galleries number: 12-4❑x$ ❑ leaching trenches number, length: - -- ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5lnsp.doc-rev.7/2612018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts r = Title 5 OfficialInspection Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 36 Beaver Brook Road Property Address r Andrew and Shannon Parisotto Owner owner's Name { information is North Andover MA 01845 11/07/2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cons.) 11. Soil Absorption System (SAS) (cant.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The soil is dry with no signs of hydraulic failure and no pondinc„_.The vegetation is normal for the area. 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.•rov.7/2612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts x Itie 5 OfficialInspection " � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :� ff 36 Beaver Brook Road Property Address Andrew and Shannon Parisotto Owner Owner's Name information is required for every North Andover MA 01845 11/07/2018 -- - ----.._.------------- - ..-- - page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 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, eta.): i I 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form,:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title i iInspection o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Beaver Brook Road e Property Address Andrew and Shannon Parisotto -- -- Owner Owner's Name information is required for every North Andover MA 01846 11/07/2018 page. CityfTown State Zip Code Date of Inspection D. System Information (cant.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties tout 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 /3-4 3C I .f 15inso doc•rev.711,.,12013 title 5 Caeca;Inspection Form:S-ibsirtace Sewage bis�asal%,stem•Page 16 or 18 Commonwealth of Massachusetts i = � itl i i l Inspection j' 7 wjn Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l 36 Beaver Brook Road ....._ _._. __ Property Address Andrew and Shannon Parisotto Owner Owner's Name information is 07 MA h Ando ver 01845 11/ /2018 required for every N _ page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 15, Site Exam: Check Slope ® Surface water ® Check cellar ® Shallow wells EleEstimated depth g g feet th to high round water: feet 126.7 _- 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: 1999 __ Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Search of records. ' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 z<e\ Commonwealth of Massachusetts i"\ i ............. .... µmyit 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 36 Beaver Brook Road Property Address Andrew and Shannon Parisotto Owner Owner's Name information is required for every North Andover.--..-----.----- MA 01845 11/07/2018 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 C. Inspection Summary: 1, 2, 3, or 6 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.doo-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 � Massage01 Town of North Andover HEALTH DEPARTMENT CHECK DATE: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) 0 Animal 0 Body Art Establishment $ 0 Body Art Practitioner $ 13 Funeral Directors $ 0 Massage Establishment $- 0 Offal(Septic)Hauler 0 Recreational Camp 0 Sun tanning $ 0 Swimming Pool $ 0 Tobacco C3 Well Construction 0 Septic Disposal Works Construction(DWQ 0 Septic Disposal Works Installers(DWI) $ Title 5 Report $ 0 Other. (Indicate), He,althAgent Initials 3�/EiLe-Applicant Yellow-Health Pink-Treasurer � '