HomeMy WebLinkAbout- Title V Inspection Report - 53 CEDAR LANE 1/29/2019 Commonwealth of Massachusetts4I' I' '<
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1oI1!1 OFM YA"r
11EAL)i 9 .tiw l 1i�Q"CVO .4
� 53 Cedar Lane R�l�
Property Address
_Thomas Beasley
Owner Owner's Name
information is North Andover MA 01845 1-7-2019
required for every _,___._—__.. ----_ ._ __._.— .__ _.__---.-__� _
page CttyfTown 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, t Ba s Neil Jam
es use only the tab N B --
key to move your Name of Inspector
cursor-do not Bateson Enterprises Inc.
use the return ---- -._.__.
key. _
Company Name
111 Argilla Road__.__..___-�_._
ran Company Address
Andover MA 01810
CityfTown State Zip Code
rerun 978-475-4786 SI-15
Telephone Number License Number
B. Certification
I certify that; I am a DEP approved system Inspector in full compliance with Section 16.340 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. C] Conditionally Passes
3. ® Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
1-7-2019
Inspect 's Sign tore 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.
t5insp.doe•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
\
Commonwealth of Massachusetts
/ °�°�^�N�� �� �=�J��������N N����������������� ����0°07�V
' � N���� �� ��/� � �����mN Nmn�����*������mn N-��m � nm
Subsurface Sewage Disposal System Form
- NotforVo|unt�ry Aeaaommqmte
53 Cedar Lane
� Property Address
Thomas Beasle
Owner Owners Name
information Is North d MA 01845 1 72010 �
neqvim�(�,avo� ~ Andover
page, City/Town State Zip
Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1. 2. 3. or5 and all of4 and G.
1) System Passes: �
F� | have not found any information which indicates that any of the failure criteria described
in 310 CK4R 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below. !
Comments:
�
|
�
2) System Conditionally Passes:
�l One o|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 peso.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following staternents. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal |k/
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 peas inspection if it is structurally sound, not leaking and if Certificate of
Compliance indicating that the tank ia |eua than 20 years old in available.
Fl Y N ND (Explain be|ow):
Commonwealth of Massachusetts
Title 5 OfficialInspection Form
n Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
53 Cedar bane
Property Address
Thomas Beasley _.._
Owner Owner's Name i
information is North Andover MA 01$45 1-7-2019
required for every _ — .__.
page Cltyrrown State Zip Code Date of Inspection
C. Inspection Summary (cant.) 1
2) System Conditionally Passes (cont.):
R 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 R ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N FIND (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:
t5insp.doe•rev,712612018 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
/
'
Commonwealth of Massachusetts
7�~40�� �� ��^�l�=�����0 N����������������� ����k����
� Q�N�� �� ��/N � ���N��0 0� n���������U��um Form
Subsurface Sewage Disposal System Form ^ Not for Voluntary Assessments
53 Cedar Lane
rope y Address
ThomasB |
Owner Owner's Name
information i's North Andover MA01845 1-7-2019
=quimdfn,��ry
page. ~'~''`—'
State Zip Code Da-t e of Inspection
C. Inspection Summary (cont.)
El Cesspool orprivy ia within 5D feet ofo surface water
[7 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. SvmtennxxOl f�| un�wsthe Board wfHea�h (and PubUcWater SmppU �
� � y)
determines
safety and environment:
El The system has a septic tank and soil absorption system (SAS) and the SAS is within
18O feet ofa surface water supply or tributary tna surface water supply.
n The system has a septic tank and SAS and the SAS is within a Zone 1 of public water
supply.
0 The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well. |
0 The system has a septic tank and SAS and the SAS |oless than 1OO feet but 5O feet or
more from a private water supply vva||^^
Method used to determine distance: Tape Measure
�
This system passes if the well water analysis, performed at a DEP certifiedlaboratory, for feual
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitratenitrogen |sequal
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. �
|
o. Other:
/
�
4) System Failure Criteria Applicable tm All Systems:
You must Indicate"Yes" or"No"tm each of the following for all inspections:
Yes No
BaCkupofaewage into feni|hvornvG(emcornpnnmrt due houvedoadodor
Fl �� ' '
clogged SAS orcesspool
�� �� Discharge o[pnOdiOQnf effluentt0th8eu�aoeofthegnmuOdVr surface waters
�� "� due toan overloaded or clogged SAS or cesspool
commonwealth of Massachusetts
Title 5 Official Inspection Form
-= Subsurface Sewage Disposal System Form Not for Voluntary Assessments
" 53 Cedar Lane
Property Address
Thomas BeasLey —
Owner Owner's flame
Information is MA 01845 1-7-2019
required for every North Andover —._
page City/Town_.—.._. State Zip Code Date of Inspection i
C. Inspection Summary (cant)
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 %day flow
❑ 0 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.
El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well,
Q 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 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
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone IC of a public water supply well
t5insp.doe•rev.712812018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
n Subsurface Sewage Disposal System Form ; Not for Voluntary Assessments
53 Cedar Lane
Property Addfess
Thomas Beasley
Owner Owners Name
information is North MA 01845 1-7-2019
Andover
required for every North A... _.�_ _... _...._.
State Zip Code Date of Inspection
page City/Town _ -.- f
C. Inspection Summary (cant.)
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)
Z ❑ 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
i
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Cedar Lane --—--------
Property;kddreis
Thomas Beasle —-----
Owner Owner's Name
information is 01845 1-7-2019
required for every North Andover MA
page. State Zip Code Date of lnspec�lion ._
D. System Information
1. Residential Flow Conditions:
4 3
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CIVIR 15,203 (for example: 110 gpd x#of bedrooms): 440
Description:
4
Number of current residents:
Does residence have a garbage grinder? Yes No
Does residence have a water treatment unit? Yes El No
Unknown finished cellar
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes 0 No
information in this report.)
Laundry system inspected? Yes ❑ No
Seasonal use? Yes No
On well water
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Have attached well water analysis
Sump pump? n Yes N No
Last date of occupancy: Current
Date
t5insp.doc-rev.7/2612 01 B Title 5 Official Inspection Form:Subsurface Sewage Disposal System•P�ge 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
53 Cedar Lane
Property Address
Thomas Beasley____._
Owner Owner's Name
information is
required for every North Andover MA 01845 1-7-2019
page. bi—ty/fowrr�- —------- State -Yip-co-de Date of Inspection
D. System Information (cont.)
2. Commerciallindustrial Flow Conditions,
Type of Establishment:
Design flow(based on 310 CIVIR 15.203): Gallons—per 6y(gpd)'
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? nYes F] No
Water treatment unit present? 1-1 Yes El No
If yes, discharges to:
Industrial waste holding tank present? F Yes F1 No
Non-sanitary waste discharged to the Title 5 system? Yes E] No
Water meter readings, if available: ------
Last date of occupancy/use: Date
Other(describe below):
-----------------
3. Pumping Records:
Source of information: Pumped 2017, owner
Was system pumped as part of the inspection? Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Measured tank ------
Inspect tank &tees
Reason for pumping: ........ ----------
15insp.doc-rev.7126/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Pa I go 6 of 18
Commonwealth of Massachusetts
-- ' ~��-��N�� �� ����j�~�����N N��������^������� ����U�0��
. � N�N�� �� ��y� � N�����N Nmm���������N��mw Form
Subsurface Sewage DimpowalSysternFormn - NotforVo|untoryAsaemannents
53 Cedar Lane
Property Address
Thomas Bea s|g
Owner dwnwr'omame
information'is North Andover MA 01845 1-7-2018
dfo
mnv|m for every State Zip Code Date r/ oonnn
page. —'��-'��
D. System Information (cont.)
4. Type ofSystem:
0 Septic tank, distribution bnx, soil absorption system
El Single cesspool
El Overflow cesspool
Privy
Shared system (yes ur no) (if yes, attach previous inspection records,|.fany) �
Innovative/Alternative technology. Attach a copy of the current operation and
�~ maintenance contract(to Ueobtained from system owner) and a copy nflatest
inspection nf the |A\system by system operator under contract
Tight tank. Attach m copy of the 0EPapproval.
Fl Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Tank & leach area original, 9-25-1374, final inspection from B.O.H. Outlet tee & d-boxvvaa replaced
info atB.O.H. �
�
Were sewage odors detected when arriving ot the site? [l Yes M No
5. Building Sewer(locate on site plan):
1.8
Depth below grade: feet
K8atar|e| of construction:
H cast iron F-1 40 PVC [] other (eXp|ain)�
Distance from private water supply well or suction hD8
Comment (on condition of joints, wenUng, evidence of leakage, etc.):
4"cast iron to septic tank. Cellar finished unable to See piping
Commonwealth of Massachusetts
r = Title 5 OfficialInspection Form
n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Cedar Lane
Property Address
Thomas Beasley
Owner Owner's Name
information is
required for every North Andover MA
01845 1-7-201
Cttyrrown _..__—.._. _ - -- — Mate Zip Code Date of Inspection
page
D. System Information (cons.)
6. Septic Tank (locate on site plan):
0.8
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: ears
v
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 0 Yes ❑ No
Tx5' x4'
Dimensions: - ____�.... —_.w.....
211
Sludge depth:
30"
Distance from top of sludge to bottom of outlet tee or baffle —
4"
Scum thickness
6„
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 11"- - - --
Tape Measure
How were dimensions determined? _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet baffle ok. Nutlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Pumped septic
tank.
l5insp.doc•rev.712612M Title 5 Official Inspection Form;Subsurface Sewage Disposal System,Page 10 of 18
Commonwealth of Massachusetts
�����0�� �� ��`��'~�����N N���������*������� ����U�0��
@N ���� �� �~�� � N�pN��0 0m ����������n��mn Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
S3 Cedar Lane
Property Address
Thomas Beasley
Owner Owner's Name
information is North Andover
MAO1O4� 1-7-2019
mnuimd�revo� ���— Zip Code D��1
nspection
page. ~`'—��
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
F-lonnorete nnehs\ El fiberglass Flpn|yethy|eno other(explain):
Dimensions:
Scum thickness |
Distance from top pf scum hm top of outlet tee orbaffle
Distance from bottom nf scum tV bottom of outlet tee orbaffle
Date of last pumping:
Comments (on pumping nauommendat|nns, inlet and outlet tee or baffle conditiun, structural integrity.
liquid levels eo related to outlet invert, evidence of leakage, eto.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material ofconstruction:
�lconcrete nlabs| fiberglass npo|yethy|ene [l other/eXp|oin\:
Dimensions:
Capacity:
Design Flow: ons per day
Commonwealth of Massachusetts
- = Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e 53 Cedar Lane
Property Address
Thomas Beasley
Owner Owner's Name
information is required for every North Andover MA 01845 1-7-2019
__... .__ _.---__
page b tjifown State Zip Code Date of Inspection
D. System Information (cont.)
8, Tight or Holding Tank(cont.)
Alarm present: Q Yes El No
Alarm level: -- — - Alarm in working order: E] Yes No
Date of last pumping: -gate-. ___._._.._—
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. No evidence of leakage. Evidence of light of carryover, pumped d-
box to clean.
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
:. Title 5 OfficialInspection Form
_ n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
_...:. / 53 Cedar Lane
Property Address
Thomas Beasley
Owner Owner's Name
information is North Andover MA 01845 1-7-2019
required for every �.._r —..__._ __ _.....
CitylTown __.. __—.._._�—_ _�_ State Zip Code Date of Inspection
page
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: 2
leaching chambers number:
❑ leaching galleries number: -
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: -......___
❑ overflow cesspool number: -............-. -.-......_..__.._
❑ innovativelalternative system
Type/name of technology:
t5insp.doc•rev.7120l2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal system• age 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Cedar Lane ...... —-----------
Pm—peWy—Address
i
Thomas Beasley —-----
Owner Owner's Na-in—e
information is North Andover MA 01845 1-7-2019 -------
required for every State Zip Code Date of Inspection
page Cltyfrown.
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont,)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface. Camera inside of pits through outlets in d-box,
no liquid to inverts of pits,
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.7126/2018 Title 5 Official Inspection Form!Subsurface Sewage Disposal System-Page 14 of 18
�\ Commonwealth of Massachusetts
- l Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Cedar Lane
Property Address
Thomas Beasley
Owner No�h'sA ame
information is Andover MA 01845 1-7----
required for every �__._._ _.�_�..__ ___._..__—...... _......-- ._ _._.,__
.�_�_...—.._._.__�__ State Zip Code Date of Inspection
page Cutyl1 awn 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.):
16insp.doc•rev.7I2612a18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I' n Subsurface Sewage Disposal System Farm - Not for Voluntary assessments
53 Cedar Lane.•.:-ems
Property Address
Thomas Beasley �._
Owner Owner's Name
information is North Andover MA 01845 1-7-2010
required for every ____e_.... -- _.__
page Cityffown 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 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,
[D hand-sketch in the area below
(1 drawing attached separately
0���
t
s
hk t~ ,h
-� f if
9 r L4
tl
J /a
t5insp.doc•rev.712612018 l'itle 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
53 Cedar Lane
Property Address
Thomas Beasley ------
Owner Owner's Name
information is North Andover MA 01845 1-7-2019
required for every
page. State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Check Slope
Z Surface water
M Check cellar
Z Shallow wells
>4
Estimated depth to high ground water: feet -------
Please indicate all methods used to determine the high ground water elevation:
z Obtained from system design plans on record
If checked, date of design plan reviewed: 5-24-1974Date
______...___
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
z Checked with local Board of Health - explain:
Desi-qn plan
El Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
As per design plan test pit data. No water found 10' deep
------------
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev,712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslarn,Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection orm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
<P'
w. 53 Cedar Lane
Property Address
Thomas Beasie
Owner Owner's Name
information is required for every North Andover MA 01845 1-7-201g
_ —w �_.._..._.._ _
page Cltyfrown 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.
M B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
Z C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: TighUHolding 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
1
j
t5insp,doc rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 18 of 18
Commonwealth of Massachusetts
City/Town of
wb System Pumping Renard
Farm 4
DEP has provided this form for use-by local Boards of'Health. Other forms may be'used, but the
Information,must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The;System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility information
1. System Location: Left/Right front of douse, Left l Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown state Zip Code
Z. System Owner,
Name'
Address(if different from location)
Cityfrown State --, C� Zi Cod®
Telephone Number
B. Pumping Record
1. Date of Pumping Date . Qu' ."Ey Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank [I Tight Tank
❑ Other(describe): �--
4. Effluent Tee Filter present? C] Yes Lea If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Nell.Bateson F6821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7.isigne
contents-were disposed:
Lowell Waste Water
C�- - C `
Houle Date
5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
iuu iuuuuuu miiu mii uu a mmu a iwuu a uu wuomi wwiuuwwm i umum iii ou i mi i i i iii iuiw
CERTIFICATE OF ANALYSIS FOR DRINKINGWATER
DATE PRINTED: 01/25/2019 Passes
Legend
CLIENT NAME: WaterWa g
,
!Fails EPA Primary
CLIENT ADDRESS: 3 St John St Fails EPA Secondary
Hudson, NH 03051 Fails State Guideline
Attention I
SAMPLE ID#: 1901-01257-001
SAMPLED BY: Water Ways DATE AND TIME COLLECTED: 01/15/2019 10:30AM
DATE AND TIME RECEIVED: 01/15/2019 12:30PM
SAMPLE ADDRESS: Beasley ANALYSIS PACKAGE: Comprehensive-Mass
53 Cedar Ln. RECEIPT TEMPERATURE: 20.10 CELSIUS
N. Andover MA
MORE LOC INFO: CLIENT JOB#
Test Description Results Test Units Pass DQ RL Limit Method Analyst Date-Time
/Fail Flag Analyzed
Calcium* <1 mg/L 1 No Limit EPA 200.7 ES-NH 01/23/19 3:08PM
Hardness(caic.) <2 mg CaCO3/1. 2 No Limit EPA 200.7 ES-NFl 01/23/19 3:08PM
Iron`. 0.107 mg/L 0.01 0.3 mg/L EPA 200.7 ES-NH 01/23/19 3:08PM
Magnesium <1 mg/L 1 No Limit EPA 2003 ES-NH 01/23/19 3:08PM
Sodium, 80.7 mg/L 1 No Lit-nit EPA 2.00.7 ES-NH 01/23/19 3:08PM
Arsenic* 0.0042 mg/L 0.001 0.010 mg/L EPA 200.8 CW-NH 01/16/19 1:25PM
Copper* 0.0035 rng/L 'l' 0.001 1.3 mg/L EPA 200.8 CW-NH 0:1/16/1.9 1:25PM
Lead* <0.001 mg/l. 11,/ 0.001 0.015 mg/L EPA 200.8 CW-NH 01/16/19 1:25PM �
Manganese* <0.001 mg/L 11/1f 0.001 0.05 mg/L EPA 200.8 CW-NH 01/16/19 1:25PM
Uranium* 2.7 ug/L 1 30 ug/L EPA 200.8 CW-NF! 01/16/19 1:25PM
Uranium 1.8 pCi/L ° 0.67 20 POA EPA 200.8 Calc. CW-NH 01/16/19 1:25PM
Nitrite as N* <0.05 mg/L d 0.05 1 mg/L EPA 300 DR-NI-I 01/15/19 5:59PM
Chlorlde* 58 rng/L ",,t 2 250 mg/L. EPA 300.0 DR-NH 01/15/19 5:59PM
Fluorides° <0.2 mg/L 0.2 4.0 mg/L EPA 300.0 DR-NF! 01/15/19 5:59PM
Nitrate as N* <0.2 mg/L r 0.2 10 mg/L EPA 300.0 DR-NH 01/15/19 5:59PM
1a11* 8.17 SU FI N/A 6.5-8.5 SU SM 4500 H B DS-NI-I 01/15/19 1:45PM
Radon 2650 pCi/L 100 10000 pCi/L SM 7500 Rn B !R-ME 01/16/1.9 11:17PM
(MA Limit)
Coliforrn Bacterla* Absent P-A/100 mL Absent No Lirnit SM 9223B DR-NFI 01/15/19 4:55PM
The results presented in this report relate to the:samples listed above in the condition in which thev were received.
RL:"Reporting limit"means the lowest level of an analvte that can be accurately recovered from the matrix of interest.
Data Qualifier(DQ)Flags:ii w Flold time non-compliant.
*MA Certified Analvsis
The Commonwealth of Massachusetts has set an Advisory „
Limit of 10,000 pCi/L for Radon in Water
Donald A.D'Anjou,Ph. D.
Laboratory Director
This analvsis meets Commonwealth of Massachusetts requirements except as noted.
State Certifications: I NI-1 1015 I MA M-NH003 I ME 1\11,100003 I RI 101513 I V't VT-101507 I
This certificate shall not be reproduced,except in full,without the written approval of Granite State Analvtical Services,LLC
Page 1 of 2
F
CERTIFICATE OF ANALYSIS FOR DRINKING WATER
DATE PRINTED: 01/25/2019 Legend
Passes
CLIENT NAME: Water Ways ,
Fails EPA Primary
CLIENT ADDRESS: 3 St John St Fails EPA Secondary V
Hudson, NH 03051
Fails State Guideline X'
Attention
SAMPLE ID#: 1901-01257-001 1
SAMPLED BY: Water Ways DATE AND TIME COLLECTED: 01/15/2019 10:30AM
DATE AND TIME RECEIVED: 01/15/2019 12:30PM
SAMPLE ADDRESS: Beasley ANALYSIS PACKAGE: Comprehensive-Mass
53 Cedar Ln. RECEIPT TEMPERATURE: 20.10 CELSIUS
N. Andover MA
MORE LOC INFO: CLIENT JOB#
Test Description Results Test Units Pass DQ RE Limit Method Analyst Date-Time
/Fail Flag Analyzed
E.coll Bacteria* Absent P-A/100rnL Absent Absent SM 9223B DR-NM 01/15/19 4:55PM
The results presented in this report relate to the samples listed above in the condition in which thev were received.
RL:"Reporting limit"means the lowest level of an analvte that can be accurately recovered from the matrix of interest,
Data Qualifier(l Flags:li=Hold thne non-compliant,
I
*MA Certified Analvsls
The Commonwealth of Massachusetts has set an Advisory
e
Limit of 10,000 pCi/I.for Radon in Water
Donald A. D'Anjou,Ph.D.
Laboratory Director
i
This analvsis meets Commonwealth of Massachusetts reou{rements except as noted.
State Certifications: I NI-1 1015 1 MA M-141-1003 I ME NH00003 I RI 101513 1 VT VT-101507 I
This certificate shall not be reproduced,except in full,without the written approval of Granite State Analytical Services,LLC
Page 2 of 2
P
y,dRTry
041�wq« q qMd.
jip� q dL
4 �
Town of North AndoveiHEALTH DEPARTMENT
sACNUS
CHECK. #, a D TIE:
LOCATION ,_ &� ;� ' %
H/O NAME:
CONTRACTOR NAME (2,
Type. of Permit mr License: (Check box)
❑ Animal $
• Body Art Establishment❑ Body Art Practitioner
❑ Durnpster
----
❑ 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
❑ Septic-Design Approval
❑ Septic Disposal Works Construction(DWC)
❑ Septic Disposal Works Installers(D )
❑ Title 5 Inspector
Title 5 Report
❑ Other:(Indicate). - --
KJ
Ile t -Agent Initials
White-Applicant 'eltaw ITeaIth Pink- Treasurer
4 '
North Andover Health Department
Community and Economic Development Division
f
I
Neil Hateson
Ba,teson. Enterprises Inc.
11 I Argilla Road
Andover, MA 01810
RE: 53 Cedar Lane
Dear Mr. Bateson:
The Town of North Andover Ilealth Department has further evaluated 53 Cedar Lane and
determined that the sewage disposal system is functioning properly. The water analysis
indicates that coliform bacteria is absent in the private well and passes Title 5. Please
submit a passing Title 5 cover sheet to this department at your earliest convenience.
S7/4 '
elVairasse,
ian J C�I-IT
irector of Public I-lealth
....... _ ................... ._...._........ _...... .... ....... ...
Page I of 1
North Andover I-lealth Departi-rent, 120 Main Street
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.9542