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Home My WebLink About- Title V Inspection Report - 338 ABBOTT STREET 3/22/2019 � Commonwealth ofMassachusetts ��N�� U�NMK� ^ NN�� N�� w��m� �� m��+��mm N-�� mm Subsu�acwSnxva0e [�ispoao| SystemOFornm - NmtforVo|untaryA�s�onmente 338 Abbott Street Property Address Paul& Kav Burnim Owner Owner's Name information Is North Andover MA 01845 3-20-2019 rmqui�dfor eve� ��_ �� Date of Inspection page. ~^`'''~'~' ode Inspection results must bm submitted mn this form. Inspection forms may not bm altered inany VxmV Please see completeness checklist at the end of the form. |mn»dant:VV»e» �� UU��0��'� Information filling �Nngo4 forms ~^~ Inspector~- ~ ~~' = uo the computer, &l\ use only the tab Neil James ""==".. key to move your Name m Inspector cursor-gonut Bateson Enterprises Inc. use the return ��- key. --'-' Nam Andover MA 01810 City/Town State Zip Code 978-4754786 S115 Telephone Number License Number B. Certification � | certify that: | mmnm [>EPapproved system inspector|n full compliance with Section 1§.34Umf Title S | (310CA0R15.0UU); | have personally inspected the sewage disposal system a\the property address listed above; the information reported below is true, accurate and complete asof the time ufmy 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] Passes 2. Conditionally Passes 3. Needs Further Evaluation bv the Local Approving Authority 4. E] Falls 3-2Q-2O18 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board ofHem|thorDEP) vvithin3OdGyuofuomp|eUngth|ninepeoUon. |ftheaystemhasodeo|gn0owof 1O.DOOgpdorgreater, the inspector and the system owner shall submit the report tnthe appropriate regional office of the DEP. The original form should be sent ho 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 mf use at that time.This |nspecd|nn does not address how the system will perform in the future under the same or different conditions oYuse. Commonwealth of Massachusetts �r�� Official 0 Inspection Form � Title N��N�� N�� V�0�� " �� yQNw��m�m� Nmm�� K[ �� ~ �m �"��nm . ��mmmm � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments | 33Q Abbott Street Property Address Pau|&�B i ----- Owner Owner's Name information is required for every Q North Andover MA 01845 3-20-2019 page, tyr�wn ----- StateC. Inspection Summary Zip Code Date of Inspection — |nspec(ion Summary: Complete 1, 2. 3, or and all cf4 and 6 | � | 1) System Passes: � [] | have not found any information which indicates that any of the failure ohteho 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 |aso than 20 years old in available, Y N El ND (Explain below): Liquid level in septic tank below outlet invert, evidence of leakage. ' uidleve| inma9dotenkbelowuuUotinverievidanoeof|aakame. Commonwealth of Massachusetts |� , Title 5 Official Inspection nspec ion F orm Subsurface Sewage Disposal SyobnnnForUn - Notfo[Vo/untaryAseeaamento 338 Abbott Street Property Address Paul& Kay Burnim Owner Owner's Name |nfoona|ionio required for every North Andover MA 01845 3-20'2019 ��_ page. ~`'''°~^'' Zip Code Date"' "Inspection C. Inspection Summary (cont) 2) System Conditionally Passes (xont): E] Pump Chamberpumos/a|armo not operational. System will pass with Board of Health approval if pumps/alarms are repaired, F1 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 ofHea|th): Fl broken pipe(m) are replaced El Y M N El ND (Explain be|mx ): 0 obstruction is removed El Y M N [I NO (Explain below): | 0 distribution box io leveled urreplaced F-1 Y M N El ND (Explain be|ovv : [] The system required pumping nmre than 4times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board ofHaa/th): Fl broken pipe(s) are replaced M Y N N Fl ND (Explain ba|ovv : � obstruction is removed MY N N 0 ND (Explain be|ow): 3> Further Evaluation 0o Required by the Board ofHealth: El Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public hea|th, safety Vr the environment. m. System will pass unless Board mf Health determines in accordance with 310 CD0R 16.3O3/1l(b)that the system (m not functioning in a manner which will protect public health, safety and the environment: t5insp.doo-rev.7/2612.018 'r itle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts | 7�~��N�� w��*��N ��°�� 1�rN | . Title �� /� � ��~�� Inspection Form Subsurface Sewage Disposal SymiemmFmrno - NotforVo|untaryAsoemamentm 338 Abbott Street Paul& Kay Burnim Owner information is required for every North Andover MA 01845 8-20'2019 page. City7uwn \StateC. Inspection Summary (cont.) Zip Code Date of Inspection — Cesspool ur privy iswithin 5O feet ofe surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will tm|/ 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: El The system has a septic tank and soil absorption system (SAS) and the SAS is within 10O feet ofe surface water supply or tributary tna surface water eupp|y | � | [] The system has o septic tank and SAS and the SAS ie within a Zone 1 ofe public water supply, [I The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. El The system has aaeptic tank and SAG and the GAS is less than 1OD feet but 5O feet or � more from a private water supply vveU°*. Method used todetermine distance: � This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal | oo|ifnrm 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 ba attached b) this form. c. Other: Septic tank, outlet pipe tod-bon&d-hox needs tobereplaced. 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes NV �� Backup ofsexmage into facility or system component due to overloaded or �� clogged SAS orcesspool Discharge or ponding of effluent to the surface of the ground or surface waters �~ �~ due toan overloaded mr clogged SAS orcesspool | oinsp.dno'rev.n26on`e Title s Official Inspection Form:Subsurface Sewage Disposal System'Page 4or1u | CoMNmonwoalth of Massachusefts �r��N�� `��~��N N��~�� 0°N�� Title�Q�� Official� @�� Inspection m�� ~ - �� ~��mm Form Subsurface SevvaWaDyspwsa[ SysbmrnForm -NotforVo{untaryASSesemanho | 338 Abbott Street Property Address Paul& Kay Burnim Owner Own � {nfonna\ion|a required for every North Andover MA 81845 3'20-2019 page. State Zip Code Date of Inspection — C. Inspection Summary (cont.) 4) System Failure Criteria Applicable toAll Systems: (cont.) Yea No �� Static liquid level in the distribution box above outlet iDve�due t0a0overloaded `~ �~ or clogged SAS orcesspool El �� Liquid depth in cesspool is less than S" below invednr available vo|urne is less �~ �~ than 1/2dayflow �7 �� Required pumping more than 4Unneoin the last year N<�Tdue to clogged or ^~ �~ obstructed pipe(m). Number uftimes pumped:____. El 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. | �� Any po�ioOnf cesspool or privy ievv|thin1OO feet Ofoou�oce water supply or | �� ~ tributary toa surface water supply. �� Any portion of cesspool or privy is within m Zone 1 of public water supply �~ .~ well. � El N Any portion of a cesspool or privy is within 50 feet of a private water supply well. Fl [� 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 mtmQEPcertified laboratory, for fecal oo|iforrn bacteria indicates absent and the presence mf ammonia nitrogen and nitrate nitrogen is equal tpwr less than 5ppmn, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached tm this hormn.] The system ise cesspool serving u facility with e design flow of20OOgpd- 10,000gpd. The system fak. | have determined that one or more of the above failure -- �^ criteria exist aodescribed in 310CMR 15.303, therefore the system fails, The system owner should contact the Board of Health to determine what will be necessary tn correct the failure. 5) Large Systems: Tobe considered a large system the system must serve afacU|tvvvitha design f/oxvof10.0O0 gpd&o15,000gpd. ^ 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 Ofa surface drinking water supply El 0 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—/VVPA) ore mapped Zone || ofa public water nupp|yvve|| tmm°vmoo'rev./oecmu Title a Official;nsp"*mn Form:Subsurface Sewage Disposal System'Page sm1v � Commonwealth of Massachusetts ��^�� Official N Inspection �� | Title ��0�� N�� U��k� | . � �� °�� wm� �wm��m�� n Form Subsurface Sewage Disposal SystemmForrn - NotforVu|unteryAanesnments 338 Abbott Street Peu/& Kay Burnim Owner Owner's Name �� infonnmUnnis required for every North Andover MA 01845 8-20-2019 _ page. °'y''"= State Zip Code "°`".. ..sv°°°m. 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 m significant threat under Section C.5orfailed 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" mr"nm"for each wf the following for all inspections: Yea No N El Pumping information was provided by the owner, occupant, or Board of Health [l M Were any of the system components pumped out in the previous two weeks? Fl 0 Has the system received normal flows in the previous two week period? El Have large volumes of water been introduced to the system recendyorampa�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? | El Was the site inspected for signs of break out? � 0 El Were all system components, excluding the SAS, located on site? �� Fl Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition uf the baffles or tees, material ofconstruction, dimensions, depth of liquid, depth of sludge and depth ofscum? �� Fl 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) nn the site has been determined based on: N El Existing information. For example, a plan at the Board of Health. �� Determined in the� � g|d (ifaoyof(h�foi|ureoribarigny|�f�dtoP� Cieetiaaue �~ �� approximation Of distance io unacceptable) [31OCK8R15.3O2/5\] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 338 Abbott Street Property Address Paul& Kay Burnim Owner Owners Name information Is required for every North Andover MA 01845 3-20-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A Description: .............. ............ Number of current residents: 0 Does residence have a garbage grinder? Z Yes n No Does residence have a water treatment unit? Z Yes n No If yes, discharges to: Bucket in cellar .......... Is laundry on a separate sewage system? (Include laundry system inspection n Yes Z Na information in this report.) Laundry system inspected? ❑ Yes n No Seasonaluse? ❑ Yes Z Na Water meter readings, if available (last 2 years usage (gpd)): On well water Detail: Sump pump? Z Yes n No Vacant since Last date of occupancy: December 2018 t5insp,doc•rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern-Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 338 Abbott Street —------ Property Address Paul& Kay Burnim Owner Owner's Name information Is required for every North Andover MA 01845 3-20-2019 page. Ci.ty/T ow"n State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: ................ Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? El Yes El No If yes, discharges to: ............. —------- Industrial waste holding tank present? F] Yes El No Non-sanitary waste discharged to the Title 5 system? El Yes El No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): ...................—------...... 3. Pumping Records: Pumped two years owner Source of information: Was system pumped as part of the inspection? El Yes 0 No If yes, volume pumped: g.a..11.o I n-s 11111----------__ .............. How was quantity pumped determined? ------------ Reason for pumping: t5insp.doc rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern-Page 8 of 18 Commonwealth of Massachusetts °�~��N�� =��°��0 N��°�� Title �� '� � ��w� �mm��0��mm Form mmm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 338Abbott Street ''"p=`,~~~'~~~ Paul".9y B rnim Owner Owner's Name information'is required for every North Andover MA 01845 3-20-2019 ....... State Zip Code Date of Inspection page. ~'`,''~'.. D. System Information (cont.) 4. Type of System: z Septic tank, distribution bnx, soil absorption system ! [| Single cesspool [l Overflow cesspool � �� Privy l � � [| Shared aymhann (yes or no) (if yes, attach previous inspection records, if any) El 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 |/4 system by system operator under contract EJ Tight tank. Attach 8 copy Of the DEPapproval. E-1 Other(describe): Approximate age of all components, date installed (if known) and source 0finformation: 45 vears old, 0 30 1074 as built plan, owner had plan, town did not have Were sewage odors detected when arriving et the site? Fl Yes Z No 5. Building Sewer(locate on site p|an>: Depth below grade: Material of construction: 0 cast iron El 40 PVC [| other(explain): Distance from private water supply well or suction line: feet CoolrOenYa (on condition ofjoints, venting, evidence of leakage, etc.): 4"cast iron through wall h) septic tank. 3' &2" cast iron in house, DO leaks visible Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 338 Abbott Street Property Aij-dress Pau 1&�B urn i m --- ---------- Owner Owner's Name information is required for every North Andover MA 01845 3-20-2019 ------------ page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: Material of construction: F1 concrete El metal El fiberglass [1 polyethylene F-1 other(explain) .......... If tank is metal, list age: y.ears ea-r s Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) F1 Yes F-1 No 7' x 5' x 4' Dimensions: Sludge depth: 32" Distance from top of sludge to bottom of outlet tee or baffle Olt Scum thickness Distance from top of scum to top of outlet tee or baffle 811 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet baffle ok. Outlet baffle ok. Depth of liquid below outlet invert 4". Evidence of tank leaking out. ----------- -------------- ------------- ---------------- ---------- t5insp,doc-rev,7126/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 19 Commonwealth of Massachusetts -- Title Official Inspection Form M=' = Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 338 Abbott Street _..__...— Property Address Paul& Kay Burnim __m Owner Owner's Name ___�..__ _._.� ._v_ __. information is North Andover MA 01845 3-20-2019 required for every ----__ ___ .._ __.-- _ _.... _.-- _-- page Clty(rown State Zip Code Date of Inspection D. System Information (cont.) 7. Crease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: .._,..-- Scum thickness Distance from top of scum to top of outlet tee or baffle ------- - — Distance from bottom of scum to bottom of outlet tee or baffle ------- Date of last pumping: Date _.......... Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc,): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan); Depth below grade; ____,r.mr,.._..____.._________—__...._..._._-----_.-- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions; Capacity: _ ____e..----__,__....._____.,...,,._...__. _..........._...___. gallons Design Flow: .._.._-_..._........_ gallons per day 15insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Off locial Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 338 Abbott Street ------------------------ Property Address Paul& Kay Burnim____ ................. Owner Owner's Name Information is North Andover MA 01845 3-20-2019 required for every ---------------- page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) & Tight or Holding Tank(cont.) Alarm present: n Yes E] No Alarm level: Alarm in working order: [] Yes El Na Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ------------ Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box badly corroded, needs to be replaced. Evidence of leakage. Evidence of carryover —--------- ---------- -------------- --------- -------------- l5msp.doc-rev,7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form Not for Voluntary Assessments 338 Abbott Street Property Address Paul& Kay Burnim -———--------- Owner Owner's Name information is required for every North Andover MA 01845 3-20-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: D Yes El No* Alarms in working order: El Yes El No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ----------- If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: .............. .......... Type: El leaching pits number: El leaching chambers number: El leaching galleries number: El leaching trenches number, length: z leaching fields number, dimensions: 1 field 20' x 45' El overflow cesspool number, 0 innovative/alternative system Type/name of technology: t5insp,doc•rev,712G/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 338 Abbott Street Property Address Paul& Kay Burnim Owner Owner's Nameinform _..._.required tion s North Andover MA 01845 3-20-2019 required for every .....................-- _ __. page Cityfrown State Zip Code Date of Inspection D. System Information (cant.) 11. Soil Absorption System (SAS) (cant.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration --- Depth —top of liquid to inlet invert __.....__._................ _w...._...... 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.): i 1 i t5insp.doc•rev.7f28f2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts -._ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 338 Abbott Street Property Address Paul& Kay_Burn im Owner Owner's Nameinform required is North Andover MA 01.845 3-20-2019 required for every —....._.___.—._....._ _._._ _._ _.... page City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): i t5insp.doc•ray.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 338 Abbott Street Property Address Paul& Kay Burnim_ ...... Owner Owner's Name information Is required for every North Andover MA 01845 3-20-2019 page. '6-1ty/Town ------------ State Zip Code Date of Inspection D. System Information (cont.) 14, Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water Supply enters the building. Check one of the boxes below: 0 hand-sketch in the area below Fj drawing attached separately 0 o S_qkv- 1 {o t5insp.doc-rev.712612018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts -Np Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 338 Abbott Street --- .............. Property Address Paul& Kay__.Burn.i-m Owner Owner's Name information is MA 01845 3-20-2019 required for every North Andover page. -City/Town7— - - State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope Surface water Check cellar Shallow wells 4 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 6-a1te1-1973 D ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Design_p Ian ,,,,,-,-," El Checked with local excavators, installers - (attach documentation) El Accessed USGS database -explain: ............- You must describe how you established the high ground water elevation: As per test pit data. ------------ ............ ...... _._.,,-,_,...__..__._-- Before ------ filing this Inspection Report, please see Report Completeness Checklist on next page. tbinsp.cloc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 338 Abbott Street --------....... ------ Property Address Paul& Kay.Burnim Owner Owner's Name n informat! is0 MA 01845 3-20-2019 required for every North Andover MA Cityrrown 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 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed Z 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 15insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 of 18 04 + Town of North Andover HEALTH DEPARTMENT ~phhl.p �.Y ty �ss+emusct CHECK# � AT'E LOCATION: H/O NAME: P __ CONTRACTOR NAME: u,,,, °u Type of Permit or License:(Check box) 11 Animal $— ❑ Body Art Establishment $ _ _ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp ❑ Sun tanning ❑ Swimming Pool ❑ Tobacco $� ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $� SEPTIC ftitems: ❑ Septic-Soil Testing $ ❑ Septic-Resign Approval $ ❑ Septic Disposal Works Construction(DW(:) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Deport " i ❑ Other:(Indicate) _ $ Herd°lth,.Ag-ent Initials White®Applicant Yellow Health Pink.-Treasurer