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Home My WebLink About- Title V Inspection Report - 9 LACONIA CIRCLE 4/16/2019 Commonwealth of Massachusetts RECBIVED Title 5 Official Inspection Form It Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 9 Laconia Cir J`OWI1 OF Property Address -44- 44-4-�` 4- --44— Lori Goodwin Owner Owners Name information is North Andover Ma 01845 3/10/2019 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, use only the tab Dean Pynan --------------- key to move your Name of Inspector cursor-do not Dean Dynan use the return Company Name key. 2 Suntaug Street QCompany Address _Ly�nfield Ma 01940 City/Town State Zip Code rerwn 508-726-9935 S112837 -—-------------------- 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, ❑ Conditionally Passes 3, F] Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails U Ihspector'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 DER The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority, Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev,7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Laconia Cir Property Address Lori Goodwin Owner .�� Owner's Name information is North_Andover Ma 01845 3/10/2019 required for every _...._ _-.. page. City/Town State Zip Code Date of Inspection C. Inspection Summary 1 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: 4 bedroom single family dwelling with pipe in stone drainfield in working order 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): t5insp.doo-rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Laconia Cir iProperty Address Lori Goodwin Owner Owner's Name information is North Andover Ma 01845 3/10/2019 required for every ------------ page. CityTrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 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): 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,V26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form Not for Voluntary Assessments ❑ 9 Laconia Cir Property Address Lori Goodwin Owner Owner's Name information is North Andover Ma 01845 3/10/2019 required for every page, City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fall 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: E] 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. n The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. R The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all Inspections: Yes No Backup of sewage into facility or system component due to overloaded or El 0 clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Laconia Cir Property Address Lori Goodwin Owner Owner's Name information is North Andover Ma 01845 3/10/2019 required for every - .21-- page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No F1 z Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool E-1 Z Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow Required pumping more than 4 times in the last year NOT due to clogged or E-1 0 obstructed pipe(s). Number of times pumped: r-1 z Any portion of the SAS, cesspool or privy is below high ground water elevation. [I z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. El 0 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. El 0 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 F ED the system is within 400 feet of a surface drinking water supply El Z the system is within 200 feet of a tributary to a surface drinking water supply D 0 the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well 15insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 Of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ~ s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v r 9 Laconia Cir Property Address Lori Goodwin Owner Owner's Name information is North Andover Ma 01845 3/10/2019 required for every .__... page. Cityrrown State Zip Code Date-.of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section 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 Z ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? ® Q 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 El 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. F-1 El 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)] t5insp.doc rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pago 6 of 18 Commonwealth of Massachusetts ...... Title 5 Official Inspection Form mm i; Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Laconia Cir -Property Address Lori Goodwin Owner ner's Name information is required for every North Andover Ma 01845 ----------- page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4-----_ Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: 4 Bedroom system with 1500 gallon tank and 1000 sq ft drainfield Number of current residents: Does residence have a garbage grinder? 0 Yes Z No Does residence have a water treatment unit? EJ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Na information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes No <400 gpd Water meter readings, if available (last 2 years usage (gpd)): Detail: see attached Sump pump? Yes No current Last date of occupancy: Date Wnsp.doc rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Laconia Cir Property Address Lori Goodwin Owner Owner's Name information is required for every North Andover Ma 01845 3/10/2019 page. CityrTown 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? El Yes 0 No Water treatment unit present? n Yes E] No If yes, discharges to: Industrial waste holding tank present? ❑ Yes [_1 No Non-sanitary waste discharged to the Title 5 system? El Yes El No Water meter readings, if available: Last date of occupancy/use: 15 ate _.. Other(describe below): 3. Pumping Records: Source of information: tank Homeowner/ Board of Health was pumped 1/2011 9 as per homeowner_ Was system pumped as part of the inspection? El Yes M No If yes, volume pumped: gallons How was quantity pumped determined? —----- ----------- Reason for pumping: t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Laconia Cir ------------------ Property Address Lori Goodwin Owner Owner's Name information is required for every North Andover 3110/2019 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 El Privy 0 Shared system (yes or no) (if yes, attach previous inspection records, if any) E-1 Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract El Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: _12I Qq5 as per as built on file Were sewage odors detected when arriving at the site? E-1 Yes No 5. Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: El cast iron Z 40 PVC F-1 other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): sewer pipe in good condition no evidence of leakage 15insp.doe-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Laconia Cir Property Address Lori Goodwin Owner Owner's Name information is required for every North Andover Ma 01845 3/10/2019-------- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 3011 Depth below grade: feet Material of construction: M concrete El metal El fiberglass F-1 polyethylene ❑ other(explain) 1500 gallon septic tank ---------- ...... ------- ..... If tank is metal, list age: years —----- Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) R Yes F] No Dimensions: 1-0'X 5'X 68 5"__ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" 0-201 Scum thickness Distance from top of scum to top of outlet tee or baffle 611 Distance from bottom of scum to bottom of outlet tee or baffle 1311 How were dimensions determined? in field with measure stick and tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc,): 1500 gallon concrete septic tank with PVC inlet and outlet / Tank in working order with separation from inlet to outlet / no evidence of leakeage cast iron cover to grade recommend pumping every two to three years depending on usage and number of occupants t5insp.doc-rev.712612.018 Titte 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Laconia Cir Property Address Lori Goodwin Owner Owner's Name information is North Andover Ma 01845 3/10/2019 required for every _._ __.._....._. page, Cityrrown State Zip Code Date of Inspection D. System Information (cant.) _ � 7, Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle - - - - --- Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date _._..__._..____._ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8, Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: - - - - Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: ...... gallons Design Flow: __._ gallons per day t5insp.doc•rev.712612016 Title 5 Official inspection Form:Subsurface Sewage disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Laconia Cir Property Address Lori Goodwin Owner Owner's Name ................. information is required for every North Andover Ma 01845 3/10/2019 page. Cityfrown State Zip Code -Date-6fInspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: El Yes El No Alarm level: -—------- Alarm in working order: El Yes F1 No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ----------- —----------- Attach copy of current pumping contract(required). Is copy attached? El Yes El No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert liquid at 0" above 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.): 8 outlet concrete D box level with 5 outlet pipes /little evidence of solids carryover/ no evidence of leakage into or out of box outlet pipes have levelers D Box cover is 12" below grade D box in good condition t5insp.doc rev.7126/2018 Title 5 officIaI Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts x = - F Title 5 Official Inspection Form i Subsurface Sewage disposal System Form -Not for Voluntary Assessments 9 Laconia Cir Property Address Lori Goodwin Owner Owner's Name information is required for every North Andover Ma 01845 3/10/2019 _�..... page. Cttyfrown State Zip Code [late of Inspection D. System Information (cont.) 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: — — ❑ leaching chambers number: --- ❑ leaching galleries number: n leaching trenches number, length: -- — ® leaching fields number, dimensions: 1 @ 1000 sq ft___ ❑ overflow cesspool number: -- ❑ innovative/alternative system Type/name of technology: - t5lnsp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 16 i Commonwealth of Massachusetts �0��0 �� Official N Inspection �� Title ��N�� 0"0�� m�� y� � ��m�� mm�� w��mw ��mmm� Subsurface Saxnm0e Dispqsa| SymtemnFomm -NctforVo|umtaryAsseaanlents 9 Laconia Ci[ 0-roperty Address Lori Goodwin Owner Owner's Name information is North Andover MaO184� �V10/�O1Q raqu|ned�rove� �6��-- pmOo. ~'^r'`~^ -"-'- Date-Inspection --- D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs ofhydraulic fo||una, level nfpVnding, damp soil, condition of vegetation, etc.): � Dre|nfieN found in green lawn area with slight slope sn not to hold rain water / soils in good condition no signs ofhydraulic failure/ nmponding/ no damp aoi|d/ grass is uniform in good condition Drain field ia2O'X5O' pvCpipe in stone conventional system in working order 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth -8Jp of liquid to inlet invert Depth of solids layer Depthofocurn |ayer Dimensions ofcesspool Materials ofconstruction Indication of groundwater inflow Yea F7 No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Laconia Cir ------------- Property Address Lori Goodwin Owner Owner's Name information is North Andover Ma 01845 3/10/2019 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.): t5insp.doc rev.7126/20118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ' - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Laconia Cir Property Address Lori Goodwin Owner Owner's Name information is required for every North Andover Ma 01845 3/10/2019 _-__-.-- — - --- page City/Town State Zip Code Date of Inspection D. System Information (cone.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t51nsp.doo-rev.7/26/2018 Title 5 official Inspection Form;Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Laconia Cir Property Address Lori Goodwin Owner Owner's Name information is required for every North Andover Ma 01845 3/10/2019 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope Surface water Check cellar Shallow wells Estimated depth to high ground water: 48"+ as per plan on file 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: 2005 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: Plans on file at BOH dated 2005 System is located in front yard and is a gravity mound Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6insp.doe•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form .......... t Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Laconia Cir Property Address Lori Goodwin Owner Owner's Name information is required for every North Andover---—---------- Ma 01845 3/10/2019 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 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed D. System Information: For 8: Tight/Holding Tank- Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 of 18 SEPTIC AS-BUILT PLAN OF LAND IN INVERT ELEVATIONS NORTH ANDOVER, MASS. OUT OP HSE,=129.38 OWNED BY INTO TANK=129�05 1 ouTbFTANK=128.80 PETER MURPHY INTO D.BOX=1E8.32 SCALE,1"=20' OATE'12I5/2005 OUT OF D.BOX=128.16 END OF PIPE=f27.63 SaottL,Giles R.P.L.S. END OF PIPE=127.55 Frank.S.Giles R.P.L.S. 50 Deer Meadow Road North Andover,Mass, LACONIA R=706. 3' CIRCLE L=1 0, 0' na eXPANSION AREA PROP.WATER LIN —' vl�NT 30, 00 C CXIS1".14�G111-4EPTIC TANK 13' 135.08 T.O.W. 13, wXiST. HSE FND. 33'+1 - ro cp W LOT 14 ^' 43,840 S.F. ASs` so%s M"OP p68,PA 'GEL 11s I ��10 ^� ij - l i Y�r �✓ r ui i! PI��'/1�i,'W��i � i8 `� �r "'�k�r'", ',.sir ,�� y+, � ` y yY +'yw i' #'" S M ✓, ^ fNy �; ,.�a AJ1k r ati r +' r v9 U ✓G dYC, ��✓ ��y�� m'q S, 9 x r r iw + ugg r �� ire '"9, e��'- �tY/O,'�"'x,V�i / Yl /� f✓ iJl lyy��^r/�y<y,Tnyl IY � ✓�*�,. T „e '`� � � �r (rI ✓Pl��/T(�Fey ✓ � �, ,� � � � �„ j�1�� Y FORM I 1 —S011,EVALUATOR FORM Page 2a of 3 Location Address or Lot No. .Lot 14 Laconia Circle On-,bite Review Deep Hole Number UP 05-1 Date 6/21/05 � _ `Time 8:00 am Weather Sunny 75 u Location(identify on site plan) See Flan _ Land Use Residential _ W_... Slope{%) 15-25% Surface Stones Few 143'dia. Vegetation Woods Landforin brumlin� Position on landscape(sketch on the back) See Flan Distances kom; �,.,..... . .. ,_,_ Open Water Body 100' +__ feet Drainage Way feet Possible Wet Area IOOr�� feet Property Line 10' -- feet Drinking Water Well —46 U0' + feet Other Cie t[i f-&nTso�j H � .or�zon soil Textu ,„�..�....pS re Soil Molar Soil father Surface(Inche (USDA) (Munseli) Mottling (Structure, Stones, Bounders, _ Cansistenc ,%Gravel 0.8'" FS.11 I OYR3/2 8-24" Bw FSL IOYR4/6 24w12011+ Cl FSL 2.5Y5/6 ESHWT 46" *MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic) Glacial Till Depth to Bedrock: NA Depth to Groundwater; Standing Water in the Hole. NA Weeping from Pit Face: NA Estimated Seasonal High Ground Water., 46" ��__� _W.. _W.. .._...,z .........�,...r [)FTC APP'ROVLD FORM..,1217195 DocumeW T3ocumCW —, Summary Record Card generated m`m21non1:2e:5upwov Joanna oafi» Page 1 .' , Town of North Andover - Tax Map # 210-1063_0119-0000~0 Parcel Id 17623 9 LACONlA CIRCLE GOODWIMY' RONALD Since Jan 2007 GOODWUN' LOR| L 9 LACON|A C|R NORTH ANDOVER88A01845 Class 101 Single Family Property Type I Residential Size Total 1.01 Acres FY 2019 UB Mailing Index Typo Loan Number AuVve/|nooC From Until RONALoGOODVVN Owner xm*r SLACON|ACIRCLE NORTH ANDOVER.MA0184S 14VAPPLETDN STREET REALTY Temporary Owner Inactive 3/14/2006 JOHNJ&E0TH8THOMP8ON.TR 14OAPPLET0NSTREET NORTH AMDOVER. MA 01845 PETER MVRPMY Previous Customer Inactive 1011/2006 9L4CON|ACIRCLE NORTH 8NDOVER.MAO1845 Account No Cycle Occupant Name Active/Inactive Bldg Id, 18715.V'9LACON|8CIRCLE Last Billing Date 1/16/2018 3170656 03 Cycle03 Active Account No.317OV56 Service Code Rate Charge Multiplier/Users M|GCFEEADM|NFEE 11 918 1/1 VVTRVVKTER 01 ALL METER SIZE 64.60 1/1 UB Meter Maintenance Account No. 317V65O Serial No Status Location Bend Type Size YTDtoom 32154229 uActivo ERTHH bBadQor wWamr 1 1 2320 ootu Reading Code Consumption Posted Date Variance 3/8/2019 2803 aAcma| 16 '6Y6 12/10/2018 27*7 aAutua| 17 1/22/2019 '85% 9/13/2018 2770 oAu(ue| 125 10/15/2018 328% 8/8/2018 2645 oActuo| 28 7/23/2018 51% 3/7/2018 2617 oActua| 18 4/23/2018 '8% 12/7/2017 2599 oActuo! 18 1/25/2018 -79% 9/11/2017 2580 oActuo| 100 10/18/2017 177% 60/2017 2480 omctum| 35 7/25/2017 99% 3/8/2017 3445 oActua| 17 4/12/2017 '21Y6 12/g/2818 2428 aActus| 22 1/23/2017 '87Y6 8/9/2016 2406 oAotua| 168 10/24/2018 269Y6 6/8/2018 2238 aAutua| 45 8/2/2016 159Y6 30/2016 2180 aAmuo| 17 4/22/2016 -55% 12/9/2015 2176 aActuo| 38 1/202016 -02Y6 9/102015 2138 oAmom| 103 10110/2015 74% 6/9/2015 2035 aAdua| 58 7/24/2015 282% 3/10/2015 1977 u8ctua1 15 4/28/2015 -2296 12/102014 1982 nActuo| 19 1/15/2015 '54% 8/12/2014 1943 uAmuo| oo 1015/2014 25% 6/11/2014 1888 aActua| 43 7/102014 172% wp pTM 6 • � Town o North Andover HEALTH DEPARTMENT WSSACHUE.ti, CHECK#: IATE: . °". (` s / CONTRACTOR NAME: k. Type of Permit or License: (Check box) ® Animal $ ❑ Body Art Establishment $_ ❑ Body Art Practitioner ❑ Durnpster $ ❑ 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 Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal'Krorks Construction(D'C O $ ❑ Septic Disposal Works installers(DWI) $� ❑ Title S Inspector $ Title 5 Report " ❑ Other: (Indicate)., -- .__-- $ 1-fe41Fh"Agent Initials "White-•Applicant Yellow-health Pink-Treasurer