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Home My WebLink About- Title V Inspection Report - 200 RALEIGH TAVERN LANE 4/22/2019 Commonwealth of Massachusetts T"Itle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 200 Raleigh Tavern Lane `°°i � Property Address Raj brien j 0 Owner _ Owner's inform required for over ___. __._ — MA 01845 4/4/2019 required for every forth And.._.._.�_�__.______..._...... ....._..__.. page, Clty[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 _Benjamin_C Osgood Jr. key to move your Name of Inspector _ cursor-do not N/A use the return ---------- key. __, Company Name >, r 157 Bluff Street Company Address Sa'j�11`wn-... _ . .,..�.. _.__ State ._.-..._._. _ �- 03079 t ll y p Code aaar�n 978-435-1324 51870 E' 6 Telephone Number License Number B. Certification I certify that: t am a DBP approved system inspector in fall compliance with Section 15.340 of Title (310 CMR 1 .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. El Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails j _ 4/5/201.9.._ — ..._.m.... — ___ Inspoctor' Igna#ure Date I The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DPP)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. 15insp.doc-row.7f28f2018 Tille 5 official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth ofMassachusetts ��"4�N �� Official � Inspection �� Title ��U�� 8�� N~��% 0 �N.= �� »NUH�,m��N Nwm�� ~ ' � �.�� u�rmm Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 20O Raleigh Tavern Lane Property Address Ray0'brien Owner Owner's Name inh,nnaVonis nmvi=w for every North Andover MA 01845 4N/2019 pmoe, c|ty7own sxme Zip Code Date ofInspection C. Inspection Summary Inspection Summary: Complete i. 2. 3. or5 and all of4 and 6. 1) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 C[NR 15.303mrin 310 CyNIR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: Fl 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^yee^. ^no^or"not determined" (Y. N. ND)for the following statements. If"not detenminmd.^ 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 Certificate of Compliance indicating that the tank io less than 28 years old imavailable, El Y F N n ND (Explain below): Commonwealth ofMassachusetts ��N�� ^��0 0��°�� U�� N0�N�* �� %^�8NN��N�=N Inspection �-��mmwm Subsurface Sewage Disposal System Form ~Not for Voluntary Assessments 2UO Raleigh Tavern Lane Property Address Ray{)'brimn Owner Owner's Name information is required for every North Andover MA 01845 4/4/2019 page. , City/Town atum Zip Code Date u[Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (onnL): El Pump Chamber pumps/alarms not operational, System will pass with Board of Health approval if pumps/alarms are repaired. LJ 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(o)are replaced n Y n m El ND (Explain bo|ow): 0 obstruction isremoved 0 Y El N Fl ND (Explain be|ow): F1 distribution box ia leveled orreplaced El Y El N E7 ND (Explain bo|ow): �l The system required pumping more than 4 times u year due to broken or obstructed pipe(e).The system will pass inspection |f(with approval nf the Board ofHea|th\: [l broken pipe(a)are replaced Y �l N Fl NO (Explain ha|ow): E] obstruction iuremoved Fl Y F1 N [l NO (Explain be|ow): 3) Further Evaluation |a Required 6y the Board ofHealth: 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 urthe environment. m. System will pass unless Board of Health determines in accordance with 310 CK0R 15.303(1)(b)that the system is not functioning in manner which will protect public health, safety and the environment: mm"ru""^rev.,mamm 'Tide o Official Inspection Form:Subsurface Sewage Disposal System^Page^*1v Commonwealth mfMassachusetts ��°�0�� 4��°��"��0 N��~�� N~�� NN�0�� 'DN0=,N�wN Inspection 0—�� " " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address Rmy[)'brien owmo, Owner's Name information is required for every North Andover MA 01845 4/4/2019 page. city«"w^ State Zip Code Date ofInspection C. Inspection Summary (cont.) R Cesspool or privy|n within 50 feet ofa surface water [l Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: F The system has a septic tank and soil absorption system (SAS) and the SAS is within 108 feet ufa surface water supply or tributary tom surface water supply. F The system has septic tank and G/\S and the SAS in within a Zone 1 of public water supply. El 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 o private water supply we||°^. Method used tn 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 bo attached Um this form. c. Other: 4) System Fm||unm Criteria Applicable to All Systems: You must indicate "Yme" or"No" to each of the following for all inspections: Yes No [-1 Backup of sewage into facility or system component due h) ovedoadedor [� �~ clogged SAS orcesspool �� Discharge orpundinQof effluent tu the au�acemf the ground oreu�aoawaters �� ~~ due toan overloaded or clogged SAS orcesspool Commonwealth of Massachusetts -= f- f Title Official Inspection Form - e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ti y 200 Raleigh Tavern Lane Property Address Ray O'brien Owner Owner's Name information is t required for every North Andover MA 01845 4/4/2019 page. Cityfrown State Zip Code Date of Inspection -------_-- C. Inspection Summary (cant.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ® ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ E The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 Q ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2612018 "i-fie 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth ofMassachusetts ��0�� '��N N�� U�� mm�m�� N � 8�~0��0 Inspection �—��wmmu Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2U8 Raleigh Tavern Lane Property Address RuyO'br|en Owner Owner's Name information is mqvireu for every North Andover MA 01845 4/4/2018 page, oty[Tvwn State Zip Code Date v(;ospemwn C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant thnoa(. ormnsvvmred''yem^{oanyquemtioninQmotionC.4abovethe |argomyatmmhamfai|ed. The owner or operator of any large system considered a significant threat Linder 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. O. You must indicate "yes" or"no" for each of the following for all inspections: Yes No 0 Fl Pumping information was provided by the owner, occupant, or Board ofHealth El E Were any of the system components pumped out |n the previous two weeks? 0 El Has the system received normal flows |n the previous two week period? Fl �� Have large volumes of water been introduced tm the system rocenUyorampu�of �� this inspection? �� l VVmmau built plans wf the system obtained and examined? (if they were not �� available note amN/A) E El Was the facility mr dwelling inspected for signs mf sewage back up? 0 El Was the site inspected for signs of break out? 9 E] Were all system components, excluding the SAS, located on site? • El 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 ofscum? �� El VVaathe had|ityovxner(and Occupants ifdi�*rent from owner) provided vvith �� ^� information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SA8) on the site has been determined based on: 0 0 Existing information. For example, a plan at the Board of Health. �� Determined inthe�e|d (if any of the failure criteria related toPadCimstissue . ~~ �� approximation of distance im unacceptable) [31UCK4R15.302(5)] mm=.*""'rev.rmmmm 1We 5 Official msp°"o""Form:Subsurface Sewage Disposal uys*rn'Page o"''o Commonwealth of Massachusetts :mmm Title 5 Official Inspection Farm - a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address Ray O'brien Owner Owner's Name information is North Andover MA 01845 4/4/2019 required for every page City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® Na Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ED No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No curLast date of occupancy: Date o t5insp.rloc-rev.7/2 6120 1 8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Pape 7 of 18 Commonwealth of Massachusetts Title~�^��0�� °��N 0�� U��k� �� n��00Q�rN��N Inspection 0—�r� � � " Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address RayO'hr|on Owner Owner's Name information is m4uired for every North Andover MA 01845 4/4/2010 page. City/Town mm|o Zip Code Date ofInspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on31OCyWR15203): Gallons per day(npd) Basis of design flow(smats/pomona/aq.ft.. mto.): Grease trap present? Fl Yes F1 No Water treatment unit present? Yes n No If yes, discharges to: Industrial waste holding tank present? El Yes Fl No Non-sanitary waste discharged to the Title S system? Yea n No Water meter readings, if available: Last date nfocoupmncy/ume: oum Other(describe be|uw): 3. Pumping Records: Source ofinformation: 12/3y18 porB()H Records Was system pumped as part ufthe inspection? Yes 0 No K yes, volume pumped: om||unu How was quantity pumped determined? Reason for pumping: Commonwealth of Massachusetts Title ❑ Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 200 Raleigh Tavern Lane `f Property Address Ray O'brien Owner Owner's Name information is North Andover MA 01845 4/4/2019 required for every page, CItyTTown State Zip Code Date of Inspection D. System Information (cons.) 4, Type of System: ® Septic tank, distribution box„ soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components„ date installed (if known)and source of information: Installed in 1981 per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 1.5 Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line; eet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe looks OK in basement t5lnsp.doc-rev.7/26/2018 `rifle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page g of 18 i I Commonwealth ofMassachusetts Title��i��0�� .��"��0 0��^��°�� 0�� mNW=,N�=N Inspection �—��mumm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2OO Raleigh Tavern Lane Property Address RoyO'briom Owner Owner's Name information is required for every North Andover MA 01845 4/4/2019 page. cityDow» State Zip Code Date ofInspection D. System Information (cont.) 6. Septic Tank(locate on site p|on)/ i. Depth below grade: feet [Naharie| of construction: Eu)ncrehm El metal El fiberglass El polyethylene other(explain) |f tank ia metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes El No Dimensions: 1500ga||om Sludge depth: <1 Distance from top 33" Scum thickness <1 8" Distance from top of scum to top �o��t�or baffle Dio�nre0mm bottom ofacum to bottom ufm�mt�m or baffle How were dimensions determined? Measure stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels am related tu outlet invert, evidence of leakage, etoj: Tank in good condition with riser to grade over outlet opening. Outlet tee equiped with an effluent filter Commonwealth of Massachusetts x = =M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address Ray O'brien Owner Owner's Name information is North Andover MA 01845 4/4/2019 required for every page. cityrrown - State Zip Code Date of Inspection 1 D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 15insp.doc-rev.7/261201 B Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ��"��0�� u�&��°��N N��°�� U��k� ---------- Title �� 'N88��N��N Inspection �—�rmmwu Subsurface Sewage Disposal System Form ~ Not for Voluntary Assessments 2O0 Raleigh Tavern Lane Property Address RayD'brien Owner Owner's Name |nmnnutiouw ,e9uimd for every North Andover MA 81845 4/4/2010 page. City/Town otu,v Zip Code Date o/Inspection D. System Information (cont.) 8. Tight nr Holding Tank(coni) Alarm present: El Yes E-1 No Alarm level: Alarm in working order: Fl Yea No Date of last pumping: ou|v Comments (condition of alarm and float switches, etc.): °Attaoh copy o[current Pumping contract(required). Is copy attached? El Yes El No 9, Distribution Box(if present must 6e opened) (locate on site p|an): Depth of liquid level above outlet invert O"' 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, ato]: Box in good condition. No sollids carryover or leakage in or out.Box 2' below grade t5insp.doc rev.7/26/2018 I'Me 5 Official Inspection Form:Subsurface Sawage Disposal System-Page 12 of 18 Commonwealth of Massachusetts ~�~�� a��°��N ��°��"�� N N0�0�� v00N��N�mN Inspection N-�� m � Subsurface Sewage Disposal System Form ~Not for Voluntary Assessments 2O8 Raleigh Tavern Lane - Property Address Nay0'bdan Owner Owner's Name information is required for every North Andover MA 01845 4/4/2019 page. cityfTnwn State Zip Code Date v[Inspection D~ SyStem Information /cont.\ 10. Pump Chamber(locate on site plan): Pumps in working order: El Yes No* Alarms|n working order: F] Yea R No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ° |f pumps or alarms are not in working order, system iem conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not |onatad, explain why: Type: Fl leaching pits number: n leaching chambers number: El leaching galleries number: 25' x4O' E leaching trenches number, length: Fl leaching fields number, dimensions: overflow cesspool number: F� innovotivm/a|tornat|voeyaiem Type/name oftechnology: Commonwealth of Massachusetts Title�� N 0��^�� N~��h �� n�pNN ��N��N Inspection �-�~m " � � Subsurface Sewage Disposal System Form ~Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address RayO'brien omme, Owner's Name information is m*vimu for every North Andover MA 01845 4/4/2019 p,o= cxyfTmwn State Zip Code Date ofInspection D. System Information (cont.) 11. Soil Absorption System (SAS) (ounL) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of leach trenches looks normal. No ponding or damp soil or unusual vegetation. 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 ofcesspool Materials of construction Indication of groundwater inflow Fl Yes 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 200 Raleigh Tavern Lane Property Address Ray O'brien t Owner Owner's Name information is North Andover MA 01845 4/4/2019 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.7/2612.018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 C`ommonwealfhf massaellusetts y` ubstirfac Se wage ewage Disposal System Form Not for Voluntary Assessments -' � 00 Ralei h Tavern Lane Property Address .. ..._. ....__.__—— ._....— py O'brlen OwnerOwner's ......_._._. _..,...__ Owner''ss Name requiredifo is every North Andover MA 0184,E required far eve _._._____..� ._—...._— _ _ r �/�/2U1� page, City/"fawn —.....__,... _.. ..-- _ Statetp Code Date of Inspection ___...,... D. System Information (cant.) - 14. Sketch Of Stowage 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 ❑ drawing attached separately ,r ilk -AC.C.-t G I ( t5insp,doc rev,7/26l2016 Title 6Official Inspection Form.Subsurface Sewage Disposal Systeri•page 16 of 18 � � Commonwealth ofMassachusetts ~�~°��N�� m��°�� N�� U�� 0N&N�w �� 'NN0�~��w� Inspection N—��mux � Subeudeoe Sewage Disposal System Form -Not for Voluntary Assessments 2O0 Raleigh Tavern Lane � Property Address RayU'brien Owner Owner's Name information is renvireu for every North Andover MA 01845 4/4/2019 page. City/Town State Zip Code Date ofInspection ----------------- D~ SystemUnforma*~on (cVOt.) 15. Site Exam: Check Slope Surface water Check cellar F-1 Shallow wells Estimated depth to high ground water 2"below a�tem � feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans onrecord If checked, date` Date 0 Observed site (abutting property/observation hole within 15U feet ofSAS) F� Checked with local Board ofHeo|th- explain: El Checked with local excavators, installers -(attach documentation) Accessed USE}S database -explain: You must describe how you established the high ground water elevation: System |nootyed in an area that was raised 2 to3feet above old existing grade. USGS maps indicate water table> S' below original Unmdo. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth mfMassachusetts ��"��N �� Official N Inspection �� Title ��A�� K�� U�01k� 0 ��N�� vN00~~�w=N 0° =�� m��nm �.mmmw Subsurface Sewage Disposal System Form ~Not for Voluntary Assessments 200 Raleigh Tavern Lane Property Address RayO'brien Owner Owner's Name information is required for every North Andover MA 01845 4/4/2819 page. CiV[rown State op000r Date ofInspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Z A. Inspector Information: Complete all fields in this section. B. CmrtiMootion: Signed & Dated and 1. 2. 3. or4checked C. Inspection Summary: 1. 2. 3. or5 completed mmappropriate 4 (Failure Criteria)and G(CheoNid) completed Z D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For14: Sketch nf Sewage Disposal System drawn onpg. i6orattached For 15: Explanation qf estimated depth to high groundwater included t51=p.o°"'rev.,nmmm Title,omm"/inspection Form:u"*=m^,"Sewage Disposal System`Page`"w," NgRT1d W r Town of North Andover HEALTH DEPAIUMENT R�sACHUgtt CHECK.#: „. DATE: ��`�� w � � �� H/0 NAME: m... ,��°,�� . CONTRACTOR NAME; ` ;"�' �� Type of Permit or License: (Check box) ❑ Animal $_ ❑ Body Art Establishment $_ ❑ Body Art Practitioner ❑ Dumpsler $_ ❑ 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 Sistetn�. ❑ Septic-Soil Testing j ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DW0 $ __ i ❑ Septic Disposal Works installers(DWI) $ j ❑ Title 5 Inspector Title 5 Report ° ."w I ❑ Other;(Indicate)__ ._....— __. $ alth Agent Initials White-Applicant Yellow- health Pink-Treasurer D 12/7/2018 ViewPoint Cloud Town of North Andover,MA https-.//tiorttiandoverma.viewpointcloud.io/#/explore/reports/1081/d7 2/2