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HomeMy WebLinkAbout- Title V Inspection Report - 507 SALEM STREET 4/29/2019 Commonwealth of Massachusetts on I Inspectim Form T'tle 5 Off'icia a' Su,bsurface Sewage Disposal System FoIrm Not for Voluntary Ass sn nts . n uisnz, Antonio mm Property Address 507 Salem St . ..... ............. Owner n r Owner's Name information reqsired f e er __,_.._______....._.m_... , ._..w..rv__._.._ _.w ,, ____...MA 01845 ... __...... 19 _.__..._.__._...._.__._._.._..._ .... _..__..w. __.... City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form,. Inspection forma may not be altered in any way. Please see completeness checklist at the end of the form. Iwt art nV When ��1 , % � illin frrr, A. Inspector no a i r use onlyt t John,on the computer, IVin:c e ......... key to move yoIur Name of Inspector � cursor- not � l rn nit St wart` Septic Service use the return Company Name � w 58, So. Kimball ;fit. r Company Address Bradford M 835 City/Town Stag _. I odl 3386 _.._._._.__ _..._....... Telephone Number r License Number r B., Cerflification l certify that: I am a DEP approved system inspector in full compliance with Section 15.340, of Title 3 ; l; have personally inspected the swage disposal system at the property address listed above; the information reported below is true, accurate and corn ilete as of the time of my inspection; and the inspection was performed basedn my training and experience in the proper,function and maintenance of on-site sewage is l ; 1 systems. After conducting this inspection l have determined that the system: M Passes f f i 2.. El Conditionally Passes 1 3. Needs Further Evaluation by the Local Approving, grit . ils I P ' r Biena w �a Dt The system, inspect s1 al, ubmit a copy Du this inspection report to the Approving Authority (Board f Health r EP), witIT1610 days of completing this inspection. if the,system has a.design flaw of 101000 gpd or greater, the inspector and the system owner shall submit it the report to the appropriate regional office the DEPI. The original fora should , sent to the system owner and copies sent t the buyer, if applicable, �n the rind authority. Please n This report only describes conditions at the,time f inspection and under the conditions of use at that time. This inspection does not address how thIe system will perform in the future under the same or different conditions of use. 15,insp. oc rev.7126,12018Titl Official:Inspection Form"Subsurface Sewage Disposal System-I Page 1 of 18 I i awCommonwealthas icia Oi T'"It'gle 5 Offm I Inspecto Fiorm Subsurface Sewage e f Disposal System dorm Not for Voluntary Assessments Ruisanchez, Antonio PropertyAddress 507 Salem Sit Owner Owners Name informaflon is MA 01845 4 19-20 19 required for every No. Andover ..e.... _..._... __..r._... ._..__.._... _ _.... _.._ _._.__. ._. City/Town State Zip Code Date of Inspection C,, In'spectilon Summary i Inspection Summary-, Complete 1, 2, 3, or 5 and, all of 4 and 1) stem asses: I have not founid any information which indicates that any of the failure criteria described in 310 CMR15.303 or in 31 CIVIR 15,304exist. Any-failure criteria not evaluated are indicated ' 1w. Comments.: , System CondiltionaIly Passes: one or more system components as described in the "Conditional Passill section need to be replaced r repaired. The system, upon, completion of the replacement or repair, as, approved b the Board of Health, will, pass. Check thie box for s", "n r"riot determined, 1 i , for the following statements. If not determined," please explain., The septic tank is metal and,over,20 yearsold* or the septic teak (whether metal r riot) 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 compil inn septic tank.as approved by the Board of Health. ,A metal septic tank,will pass 'Inspection if it is stru,clurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. El Y I (Explain below). G , _...... _ . __........._.__. a .. v . t5insp.doc reap.7/2612018, Tillie a Official Inspection n Form:Subsurface Sewage Disposal t yster .Bags f 18 I I uommonwealth of Massachusetts n " 5Inspect'imon k® s oral Subsurface Sewage System FormNot for Voluntary Asses tints Ruisanichez, Antonio, s 57Salem St Owner Owner's Name information is MA 01845 9-2019 r ui�red for every Nq.. ___...._ ... __w...__.m „ ... w_.._..__ _.._._ _... _N. w City/Town State I Code Date of Insplection page* C. Inspection Summary (cont.), System Condifilonally Passes (coat.): Pump Char her pumps/alarms not operational. System will pass with Board of Health approval if mps ,l rms are repaired. El Observation of sewage backup r break out or high static water level in the distribution box due to broken or obstructed pipe(s) r due to a broken, settled or uneven istri"buti rr box. System will pass inspection if(with approval of Board of Health): broken files are replaced [:1 Y _ N (Explain below)- obstruction is removed E] N (Explain below)- E] distribution box is leveled r replaced N (Explain below): The system required ir+ umpin more than 4 times a year due to broken or obstructed i e s . The system will pass inspection if(with approval of'the Board of Health): broke i s are replaced F1 Y El N El ND (Explain below): obstruction is removed ND (Explain below): 3 Further Evaluation s Requillried by the Board f' eatth:� El Conditions exist which require further evaluation by the Beard of Health in order to determine if the system is failing to ,protect public he� lth, safety or the environment. w a. stem will ass less Board f Health I determines � cc r � with � CMR 5.3 3 that the systems not functioning in a manner which will protect public health, safety and the environment:, t5in p.do-rev.7126/2018 Title 5 Official Inspection Forni,Subsurface Sewage Disposal al System•Page 3 of 18 Commonwealth of Massachusetts .0p; icia ion Tmtle 5 Off" m I Inspect" Form Not for Vol untaryAss,essments Subsurface Sewage Disposal System Form Ruisanchez, Antonio Property Address 507 Salem Sit, ...................... Owner 0 w n e r's Name information is No Andover MA 01845 04-19-2019 required for every —---1--- -- "­­`-,-­,--,- ­­,-,-­-­----, -'' , ,-, page. CitytTown State Zip Code Date of Inspection C. Inspection Sum ar c t.) El Cesspooll or privy is within 50 feet of a, surface water Cesspool or privy is within 5 feet,of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (arid Public Water Supplierjf any) determines that the system is furilc born ng in a manner that prot cts the public health, safety and environment: 0 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., El 'The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply, [] The system has a sepitic tank and SAS and the SAS is withilln 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 cloliform,bacteria, indicates absent and the presence of ammo nia 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: 14), System Failure Criteria Applicable to All Systems: You must indicate "Yes"' or"'No" tio each of the following for all,inspections,,, Yes No Backup of sewage into,facility or system component due to overloaded or clogged SAS or cesspl l Discharge or nding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or ces,spoo,l ffifnsp.doc-rev,7/26/2018 Title 5 Official:Inspection Form,Subsurface Sewage Disposal,Systeni-Page 4 of 18 uommonwealth of Massachusetts ion Form Totle Offmici'al M. � �Voluntary�, h ace Sewage, Disposal System Form Ruisanchez, Antonio Property Address 07 Salsa,St information is IVIA, 845. ru�irl �for every .. .. _...._And _ - .....ver __..._..__.._._.... City/T ry State Zip Code Date ofInspection F C. 1 Inspection Summa,ry (cont.) 4), System, Failure Criteria Applicable to All Systems: (cont.), Yes No StaticEJ N liquid i level in the distribution boxy above outlet invert,due to are overloaded r clogged SAS or cesspool Liquid i Iie thu in cesspoolis less than 6" below invert or available lu me is less than 1 flow Required pumping more than 4,times, in the last year NOT due to clogged or 'obstructed l s . Number times pumped:�I Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion ofcesspool or privy is within 100 feat of surface water supply,l r tributary tar to a surface,water supply. Any portion of a cesspool or privy is within a Zone a public water supply l 1 Any portione s o 1 or privyis within 50 feet a private water supply well Any portion a cesspool r privy is lens than 1,00 feet but greater than 50 feet. from a private water,supply well with no acceptable water quality,analysis. [This system asses if the well water analysis, performed at a D,EP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen, and nitrate nitrogen is equal to or less than 5 provided that no other failure criteri'a aretriggered. A copy of the n l sis and chain of custody must be attached to this form.] The syst r is a, cesspool serving a,f'a ility with a design flow of 2000, gpd- 101000n 'The system fails. l have determined that one or more of the above failure criteriaexist as described in. 310 CAR 151.3103, therefore the system ails. The system owner sih uldcontact the Board of health to determine what will be necessary to correct the failure., LargeSystems: be considered a large system the system must serve a facility with design flow of 101,000g pd 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 C. . Yes, N the s ster i is within 400 feet of a, surface drinkilng water,supply " 0 E] the system is within 200 feet f'a tributary to a sunrtace rir kin rater supply the system is located in a nitrogen sensitive area Interim Wellhead r t ti+ El 1:1 Area IW r a mappedZone 11 of a public water supply well t5ira , 'oc•rev. 1 1 1 Title 5 Official Inspection F ri ,Subsurface Sewage Disposal System Bags 5 of 18 _ Commonwealthac T'Itle 5 Official Form w � q Subsurface SewageDisposal System rirr� � �"� l rat r �Assessments w� '. ,� Ruisanch ez 'Antonio, Property Address j Owner Owner's,Name information,is MA 01845 required for every ___..�__. _ ___..._. �. _...._.___.._. �m,„�_ _._ _.._.__ �..„_..._. _20 1,9 page, City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) � l It yes"' any y re a significant u answered rr u���tNrr �� "��tur� . he system � considered,w �t threat, or answered yes"'to any question in Section C above the large . The owner or operator of any large system considered a significant threat u n r Section G.5 oir failed under Section C.4 shall upgrade ud the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional! office of the Department. . You must indicate `yes" or"no" for each of the folIllowing for a "Inspections Yes No Pumpinginformation was provided by the owner, occupant, or Board of Health 01 1Z Were any of the system components pumped out in the previous two weeks? 0 El Has the system received normal flows in the previous two week period' El H Have large volumes of water been introduced to the system recently or as part of this inspection?. Were built plans of the system obtained and examined?. (If they were not available rote as 1 Was thie facility r dwelling inspected for signs sewage back up? Was the site inspected for signs of brash out? Were all system commoner tr>, excluding the SAS, located on site" Were the septic teak manholles uncovered,, openied, and the interior of the tarp inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depths of scum" 0 E] Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of su surface sewage disposal systems.? The size and location the Soill Absorptilon System on the site has been determined based n 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 1 .3 2 5 ] i i l irm ,'oc-rev.7126/2018 Tille 5 Official Inspection Form,,Subsurface Sewage Disposal System.Paige 6 018 I r.yCommonwealth of Massachusetts ................' '" ic" " ia Subsurface Sewage C i s � sal System Form Not for Voluntary Assessments Ruisanchez, Antonio Property 57 Sale S ....._ ..........._ Owner Owner's Name Nrrrtrl is . Andover M 5 - 21 9 ;r u fired for __._.... _ _.._._._._._ _... pale, City/Town State Zip Code Date of Inspection U, System Information u R,esidential RowCon,ditions,.- Number of bedrooms, (design): Number of bedroomsc al DESIGN flow based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): _._.__._..._. _..__.. Description, Number of current residents: Does residence have a garbage grinder? Yes E] No Does residence have a water treatment unit? 'Yes _El No Is laundry on a separate sewage system? (include laundry system inspection Yes N information in this report.) Laundry system boast Yes [I No ,S sonal use? El Yes M N Water meter readings, if available (last 2 years usage , " � tI Sump pump? Yes No, cu �qd Last date occupancy: ___ ®._._.__..n.. t 15insp,doc rev.'712612.018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System 4 Page 7 of 1 Commonwealth ' a sac a ic" I Inspect" N �. "''d I e 5 Offm' i a ion Form r Not6'j Till for Voluntary Assessments Subsurface Sewage Disposal System Ruisanchez,p nt ni Property Address 507 Sim Sit Owner Owner's Name information is No MA 0-,1814-5 required for every Andover City/Town State t Zip Code Date ofInspection M System Information (cont.) 2. Commericiallindustrial Flow Conditions: Type,of Establishment: Diesign flow(based, on 310 MR, 15,203)- G NN n peri day(gpd) Basis of designflows is rs ns s . t., etc.) Grease trap present?" El Yes No Water treatment unit fires nt es No Industrial waste holding teak present? El Yes El No n sianitary waste disichargied to the Title 5 stem" Yes 0 No Water meter,readings, if available: Last date,of occupancy/use: __._... —... Date Other(describe iw . 3. Pumping Stewrt's Source of information,". Was system pumped as part of the inspection? Yes N 15,00 If yes, g io n How was,quantity pumped determined?. maintenance Reason for pumping,-. i 1 ®retie. Official Inspectionrn Sir urf sewage Disposal terra.P of 1 i Commonwealth 'y7y T"Itle 5 Off"icial.......... ion Form I M A r Subsurface Sewage Disposal System Form 1 W N Not for Voluntary Assessments Ruisanchez, Antonio Property Address 5,07 Salem Owner Owner's Name information't's N . Andover M 1 �5 --`�9-2 9 requiredfor ever �_ ..._..________..... .___....._ __._._.._.______....____..._.. _._., _ _ ........ _._.__._..__._.._...... ........ page City/Town State Zip Code Date f hi e tion D. System Information (cont.) . Type of System: Septic tank, distribution box, soil', absorption system Single cesspool Overflow cesspool Privy Shared system (des or irno) (if yes, attach previous inspection records, if any), Innovative/Alternative technology. Attach a, copy of the current operation and m iint nand contract(to, e obtained from system owner and a copy of latest inspecti n of the I system y system operator under contract 'Tight tank,, Attach a copy of the E approval. Other(describe): Approximate age of all components, date 'In talled' (,if l a wn and source of information: Were sewage odors detected when arriving at the site" El Yes X No 5, Building Sewer(locate on site plan): 1 Depth below grade- fe 11 et-"I-,,-,, Material of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction lime: t Comments, m condition of joints, venting, evidence of leafage, etc. 1 1 cast iron thr floor thin ,d -rev.7/2W20,18 Title 5 Official Inspection Form,Subsurface wage Disposal System.Page 9 of 1 hCommonwealth of MassachusettsP icia T"tleInspection 1 � � Subsurface Sewage D'I"Isposall Sys,tem Form Not,for Voluntary Assessments Ruisanchez, Antonio Property Address 507 Salem St Owner Owner"s Naas information is . Andover M - 9 2 19 r u it for even _.._._ _.____._... . _..._._____...... . _._.._. page, City/Town State Zip Code Date of Inspection D. System Information (cont) 6, Sept'lic Tank (locate on site plan): Built to grade Depth below grade: feet Material of construction: concrete El metal El fiberglass polyethylene other(explain) Is age confirmed by a Certificate of Compliance? (attach a copy of'certificate) El Yes [:] N 1 011F Sludge depth: 22 Distance from top of sluidge to bottom of outlet tee or batty _ __..._ n._._._._._ __...._.. ... __..__.._..._�....m_._... ist nce tr rn top of scum to top of outlet tee or baffle 1611 Distance from bottom of scum to 'bottom of outlet tee or baffle Sludge,j q /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 lelakage, eta.): Both baffles are in good shape. leafage,, liquid levels are good. Filter on outlet tee should be cleaned trig" a ear..ry t ire , -rev.7/' 1 1 itl iffi i l Inspection Forma:Suibsur,f rageDisposal System.Page 10 of'l Commonwealth M Tmtle 5 Offincial pAl 'p m Inspect"ion Subsurface Sewage Disposal System Form Not for' lunt ry Assessments Rui,sanchez, Antonio _ _. ....._ _... �� _. _...._ Property Address 7 Salem St Owner Owner's Narne informiation,is 9 require � r .._MA 0 1 845 .. page. t own Stag Zip C Date f I s ti l� U., System Informationcoat. '. cease rap (locate on site lace: Depth below grade: feet Material of c s rUction: El concrete metal fiberglass polyethyl neother lain),: Scum,thickness Distance from top of scum to top of outlet tea or � ' �m�. _.__._.-___._._.._....,��rv------ Distance from bottom of sicum to 'bottom of outlet tea or baffle Date! of last pumping: t Commentspumping recommendations inlet and lutl t tea or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence,of leakage, etc.) 81. Tight or HoldingTank tank,. lust.be pumped' at time of inspection) on site wlan)- Depth below grades ....... Material of construction: i concrete, metal fiberglass polyethylene other(explain): Dimensions: ....m W . .m ., �� n. w w_....r.._.__...._ m_....__m_ .. ., .m ..............r._._.. _..__.... � ... .__...__�_ Capacity: gallons Il ns.per t In pAoc•rev,7126120 1 'ritie 5 Official Inspection F fm'.Subsurface Sewage-Disposal System-Page 11 of 18 Uommonwealth Tmtle 5 Official Inspect" Form ion ry +ih Subsurface wage Disposal sa y's r�10 Ruisanchez �� for Voluntary Assessments . w Rroperty,Address 507 Salem S' Owner Owner's Name Information is MA 01845 m _..__._ _______.....m...._..___. __..._._ _....___ requiredevery _ _._ . _.._.__.... .itI/T n State Zip Code Date of inspection page „ D. System Information (cont) 8. Tight or ''Un (coat.,). Alarm present. "des, Alarm _._..._.:,....__ _.... _.__ ._ in working Yes N Date,of last pumping-. Date.1 Crneats (condition of alarm and float switches, tc., Attach copy of current pumping contrast required). Is copy attached? Yes N 9. Distribution x (if present must be opined) (lociatie on siteplan): Depth of liquid level above outlet invert ......... Comments (note if box is level and distribution to outlets equal, any evidence of solids carry er, any evidence of leakage into or out of box, etc.) � al distribution, no no solids carryover G v Title Official In pie don'Forums:Subsurface Sewage Disposal System Page 12 of 1 I w Commonwealthache icia Tl"tle 5 Off"' 1 %v o n F'o rm Ins �" .. SubsurfaceDisposal System Not for Voluntary Assessments ,u i Property Address 507 Salem St ...... Owner Owner's Name infor�m tion is No Andover MA 01845 9 9 required for every City/Town Zip Cody p t � twrm _ D, System Information (cont.) . Pump Chamber(locate on site plan): Pumps in workingorder'. Yes Alarms in working order: Yes 1 Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.),. Tested alarm & pump by lifting up floats manually in pump chamber. Both the,alarm and pump are workinn..__q at_ the_ time.. ......_.inspection. - . l r alarms are not in working order, s ste is a conditional pass. 11. S, lil AbsorptIN ion System (SAS) 11 at on Site plan„ excavation ni t r ��ired): It SAS not located, eXplain w Type,., leaching: pits number: �����.._..__......... El _.__ leaching chambers number- 'El leaching galleries number: El leaching trenches number, length: _....__. _.. _.._. - 25X 40, leaching fields number, imensi ns- Ej overflow cesspool number: _..___........ .., .�..... innovative/alternativesystem V Type/name of technology* _... _.. _._ __... ..._ t5insp.doc•re w 712612018 Title 5 Official'Inspection Form:Subsurface,Sewage Displosal System w Page 13 of 1 Commonwealth of Massachusetts Y Tmtle 5 OffolIc"lall Ins ecti'an i"orm M" q -- Subsurface Sewage Disposal System Form - Not for Assessment 77 . Property Address .............. Owner Owner's Name information fori everyNo, Andover Andover 9 2 9 requiredCity/Town Mate Zip Code Date f Inspection p' M System Information (cent.) 11. ll Absorptibn (SAS) (coat.), Comments (note condition of soil, signs of hydraulic failure, legal of pondinig, damp soil, condition ition f vegetation, etc.): Nq hy raulic faillure, no_p ipg, no,4@mR soils 12. Cesspools (cesspool must be pumped as part of Inspection), (locate on site plan)-. Number and configurationDepth—top, f liquid to inlet invert ...�--_w_ ....__.._... .. .-r_._...___ ....____........... Dimensions of cesspool, Materials, of'construction Indication of groundwater'inflow Yes Comments,+ nts (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t51nsp.do .rev®71 /,2018Title 5 Official InspectionForm:Subsurface Sewage Disposal System-Page 14 of 1 commonweaith of Massachusetts ............. ion icial Inspect TIt.le 5 O,ff'm Form � . :.. DisposalSubsurface Sewage Not four Voluntary Assessments, � " isac Grp Property Address 507 Salem , ....... ........... owner Owner's Name Inf rrnnt"n veNo M 9-2 fo 0,19 r . Andover _._. _.__.. _.___ _ . _ ... __._ _ state Zip Code Date of Inspections page. City/Town D, System Information (cont.) 3" Privy (locate on site plan): afionl- Dimensions Depth of solids Comments (note condition, soil, signs hydraulic i l , 'l l ling, tl �� g t t a etc. Tillie Official,inspection Form-SubsurfaceSewage�p �system��"� � 115insp,Aoc rep.7/2612018 . ^mmonwealth of Massachusetts, ion officiall, Inspec Form Tmltm, NSubs le 5, rf ce Sewage Dilsposall System, Form Not for Voluntary Assessments AntonJo Property Address 5,07 Salem Owner Owner's Name No. Andover C't y/Towrn State Zip Code Date of Inspection D. System Information (coat.) 14. Sketch, Sewage D ispos 1 y 't+ r : Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks, L c to all wellswithin 100,feet, Locate,bare public water supply enters the building. Check one of the boxes, below: El hand-sketch in the area below drawing attached separately I i t5inspAcc r 1 Tftl Official inspection Forte;Subsurface Sewage Disposal S tern. '� 16 f 1 Commonwealthash a e III Nt -==-7.711 ection Form icia tie 5 Off I Ins fK - �_ T 0 *� Y S u &urf ce Sewage Dilsposal System Form Not for Vlater ssessments Lo Ruisanchez, Antonio Property,Address 507 Salem St ..... ............ Owner n r°s Warne requiredinformation is MA 01845 19-2019 Andover fir „_.._.._.. _._.... ___ ___ _.____.__... __._.._ .__ _..__ page. fit /To State ,dip Code Date In tion D. System Informaltion, (cont.) 5. Site Exam- Check Slope Surface water 1 Check cellar Shallow wells Estimated depth to high griound watery _..._ _.._... . __..__._._._...... feet Please indicate all methods used to determine the high ground water elevation, Obtained from system design pleas can record plan,If checked, date of design reviewed: ----.- Observed site abutting propertylobservation hole within 150 feet of SAS) Lq Checked with local Board of Health -e l in: u lied file El Checked with local excavators, installers- (attach documentation) Accessed USES database ­explain: Essex c+c n�ty_s 'il m You must describe how you established the high ground water elevation: Esex country soil �� , suet#30., Canton soil, water r 76' deep---, Before filing this In,splection Report, please see Reportr Completeness Checklist nex�t page., t5insp oc-rev,7/,2612018 Yule 5 Official InspectionForm:SUbStuface Sewage Disposal System.Page 17 of 1 Commonwealth of Massachusetts ion Form imcmial Inspect ' TmIlItle 5 Offm N Not for Voluntary Assessments S,ubsurface Sewage Disposal System Form � Isar Property Address 507 1 Salem St Owner 9 information isOwner's Name MA 01845 I ., And . .............. ..._ _ _...... _ .w. _... over - A�- reveryState Zip Code Date of inspection City/Tows E, Report Completeness Checklist Complete all applicable I sections, this for �r��� i N A. Inspector Information: Complete allfields In this section. B. Certification-, Signed & Dated and 1, 2,,, 3, or 4 checked G., Inspection Summary: Y 2, 3, or 5 completed as appropriate (Failure Criteria) and 6 (Checklist) completed , System Information: ' r ight/Molding Tank Pumping contract attached For : Sketch of Sewage Disposal System drawn on pg. 16 or attached, For 5: Explanation of estimated depth to high groundwater included .7/2612,018 Title 5 Official,InspectionForm:Subsurface sewage Disposal systern Fags 18 of 1 AL Commonwealth of Massachusetts mom's tle 11 a spect 5 0�ffw 0 1 In ion Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 507 Salem Stre�t Property Address Mark Perry Owner Owner's Name Information Is, North Andover IMA .011845 8/2212,016 required for every page. Cfty/Town state, Zip Code Dated iInspection R. System Informat'lion (cont) Sketch,Of Sewage Disposal Systern: Provide a,view of'the sewage disposal system, Including ties to at least two permanent reference landmarks or benchmarks. Locate all,wells wti . Locate where public water supply enters the building. Check one of the boxes below: hind-sketch i In the area below drawing attached useparately A jl A C)2. 16 0 ne t5ins 3113 1111e 5 Oftal Ins pedton,Fwm:SUbSurfaoe Smogo Dlspo&M System Page 15,of 17 w Cumrwy,ftd Card arfiled 1 1 4; P b Karen Hanlon " 1 e . # 21 Tax 38,0*0 107 0000*0 Parcel �'d 10410 607SALEM STREET MARC.4i LAU RE PERRY _,.07 S - NORTH ANDOVtRI MA 01846 1ALEM STREET 1 Mnl aril Proper Type 1 Rldr�tit Size Total : FY 201 fi lii&A' a � `." Tm Loan Number Activellbact. From1 MARC.& EN PERRY Owner S5 RgeT NORTH ANDOYER,MA 01845 E' 1N' Previous Customer inactive 1 1 1 OISARORa, LEA&REE N "E ,MA 01845 ent M . , t"-N w cycle u Name ti nacti + Bldg.1 .'1 . - PALE feast Wiling Date7126/20,116 , 3160,131. P3 Cycleactive n i Ai nt Account Nd. 1. s r l de: Rate Charge Mult, l li r U MIS�FEP,ADMIN FEE -, - 1+ 7.62 1' WTR'WATER. M k , OVALL METER,'SIZE w UB'Meter Maintenance ,account No,.11601,3,1 Serial,1,No Status Location Band 7YpQ SIZO YT' Cans, 986 'Date Reading .W METE-METE w Water, 0.1630.63Consumption Posted Date Variance / 1 1- 1 d AcWal 32 812/20,16 / 261 6 1,949 a Actual � . /22,2 1 - % 6/3/20 16 1 ' a Actual 48 7124/2016 ` % 6�,01014. 1034. a Achia-1 37 '7/16/2014 37%, 0 � as Actual! 31 � 1 1, 271 11112 1 -1 12 12 1 - 15,701 a Actual", 27 111 " 1 .7 - /7/ 01 3' 1.514 +t a al! 24 "/24/2013 9% 3i.7/�01'3, 1400, �a Actual 22 4122/2013 - % 1 2/ � 1 2 a Actual 27 11912,013 r- % ' 1 1 2 10 a Actual 3 '1 1 12'. -5% 12/ 12 11 1 �7 a Actual 20 111 '1 12 % 2,1 u11 t ail 17 12 2 11 3 3?'412 0 I'd 1195 a Actual 24 4/14/2010 .5% a s r r e j ° SUBSURFACE SEWAGE DISPOS,AL SYSTEM INSPECT,JON FOR PART �w SYSTEM INFORMATION(cam ed ofInspecton-, (I r ^. 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