HomeMy WebLinkAbout- Title V Inspection Report - 115 COLONIAL AVENUE 5/2/2019 Commonwealth of Massachusetts
z ici'al Inspection,
T"Itle 5 Off" Form
S
M Subsurface Sewage Disposal System Form Not for Voluntary Assessments
115 Colonial Avenue
Property Address
Kimberl Caron
Owner 6;��ner's Name
information is North Andover MA 01845 4-11-2019
required'for every
page. Ci'ty/Town State Zip Code Date of Inspection
Inspection results must be subm,itted' on this form. Inspection forms may n ot��e ,any
wro
wo,
way. Please see completeness checklist at the end of the,form.
Impoda,nt:When
filling out forms X Inspector Information �f
wn'
on the complute�r,
use only the,tab Nell Jaimes Bateson
key to,move your Name of Inspector
cursor-do not Bateson Enterprises Inc.
use the return Company,ny Name
key.
111 Argilla Road .............
Company Address
Andover MA 01810
Cityffown State Zip Code
.978-475-4786,
Telephone Number License Number
B1. icion
I certify that: I am a DEP approved system inspector in ful"I compliance with Section 15.340 of Title,5
(310 C 5.0010); 1 have personally inspected the sewage disposal system at the property address
listed e; 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. Needs Further Evaluation, by the Local Approving Authority
4. Fa 11
A
4-11-2019
. ....................
InspektWs signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Bogard
,of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
1 01000 gpd or greater, the inspector and the system owner shall submit the report to the it rate
regional office of the DER The original form should be sent to.,,t1 p:systern°owner and copies, se-nt'to,
the buyer, if applicable, and the approving authority.
Z. r
-:;:40 n-der the
cond'41"ons of use at that time., This inspection dbes not address how the system- w1114 p erforin
#60%
-r I q...U dr,9r I N f.- F, x0 A- 'r- fN....... 4 C. A r%—
.OQ I of 18
Commonwealth of Massachusetts
TmIt-die 5 'Adam"'-ic,,-Ycmici"al Inspectmion Form
I - >
Subsurface Sewage Disposal System, Form Not for Voluntary Assessments,
115 Colonial Avenue
Property Address
Kimberly Caron
Owner Owner" Name
information is
North Andover M 018,45 4-11-2019
required for every
City/Town State Zip Code Date ofInspection
page.
C., Inspection Summary
Inspection Summary-, Complete 11 21 3, or 5 and all of 4 and 6.
1) System Passes
El I 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,,
2) System Con diltioilly Passes:
ZI 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 dyes", "no" or"not determined" (Y,, N, ND)for the following statements,, If"not
determined," please explain.
The septic tank is mieta,l and over 20 years old* or the,septic tank (whiether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
i i
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 i1fa Certificate of
0
Compliance i,ndicating that the tank is less than 20 years old' isavailable.
F1 Y Z N ND (Explain below):
16insp.doic rev.712612018 Tifla,5 Offidal inspection Form:Subsurface Sewage 0140541 SlYatem,•Page 2 of 10
Commonwealth sacs
'T"Itle 5, cta
Subsurface Siewage Disposal System Form Not r " l' rtt r Assessments,
� 115 Colonial Avenue
Property Address
Kimberly Carom
Owner Olwnees,Name
information is North Andover MA 01845, -1`i-20 19
required for eves
page.
it /To State dip Code Dat In do
C. Inspection (coat.)
2) System Conditionally Passes (cont.)I.v,
El Pump Chamber pumps/alarms not operational. Sys,tlem will pass with Board of Health approval it
paps/alarms are repaired.
El Observation of sewage backup,or'brash 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 i (with approval of Board of Health):
broken pipe(s) are replaced Y Z N N (Explain below):
obstruction is removed l N (Explain below):
distri ut[on box is leveled r replaced l (Explain below):
El The system required pumping more than 4 t1ir es a year due to broken or obstructed pip s . The
system will pass inspection i (with approval of the Board) of Health):
broken pip s are replaced N ND (Explain 1 w�):
obstruction is removed E] N Explain below):
i
3 Further Evaluation is Required, by the, ar* ''i of Health.*
Conditions exist which requirefurther evaluation by the Board at Health in order to determine, i
the system is failing to protect public health, safety or the environment.
. System will pass unless Board of Health determines In accordan,ce,with 31 CIVIR
5.3 ,3 l ' that the system is, not functioning in a manner which will protect public health,
safety and the environment:
i
t5in pA rev,7/261201,6 Titie 5 official In3pa Lion Form,SuWurfaca Sewage E)jspoaal System,-Page 3 of 18
Commonwealth s c setts
ecion For 1"Ifti 0itle, 5 Offi"cial
I i>
Subsurface Sewage Disposal System Form Not for Voluntary Assessment
115 ColonialAvienue
Property Address
i
Kimberly Caron
Owner Owner's Name
information is Forth Andover MA 0,1845 - -2 19
required for eves
page
City/Town State Zip Code Date Inspection
t
t
C. Inspection Summary (cont.)
Cesspool or privy is within 50 feet of a surface water
Cesspool r privy is it irr 50 feet of a, bordering vegetated wetl< rid or a salt mars,h
., System will fall unless the Board of Health (and Public Water Supplier,, if any)
determines that the system is ti'l ►ning ii manner that protects the public health,
safety and environment:
E] The system has a septic tank ai ' still absorption, system (SAS) and the SAS iswithin
100 feet of asurface water suppily or tributary to a surface,f water supply.
[:1 The system has a septic tank andi SAS and the SAS is within a Zone I of a public water
Supply.
The system has a septic tank and SAS and the SAS is within 50 teat of a, private water,
supply well.
[3 The system has a septic tank,and SAS and',the SAS is less than 1 feet but 50 feet or
more from a private water supply well".
Method used to determine distance
This system asses it thewell water analysis,, e arm t a certifiedlaboratory, for fecal
w 4
caiitrr�r bacteria indicates absent and +t presence ammonia nitrogen, � n nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy ofthe analysis rust
be attached to this form,,
c. Other®
Pump septic tank.,Iinlet cloveir on, septic tank and -box needs to be replaced,. -box ,needs riser
installed, box 2'6" deep
i
4)
i
System Failure Crifteri'a Applicableto All Systems:
You must indicate "'Yes" or"No" to ea,ch,oftl e t l' wiry for all 'inspections
Yes No
El Z Backup at sewage into facility r system component due to overloaded or
clogged, SAS or cesspool
El z Discharge or pondlIng of e luent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
1 In . .rear.7/26120118 Title 5 Offidal Inspection Form:Subsurface Sewage D'IVOsal SWOM-page 4 tit`11
Commonwealth Massachusetts
mm
M
A.
TI le 5 0-,TTIcia11 ns, ection Form�
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
115 Colonial Avenue
Properly Address,
Kimberly C r iru
Owner Owner's Name
information is North Andover M 1 5 4-1 -2 19'
required for even _ „. ..
City/Town State Zip Code Date of Inspection
C. Inspection Summary (ct)
System Faillure Crilteria ApplicableAll Systems: (cont.
Yes No
Static li uid level in the distribution box above outlet invert due to an overloaded
r clogged ;SAS or cesspool
El E Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
1:1 N Required pumping more than 4 tunes in the lust year NOTduie to clogged or
obstructed pip s Number m r tunes pumped:
El Z Any portion of the SAS,, cesspool or priory is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
EJ Z
tributary to a surface water supply.
E] N 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 5 feet a prliv to water supply well.
iEl 2 Anyportion n of a cesspool or privy is less than 100 feet but greater than 50 feet
l grater unlit analysis, [This
tarn a private water l III with, n acceptable '�
system passes it thewell water analysis, performed t I certified
laboratory,for fecal c rlif rm bacteria indicates absent and the presenice
of ammonipa nitrogen and nitrate nitrogen is equal to or'less than 5 pp
r °i�d �d' that n therfailu�r ,criteria are triggered., copy tour l sis
and chain of custody rust ble attached to this form.]
.
The s steirn is a c sip l serving facility with a design flowt'2 gpd-
Q d.
The system falls. I have determined that one or more of the v ,failure
D z: criteria exist as described in 310 C R 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 15,000gp .
For large systems, you must indicate either eyes,''' or"'no"to each of the following, in iaddit,ion, to the
questions in Section GA.
Yes No
the system is within 400 feet of a surfacedrink,ing water r supply
F-1 El 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—'I A) or a rapped Zone li of a public water supply well
t51nsp.doc rev,7126/ 1 •i tie 5 Official inspe t !Fora:subsurface,Sewage Di sp Usa I sysit,em w Page 5 of 1 o
Commonwealth of Massachusetts
pr�
Tot,lie Foirm
Subsurface Sewage'Disposall System Form, Not for Voluntary Assessments
5 Colonial Avenue
Property Address
Kimberly Caron
Owner ner"s Name,
information is, North Andover Mari 45 - 1-2
019
required for r � .,a Statei at Ili mm
. .,
City/Town
r
C. Inspecti (cone.)
If you have answered "yes"' to,any question in Section' C.5 the system is considered a significant
thre at, or answered "yes" to any question in Section C.4above the Barge system has failed. The
owner or operator of any large system considered a significant threat sunder Section C,5 or failed
under Section G.4 shall upgrade the system inaccordance with 310 CMR 15.,304,. The system owner
should contact the appropriate regional office of the Department.
1. You must'ire i "yes" or"null'for each of the following for a ns,pei tions:
Yes No
# # P
Pumping information was provided by the owner, occupant, or Board of Hea,lth
El 0 Were any of the system components pumped out in the r ° i s two weeks
0 El Has the system received normal flows in the previous two week period?
El E Have large volumes,ofwater beenintroduced to the system recently or as part f'
this inspection
El 0 Were as, built pleas of the system obtained and examin if they were not
available rote as bU41
'Was the facility or dwelling inspected for algae of sewage back u
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
Were the septic talk manholes uncovered, pened', and the interior of the teak
inspected for the,condition of the baffles or tees, material of construction,
dimensions,s th of liquid:, depth of sludge and depth of scum?
Was the facility owner(and occupants if different,from owner) pirlovided with
0 El information n the proper maintenance of subs,urf sewage disposal systems.?
The size and location of the Soil Abs or ion System (SAS) ors the site has
been determined based
i
Existing 'information, For example, a plan at the Saard ofl-lealth.
0 El Determined in the field if any of the failure criteria related to Part C iS at issue,
approximation f distance is unacceptable) 3 CMR 15,3 2 5
i
i
Mnsp.do rev.7/26/2018 Title 5 Offidal Inspoction Form,Subsurface Swage Disposal S sit a.Fags 6 of 1
Commonwealth of: Massachusetts
a
I Raftection Form
Title 5 OT,ficial Ins
Subsurface Sewage Disposal, System Form Not for Voluntary Assessments
Property Address
Kimberly Caro
Owner Owners Name
information is North Andover M 01845 4-11-20,19
required for every .
fit Town State Zip Code Date of Inspection
D. SYS'tLem Information
1. Residential Flow Co , 4 'l ns
Numberbedrooms (design).* � Number bedrooms (actual). _..�
6
DEN��l w�based ors 3 C �IR 15,2 3 (for xa le g �# t� r � .�s � .
Description.-
Number of current residents:
Does residence have a garbagegrinder? Yes El l
Does residence have a water treatment omit? El Yes H No
If yes, discharges to:
Is laundry one a separate sewage system? (include laundry system inspection, El Yes N N o
information in this report.
Laundry system inspected?. Yes
Seasonal use? E] Yes N N
Water meter readings, if available(,last 2 years usage, (gpd)). _
Detail*
sump pump"?. El Yes Z No
Current
Last date of occupancy: ,,.
Date
t5insp.doc rev.V2612018 Tide 5,Officlal Inspection Foy:Subsurface,Sewage Disposal System-Fags 7 of 1
Commonwealth, Of MaSSaGh usetts
} Insupftectmilon Form
S ��� � � � � � F Not for Voluntary Assessments
y
115 Colonial Avenue
Property Address
Kimbept_q_�,,,ron
Owner Name
information is
required for every
page, City/Town State Zip Code Cate of Inspection
4
D. System Information (cone.
2. Commerciallindustrilall Flow Conditions*
Type of Establishment.-, . ,
Desig n flow(based on 310 CM R 152M Gallons per day(gpd)
, _ ..... .
�Bas,is of design flow(seats/persons/sq.ft., etc.),"
.... ... � .mm
Grease,trap present? El Yes No
i
Water,treatment unit presents Yes
If yes, discharges,to: ... ..mm .....„ . �„ �...., ... ,..��
Industrial waste holding teak resent Yes 0 No
Non-sanitary waste discharged to,the T'�itle 5 system? s
El No
Water meter reading ifavailable: .. .. ..
Last date of occupancy/use: mm. ..
Date
Other (describe below).
Source of information: .Owner� .....
Was system pumped as part of the inspection? Yes
H No
If yes, volume pumped*
How was quantity pumped determined?
Reason for ring:
i
t5fnsp,doc•rev,712612018 Title 5 Official Inspection boom:Subsurface Sewage Disposal system•Page 8 of 18
&,01\
Commonwealth of W�ssachusetts
Title 5 OI Inspectmion Form
w.
Subsurface Sewage Disposal System Form Not for Voluntary ss ssments
115 Colonial Avenue
Property Address
Kimberl Gar on
Owner wner's Name
information isNorth Andover M 15 - _2 9
required page. for err �. .m . .,
City r r r1 state Zip Code Date Inspection
D�. System Information (c � t.
4. Type of System.
0 Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool,
Privy
Shared system (des or n it yes, attach previous inspection records it any)
E] Innovative/Alternative technology'. Attach a copy of the current operation and
maintenancecontract(toe obtained,from system! owner) and a copy Mutest
inspection of the l system by system operator under contract
1:11 Fight teak. Attach a copy of the DEPrli,
i
Other(describe).
Approximate age of all components, date installed (if known) and source of information:
No as built B,,O.H,, in 12-20-1995
i
Were sewage odors detected when arriving at the site's Yes
No
5. Building Sewer(locate n siteplan):
2
Depth below grade* feei''
Material of construction
El cast iron M 40, PVC EJ other(explai�n)*
Distance frm private water supply well or suction line:
feet
Comments (ors condition of joints, enting, evidence of leafage, etc.),
4
PVC through wall,to septic tank,, 3" PVC in louse, no lams'risible
t 51re p.d -rev. /2 1 01 -Wife 5 omGial InspBdIon Foam Subsurface Sewage Di,5posal Syat ,TP'5910 0 of 1
l
Commonwealth of Massachusetts
a4 ry
ion Form
Title 5, Official Inspect"
Subsurface Sewage, Disposal Si,y�stem Form Not for Voluntaryss seen s
115 Colonial Avenue
Property r
Kimberly Caron
Owner Owner's Name
information is
018,145 4-11-2019
required for ever- th M'A m,
e# City/Town State Zip Code Date of Inspection
pag
D. System! Information (cunt.
6. Septic Tank(locate on site plea):
1
Depth below gads:
fit
Material of construction:
concrete Emetal EJ fiberglass, polyethylene other(explain)
If tank is metal list r
years
Is age confirme Certificate of Compliance? (attach a copy of certificate) Yes N
' 5' x '
Sludge depth:
25'1
Distance from top of sludge to bottom of outlet tee or baffle
1 211
Scum thickness
311
Distance from top of scum to top of outlet tee or baffle ..
Distance,from bottom of scum to bottom f outlet tee r baffle ���
Tape Maur
How were dimensions determined
Comments n pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as rafted to outlet invert, evidence of leakage, etc.,)*
Inlet cover cracked, installed steel cover temporarily, inlet tee ok., Outlet tee ok. Depth of liquid t
outlet invert. No evidencef leafage. Septic tank reeds to be pumped. Inlet cover needs to be
replaced,
i
t inisp.d -re F 712,612018 Title Official,Inspection Form:Subsurface Sewage Disposal K •Page 10 of
uommonwealth of Massachusetts
..........
C.0
*tie 5 0 T1 uluncial Inspection Form
TJ
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
115, Colonial Avenue
Property Address
Kimberly Caron
Owner Owner's Name
information is North Andover MA 01845 4-11-20191
requ i red for every
. City(Town State Zip,Code Date of Inspection
page
D. System Informat ion (cont)
7., Grease,Trap (locate on site plan):
Depth below grade-. feet
Material of constructiom
El concrete El metal, E] f i berg lass El polyethylene E] 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 pumpling, recommendations, inlet and outlet tee or baff le condition, structural integrity,
liquid levels as related to outlet invert, evidence,of leakage, etc.),
...........
.......... ............
8. Tight or Holding Tiank (tank must be pumped at time of insplectilon) (locate on site plan):
Depth below grade.
Material of'constru,ction*
E] concrete El metal [:1 fiberglass [j polyethylene Ej other(explain),
Dimen sions,*
Capacity, gallons'
Design Flow*.
gallons per day
t5 ins p.doc-rev.7/26/2018, Ti tie 5 o ffici aii insp a tion Form:S ubsurface Sewage Di sposal Sys ter -Page 11 of 16
Commonwealth of Massachusetts
f
Toltle 5 Uir-Ticial lns"%kection Form
P
Ito Subsurface Sewage Disposal, System Form Not for Voluntary Assessments
115 Colonial Avenue
Property Address
Kimberly Caron
Owner Owner's Name
information is North Andover MA 01845 4-11-2019,
required for every
City/Town State Zip Codle Date ofInspection
page.
D, System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: 0 Yes El No
Alarm level: Alarm inworking order El Yes N o
Date of last pumping*
Date
Cornments (condition of alarm and float switches, etc,.),*
Attach copy,of'current pumping contract(r uired). Is copy attached? El Yes N o
9. Diist rib u,flo,n 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 iinto or out,ofbox, etc.),:
D-box level &distribution equal. D-box has, corrosion holes at liquid level. Evidence of ciarryover. D-
box needs to, be replaced.,
............
151nsp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage oisposai to-Pa e'l 2 of 18
m.
Commonwealth of'Massachusetts
own E
Itle 5 OTTIcial Ins ect,mion Form
M Subsurface Sewage Disposal System Form Not for Voluntary Assessments
115 Colonial Avenue
property Address
Kimberly Caron
Owner Owner's Name
information i's
North Andover MA 0 184 5 4-11-2019
required for every
City/Town State Zip Code fWof Inspection
page.
D. System Information (cont.)
10. Pump Chamber(locate on site plian):
Pumps in working order: F1 Yes N o*
Alarms in working order: El Yes N o*
Comments (note condiflon of plump chamber, condition of pumps and applurtenances, 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 requiredi):
why
If SAS not locatedl explain ,
Type,
0 leaching pits number: -------
11, leaching chambers number:
0 leaching galleries number,
leaching trenches number,,, length- 2 trenches 65'
z I ol n g,
El leaching fields number, dimensions:
overflow cesspool number:
El innovative/alternative system,
t5insp.doc rev,7126/2018 Title 5 Official Wspection Form:Subsurface Sewage Disposal System-Page 13 of 18,
Commonwealth of Massachusetts
i 5, Off"ic"ial Inspecti,on Form
�.
Flo,
S s ',r" ce Siewage, Disposal System Form Not foir Voluntary Assessments
m 15 Colonial Avenue
PropertyAddress
,K, limberly Caron
Owner Owner's Name
information i
North Andover MA 01845 - 2
required every
r q City/Town State f Inspection
t
D. System Information (cone.)
11. Soil Adsorption System (SAS) (coat.)
Comments (note condition of soil, signs of hydraulic Bailors, level of ponding, damp soil, condition of
vegetation, etc.)*
Soil ok. Vegetation oak. No sign of pondingsurface.
12., Cesspools (cesspool must be pumped as part inspection) (locate on site, plan):
Number and configuration
Depth—top of liquid to, inlet invert
Depth ofsolids layer
Dimensions of clessipool
Materials of construction
Indication of groundwater inflow s
E] N o
Comments (note condition soil, signs hydraulic failure, level � r� i ig, n i i rw et i ,
etc.)
t5inspi.doc r v.71 1. 1; ' Title 5 officiai inisipec,tion Form;Subsurface Sewage Chia ai System Page 14 of 110,
Commonwealth of Massachusetts
mt,le 5 Oyncia
Inspec
rk
Subsurface ��� � ��� � � - Not for Voluntary Assessments
1 5 Colonial Avenue .
Property Address.
Krimberly Caro
Owner + n is Name
information is North Andover 5, 1-2019
required for every City/Town State Zip,Code Date of Inspection
D,
i
SystemInformation (c )
3. Priory (locate on site pit :
Materials of construction,
Dimensions
Depth of s,olids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc* :
i
Tide 5 Offi d 611n tion Form. a b3u rface Sewage D d s p osaI SY S l r .Page 15 of 1,a
Commonwealth of Massachusetts
'T'itle 5 OITTIcial Inswp'%ecti on Form
0 Subsurface SewagIe Disposal System Form Not for Voluntary Assessments
11 5 Colonial Avenue
Property Address
Ki mberly Caron
Owner &;ner's,Name
information is North Andover MA 01845 4-11-2,019 J
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.),
14. Sketch Of S age Dis,posall 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 blulilding. Check one of the boxes below*
hand-sketch, in the,area below
drawing attached, separately
V&4-
Bc
t5insp.doc rev.,7/2612018 Tile 5 otriciai inspection Form:SUbsurface Sawage Disposal SYSWM Rage 16 Of 18
Commonwealth of Massachusetts
Toltle 5 ocoial Inspection Form
Subsurface Sewage Disposa,l System Form Not for Voluntary Assessments
I..................
115 Colonial Avenue
Property Address
Kimberly Caron
Owner Owner's,Name
information is North Andover MA 01845 4-11-2019
required for every 7-
page. di't�y 'own Mate dip Code Date of Inspection
D, System I nfo rm ation (cont.)
15. Sfte Exam4
Check Slope
Z Surface water
Z Check cellar
Z� Shallow wells
>4
Estimated depth to high grou�nd' water: feet
Please indicate all methods used to determine the high ground water elevation.,
Obtained from system design plans, on record
110-17-1995
date of de i
If checked, s gn Plan reviewed, Date
Obsere ed' site (abutting property/observation hole within! 150 feet of SAS)
Checked with local Board of Health -explain:
Design plan
Checked with local excavators, installers - (attach documentation)
Accessed USES database- explain*
You must,describe how you established the high ground water elevation,
As per test pit data on design plan.
........... --—------------------
Before filing this Inspectillon Reportq please see Report Completenes,s Checklist on, next page.
t6insp.dinc rev.712612018 'ritte 6 official Inspection Form:Subsurface Swage Di Sal Systern Page 17 of 18
Commonwealth of Massachusetts,
Title 5 c a,l Inspection Furrn
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
115 Colonial Avenue
Property Address
KimOy
ber Caron
Owner Name,
information is
North And rove MA 018,45 14-11,-2019
reqIuired for eviery --
City/Town State Zip Code Date of Inspection
parg e.,
E, Report Completeness Checklist
Complete,all applicabie sections of this form inclusive of:
A. Inspector Information: Complete all,fields in this section.
Z B. Certification: Signed & Dated and 1, , 3, or 4 checked
C. Inspection, Sum mary-
11 2) 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
D. System information:
For 8: Tight/flold ire g 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
t6insp.doa»rev,7/2612018 Title 5 Official inspection Form.subsurface Sewage!Dispo5al System-Page 18 of 16
Town of North And over,
Tax Map # 2101-107,B-012S,00100-0
Parcel ld 182,42
116 COLONIAL AVENUE
CAROM, KIMBERLY Since Jan 2010
115 COLONIAL AVENU E
NORTH ANDOVER MA 018145
Class 101 Single Family Property Type 1 Residential
ZonIng2 1 I s,idiential Zonlng3 1 Residential
Size Total 0.5 Acres
FY 21019
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
I MBERLY CAROM! Owner Active
115 CO LO NIAL AVE N U E
NORTH ANDOVER,M�A 01845
CAROM,JOHN JR. P,ayolr Inactive 12/30/20113
115 COLONIAL AVE
NORTH ANDOVER, MA
01845
KIMBERLY CA PHONED TO REQUEST THAT WE REPLACE JOHN'S NAME WITH HERS ON THE BILL,
UB,account Maint.
Accouat No Cycle Occupant Name Active/inact[ve
Bldg Ild. 13325.0-115 GOLONIALAVENUE, Last Billing Date 3/,8/2019,
2100023 02 Cycle 02, Active
UB Services Maint.
Account No,2100023
Service Code Rate Charge MultiplierlUsers
MISCFEE DMIN FEE 0.63518 7.82
WTR WATER 01 ALL,METER SIZE 26,60
UB Meter Maintenance
Accou!int No. 2100,023
Serial No Status Location Brand Type Size YTD Cons
361855,66 a Active EFT HH b Badger w Water 1w 2
Date ReadIng Code Consumption Posted Date Variance
2/1/ 19 794 a Ac,tu a 1 7 3/19/20,19 40%
11/1/20,181 787 aActual 51 12112/2018 -164%
8/1/2018: 782 a Ac,tual 14 9/20/20,18 13%
5/142018 768 a Actual 12 6/20/2018 5%
2/1/2018 756 a Actual 13, 3/28/2018 -3%
10123/2017' 743 a Actual 11 12/29/2017 -19%
8/1/201 Actual 15 9/20/2017 4%
5/1/2'017 717 a Actual 14 6/26/2017
2/1/2017 703 a Actual 16 3/14/2017 23%
11/1/2016 687 a Actual 13 12/19/2 0,16 -56%,
8/1/2016 674 a Actual 29 9/21/2016 16%
5/2/2016 645 a Actual 25 6/21/2016 29%,
2/112016 6120 a Actual 20 3/28/2016 -28%
10/30/2015 600, a Actual 26 12/30/2015 63%
8/3/2015 574 a Actual 17 9/14/2015 20%
5/1/2015, 557 a Actual 13, 6/22/2015 -23%
2/4/2015 544 a Actual 118 3/20/201 11%
11/ /2014 526 a,Actual 16 12/15/201:4 -43,%,
8/5/2014 5110. a Actual 26 9/1112014 25%
5/12/2014 484 a Actual 24 6/12/2014 %,
2/312014 460 a Actual 22 /1 7/2014 26%
11/1/2013 438 a Actual 16 12/20/2013 32%,
8/7/2013 422 a Actual 13 9/18/20 13 -'7%,
517/2013 409 a Actual 14 6/18/2013 14%
2/4/2013 3195, a Actual 13 3113 13 10%
G
Z� fiA
0
Town of North Andaver
HEALTH'� �� � " .
h
. U t'
�9Y�/M1M N�I
�I
IEC . « ''ffi NliZ?l1vv V� d^" °i!ku�A J
euivutt N
� 1
rp
�� YM �f�vxm,fm �ra ! rw!
�d N�mvi I'4�^^i mx�nx�amfdv""°N
NAME:
,CO RACT O..
Typ,e,,,,o Permit License: (Check box)
0 Animal
* Body Art Establishtnent
* Body Art Practitioner
Dumpster ..
service Type. ,
FUlleral Directors
Massage Establishmetit
Massage P i ,
0 Offal tic)Heeler
LI, Recreational Camp
Sun tanning
Swi'"Iming P0011 �
0 Tobacco
0, TrashlSblid Waste Heeler
Well Construction �
SEPTIC Sy's,tetns:
Septic-Soil Tes
Septic Disposalworks C nish-u n
Septic Disposal Works,Installers
�r
"Title 5 Inspector
Title 5,Repiort
µ����.�� ��' J runr,. TRnm A� ialkii�fi.
.110
V
A
w .rwm�r �ie:wxi'�eu �r""ra're,�'....,:.F+r—.,e.e�-1• +,Rr,rwveaM'w,r+�MN�Iy�'r..Esau'+�wnm.�4N✓w�4ti�wvw.im�iwmr�iW1"w�rw+.�.wrw
Other:U e
a gent Initials",