HomeMy WebLinkAbout- Title V Inspection Report - 7 DUNCAN DRIVE 5/6/2019 Commonwealth of Massachusefts
ion Form
iE UTTIcia
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
7' Duncan Drive
Property Address
L,inda Dean
Owner Owner's Name
informati n is North Andover MA 0 1845 5-2-2019
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 alt d
any
I 1
way. P lease,see completeness the at the end of the form. I OWA 1 ogs
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Important:When
A, Inspector Information,
filling out forms . R
on the computer,
use only the tab Nell James Bateson
key to more,your, Name of Inspector
cursor-do not, Bateso�n Enterprises Inc.
use the return
Company Name
key.
111 Arg 111aR. oad
Company Address
..Andover MA 01,810
CityfTown State Zip Code
978-475-4786 S115
Telephone Number License Number
B. Certificabion
I certify that,,- I am a DEP approved system inspector in full comp'liance with Section 15.3,140,of Title 51
(310 CMR 15.0001); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported low 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. 0 Conditionally Passes
3. El Needs Further Evaluation by the Local Approving Authority
4. Felils
5-2-201 9
T I ",e tor',, ignat-ur Date
P V
The system inspector shall submit a copy of this ins plection, report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this, 'Inspection. If the system has a des,ign flow,of
101000 gpd or greater, the inspector and the system owner shall submit"the report to the appropriate
regional, office of the DE,P. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving aut' rity.
Please note: Thi's report only describes conditions at the time of inspection and under the
condkions of use at that,time.Thi'so inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5 in s,p.doe-rev.7112612018 Title 5 0mcial inspection Form,Subsurface Sewage Disposal System,-Page I of 18
Commonwealth of Massachusetts
1�tle 5 UTT[cial Inspect'
Ti ion or
Subsurface Sewage Wis,posa 1 System Form Not for Vl ntar Assessments
7 Duncan Drive
Property Address
Linda Dean
Owner" r rr is Name
information isNorth Andover MA 01845 5-2-201
required for every
City/Town State Zip Cody Date of Inspection
C, Inspection
J
Inspection Summary. Complete t , 21 3" r 5 arld all of 4 and 6.
1 System Passes:
1 have not found any information which indicates that any of the failure criteria described
ire 310 CMS. 15.303 or in 3,10 CM 15.304 exist. Any failure criteria not evaluated are
indicated below..
Comments*
1
one or more system components as described in the"Conditional Pass."" section n�eed to be
replaced or repaired., The system, i n completion ofthe repl cernent or repair, as approved .
the oar f Health, �� .
Check the box for"yes", "ono" r`snot determined" " 1' , l' for the following statements. If"not
determined,"," please explain.
The septic tank is, metal and over 20 years '1 *' r the septic teak whether metal or riot) is structurally
unsound, exhibits substantial infiltration or exfiltration or teak failure is imminent. System will pass
inspection if the existing teak ins replaced with a complying septic teak as approvedby the Board f'
Health.
metal septic teak will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank.is less than 2 years old is available.
0 Y (Explain below):
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Commonwealth of Massachusotts
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ficia
tle 5 Ut I I'nsr%ection Form
' '0
Subsurface Swage Diffisposall System Form Not for Voluntary A,sses,sments
I
Duncan Drive
Property Address
1
Linda Dear"
r
Owner Ownef's Name
information is North Andover A 01845 5-2-2 9
requirpage.ed for v �
State Zips Code Date of Inspection
C. Inspection .. ,: (cont..
2 System Con ll l n ll Passes (coat.):
E] Pump Chamber ur s l arr as not operational. System will pass with Board of Health approval i
pumps/alarms pumps/alarms are repaired.
Observation ofsewage backup or break out r high Static water level in the distribution boy dui
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will �
pass, inspection it(with approval of'Bogard ofHealth)'.
broken ken i s are replaced 0 Y Ej N El ND (Explain below),,
E] obstruction is removed _ Y N N Ex lain below)-
distribution box is leveled r replaced (Explain below):
El The system required pumping. more than 4 times a year due to broken or obstructed pips). The.
system,will pass inspection if(with, approval of the Board of Health)*
EI, broken pipe(s) are replaced Y E] N El N (Explain below):
obstruction is removed N Ej ND (Explain below):
3 Further Evaluation, is Requ.11retd by the Board of Health:
El Conditions ns exist which require further evaluation by the Board of Health in order to determine it
the system is tailing to protlect public health, safety or the environment.
a. System will pass unless Board of Health detiermines 'in accordance with
1 .3 3 that the system is not functioniffinig in a meaner aic a will Protect t public publ'ic health,
safety and,the I r r meet.
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Commonwealth oIf Massachusetts
T a Id idftk An,An E a, 0
1, cial Inspection Form
1'e 5
M Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Drive
7 Duncan
Property Address
Linda Dean
Owner Owners Name
information is North Andover MA 01845 5-2-2019
required for every
City/Town State Zip Code Date of Inspection
page.
C. Inspection summary (cont.)
El cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within, 50,feet of a boIrderi'ng 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 pIublic health,
safety and environment:
E] The system has a septic tank and soil absorption stern (SAS) and the SAS is within
100 feet of asurface water supply or,tribIutary to a,surface water supply.,
E], The system has a septi�c tank and SAS and the SAS is within a Zone 1 of a public water
supply.
E]i The system, has a septic tank and SAS,and the SAS is within 5101 feet of a private water
supply well.
F1 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 wiell",
Method used to,determin,e distance-.
TIIIIIIItls system passes if the well water analysis,, performed at a DEP certified laboratory,, for fecal
colifoIrm bacteria in lcaties absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less,than 5 ppm, provided that no oIther 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 fo[towinig for all inspections,-,,
Yes No
1:1 z Backup of sewage into facility or system component due to overloaded or
clogged, SAS or cesspool
Discharge or nding of effluent to the surface of the ground or,surface waters
El 0
due to an, overloaded or clogged SAS or cesspool
t5 ire sp.doc-rev.71216/2018 Title,5 Official Inspection Forn Subsurface Sewage Disposal System,-Page,4 of 18
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Commonwealth of Massachusetts
MENEM
T"tle 5 .Ftticial lnswpl%ection Form
Subsurface Sewage Disposal System Form Not f �r Voluntary Assessments
Duncan Drive
Property address
Linda Dean
Owner ' Name
information isrequired for every North, °e' MA 01845 5-2-2
page. Cit own Stag Zip Code Fate of Inspection
C. Inspection wry (writ.
4) System Failure Criteria Applicable to All Systems; (coat.)
Yes No
Static liquid Pavel in the distribution box above outlet invert due to,are, overloaded
r clogged SAS or cesspool
Liquid depth, in cesspool is less than " below invert or available volumeis Iles
than %day flow
Required', pumping more than 4 times in the last year NOT due to,c,logged or
El E obstructed a�(s). Number of times pumped.
ad
Any portion of the SASS cesspool or privy is below high, grounds water elevation.
Any portion of'ces,spool or privy, is within 100 feet of a surface,water supply or
El E 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 N Any portion of a cesspool or privy is within, 50 feat of a private water supply well.
E] 0 Any portion of a cesspool or privy 'is lass than 100 feet but greater than 5 feat
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 c lif rr a bacteria in is at s absent and the presence
f ammonla nitrogen and nitrate nitrogen is equal to or less thian 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and, chain of custody must be attachedto this,forma.]
The system is a cesspool serving a facility with a design flow of 2, d^
El 10
The system falls. r have determined that one or more,of the above failure
criteria exist as d'ascrihled in 3101 CMR 15.3,03, 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: considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For Dirge systems, you rust indicate either°`Yes" r"'no"'to each ofthe following, in addition to the
questions in Section, CA.
Yes N
El Fil the s stem is within 400 feet ofa surface drinking raater supply
1:1 Ell the system is within,200 feet of a tributary to a,surface drinking water supply
11, El the system is located in a nitrogen sensitive area (interim Wellhead Protection
l
Area l�"l " r as e 1 1� n� f a public water,jury well
1,a .do -rev,7126121018 Title!5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 1
D
Commonwealth of Massachusetts'Ti 5 uirucia
't I e I' Inspection Farm
a Subsurface Sewage Disposal System Form Not for luntary Assessments
"" Duncan Drive
Property Address
f
Lundy Dean
Owner Owner t s Name
information is North Andover MA 01845 5-2-2019
required for every
p . Cit fT ^ State Zip Code Date o In p cf n
C. Inspection Summary (
If you have answered "yes" to any question in Section C.51 the system is considered a significant
threat, or answered It 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 Cw5 or failed
under Section CA shall upgrade the system in accordance with 3 C R 15.3 M, "Tire system owner
should contact the appropriate regional office of the Department.
6. i
'You! must i "Icafe "yes"' or"no"for each of the followilnq for all iris mi s
Yes N
D
0 F] Pumping information was provided by the owner, occupant, or Board' of Health
El N 'Were any ofthe system components pumped out in the previous two weeks?
0 El Has the system received normal fl ws in the previous two week period?
Have large volurnes,of water been introduced to the system recently r as part of
El M
this inspection?
Were as built plans of the system obtained and examined'? If they were not
E El available note as 1
Was the facility or dwelling inspected for signs,of sewage back
Z [I Was,the site inspected for signs of break outs
0 Ej Were all system cornponents, excluding the SAS, located on site?
z 1:1 Were the septic tarok manholes uncovered, opened) and the interior of the taro
inspected for the condition of the baffles or teas, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
l
1
Was the facility owner and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soill Absorption System SAS) on the site has
been determined used on:
t
Existing information. For example, a plan at the Board of Health.
Determined its the field if any of the failure criteria related to Part C is at issue
approximation r
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Commonwealth, of Massachusetts
. : wT I nie u icia
InspectionForm
S � SewageDisposal System Not for ` hint r � sessmen s
w..
, Durican Drive
OR66-e rty Address
L'Inda Dean
Owner Owners rarer
requiredinformation is
for eves
North Andover MA 01845 -29
k City/Town State Zip Code Date I�t a tion
page
Information
. Residential Flow Conditions.:
Nun er of bedrooms (design): 4 Number of bedrooms (actual):
4 ,
DESIG N flow based on 3 10 C M R 15.2 3 (for example: 110 gird x#of bed room ,)
Description*
i
1
Number of current residents: .mm...
Does residence have a garbage river Yes No
Does residency have a water treatment unit? H, Yes El N
Main plumbing
If yes, discharges to: .�
Is laundry on a separate sewagie system,? (Include laundry system inspection
E] Yes E N o
information in this report.)
Laundry system inspected El Yes F '
Seasonal! use" El Yes Z N
"water raster readings,, if available (fast 2 years usage (gpd)): On well water
Detail:
Sump pump. 0, Yes 0 No
Last date of occupancy: Current
„.
Date
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t5insp,doc-revs. / 18 Tiede 5 Officiat Inspection Form SubsurfaceSewage Disposal System•Fags 7 of 1
Commonwealth of Massachusetts,
Ti c ion Form
'"tie 5 Off'i*cial Inspect
Subsurface Sewage Dlftsp,osall Sy em Form Not for Voluntary Assessments
mill '7 Duncan Drive
Property Address
Linda Dean
Owner Owner's Name
information is North Andover MA 01845 5-2-2019
requ ired for every
page. City/Town State Zip,Code Date of inspection
D. System Information (cont.)
2. Commercial/lIndustrilal Flow Conditions:
Type of Establishment:
Design flow(based on 310 CAR 15.20'13 *
Gallons per,day(gpd)
Basis of design flow(seats/persons/sqft, etc.),:
Grease trap, present? El Yes
Water treatment unit present.? El Yes No
If yes,, discharges to-
Industrial waste holding tank present? El Yes [:1 N 0
Non-sanitary waste discharged to the,Title 5 system? El Yes N o
Water meter readings, if available&
Last date of ace upa,nay/use
Dat,e
Oth�er(describe below)-
3., Pumping Records:
Pumped 2017, owner
Source of information,,
Was system pumped as part,of true inspection? Z Yes O No
1500
[f,yes, volume, pumped: gallons
How was quantity pumped determine
Measured tankd?
g. _�n s_R
f fees
Reason for pumpin
151'nsp.d rev 712612018 Title,5 Official Inspection,Form:Subsurface Sewage Disposal System-Page 8 of 18
oc .
Commonwealth ofUlassachusefts
-UItIe5, , UTTicial I'nsw4%ection Form
Subsurface Sewage Disposal System Fore t � � � �� � � r t
7 Duncan, Drive
Property Address
inch Dean
Owner Ownees Name
information is North Andover IVIA 01845 5-2-2019
required d �r eves
�]t i State Zr Code Date f Inspection
page, I
D., System Information
4. Type of System:
Septic tank, istri tion box,, soil absorption system
Slagle cesspool
Overflow cesspool
El Privy,
El Shared system (yes or no) (if yes, attach, previous inspection records, if any)
El Inn t Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtainedfrom, system owner) and a copy of latest
inspection, the I system by system operator under clontr,act
El T'ight tank. Attach a copy of the DEP approval.
E] Other(describe):
Approximate age all components, date in t ll iif ow and source of information:
9 years 5-25-20,00, plan
Were sewage odors detected when arriving at the site? El Yes, 0 No
5. Building Sewer(Ilocate on site plan):
Depth below grade, 1.3
. „
feet
Material ofconstruction:
El cast Iron Z 40 PVC El other(explain).-
Distance from private water supply well or suction line: feet
, „ d
d
d
Comments (ors condition of joints, venting, evidence of le ll g , etc,.,),:
" PVC through wall to sept,ic tank, 3" PVCr in 'house, no leaks visible. Trap door to access clean out
plug
f
t lnsp.do *rev.7126/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System 9,of 1
Commonwealth ssc
.. ��. icial Inspection Form
V
Tive 151 ff
a
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
'7 Duncan Drive
r perty Address
LindaDean
Owner rr's
information is
required for North Andover J
page. fi row St i Inspection
D. System Information cone.)
6., Septic Tank (locate on siteplan):
.3
Depth below grade: t
Material f nstr ctll r '
concrete El metal fiberglaSs El polyethyleneEl other(explain)
a
If tankis meta,l, list age*
dears,
Is age con
fir me Certificate f Compliance? (attach a copy of certificate) El Yes [:1 No
,
' x5' x "
Dimensions-
Sludge
Distance from top of slings to 'bottom, of outlet tee or baffle
Scum thickness .mm,.
811
Distance from top of scum to top of outlet tee or baffle �... .
Distance from bottom of'sculm to bottom f outlet tee or baffle
Tape Measure
w were dimensions determined?
Comment (ors pumping recommendations, Inlet and outlettee or baffle condition,1 structural integrity,
liquid levels as related to outlet Invert, evidence of leakage, etc.):
Inlet tee . Outlet tee ok. Depth of liquid t outlet invert. No evidence of leakage. Pumped septic
tank.
t5ins,p.doc rev.712612018 Title! ffi 1 1 Inspection Form:Suibsurface Sewage Disposal al "yst r .Bags 10 of 1
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Commonwealth of Massachusetts
Icia
V "tie 5mm U0""-TEJY'40 m I Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Duncan Drive
Property Ad 're
Linda Dean
Owner Owner"s Name
informati n is North Andover 5 5� 2-201
required for eves � ...�
page,. City/Town State Zip Code Date of Inspection
D.' System Informatio court.,)
°. Grease Trap (locate on site plan):
Depth below grade.-
feet
Material l construction'.
El concrete Ej metal fiberglass, El polyethylene other(explain);
w
r
Scum thickness
Distance from top of scum to tops of outlet tee or baffle .
Distance from bottom of scum to bottom of outlet tree or baffle
Date of last pumping: .,,,..
Comments pumping recommendations, inlet and outlet tee or baffle condition,, structura,l integrity,
liquid levels, s related to outlet invert, evidence of leakage, etc.):
4 Tight r Holding T (teak must be pumped at time f inspection) (locate on site plea):.
Depth below grade:
Material of construction*
El concrete El metal Fj fiberglassother lain):
Dimensions:
ns: �....� _
Capacity: gallons
Design Flow: gallons per day
,k inspi.do rev.7126/2018, Title 5 Official Inspection Fora:Subisuirface Sewage Disposal System-Page 11 of 1 A
Commonwealth of Massachusetts
m T
Mo%kci Ins a o rm
Subsurface Sewage D ilsp,osal System Form Not for VoluntaryAssessments
7' Duncan Drive
-0�-roperty,address
Linda Dean
Owner Owner's Name
ire form�ation is, North Andover MA 5-2-2019
requilred for every City/Town State Zip Code Date of Inspection
page.
D. System Information (cont,.)
8. Tight or Holding Tank(cont.)
Alarm present: El Yes, N o
A
/Alarrn level: Alarm,in working order: D Yes
Date of'last plumpingl- Date
Clommients (condition of alarm and float switches, etc.),:
Attach Copyr of current pumping contract(required). Is copy,attached? Ej Yes
9. Distribution Box it present must be opened) (locate on site plan):,
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids,carryover, any
evidence of leakage into or out of box, etc.),
D-box level & distribution e l, has flow equalizers. No evidence of leakage. Evidence of carryover
pumped d-box to clean
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Commonwealth of Massachusefts
Title 5 Off'l'cialect" Form
Subsurface Sewage Disposal System Forte fir� �Nr� ssessments
Duncan Drive
Property Address
Linda Dear
Owner Own r's Name
required for every State Zip Code Date of Inspection—
page. dfy�own,
D. System Information (cone.)
10. Plump Chamber(locate on site plea):
Pumps in working inn order: Yes N"
larm in working order-
Comments �
Commen s (mote 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 Sys (SAS) (locate site plan, excavation not required):
If SAS not located, explain why
Type:
leaching pits number: mm..., ...
leaching chambers
number.-
leaching galleries numbers
leaching tr nches numbiler, lard h,- 2 trenches 5 '
reaching field's number, 1mensi ns:
overflow cesspool number;
4
innovative/afternative system
Type/name of technology,
t5 insp,do -rev.7126/20 18 Title 5 Official Inspection Form:Subsurface Sewage iDi posit System-Page 13 of 1
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Commonwealth of Massacuiusetts
. Tl*tle 0 Utticial
Am-inse I� Form
I Subsurface Sewage Diposal System Form Not for Voluntary Assess nts
7' Dun,can Drive
Property Address f
1,
Linda Dear
Owner Owner's Name
required for every page. fit " wftt Ire
D. System Information c ,
1. Soil,Absorption System (SAS) lont.
Comments'(note condition of soil, sig,n,s of hydraulic,failure, level of ponding, damp soil, condition of
° fiat etc.).
Soil ok. Vegetation * No sign of ponding to surface. Trenhces are T Wide
Eln In Drains
12, Cesspools (cesspool must be pumped as part of inspection) (locate on site plea):
Number and configuration
Depth top of liquid to inlet invert
Depth of solids layer
Depth of scurn layer .
ir° ensi ns of cesspool
Materials of construction
Indication of groundwater inflow El Yes El N ,
Comments n n i i n of soil, signs hydraulic failure, level of ponding, condition of vegetation,
etc*
i
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I
Commonwealth of Massachusefts
A 'tficial Inst%ection Form
T'Iltle 5 U
Subsurface Sewage, Disposal'System Form� Not for Voluntary Assessments,
7 Duncan Drivie
Property Address
Linda Dean
Owner Owner's Name
hformation is North Andover MA 01845 5-2-2019
required for every pa . nspe C,ity/Town State Zip Code Date of Iction,
ge
D. System Information (cont.)
13. Privy (loofa on site plan):
Materials,of construction,
Dimensions
Depth of solids
Comments (note condition of soil, signs of'hydraulic failure, level of nding, condition of vegetation,
etc.)®
dM
t5insp.doc,-rev.7/2612018 Title 5 Official Inspection,Form".Subsurface Sewage Disposal System Page 15 of 18
Commonwealth of Massachusetts
Tit,-Ie 5f ufficial Insvp%ect"ion FormAW
m Subsurface Sewage is s ll' System Forte - �`VoluntaryAssessments
Property Address
Linda Dean
Owner Owner's Name
information is North Andover MA 0115 5-2-2019
required for even .pir "Zi e of Inspection
1
D., System Information (coat.)
® Sketch Of Sewage D11sposall System:
Provide view of'the sewage disposal s stir , including ties to at least two, permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supple eaters
the building. Check one ofthe boxes below:
hand-sketch in the area below
awing attached separately
IL
L4
F* F
Ir\
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Commonwealth of Mas,sachusefts
T"Itle 5 Offi'ci'al Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Duncan Drive
-P'r—o�e—rty Address
Lira Dear
ni wuummmoimmr wu rmnwummmmu .. mmmmm w mnuummnrnnrrrrmrmm uummmmxv f
Owner Owner's Name
North,information is ear A 5 5 2-2
required s fir eve � � �..
page.
fit Stag + Inspection
D. System Information (cont.)
5. Site 1 :
a
Check,Slaps
Surface water
i
Check cellar
Shallow wells
r
Estimated' depthto highground water:
feet
Please indicate all methods used to determinethe high h ground water elevation:
Obtainedfrom system design pleas on record
It checke , date of desGn Plea reviewed: 9-15-1998,
Date
Observed site (abutting property/observation, hale within 150 feet of S .S
Checked with local Board of Health -explain:
D i .lan
Checked with local excavators, installers -(a,ttach documentation)
Accessed USGS database -explain;
You, must describe how you established the high ground water elevation:
s per test pit data on design ,plan
Before filing this Inspection Report, please see Report,Gornpleteness Checklist on next page.
t in p. o r v. "1 l 018 Title 5 Dahl inspection Form'Ubsurrf Sewage Disposal System-Page 17 of"
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Commonwealth assase
'FormTitle 5 OtTicial Insw%ection
S � � r` c Sewage Dia na! Sy em r s e ents
" Duncan Drive
Cinch Dear
Owner Owners Name
information Is North Andover 9
required for every City[Town
Sta,te ZipConde Date of
Inspection
mm
pag�e.
E. Report Completeness Checklist
Complete all applicable sections of 1s form inclusive i:
. Inspect r Information: Complete all fields in this section.
B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
i
i
(Failure Criteria)and 6 ('Checklist),completed
f
D. System
Y
For *. Tilgh Holdin n Pumping contract attached
For 14., Sketch; Sewage Disposal S s a � raven on pg. 16 or attached
For s: Explanation of estimated depth to high groundwater included
t6 w nsp.doc,*rev,712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-P'epe 18 of 1
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Commonwealth of Massachusetts
Uty/Town of
riot r ,um 1
ystem Pumping Record
n
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Boardsorm 4
w 'Health. Other for , but the
Information-must be substinflally the tame as that provided here. Before usi . i ..,check wiffi your
Haab to determineforte they use, : stem Purnping Record us a Submitted
9
the local Board e h or other approving authorfty.
As Facility Inform' ation
I
..
System Location: Left/ � Left I Right rear of-house, Left. "right,si houses Left I
Right side of building, Left fight rontof'buildifig, Left Rightrear cif building, Under dock
Address
CKYf Town Statez'
. System Owner.
1
Name
. I
i
t
Address different from lcaflrr
Cityrowrr " t Zip Code
Telephone Number
B. Pumping
1. Date of'Pumping Diate 2. QuanUty Pumped,: Gallons
3. 'Type-of systen, El Cesspool(s) [1,,Z Tank EJ Tight Tank
Other(descrlbe);-,
e 10 If yes,,was it cleaned'? [3- Yes Cj No
4. EffluentTeeFilt rpresent? El Yds C90,11 '0
5. Condition System:
Systems Pe y
'elf. a
Name Vehicle Ucense Number
BatesonElite r yes Ina
w
Company
7. Location where content&were disposed,-
Lowell Waste Water
dt
f PHta-lul-e- Date
0brmC o 3 System Pumping Record 'age,I of
1
pl 6r , /�r
O
TOwn of North Andover
HEALTH DEPARTMENT
y 1,
22
CAS , 4
H/O NAME-.
112
CONTRACTOR NAMR ell" L
�xrwyrrxxs�ew ��
Mw
J
�r
J
z
1
Type of Permit License.- (Cheek x
Animal
Body Ay-t Practitioner
0 Dumpster
Eli Food Service
0 Massage Establishment
Massage Practice
Offal S' Hauler
11 Recreational Camp
0 Sun tanning
SwiMming,Pool
tobacco
sSWaste
�i
Well Construction j
I
SEPTIC Systems#
0 Septic-S'011 T s ri
Septic- Approval
El Septic Disposal Works C n chi (DIVO
l
Title 5 Inspector
loP
Title,5 Report
'h " (Indicate)—
He
Initials
i
White
Applicant, w-HealthPink-l-Treasurer