HomeMy WebLinkAbout- Title V Inspection Report - 32 SOUTH CROSS ROAD 5/6/2019 Commonwealth of Massachusetts
Title 5 Off"icial Inspect'ion Form
Not for Voluntary Ass
Subsurface Sewage Disposal System Form, essments
32 South Cross
PropertyAddress
Serhii Z,hak
OwnleIr Owner's Name
information is North Andover MA 01810 4-310-2019
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this,form. Inspection forms may not q d in any
P
way. Please see completeness checklist at the end of the form.
Important:When
filling,out forms A. Inspector Information
ON
4
on the computer',
nly t Nell James Bateson
use ohe tab
key to move your Name of Inspector
curs,oir-do not Bateson Enterprises Inc.,
use the return
Company Name
key.
111 Argflla Road
Company Address
Andover 18110
City[Town State Zip Code
978-475-4786 Sl 15,
Telephone Number License Number
B. Certification
1, certify thart. I am a DEP approved system inspector in'full, compliance with Section 16.340 of Title 6
(3110 CIVIR 15.000); 1 have personally inspected the sewage disposal system,at the property address
listed above, the information reported below is true, accurate and complete as of the time of my
inspection,; and the inspection was performed based on my training and expen I ence in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system*
1, Z PIasises
Z Conditionally Passes
3. El Needs Further Evaluation by the Local Approving Authority
4. Fails
'Ail 4-30-20 1 19
1nsiJ ant§P+Sign,atu rf,/ Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
101000 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 d'iff6rent conditions,of use.
t5inisip.doc-rev.712612018, Title 5 4fficial Inspection Form:Subsurface Sewage Diisposal System-Page 1 of 18
Commonwealth of Massachusafts
Tintle cial Inspecti"on Fors
Subsurface Sewage Disposal System Form Notf+ rVoluntary,Assessments
2 South Cross
Property Address
Srhi'i Zhak
Owner Owner's Name
information is North Andover MA 018`10 4-30-201191
required �r r � " w Ott ?i; C ...
f Ins fin
page.
C. Inspection Summ .,
Inspection Summary* Complete 1, 2, 3, or 5 and all of'4 and 6.
System Passe.
1 have not found any information which indicates that any of the failure criteria described
in 310 AMR, 15.3,03 or in 310 CMR 15.,304 exist. Any failure criteria not evaluated are,
indicated d el .
r
Comm nts-
r
'r
2 System Conditionally Passes.a
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.
i
Check the box for If yes", Unoll r 111n t determined" , N# NCB) for the following statements. if"not
determined,)) leas explain.
The tic tarp .* r 2 l � septic rn t l r riot) is structurally
�� rrn�t�1 � ° � ��r� 1�d'� r the t� t�r�
unsound,, exhibits substantial infiltration r xfiltr tion or teak failure "is imminent. System will pass
inspection if the existing teak is replaced with a complying septic tank as,approved by the ar+d of
Health.
.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the teak is less than 20 years old is available.
EJ Y El N El l ' (Explain below
1
t in p.do w rev,7/2612,018 Title 5 Official vial Inspection Form:Subsurface Sewage Disposal System Fags 2 of 1
Commonwealth of Massachusetts
T Ad-
itle 5 Utticial Inspection Form
� I
Subsurface Sewage Dispersal'System Form Not for Voluntary Assessments
32 South Cross
1
Property Address
Sarni Zhak
nI r Owner's Name
information i
r ��� r r North Andover - 30-2
019
Cit own, State Zip Cody, Date of Inspection
C. Inspection Summary, (cont)
2, System Conditionally asses (coat.):
Pump Chamber pumps/alarms not operational. System will pass with,, Board of'Flealth approval if
pulps/alarms are repaired.
El Observation of sewage backup or break out or high static water level el in the distribution 'box due
to broken or obstructed 1 r due to a hr , settled or uneven distribution box. System will
pass inspection if(with approval of Board .l altl .
i
J
broken pipe(s) are replaced N N (Explain below):
1
obstruction is removed D (Explain below):
0 distribution box is leveled or replaced Y D Explain below):
wr
The system required pumping more than 4 times a year due to,broken or obstructed p p s . The
system will pass inspection of(with approval the Board of Health):
El: broken pipe(s) are replaced N Ej ND (Explain below):
0 obstruction is r Y N El ND (Explain below):
a "
3) Further Evaluatilon is Required by the Roardlof Health: "
El Conditions exist which require further evaluation by the Board Health in order to determine i
the system is falling to protect public health, safety or the environment.
1. Seem will pass unless Board ofHealth determines in accordance wilith 3,10 CMR
° 5.3 3(1)1' that the,system is not functioning ire a inner which rill protect,public health,
safety and the environment:
f irr p,do f rev.71 d 1 Title 5 Official Inspection onForm:Subsurface Sewage Disposal System Fags 3 of 1
Commonwealth ofMassachusefts
Title ,5 Otticial Inspection
rx
4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
32 South Cross
Property Address
Srii Zhak
Owner Owner's Name
information is'
required for ever
; . City/Town City/Town State Zip Code Date of inspection
pa
C. Inspection Summary (cont.)
E] Cess + �I or privy is within 50 feet of a surface water
EV
�l
] Cesspool or privy is within 5,0 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 Pin a manner protects the public health, �
safety and environment:
[:], The system has a septic tank and soilabsorption system (SAS) and the SAS is within
100 feet of a s, rfaca water supply,or tributary to a surface water supply.
[I The,system has a septic teak and SAS, and the SAS is within a,Zone I of a public water
si 'I .
Ej The system has a septic tank and SAS and the SAS, is within 5 feet of a private water
supply well.
The system has a septic tank and SAS and the'SAS is less than 100 feet but 510 feat or
more from a private water supply will
Method used to determine distance:
This system passes if the wel]water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, ,provided that no other failure criteria are triggered. A copy of'the analysis must
be attached to this form.
c., Otla'r
t
4),
t
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1
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m ,
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System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or "'to each of the following for all ins + tl ns
t
� n
Yes No
Backuip of sewage into facility or system component due to overloadedr
0
clogged SAS or cesspool
0 11 Discharge or plonding of'effluent t ►the surface of the ground or surface waters,
due to are overloaded or clogged SAS or cesspool,
t51nsp.doc.rev 7/26120 18Title 5 Official Inspection Form,Subsurface,Sewage Disposal System-Page 4 of 18
Commonwealth of Mass c u etts
mcia,
Z Tint,le 5 Offil I Inspection Form
ON
Subsurface Sewage Disposal System Form ,-Not for Voluntary Assessments
32 South Cross,
Property ddr .. ,.
� t
Serhii Za
Owner Owner's Name
information
i North Andover 3 -2 9
even required for _ _. _�... .
Pale. Cityffowri State Zip Code Date of inspection
C. Inspection
4) System Failure Criteria Applicable to,All Systems: (coat.)
!
!
Yes No
;static liquid level *n the distribution box above outlet invert due to an overloaded
r clogged SAS or cesspool
Liquid depth, in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
El E Required pumping moire than 4 times in the last year NOT dire to clogged or
obstructed li s). Nurriber of tires pumped*
El 0, u
Any portion of the SAS, cesspool or privy is below high ground nd water elevation.
Any portion of cesspool or,privy is within 1 feet of a surface water supply r
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 f a cesspool or privy is,within 50 feet ofa private water supply well.
Any portion of a cesspool or Privy is less than 1,00 feet but greater than 50 feet
from water ater supply well w th no,acceptable water qualityanalysis.' [ThiIs
system passes, 'if the well water anialysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent arr the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure fai!lure criteria are triggered.A copy, f the analysis
and chairs of'custody resat be attached to this form.]
The,systems is a cesspool serving a facility with a design flow of 2000 g -
, d.r-1 Z a
The system fails., 1 have determined thiat one or,more of the above failure
criteria exist as described in 310 CMR 15.3 3, therefore the system falls. The
owner should contact the Board of i e
systempith t �d�t�rr�ir� �l��t will
necessary to correct the failure.
!
5 Large Systems: To be cons,ildered, a large system thesystem rust serve facility with a.
' sirs flow of 10,000 gpd to 15,000 gpd.,
For large systems,, you must indicate either`yes" r"no"to each of the following, in addition to the
questions in Section C.4.
Yes No
the system is withiln 400 feet of a surface drinking water u l "
1
the system i's within 200 feet of a tributary to,a,surface drinking water supply
the system is Iodated in a nitrogen sensitive area (interim Wellhead Protection
E] El, Area—I r a mapped'Zone, 11 of a public water supply well j
!
t5insp,doc*rev.7/26112018 Title 51 Official Inspection,Form:Subsurface Sewage Disposal System-Page 6 or 1
Commonwealth of Massachuseft
Tn'Itle 5 icia o
l Inspecti' For
Subsurface Sewage Disposal System Form Not for V luntary Assessments
3 2 South Cross
Property Address
Serh,ii Zhak
Owner Owner's Name
information is
North Andover MA 01810 4-30-2019
required for every
page. Qtyffown State Zip Code Date of Inspection
C, I col (count.)
If you have answered "yes"'to,any,question in Section C,5 the sy stem ils considered a significant
threat, or answered "'yes" to any question in, Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CI R 15.304. The system owner
should contact the appropriate regional l office of the Department.
6. You must indlicate "yes" or"no"for each of the followilng for a/1 alnspecUons:
Yes No
tl
Pumping information was provided by the owner,, occupant, or Board of Health
o
El N Were any of the system components pumped out in the previous,two weeksday
?
N El Has the system received normal flows In the previous two week period?
Have large volumes of water been introduced, to the system recently or as part of
Ej N
this inspection?
Were as built plans of the system obtained, and examined? if they were not
available note as N/A)
El Q Was the facility or dwelling inspected for signs of sewage back up
0 El Was the,site inspected for signs of break,out?
Z El Were all system components,, excluding the SAS, located on site?
0 El Were the,septic tank manholes uncovered, opened, and the interior of the tank
inspected forthe condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of'sludge and depth of scum?
N El Was the facility owner(and occupants ifidifferent from,owner), provided with
information on the proper maintenance of'subsurface sewage disposal systems?
The solze and location of the Soil Absorption System (SAS) on the site has
been determined based on:
z n Existing information,. For example, a plan at the Board ofHealth.
N El Determ ined in the field if any of the failure criteria related to Part C is at issue
approximation of distance, is unacceptable) [310 CMIR 15.302(5)]
t5hsp.doc rev.7126/201,8 Title 6 Official Inspection Form:Subsurface Sewage Diisposal System-Rage 6 of 18
Commonwealth assac se
T"Itle 5 Ufficial Inspect,'i4on
A Subsurface Sewage Disposal System Form NOtr for Voluntary Assessments
3W
32 South� rss
Property Address
f
Seraa Zhak
Owner Owners Naas
in�c� i ti� �s �
required r r North Andover � , � 3 -2 �
w .
St Zi InspectionCity/Tows
w
System Information
1. Residential Flow Cits'
Number of bedrooms (design) Number l r m (actual): 440
�
D ES IGN flow based on 310 CM R 15.203 (for example: 110 gpd x bedrooms): _�.. ..
Description:
i
i
2
Number of cuIrrent r u erg s --
Does residence have, garbage grinder _ Yes E No
Does residence have a water treatment unit? Yes Z N or
d
If yes, discharges
� U
Is laundry on a separate sewage system" ' (include laundry,system Irrs c r �n El
i
Laundry system inspected? Yes No
Seasonal use? F1 Yes Z No
Water meter readings, if available (last 2 years usage (gpd)): as
Kalil:
'Sump pump? Yes 0 No
Current
Last data of occupancy: Datet insp. .rev.7/260018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1
f
Commonwealth of Massachusefts
Tiltle 5 0 "ic'ial Insuouect" Form
1 Subsurface Sewage Mis p osal System Form Not for Voluntary Ass s nts
r 32 South Cross
Property Address
i
Serii Z ,
Owner Owner's Naas
Information'is North Andover MA 018103 29
required,for every
Cityffown State Zip Code Date of Inspection
D. System Information � .
1
. Commercial/Industrial, Flow Condiflionsm.
Type,of Establishment,
Design flow(based n 310 CMR 5.2 3 :
Gallons per day
�Basis,of design flow eat rs ns s .ft., etc.):
Grease trap rent Yes
Water treatment unit present? El Yes 0 No
If yies, discharges to:
Industrial waste holding teak present? Yes Ej Igo
Non-sanitary waste discharged to the Title 51 system El Yes 'a
Water meter readings I if available,.,
Last data of occupancy/use: Date
(describe below):
3* Pumpiling Records:
Pumped 2 5, owner
Source i rmatl+ r : .mm ..._ .
i
Was system, pumped as part of the inspection? Yes N If yes, volume pumped: 15010
1
1
gallons
tank
How was quantity pumped eterm�ine .:Measured
Inspect tank& tees
Reason for pumping:
o�
t5in . ac rev.712612018 `titre 5 Official Inspection Fora:Subsurface Sewage![deposal System-Page 8 of 1
Commonwealth of Massachusetts
T"Itle 5 Uff,icial Ins,*p1%,ect"ion Form
Subsurface S � � C� � FormNot for Voluntary aAssessments
32 South Cross
Property Address
1
Owner Ow r'sr
�rr � trarl }
i North Andover 1 1 -30-20 I
required or eves _ ....
page. City/Town, State Zip Code Date,of Inspection
D SyS
. tem
Information (coat.,),
. Type System.
Septic tank, distribution box, soil absorption, system
Single cesspool
El Overflow cesspool 0
El Privy
Shared system (yes or if yes, attach previous inspection records, if any)
E] Innovative/Atternative technology. attach of the current operation arid
maintenance contract t 'e,� tain d from system owner) and of latest
inspection of the l A system by system operator ender contract
Tlig t teak. Attach a copy of the DEP approval.
El Other(describe):
Approximate age of all components, date installed i 'known and source of inf rmati n
2years old, 6-5- 992, as built,plan
a
Were sewage odors detected when arriving at.the site El Yes Z Igo
5. B l �ig Sewer(locate on, s,ite plan): F
Depth below grade:
feet
Material of construction
cast iron 2 40 PVC other(explairi).-
Distance from private water supply well or suction, lin :1 feet
Comment condition of jousts, venting, evidence of leafage, etc.,)-:
", Cast Iron through h Fall., 3" PVC in house, no leaks,visible.
t insp,lo v.7126/2011 gills 5 Official Inspection Farm.Subsurface Sewage Disposal System 'Page 9 of 18
Commonwealth of MassachusoTm
ion Form
Title 5 ^wfficial Inspect"
Subsurface Sewage DI'sposall System Form Not for Voluntary Assessments
32, South Cross
Property Address
Serhii Zhak
Owner Owner's Name
information is, North Andover MA 01810 4-30-2019
required for everymm
page. City/Tow,n State Zip Code Date,of Inspection
D. System Information (cont)
6. Septic Tank (locate,on site plan):
0.3
Depth below grad:
feet
Material of construction:
concrete El metal E]fiberglass El polyethylene [:1 other(explain)
If tank is metal, list aige*
years
Is age co nfl�rmed by a,Certificate of Com p I la n ce (attach a copy of certificate) Yes No
loll x 5' x 4'
Dimensions:
4
Sludge depth:
2911
Distance from top of sludge to bottom of outlet tee or baffle
11
Scum thickness
8
Distance from top of'scurn to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle,
How were dimensions determined? Tape, Measure
Comments (on pumping recommendations,, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok,.. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Pumped septic
tank.
t5lnsp.doc-rev.712 0,18 Tille 5 Official Inspe taon Form Subsurface Sewage Disposal System 'Page 10 of 18
Commonwealth of Massachusefts
Title
r
S r ce Sewage 11s s System Fora loot t+ r ' l�r�t�irAssessments
32 South Cross
Property Address
Owner Owner's Name
Information�
North rth Andover A -3 -2 9
required d for eves InspectionW ...�.
Git own State Zip Code t
D. System Information (cont.)
7. Grease Trap (locate on site plan.
Depth bellow grade,: feet
t
Material of constructiow
El concrete El metal, El 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 (ors r i mmen ti ns inlet and outlet tee r baffle condition, str t r l integrity,
li i i l levels as related to outlet invert, evidence of leakage,, etc.,):
. Tight or Holding Tank (teak must be pumped at time of Inspection) on site plan)-
Depth below grades
Material l of construction:
0
El concrete E], metal ul fiberglass El' polyethylene [:1 other(explain)-
Dimensions:
Capacity: gallons
.m .
Design Flow-,
gallons per day
t in .ado .rev.712612018Title 6 Official Inspection Form.Subsurface Sewage Disposal System w Page 11 of 1
Commonwealth 'Massachusetts
Title o Otticial Ins, ection F'orm
SubsurfaGOSewage Disposal'System Form Not for V l n r Assessments
m
w
32 South Cross
Property address
Ser it Zhak
Owner Owner's Name
information is North Andover MA 01810 430-2019
required for every Mate Z Code Date of Inspection
tion
pagewD, System trr p p
r
Information coat. t
'l
TightrHolding Tank coat,
alarm resnt.� F-1 Yes E] N
Iar l� l: — Alarm working order: El Yes N
Date f last pumping:
1
,Comments (condition of alarm and float switches, etc.):
J
I
Attach copy of current pumping contract(required). is copy attached? Yes
9. Mstriibutio,n Box if present mast be opened) (locate on siteplan):
0
Depth f liquid level above outlet invert �
Comments (note if box is level and distri utioln to,outlets equial, any evidence f solids carryover, any
evidence f leakage into or out of box„ etc.),-
i
-box level &distribution equal., evidence of leakage. Evidence of carryover, pumped d-box to
clean.
i
t5in .do -raw*,7/26/2018 Tiltte 5 Official Inspection Farm-Sulbsurface Sewage Disposal System-Page 12 of 1
I
j
Commonwealth f Massachusetts
. n 'a
Tit,le 5 utficial, 1'ns-pmhecti,on Form.
Subsurface Sewage Disposal System Form Not for Voluntary ►sass rats
a
32 South Cross
PropertyAddress
Serhii IZha
t
Omer Owner's Name
i1
n rm tion i Nosh Andover 1 1 -3 -2
1
required for eves � �� �.�mm _,�.
it+, own Zip Code Date of Inspection
D, System Information (cont.)
. Pump Chamber(locate on site, 1 :
Pumps in working order. Yes 0 No
Alarms in working order, Yes
Comments (rota,condition of'pump chamber, ondiltion of pumps and appurterianicies,,1 etc.),
i
It u m 1 s or alarms are not in working order,, system is a conditional pass.
11. 11* s rr ti i System (SAS) (locate on site plan, exciavat,ion not required),
It SAS not located, lain why,
T' a,
leaching plits, number.-
leaching _.� ...
El leaching galleries number,
leaching trenches number, length,
5 trenches 50
long
leaching fields number, dimensions: � .
overflow cesspool number*
i nova i e ft rn t system
Type/name,of tahnai ,
t insp,d -rev.712612018Title at,Inspection Form:Subsurface Sewage Disposal System-'Page 13 of 1 Y
I
Commonwealth, of Massachusetts
,M
ion Form
Title 5 Ufficial Inswaftect'
w Subsurface Sewage D-1sposall System Form Not for Voluntary Assessments
32 South Cross
Property Address
,email Zhak
Owner Owners Name
information is North Andover, A 01810 4-30-2019
required for everymm..
page
Citron State dip Code Date Inspection
r
D, System Information (cont)
11. Soil Absorption System (SAS) (cunt.)
comments (note condition soil, signs of'hydraulic fa,ilure, level of poinding, damp soil, condition of
vegetation, etc.
t
Soil ok. Vegetation ok. No sign of ponding to surface.
2. Cesspools (cesspool must be pumped as part of inspection) (locate on site I 'n):
Number and configuration ---
Depth top of liquid to inlet'invert �..
Depth of'solids layer
Depth of scum layer
Dimensions of cesspool
....m. .
Materials of construction
Indication of groundwater inflows El Yes Ej, No
Comments uments (note condition of s i], signs of hydraulic failure, level of ponding,, condition f vegetation,
etc.)*
r
Inspection Form-Subsurface,Sews a Disposal stem�P .e 1' f 1
�, t�� ,.d�e �rev. � � �I Mlle �fr•N � ��In p
Commonwealth of Massachusefts
ion
1i t I e 5 UAv%� T'I' Ei t Form
ot for
Subsurface Sewage Disposal System For I' Iarssessr
ents
32 South Cross
Property Address
Serhii Zhak
Owner Owner's,Name
information is North Andover MA 01810 4-30-2019
required for eve�ry
CitylTown State Zip Code Date of Inspection
page.
D. System I nformation (cont.)
13. Privy (locate on site plan):-'
Materials, of construction:
Dimensions
Depth of solids
of vegta
Comments (note condition, of soll, signs of hydraulic failure, level of ponding, condi tion e tion,
etc.):
t5fnsp.doc•rev.7126/2-018 Title 5 Official inspection Form, Subsurface Sewage Disposal System Page 15 of 18
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f
Commonwealth of Massachusefts
ww.ww 1 Anmmiirr—wh-✓—+
TI"tie 0" U#"%tA,*td"EicNiaI Insmectuion
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s r ce Sewage Disposal System For - r �� ��r + r t
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Property Address !.
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Information is
Owner dw--ners Name,
required for eves North Andovermm
m m
page. City/Town Ott Zip Code Date of Inspection
a
D. System Information (coat.)
1 ., Sketch Of Sewage D'Isposal System.:
Provide view the sewagedisposal system I including ties t� at least two permanent refer l
landmarks r benchmarks. Locate all wells within feet. Locate where public water supply enters
thie building. Check one of the boxes below-
hand-sketch in the bielow
El drawing attached,e separately
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t 1nsp oo -rev.7126/2018 Title, Official inspection Form Subsurface Sewage Disposal System.Pag,e'16 of 1
Commonwealth s c i seft
iNtle b otticial
Disposal'Subsurface Sewage Form ,Not for Voluntary Assessments
t
32 South Cross
Property
Srlii Zhak
Owner Owners Name
infor MA 01810 4-30-2,019
i North Andover
required for every CityfTown State Zip Code Date of Inspection
D, lnformati coat.
5.. Site Exam
E� Check S1e
Surface,water
Check cellar
;shallow wells
4
Estimated depth to high groundwater* . . �.
Please s indicate all methods used to determine the high ground water elevation,
Obtained from system design pleas on record
3-5
, 1 9 1
Itchecked! ate sag plea reviewed:
.
Date.
Observed site (abutting property/observation bole within '160 feet of SAS)
Checked with local Board of Health -explain:
sign plea
F� Checked with local eXcavatiors, installers- (attach c m nt ti
Accessed USGS database-explain,:
d
s
You must describe how you established the high, ground water elevation,:
As per test pit data on design plea
Before filing guile Inspection Report, pleasesine Report Completeness C cki'llst next page.
I
7126/20118 Title 5 Official'Inspection Forn Subsurface Sewage Disposal System
•Page 17 of 18
I
Commonwealth of Massach s s
01
A 0 t
itie 5, Offal Inspec,ici
ion
Form
I
(IF
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
32 South Cross
rope , Address
Serii Zhak
r
Owner Ownees Nameo
information is
required for every
e �tyffowr state Zip Code Date I�� r�ti
E,. Report Completeness Checklist
Complete all applicable sections of this form n l save
A. Inspector Information: Complete all fields in this section.
B. Certification: Signed & Dated and 1, 2 3, or 4 checked
C. Inspection Summary:
(Failure Criteria)and (Checklist)ks completed
D. System Information:
� 1
For : 'i ht./H l In Teak—Pumping contract attached
r : Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 5: Explanation estimated depth to high groundwater included,
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a
f la p,. -rear.7/2612018, Title 5 Official Inspection Form,Subsurface Sewage Disposal si System-Page 118 of 1
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Summary ocord Card generated on 4123/20,19 2,07:18 PM by Karen Hanion Page 1
Town olf North Andover
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iax Map if 2191111.10113 vu buu UUUU U
Parcel ld 13,248
32 SOUTH CROSS ROAD,
SERHII &YULIYA Z,HAK
312 SOUTH CROSS ROAD
NORTH ANDOVER MA 01845
Class 101 Single Family Property Type I Residential
Zoning2 I Residential ZonJng'3 1 Residential,
,Size Tota 1 1 Acres
FY 2019
UB Mail Index
Name,/Ad'dress Type Loan Number Active/Inact. From Until
SERHII &YUILIYA ZHAK Owner Active
32 SOUTH CROSS ROAD
NORTH ANDOVER,MA 01845,
LECHLEIDER,l MARTY Previous Customer Inactive 5/20/2011
32 S .CROSS RD
NO,ANDOVER, MA
01845
UB Account Malint
Account No Cycle Occupant Name Active/InacUve
1311dg Id. 13992.0-32 SOUTH GLOSS ROAD Last Billing Date 3/8/2019
2100544 02 Cycle 02 Active
UB, Services Maint.
Account No.2100544
Service Code IRate Charge Multiplier/U'sers
MISCFE,E AD MIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 41.80
UB Mete r 'Maintenance
Account No.2100544
Serial No, Status Location Brand Type Size YTD,Cons
36388,069 a Active ERT HIH b Badger Water 0.630.63 '1024
Date Reading Code Consumption Posted Date Variance
2/4/20*19 995 a Actual 11 3/1,9/201,9 -72%
11/2/ 181 a Actual 39 12/1212018 -22%,
8/212018 945, a,ActUal 50 9/210/2 O 18 272%
5/2/20,18 895 a Actual 13 6/20/2018 131%
2/2/201 aActual 12 3/2 8/2 0 18 -80%
11/1/2017 870, a Actual 57 12/2912017 82%
8/3/2017 813 a Actual 32 9/2 0/2 0 17 181%
53/2017 781 a Actual 11 6/26/21017 3%
2,13/2017 770, a Actual 11 3/14/2017 -84%
11/3/21016 759 a Actual 66 12/191/2016 -37%
8/4/2016 693 a Actual 103 9/21/2016 777%
5/6/2016 590 a Actual 12 6/21/2016 -131%
214/20,16 578 a Actual 14 3/28/2016 -81%
1,1/3/20 15 564 a Actual 69 12130/2015 -6,%
8/6/2015 495 a Actual 75 9/14/2015 317'%
51'7/2015 420 a Actual 18 6/22/2015 43%
216/20,15 4012 a Actual 13 3/20/2015 -65%
'11/3/2,0114 389 a Actual 36 12115/2014 85%
8/5/2014 353 a Actual 19 9/11/2014 146%
519/2014 334 a Actual 8 6/12/2014 - %
2/7/2014 326 a Actual 12 3/17/20 14 -63%
11/1/'20 1"3 314 a Actual 29 12/20/2013 36%
815/2013 Actual 23 9/18/2013 14%
5/2/2013 262, a,Actual 18 6/18/2013, 89%
2/6/2013 244 a Actual 11 3/13/201 -60%
10/31/2 0 12 233 a Actual 24 1211 /2012 -36%
Commonwealth of Massachusetts q
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1
Pumpling Form 4
+.
DEP has provided this form for umby local Boardsof-Health. Other formis may,babsed, but the
Information-Must be substintially the tame as that providedhere. Before using.this form,check with your
1
Boardoca
determine the forts they use. The, Ire r
to i Board of Health or other approVing authority.
SystemAt Facility InforMation
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Right side of building, f building, Left/Right rear bf building, Under deck
Address
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ofty1rw , State Zips Code
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Z. System Owner,
Name'
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Address if different from
cityrTww statl�
Telephone Number
.B. Pumping
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1.
Date of Pumping Date 2,W Qunty Pumped: Gallons
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3. Type-of system: Less l(s) 0--�epfic Tank Tight Tank
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Other(describe):
4. Effluent Tee Filter present. El Yes al,40 If yes, was it cleanedED-
_ Yes El N
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5. Condi'tion of System. .
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6.
Systern Pumped By.
eit,Batesb2 F5821
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I' m Vehicle LicanseNumber
Bateso�n E te rises Ins,
Company
T Locafion w content&were disposed:
Lowell Waste Water
Date
5fbrm, . o6 08103 System PumpingRecord pagp,
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Tbwnof North Andover
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CONTRACTOR NAME:
Type of'Perm'it or,
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Body Art Est bhshinen
0 Body Art
Dum ster
,food Service Type,
0 Funeral Directors $
Massage Establishment
Massage Practice
0 Offal(Septic)Heeler
Recreational Camp
Sun tanning
Ong Pool $
Tobacco
TrashlSolid Waste Hauler
W01 Construction
septic-Soir st n
Septic,-Design Approval .�
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Septic works r C nslruc ' � WO �
Septic Disposal Works Installers(DWI),
0 "title 5 Inspector
Title 5 Rat
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