HomeMy WebLinkAbout- Title V Inspection Report - 120 GRANVILLE LANE 5/15/2019 Commonwealth of Massachusetts
11 A. U a 111 1
. ...... 5' Form
3 TI'Lle 5 vt""fficia nspec ,ion
e g osal System Form Not for Voluntary Assessments
Subsurface Swae Disp
120 Granville Lane
Property Address
Maureen Hunter
Owner Owner's Name
information is North Andover m,A 01845 5-3-2019
required for every cityfrown State Zip Code Date of Inspection
page.
Inspection results must be submitted on this form. Inspection forms may not be altered gin any
'way. Please see,completeness checklist at the end of the,form.
t
0
I'm portant;When
A. Information
filling oq,t forms Inspector
on the compu�ter,
Neil James Bateson
use only the tab
key to move your Name of Inspector
cursor-do not Bateson Enterprises Inc.
use the return
Company Name
key.
11 rill a Road ..... .......
Company Address
Andover IVIA 01810
City/Town State Zip Code
978-475-4786 S115
Telephone Number License Number
13. Certification
I certify that: I am a DEP approved system iinspector in full compliance with Section 15.340 of T'it,le 5
(310 CMR 15.0010); 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 tralning 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. El Conditionally Passes
3. n Needs Further Evaluation by the Local Approving Authority
5-3-2019
4
Ins py orm,toature 'Date
The system inspector shall submit,a copy of this inspection report to the Approving Authority (Board
of Healt�h or DEP)within 30 days ofcompleti,nig th�is inspection,,. If the system, has a design flow of
1 10100,01 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 ies sent to
the buyer I if applicable, and, the approving authority.
Please note: Thi's report only describes condlitilons at the t,ime of inspection and under the
cond'Ifions of use at that erne.This inspection does not address how the system will perform
a
the future under the same,or different condiftffillons of use.
1.5insp,do r-•rev,7/2612018 Title 5 Officiail Inspection Form,Subsurface ewage Disposal System-Fags I of 18
Commonwealth olf Massachusetts
icial Insoo,%ectmion Form
Tutle 5l Off'4'
r I P
Subsurface Sewage Disposal Systems ors for s s s r nt
120 Pranville Lane
Property,address
-------
Owner Owner's Name
informati nisNorth Andover er MA 01845 5-3 '2 9
................
required for eves _ .
page. State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary* Complete C 1ete ,� 2z �1 r 5 a Illof4 and 6.
System 'Passes.
1 have not found n in rmati n whic indicates that any t I� �i1 r rit ri scribed
in 3 C �"15.3 � r in 31 CMI 15.3014 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Systems C nditio tall, Passes:
El one or more system components as described in the "Conlditilonal Pass section need to be
replaced or repaireld. The stern, upon completion of the replacement r repair, as approved by
the Board of Health, will pass.,
Check the box for"'yes", "no" r"not determined"ined" rya for the following statements. i '"not
t rrnin ed "' p le ase expl in.
The septic tank is metal and over 20 years old* r the septic teak (whether metal r not) is structurally
unsound, exhibits substantial infiltration or,e tiltrati n or tank,failure is irnirnin nit. System will pass
inspection it the existing tank is replaced with a complying septic tank as approved by the ar
Health.
metal septic tank will pass inspection if it is structurally sound, not leafing and it a Certificate
Compliance indi ting that the tank is less than 20 yearsold is mailable.
El Y
E] N El ND (Explain bellow):
N$
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t5insp.doc*rev,7/26/2018 rifle 5 Officiat Inspection Form,Subsurface Sewage Disposal System Pugs 2 of 1
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Commonwealth of Massachusetts
V IF
10
tticial Inspect" n orm
T'Otle, 5 0"""4"m
w
Subsurface Sewage Disposal'S sted Form - Not for Voluntary Assessments
illel Lane
p W
Ar—operty Address
Maureen Hunter
Owner Owner's a
information is
North2 0 19
n � .m
required for every CityrTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.).-
E]
�l mb p r ps l lrr rational. System will pass with Board of Health approval it Pump
ur ps al lrms are repaired.
0
] Observation of sewage backup , r break out or high static water level in the distribution
'
to broken or obstructed s) or due to a broken settled or uneven distribution box. System will
pass inspection it with approvial ofB,oard off"Health):
broken i s are replaced N (Explain below);
obstruction is removed Y N ND (Explain below):
distribution box is leveled or,repriced Y N 0 N (Explain below):
El The system m ired pumpingmore than 4 times a year due to broken r obstruct i l s The
system will pass inspection it(with approval of the Board of Health):
Ej broken pipe(s)a are replaced E] Y E] l l N (Explain below):
E] obstruction is removed El Y El N ND (Explain below),
3) Further Evaluation is Required by Board, f'R It
0
Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing,to protect public health,, safety or the environment.
. ,system will pass unless Board of Health t rr ines in accordance with 310, CIVIR
1 .3 3 b that the system is not function"linig in a manner which will protect public health,
safety and the en it rrment
t lrr p. o .rev.71 J 1+ Title Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of I
r
i
f N
Commonwealth of Massachusetts
T"tie 5 uo"'kfficiaon
Subsurface Sewage Disposal �S stem Form Not for Voluntary Assessments
1,20 Granville Lane
Property Address
Maureen Hunter,
Owner r' —Name
information,is MA 01845 5-3-2019
requi redr every North Andover State Zi p Code
Date of Inspection
page. Cityffown
r
C,
Inspection Summary (cnt.
E] Cesspool or privy is,within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland r a, salt marsh
b., System will fail unless the card Health + Public lip ter Supplier, i
determines that the system is functioning in, a meaner that protects the public health,
safety and envoironm,ent.d
E] The system has a;septic tank andsoil absorption system SAS, and the SAS is,within
1010 feet of a surface water supply r tributary to a surface water supply.
El The system has a septic tank and SAS and the SAS is within a Zone of a public water
supply.
E] `the system has a septic teak and SAS and the SAS is within 5 feet of a private water
supply l well.
El 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 w ll".
Method used to tear i distance:
This s stern passes if the well water analysis, perfbrme dat a DEPcertified laboratory, for facer
ammonia nitrogen lino nitrate lte nitrogen is equal,
clutarr�u turf indicates absent u�u the presence au'�
to or less,than , provided that no other failure criteria are triggered. A copy of the analysis must
e attached to this form.
. Other:
a
G
System, Falill"ure Criteria Applicable All Syst ms
You must indicate"Yes" or"'No,"t each of the llowing, for all nspectrl uruls.w
Yes N
Backup of sewage into facility r steno component due,to overloaded or
1:1
1
clogged SAS or cesspool
Discharge or drug effluent ent t the surface� the r n r su�� �waters
due t o overloaded r clogged SAS orcesspool
thin p..d r,ev.7/26120118 Title 5 Official Inspection Form:Subsurface,Sewage Disposal System-Page 4 of 18
Commonwealth ofMassachusetts
. ..... ion
TI'tle 5 Off"
Icial Form
[
pM i
Subsurface Sewage Disposal System Form Not for Voluntary ssessm nts
120 Granville Lane
Property Address
1
Maure n Hunter
t
Owner Owner's Name
information is North Andover MA 01 845 5-3-20 19
required for every
�� State ZipCode Date Inspection,
page.
C. Inspection Su (coat.)
System Failure Criteria Applicable to All Systems:. (coat.)
Yes No
El 0 Static liquid legal in the distribution box above outlet invert dine to,are overloaded
or clogged SAS or cesspool 's less
El, 01 Liquid th in cesspool is less than " below Inert or avail avallab le volume I
than 1/2day fly
Required pumping more than 4times i the last ear dui clogged r I
El z
obstructed i Number of times u � �.
El z Any,portion of the SAS, cesspool or privy is low high groundwater elevation.
Any portion of cesspool or priory is within 100 feet of'a surface water supply or
El Z,
tributary to a surface water s,up l .
4
Any portion of a cesspool or privly is within a Zone 1 f a, public grater supply
El z gallt
Any portion f a cesspool 1 r priory is within 50,feet of a private grater supply gall®
El z Any portionf a cesspool or privy is less than 1010 feet but greater,than 50 feet
from a privatewater su,pp,ly well with no acceptable water quality analysis., [This,
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates,absent and the presence
f ammonlia nitrogen and nitrate n ur a Is equal to or less than, 5 ppmo
rvied that no other failure criterila.are,triggered. A copy of the analysis
and chain of custody must be attachedto this fora.]
The system is a cesspool serving a facility with a design flog of 2000 g -
E
1101,000 gpd.
The system fails. I have determined that one or more of thie above failure
El 0 criteria exist,as described in, 310 CM R 15.303, therefore the system fails. The j
system own r should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a lar system the system must serve a facility with
design flow of 10,000 gpd to 15,000g ,
For large systems, you must indicate either"yes" r"no" to each of the following,, in addition to,the
questions in Section G w .
Yes No
El 1:1 the system is within 1400 feet of a surface drinking water supply
El F-1 the system is within 200 feet of a tributary to a surface drinking grater supply
0 El, the steno is located in, a nitrogen, sensitive area Interim Wpllhead Protection
Area IWI r a mapped Zone II of a public water supply well
15 in spWd -rev.71,2612018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Fags of 18
Commonwealth of Massachusetts
ell e, 50
ff I Inss%ection
p icia
Subsurface Sewage Disposal System Forte d � ��
120 Granville Lane
Property Address
Maureen, Hunter
Owner Inr's Nameinformation Is MA 01,845 5-3-20,19
f
requiredNorth Andover
gage City/Town
Ott ZipCo a f Inspetrlr1
C. Inspection Summary (cont
If you have answer d '°yes" to any,question in Section C.5 the system is considered a,significant
" � the burgs system has failed. The
threat, � u�r� r � � �r��turr uru �� tur� �� .
owner r operator f any large system considered significant threat,under Section C. r failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
t
should' contact the appropriate regional office the � � � *
6. You must Indicate yes r for h olf the following for all'inspections:
Yes N
Pumping Information was provided by the,owner,, occupant,, or Board of Health
Were any of the system components pumped out in the previous two weeks.
;s the s ster i received normal flows in, the previous two week period?
Have large volumes of water been introduced to the system recently r as, part of
this inspection?
Were as built plans ofthe system obtained and examined? If they were not,
[A El available note as N/A)
E El Was the facility or dwelling inspected for signs of sewage back. up?
Was to site inspected for sinus, of break out?
E E] Were all system components, excluding di!u the S S,1 located on site"
0 El Were the septic tarry manholes uncovered, opened, and the interior of'the tan
inspected for the condition of the baffles or teas, material of construction,,
dimensions, depth offilquid, depth of sludge and depth f sc ulm?
1N El Was the,facility owner(and occupants if different from owner) provided with
information n the proper maintenance of subsurface urface sewage disposal systems?
s
The size and location f the Spill Absorption System (SAS) our the site has
been det rmilned based n:
Existing 'inforrnation. For example, a plan at the Board of Health.
iDetermined in tla fi ld of any of the failure criteria, related to C is at issue
approAmation of distance is unacceptable) C R 15.302(5)]
t i p. o -rev.7/26/2018 Title Official Inspection Form:Subsurface Sewage Disposal Systlem-Page 6 of 18
alth of Massachusetts
Commonwe
i v1 1n,s1&%ecA-0 Form
Subsurface Sewage Disposal System Form Not for Vohint r` ss s sments
120 Granville Lane
Property Address
Maureen Hunter
Owner Owner's Name
information is North Andover MA 01845 .5-3-2019
re q u i red for eve ry State Zip Code Date of Inspection
page. City/Town
D. System Information
1, Resiftnt*ial Flow Conditiions:
3 3,
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 g,pd xl,#of bedrooms): 450
Description,.
Number of current residents:
Does residence, have a garbage grinder? El Yes 0,, No
Does residence have a water treatment unit? El Yes 01 No
If yes, discharges too
Is laundry on a separate sewage system? (Include laundry system inspection El Yes E No
information in this, report.)
Laundry system inspected? E] Yes E] No
Seasonal use? Yes No
Yes
Water meter readings, if available(last 2 years usage (gpd)):
Detail"
Sump pump? El Yes Ej No
Current
Last date of occupancy: Date
t5insp.doc-rev.7/26/2018 Title 5 Officiat Inspection Form,Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
an AN
tt
,.
T"'tle 5 0C' ion Form
Cai inspe
Subsurface Sewage ssl System Form�� ' wl�urw� � � �
4 f
12,0 Granville Lane
Property Address
Maureen Hunter
Owner Owner's Name
information a North And01845 5-3-201 9
r �ii� for �„�.�oveir MA . �
��t �ownZip Code
Date of inspection
page
D. System Information (cont)
2* CercIlInsl Flew Conditions:
Type of Establishment*
Design flaw('based on 310 C R 5.2 3)a . .. ...��
Gallons per day
Basis of'des,ign flow seatsl rs ns/sq , etc.)
Grease trap, present? E Yes
No
El Yes [:1 No
Water treatment unit
If yes, discharges o: .
Industrial waste holding tank present.?
Non-sanitary Non-sanitary waste discharged to the Title 5 system? s El No
Water meter r a i . s if available:
Last date of occupancy/use: Date,
rir(describe below)*
3, Pumping Records-,,
Source of information-. Pumped last year, owner
.s system pumped as part the inspection es 'E] No
If yes, volume, pumped4
gallons
How was quantity pumpeddetermined?
Inspect tank &-baff,les, tee
Reason for pump
t5insp,d rev.712612018 Title 5 Official Inspection Form-Subsurface Sawage,Disposal System-gage 8 of 18
Commonwealth of Massachusetts
T T I C E 01 t I e 5 UJ"""TE j
Subsurface Sewage Disposal SystemForm Not for Voluntary Assessments
,Granville Lang
Property Address
Maureen Hunter
Owner Owners Name C
information is MA 01,845
2019
required for ever th Andover �.m _ a
but [Town State Zip Code Date of Inspection
D. System Information (cont.
. Type of System"
l
Septic teak, distribution fox, soil s ti r system
Single cesspool
Overflow ess �1
Privy
Shared system (yes or n it yes, attach revi � s inspection records, it any)
El Innovative/Alternative technology. Attach a copy of the current operation and
maintenance,contract(to be obtainedfrom system, weer and a copy of latest,
inspection of the I system by system operator under contract.
E] Fight teak. Attach a copy of the DEP approval.
Other(describe):
Approximate age of all components, date, inst cll it known)wn and sourceof information:
2 ears, old, tarry & leach pits. 10-15-1977, as built plan,, -box &outlet tea in septic tank was
replaced 2006
Were,sewage odors detected when arriving at the site? Yes Z No
5. BuildlIng Sewer(Locate on siteplan)",,
2
Depth below grade: . _.
feet
Material of construction:
past iron Z,40 PAC .,
Distance from private water supply well rsuction lire: feet
. . mm
Comments (ors condition ofJoints, ven In ,i evidence of leakage,, etc.):
3" Cast Iron through floor, " PVC in house, no leis,visible.
Mnsp do ,rev.7,12,612018 Title 5 Official Inspection Form:Subsurface Sewage Disposell System-Page 9 at 18
Commonwealth of Massachusefts
Title 5 uTticial ins-0-ection Form�
"w� Form
Not,for Voluntary Assessments
Subsurfacey
2 Granville gene
Property Address
E
Maureen Hunter
OwnerOwner's Name
information is North Andover, MA 011845 5-3-2019
required e r �
�t State Zip Cody t
D, System Information (cont.
6. Si Tank(locate on siteplan):
1
Depth below grade,
Material of construction:
metalconcrete El, El fiberglass polyethyleneother(expla,in
If tank is metal, list age* dears
confirmedIs age Certificate of Compliance? (attach,a copy of certificate) El Yes No e
x 51'x
Dimensions*
nsions*
11
Sludge depth-
3 11
Distancle from top of sludge to bottom outlet tee or baffle -
11
Scum thickness
V,11
Distance n from top of scum to top of outlet tee or baffle
i
'lst nice from bottom of scum to bottom of outlet tee or baffle
How were dimensions d termin d 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 baffle ok. Outlet baffle ok. Outlet,tee ok. Depth f liquid t outlet invert. No evidence ofleakage.
Inlet cover has riser 11 deep. Pumped, septic tank.
i
t insp.do -rev„712612018 Title, Official Inspection Forn Subsurf Sewage Disposal System Page 10 of 18,
Commonwealth of Massachusetts,
m.
Tive 5 0""fficierFor
Subsurface Sewage Disposal Sys item Form -Not for Voluntary ssess eats
120 Granville Cares
----
Property d+d s
Maureen Hunter
Owner Owner's Name
Andover
require r every � State�
Zip Code Date f I�� ecti n
page.
City/Town
i
D.
System Information (ct.
7. Grease Trap (locate,on site plan):
Depth below grade: feet
Material of construction'.
a
El concrete El
metal, fiberglass glass Ej polyethylene Ej other(explain):
Scum thickness
Distance from trap of scum to top of outlet tee or baffle
i
i
Distance from bottom of scum to,bottom of outlet tee or baffle
le
Date of last pumping: Date
Comments n pumping In recommendatilons,, inlet and outlet tee or baffle condition� structural integrity
liquid lever as related to outlet invert, evidence of leafage, etc.):
, 'Tight or Holding Tank(tank nest be pumped at time of'Inspection) on site plan);
Depth below grade: ----------
Material, of construction:
El
n r t metal fiberglasspolyethyleneother(explain):
i'
gallons
Design 1 w- l ons per day
„ .
t5inisp.doc raw.7126/2018 Title Official Inspection Form,Subsurface Sewage Disposal System,Page 11 of 1
Commonwealth of Massachusetts
-icia ,
uy,j 0 1� Ins,-Ah-ect" Form
Tol"Itle 5
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. o
120
Gr n ill Lang .�..
Property Address
Maureen ureter
Owner Owners dame
inform ion,is, Andovet` M � ° -3-2 9
required for every __.
North
itr+ rn State Zip Cody Date Inspection
page4 _
D. System Information (cont)
. Tight or Holding Tank c t.
Alarm present* El Yes
Al � � Alarm + r ng r �r� es No
J
i
f
Date of last purriping:
Date
Comments , n t n of'alarm and float switches, etc.):
1
° Attach cope of'current pumping contract(required). Is copy attached? El Yes Ej N
9. Distribution Box present must,be,opened) (locate; on siteplan):
Depth of liquid legal above outlet invert .
Comments rote if box is level and distribution to,outlets equal, any evidence of solids rry �r, any
evidence c of leakage into or out of box, etc,)*
-box level &distribution equal, has flow levelers. No evidence of 1 a a e�. Evidence of carryover,
pumped d-box to clean.
i
i
i
s
t uni p.d c rev. 126l 1 Ti le 5 Official IIn p ection F orm Subsurface Sewage Disposal System•Fags 1,2 of 1
i
Commonwealth of Massachusetts
cial Title 5 01ffi
Inspectimon Form
Subs,urface Sewage Disposal System Form Not for Vol untary,Assessments
Property Address
Maureen, Hunter
Owner Owner's Name
information is W, 01845 North Andover
required cr eves ty
,tyffown State i C e �
D. System Information (cone.)
101. Pump Chamber(locate on, site piano):
Yes N10*
Pumps In working order.
Alarms in workingorder:
Yes 1 *
Comments note condition of pumpchamber, condition of pumps and appurtenances, c. w
.. t
if pumps or alarms are,not in working rd r,, sys is a conditional, pass.
11. Soil Absorption System (SAS) on site plan,, excavation not required)µ
if SAS, not located„ explain why:
i
Type:
leaching pits number: , .
El leaching chambers number:
E] leaching galleries number-.
leaching trenches number, length-
leaching fields number, dimensions:
El overflow cesspool number:
El iinn /alternative system
T a mar a of technology-,. ��. ... .�
t insp.do -rev.7/26120118 This 5 Official Inspection,1io Form.Subsurface Sewage Disposal System.Page 13 of 18
I
W � Commonwealth, of Massachusetts
Insr%ecti"on s
d
T5itle Onicia
Subsurface Sewage Disposal System Form Not for Voluntary,Assessments
1,20 Granville Lane
,
Property Address
Maureen Hunter
Owner Owner's Name
information is North Andover MA 01845 5-3-2019
required for every
�� rr� St dip+ r� p+�+ on
—'—"'--
page.
D. System Information (
11, Soil Absorptilon, System (SAS) (coat.) �
Comments (rote condition of soil, signs of hydraulic fa,ilure, 1+ v 1 of ponding, da,rnp;soil« condition; of i
vegetation, etc.):
Soil ok. Vegetation ok- No sign of poniding to surface. Camera er, inside of pits
through 1e s ire d-box, no, liquid invert.
i
2. Cesspools (cesspool 1 must be dumped, as part of inspection) (locate on site plan):
Number and configuration
Depth top of liquid to Inlet invert
t
Depth of solids layer
a '
n
Depth f scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow Yes Il
Comments (note condition of soli, signs f hydraulic failure,, level of ponding, condition of vegetation,
etc.),
t5 insp.d -rev.7126/2018 Tilde 5 Official inspection Form,;Subsurface Sewage Disposal System-Page 14 of 1
Commonwealth of Massachusetts
AMMI "AII IN
o;;
Totle 51 Unicial Insplect"i,on Form
isposall System Form Not for Voluntary Assessments
Subsurface Sewage DI
12,0 Granville Lane
Property Address
Maureen Hunter
Owner, Owner"s Name
information is MA 01845 5-3-2019
required for every North Andover State- Zip ors
Code Date of Inspectio
page. City/Town
D, System Information (cont.)
13. Privy(locate on site plan):
Materials of construction''.
Dimens,ions
Depth of solids
Comments (note condition of Soil, signs of hydraulic failure, level of pondinig, condition of vegetation,
etc.):
t5i nsp.doc-rev.7/26/20 18 Title 5 Official Inspection Form,Subsurface Sewage Disposat System-Page,15 of 18
Commonwealth ofMassachusetts
Title 5 Off*cial Inspection Form
Subsurface Sewage Misposal System Form Not for Voluntary Assessments
Property Address
Maureen Hunter
Owner Owner's Name 1
required for eves North Andover —
Cftyffown State Zip Code Date of inspection
U. System Information (cont.)
14. Sketch Of Sewage Diisposal System:
Provide a view of the sewage disposal system, Including ties to at least two permanent reference
landmarks r benchmarks. Locate all wells within 100 feet. Lociate where u'� l c water supply eaters
the building. Check one of the boxes below
hand-sketchIn the area low
drawing attached separately
Lt
497)
FIN
n �
s �
fi
r
.s
I
4
t5insp,doc rev.7126J2018 Title 5 Oiffi ial Inspection Forml:Subsurface Sewage Disposal System,Page 16 of 18
Commonwealth of Massachusetts
p ion
J Hicial Ins """ect Fbrm
Twitle 5 Am'
. A Subsurface Sewage Disposal System Form Not for Voluntary Assessments
120 Granville Lane
Property Address
Maureen 'Hunter
f
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.�w.rwrm xmm�niuulwiurmrmrm nmm-�++rrummmmwrni f`
OwnerOwner's Name
information is North Andover 84,E 5-3-20�19
required for every City/Town Mate Zip Code Cate of Inspection
D. System Information (cont)
5. Site Exam:
Check Slope
Surface water
m
Check cellar
Shallow wells
4
Estimated depth to high ground wat
feet
Please 'Indicate all methods used to determinethe high ground water elevation:
Obtained from system design pleas on record
If checked, date ,sirs plan reviewed- . ..... ..,
Date
Observed site (abutting property/observiation hole within 150 feet of SAS)
Checked with local BoardHealth explain_:
P��sAn, play
Checked with local excavators, installers (attach documentation)
Accessed USES databaseexplain:
u must describe how you st llshe ,the high ground water elevation:
As per test pit data on design plea
r
i
i
Before filing this Inspection ecti e vert, please see Report Completeness Check.list on next page.
Il a p,do rev.7/ 61 018 Title 5 OffildW,Inspection Farm:.Subsurface Sewage Disposal System, Page 17 of 1
Commonwealth of Massachusetts
P, M .: .. TI
e 5 c
Subsurface Sewage Disposal System Form �Not for' I�ur�wt r ssessments
120 Granville Lan
Property Address
f
Maureen Hunter
Owner Owners Name
. t
information is North AndoverMA 01 845 If
require!d for every City/Town
m..mm . State Zip Cede Date of Inspection
page-
E.,
Checklissit
Complete all applicable sections of this form inclusive of:
A. Inspector l r -. Complete all fields in this section.
Ej B,. Certification- Signed & Dated and III 2 3 or 4 checked
Z C. Inspection Summary-
1 F 21 3, or 5 completed s appropriate
i
t
('Failure Criteria) and 6 (Checklist) completed
D. System Information-.,
For 8, Tight./Holdingand —Pumping contract attached
For : Sketch of Sewage Disposal System drawn n pg. 16 or attached.
For 15: Explanation of estimated depth to high groundwater Included
1
i
t5in p. *rev.W26/2018 Till foal Inspection Form:Subsurface Sewage Disposal s em.Page 18 of 1
2,PM by Joanna a,b Pagel
,Sumimary Record Card generated on 4129/2019 12:23:5 S fi
Town of North Andover
WTW
iax Map # 210-406,G-0072-0000,0
Parcel Id' 17707
120 GRANVILLE, LANE
HUNTER, MAUREEN, E. Since Jan 2014
120 GRANVILLE LANE
NORTH ANDOVER MA 01845
class ...... 101 Sirsgle Family Property Type 1 Residential
"de
Zoning2 1 Residential Zoning,3 1 Rest ntiall
Size Total 1 Acres
F'Y 2019
UB Mailingjndex Active/linact. From Until
Name/Address Type Loan Number Active
MAUREEN HUNTER Owner
120 GRAN "II LANE
NORTH ANDOVER MA 01 845
GALVIN,PETER Previous Customer Inactive 8/15/2,006
52 MILLPOND
®ANDOVER, MA
01845
MIGHAEL MCGONEGAL Previous Customer Inactive 9/13/2 013
120,GRANVILLE LANE,
N ORTH AN DOVE Rt MA 0 1845
UB Account Marna.
Account No Cycl rat Name Active/Inactive
Bldg,Id., 17393.0-120,GRANVILLE LANE Last Billing Date 4/9/20119 Active
3170063 03 Cycle 03
UB Services Maint
Account No.3170063
Service Code Rate C,harge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 11
WT'R WATER 1011 ALL METER SIZE 19,00
UB Meter Maintenance
Account No.3170,0163 Brand Type Size YTD Cons
,Serial No Status Location
32772944 a Active ERT HH b Badger w Water 0.63 0.63 374
Consumption Posted Date Variance
Date Readilng Code
3/7/201 9 543 a Actual
12/7/2018 538 a Actual 5 1/22/2019 101%
9/11/2018 533 a Actual 5 10/15/2018 .3%
6/7/2018 528 a Actual 5 7/2312018 -19%
3/6/2018 523 a Actual 6 4/23/2018 1,5%
112/6/2017 517 a Actual 5 1/25/2018 13%
9/11/2017 512 a Actual 5 10/18/2017 -21%
6/6/2017 507 a Actual 6 7/25/2017 15%
3/6/20117 501 a Actual" 5 4/1,2/201,7 31%
12/8/2016 496 a Actual 4, 1/23/2017 -33%
6 16 201%
9/712016 492 a Actual 10/24/201
6/7/2016 486 a Actual 5 8/2/2016 -2%
3/712016 481 a Actual 5 4/2212016 -28%
12/8/2015 476, a Actual 7 1/201/2016 11%
9/8/2015 469 a Actual 7 10/16/2015 15%
6/8/2015 462 a Actual 6 7/24/2015 -1%
319/2,015 456, a Actual 6 4/28/2015 20%
1:2/9/2014 450 a Actual 51 1/15/2015 -14%
9110/2014 445 a Actual 6, 10/15/2014 17%
6/9/201 Actual 5 7/16/2014 -29%
3/10/2014 4314 a Actual, 7 4/1 1/20,14 -2%
11 2/9/2013 427 a Actual 7 1/17/2014 46%
A
Ith f Massachusetts
Commonwea
f
City/Town of
System, Pumping Record
Form, 4
DEP has-provided this for for use,;by to Boards,ofi Health. Other formt may"be u sed,but the,
Informadonii,must be substintially the tame as that pjovided here. Before using.dais form,,check wIth your
locil, Board of Health 6 determine this for MO they use.TheSystem Pumping Record,must be submitted to
the local Board of Health or other approving authonfty.
AN Facility InforMation
1. System Location: Left/Right front,pf house, Left]Right rear of hous, L rig,h side"qf Left 1
Right sideof bu 11ding, Left/ fight frbnt of b,uildihg,, Left Right rear difbuilding, U n, eck
Address
4.01
Caw state Zip Code
2. System Owner.
Name*
Address Qf different fTom,tocaflon)
City/Town
e
Telephone Number
B. Pumping Kecord
1. Date of Pumping uan,, Pumped:
Date Gallons
3. Type-of system:, Ej Ciesspool(s) Diiiii e is Tank Tight Tank
Other(describe)
Effluent Tee Filter present? ' Yes� Wo Ifyies,was i"t cleaned? ET Yes El No
5. Condifilion of System:
6. System Pumped By:
—Nell'.Ba F5821
Nlame Vey"cle License Number
Bates rises [no
. ...............
Cornpany
7. Location where content&were disposed:
Lowell Waste Water
pi kue
Signiq,a eu Date
t5fbrm4.doc*08103 System Pumping Recorde page 1 of 1,
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'Town ,of North Andover
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LOCATION:
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CONTRACTOR
Tv f Permit or License, (Check box.)
t
0
• Body Art shtn
• Body Practitio,ner
11 ump
u 'Directors
Massage Establishment
• Massage Practice $1
• Offid(Septic)Hauler
All
• Recreational Cam
Sun tanning
Swimming,Pool'
0 Tobacco $�
TrasWSolid Waste Hauler $
_f
Well Construction
S y stems
0 Septic-Soll Testing
Sept"' Des Ign Approva
Septic Disposal works Ciontructlion,
Title 5 Inspector
Title 5 Report
Other.(Indicate) 1
Wft � j
Hea,it Agent
i
t, Initial
hit Applicant n� Yellow Pine Treasurer
Y
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