HomeMy WebLinkAbout- Title V Inspection Report - 106 ROCKY BROOK ROAD 5/22/2019 Commonwealth of Massachusetts
POOR
M;
Z Tille b' Ic nspection ohm
Jo Subsurface Sewage Disposal System Form Not for Voluntary Assessments
.. ...............
17- 106 Rock yB"rolo-k Road ........ ....................................... .............
Property Address
Irl'na & Aleksandr Shneyderman
..
Owner's ..................................... ..................... ...... ............
Owner Name
information is North Andover Ma 01845 05-16-2019
required for,every
...........................City/Town State Zip Code Date of Inspection
page.
Inspection results must be submitted on this form. Inspection forms may not, be altered in any
way., Please see completeness checklist at the end of the form.
6
V
V6141
Important:When
filling out forms A. General Information
on the computer,
use only the tab
key to move your 1 Inspector-
4 01
cursor-do not
F. Paul Cardone
............ ......
use the return Name of inspector
key. Alt
Septic Compliance, Inc.,
........... ...........................
Company Name
37' 1/2 Baremeadow Street
................Company Address
Meth uen Ma. 01844
City/Town State Zip Code
978-815-3115 or 978-681-0726 3294 .............
Telephone Number License Number
13, Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
infor tion r rte el ow i tr accurate a spec
,end complete as of the time of theinspection. The intion
maepod b , s ue,
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved sated inspector pursuant to, Section 15.340 of
Title 5 ('310 CMR 15.000). The system:
Passes Conditional[y Passes Fails,
El Needs Further Evalualtio b Local Approving Authority
............. ..........
I edor's Signature Date
The system inspector shall submit a copy of this inspection report to the Appiroving Au�thority (Board
of Health or IDEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
r gioinal off ice of the, DEP, The original shouild be sent to the system owner,and copies sent to,the
buyer, if applicable, and the approving authority.
a
****This report only describes condiftions at the time of'ins pection and undier the conditions of use
at that time, This inspection does not address, how the,system will perform in the future under
the same or different conditions of use.
t5ins,,doc rev.,6/16 Title 5 Official inspection Form:subsurface Sewage Disposal System Page 1 of 17
Commonwealth of Massaeusetts,
Title 5 Ca nspection Form
.............
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
106 Rock Brook Road
Property Address
Irina &Aleksandr Shn an
.......w mm..............
Owner Owner's Name
information is
North Andover Ma 01845 05-16-21019
required for every .............
page. C,ityfrolwn State Zip Code Date of Inspection
B. Certifi cati on (cont.)
Inspection Su�mmary. Check A,B,C,D or E always complete all of Section D
A) S' s mi Passes:
1 have, not found any i nformation which indicates that any of the failure criteria described
in 310 CMR 15,,303 or in 310 CMR 15.3,04 exist. Any failure criteria, not le is are
indicated below,
Comments:
The reason that this system has failed i't, is,a two trench system only one of the trenches is leaching
properly.
................
13) System Conditionally Passes:
El one or more system components as described in the "'Conditional Passly section, need to, be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Heallth, will pass.
Check the box for"yes", "no"'or"not determined" i(Y, N, ND) for the fo ill owin g statements. If"not
determined," please explain.
The septic tank is metal and over 20 years,old* or the sept,ic,tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltratin or tank f lull ure is imminent. System will pass
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 lealking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
D Y Ej N ND (Explain blelow):
t5 ins.doc•rev,6/16 TiHe 5 Official inspection roan,Subsurface Sewage Disposial System Page 2 of 17
Commonwealth of Massachusetts,
................
Title !'i Official Insuplection i=orm
Su,bsu,rface Sewage Disposal System Form Not for Voluntary,Assessments
1,06 Rocky Brook Road
..................................................... ........... .......... ............ ..........
Property Address
Irina & A1eksandr Shn,eydierman
Owner Owner's Name
information is North Andover Ma 01845 05-16-2019
required for every __............. ................ .....
page. City/Town State Zip Code Date of Inspection
�B, Certifitation (cont)
E] Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumips/alarmis are repaired.
B) System Conditionally Passes, (cont.):
El Observation of sewage backup or break out or high static water level in the distribution box due
to broken: or obstructed p1pe(s) or due to a broken,, settled or uneven distribution box. System will
i pass inspection if(with approval of Board of Healt
E:11 broken pipe(s) are replaced E] Y 0 N Ej ND (E lain below).
Ej obstruction is removed F I I I Y E] N F ND (Explain below):
distribution box is leveled or replaced 0 Y 0 N 'El ND (Explain below)*
........... ------......
............
® 'The system required pumping more than 4 times a year du�le to broken or obstructed p1pe(s). The
system will pass inspection if(with approval of the Board of Health),:
Ej broken pipe(s) are replaced Y E] N ND (Expllain below):
El obstruction is removed Y N ND (Explain below):
...........
..........
...........
C) Fu,rther Evaluation is Required by the Board of Health:
Conditions exist which requIre further evaluation by the IBoard of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of'Health determines in accordance with 310 CMR
1.5.,3013(l)(b)that the system is not functi oni ing ire �eir which will protect public health,
a mann
safety and the environment:
Cesspool or privy is within 510 feet of a surface water
Ej Cesspool or privy is,within 50,feet of a bordering vegetated wetland or a salt marsh
t5ins doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Rage 3 of 17
64
Commonwealth of Massachusetts
...................... ..........
Tit,le 5 0,ff�icial Inspection Form
xf
Subsurface Sewage IDisposal System, Form Not fori'Voluntary Assessments,
106 Rocky Brook Road ...............
Property Address
bins & Aleksandr Shneyderman
Owner 6 wn e r's Name
information is
North Andover Ma 018145 0,5-1 161-12 0 19
required for every .......
page.,, own State Zip Code Date of Inspection
B, Certification (cont)
2. System will fail unless,the Board of Health and Public Wtiter Su,pp,lier, 'If any)
deterrnln that the system is functioning in a manner that protects the public health,
safety and environment:
[:1 The system has a septic tank and spill absorption system (SAS) and the SAS is within
100 feelt of a surface water supply or triibutary,to a surface water,supply.,
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
[:1 The system has a septic tank and SAS and the, SAS is within 50,feet of a private water
su�ppily well.
The system has a septic tank andl SAS and the SAS is less than 100 feet but 50 feet it
more from a private water supply well".
Method used to determine distance-.
This system passes if the well water analysis,, performed at a DEP certifiled laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogien and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other faillurei criteria are triggered. A copy of the ana,lysips must
be attached to this form.
I Other:
...............
......------- .......
Di) System Faffure Criteria Applicable to,All Systems:
You must indicate "Yes' or"No"to each of the followling fo,r all inspections-,
Yes, No
Backup of seWlage into,facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or cloggled SAS or cesspool
N El Static liquid level in the distribution box above,outlet invert,due,to an overloaded'
or clogged SAS or cesspool
Liquid depth in cesspool is, less,than 6" below invert or available voilume is less
than 1/2:day flow
t5ins.doc-rev.611:6 Title 5 Official Inspection Form:Subsurface Sewage Disposat System-Page 4 of 17
Commonwealth of Massachusetts
at Am E Ail 0
MF--
t1b 5 vnicial Inspection orm�
Sub
Not for Voluntary Assessments surface Sewage Disposa! Systlem Form
106, Rocky Brook Road
Property Address
Irina & Aleksandr Shney.derman ............. ................I—
Owner Owner ji s,Name
information is
North Andover Ma 011845 05-16-2019
required for every ..........
page. 6 1'y'I...I...I I/Town State Zip Code Date of lnsp�l 'n..............
it do (conk,)
Yes No,
Required pumping more, than 4 times in the last year NOT dui to clogged or
E] Z obstructed pipe(s). Number of times pumped:
1:1 z Any portion of the SAS, cesspool or privy is below high ground water elevation.
El Z Any plortion of cesspool or privy is within 100 feet of a surface,water supply or
tributary to a surface water supply.
1:1 z Any portion of a,cesspool or privy is within a Zone 1 of a public well.
Any plortion of a cesspool or privy is within 50 feet of a private water supply well.
El z Any portion of a cesspool or privy is less than 100,feet but greater than 50 fleet
from a private water supply well with no,acceptable water quality analysis. [This
system passes if the we,111 water analysis, performed at a DEP certified
laboratory,for fecal cofiform bacteria iridicates absent and the presence
of am,monla nitrogen and nitrate niltrogen, 'is equal to or less than 6 ppm,
provided that no other failure criterila are triggered. A copy of the analysis
and chain of custody must be attached to,this form.]
El Z The, system is a cesspool serving a facility with a design flow of 21000gpd-
101000gpd.
z El The system fails. I have determin that one or more of the above failure
criteria exist as described in 310 CM R 1 51�303, therefore the system fails., The
system owner should contact the Board of Health to deters e what will be
necessary to,correct the failure.
E) Large Systems: To be considered a large,system the system, must serve a facility with; a.
design flow of 10,000 gpd to 15,0010 gpd.
l
F lu or large systems, yo must indicate e oi
Iither yes" or"no" to each of the following, in aiddition to the
questillions in Section Di.
Yes No
01 1:1 the system is,within 4100 feet of a surface drinking water,supply
El D the system is within 2010 feet of a tributary to a surface drinking water supply
El El the system, is loicliated in a nitrogen sensitive area (Interim Wellhead Protection
Area—I A) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any,question in Section E the system is considered a significant threat,
or answered "'yes"' in Section D above the large,system has failed. The owner or olpeIra,tor of any large
system considered a significant threat under Section E or failed under Section D shell Bpi grade the
system in accordance with 310 CM R 15.304. The system owner should contact the appropriate
regional office of the Department.
t5jins.doc-rev.6116 'Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
X ion F�� !
CA T"Itle bm'm UJO""TO*To"icial 1'nspectw
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
r
J'Al 106 Rock y B ook Road
'-"......................................................... ...........
Property Address
Irina & Alek say d'r Shn.derman.............................-,................................. ................................................... .......
Owner Owner's Name
information is
North Andover Ma 0 184 5 05-16-2019
required for every ......
pagle. City/Town State Zip Code Date of Inspection
Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following-
Yes No
M E] 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?
E F1 Has the system received normal flows, in the previous two week period?
El E Have, large volum�es of water bseen introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined? If they were not
a
vl'lable note as N/A)
a
Was the facility or dwelling inspected for signs,of sewage back up?
Was the site inspected for signs of break out?
E El Were all system components, excluding the SAS, located on site?
F-1 El 'Were the septic tank manholes uncovered,, opened', and the interior of the tank
inspected for the condition of the baffles or,telex,, material of constructilon,
dimensions, depth of lei qDui d, depth of'sludge and depth of scum
Was the facility owner(and occupants if different from,owner) provided with
E El 0 1
information on the proper maintenance of'subsurface sewage disposal systems?
The size andI location of the Spill Absorption System (SAS) on the site has
been determined based on:
E E] Existing information. For example, a plan at the Board of Health.
Determined in the field' if any of the falllure criteria related to Part C is at issue
approximation of distance is, unacceptable) [310 MR 15.302(5)]
D. System Information
Residlential Flow Conditions:
4 4
Number of bedrooms (design),- -- Number of bedrooms (actual).
440
D ES I G N flow based on, 310 C M I 5.20 for exam ple,-, 110 g pd x#of bedrooms,
t5ins,.do,c-rev,6,116 Title 5 Official Inspection Form Stibsurface Sewage Disposal Systiern»Page 6 of 17
Summary Record Card generaled on 5/17,12019 8,06,29 AM by Karen,Hanlon Page I
Towns of North Andover
Tax Map # 210*-090.A-0054*,0000.0
Parcel ld 14287
1106, ROCKY BROOK ROAD,
ALEKSANDR & IRINA SHNEYDERMAID
, ROCKY BROOK ROAD
NORTH ANDOVER MA 1 845
Class 101 Single Fam,ily Property Type 1 Residential
Zoning2' 1 Residential Zonlng3 I Residential
Size Total 1. Acres
FY 2019
UB Mailingindex
Name/Address Type Loan Number Active/Inact. From Until
,ALEKSANDR&IRINA SHNEYDERMIAN Owner Active
106 ROCKY BROOK ROAD
NORTH ANDOVER MA, 01845
WAISNOR, N Previous,Customer Inactive 81/29/2012
106 ROCKY BROOK ROAD
NORTH ANDOVER,MA
01845
UB Account Maint., ActIve/Inactive
Account No Cycle Occupant Name
Bldg Id. 18059.0-106 ROCKY BROOK ROAD Last B1111ing!Date 4/9/2019 Active
3180088 03 Cycle 03
UB Services Maint.
Account No. 3,180088
Service Code Rate Charge Multipiler/Users
MISCFEE ADMIN FEE 1 1 9.18,
WTR WATER 01 ALL METER,SIZE 148.15
UB Meter Maintenance
Account No. 31800,88 Size Y'TD Cons
Serial No Status Location Brand Type
13240305 a Active 00 METE METE w Water 1 1 1623
Date Reading Code Consumption Posted Date Variance
3112/2019 2122 a Actual 33 4/16/2019 13%
12/12/2018 2089 a Actual 29 1/22/2019 -54%
9/14/2018 2060 a Actual 67 10/15/2018 87%
6/12/2018 1993 a Actual 35 7/23/201,8 -3%
3/12/2018 1958 a Actual 35 4/23/2018 5%
12113/2017 1923 a Actual 34 1/25/2018 -40%
9/13/2017 1889 a Actual 57 10/18/2017 47%,
6/13/2017 1832 a Actual 40 7/25/2017 9%
3110/2017 1792 a Actual 34 4/121/2017 -12%
12/1212016 1758 a Actual 40 1/23/2017 -57%
9/12/2016 1718 a Actual 88 10/24/2016 16,10%
6/17/20,16 1630 a Actual �37 8/2/2016 4%
3/14/2016 1593 a Actual 34 4/22/2016 -12%
12/14/2015 1659 a Actual 40 1/201/2016 ,513%
9/11/2015 1619 a Actual 84 10/16/2015 32%
6/11/20,15 1435 a Actual 59! 7/24/2015 79%
3/118/2015 1376 a Actual 36 4/28120 15 -17%
12115/20,14 1340, a Actual 42 1/15/2015 -52%
9/16/2014 1298 a Actual 94 10/15/2014, 115%
6/12/2014 1204 a Actual 41 7/16/20,14 1 "�,
3/14/2014 1,163 a Actual 34 4/11/2014 -17%
1,2/16/20,13 1129 a Actual 44 1/17/2014 .39%,
9/13/2013, 1085 a Actual 70 10/1512013 615%
6114/2013 1015 a Actual 4O 7/24/2013 -4%
3/20/2013 975 a Actual 47 4/22/2013 3%
,40 1/9/20,13 8%
12/13/20,12 928 a Actual
Commonwealth of Massachusetts
AMPEML fir fir
z I Itle 5, %ifficial Inspection Form
......................... ......
d 7'
Subsuxface Sewage, Disposal! System Form Not for Voluntary Assessments
Ar 1,06 Rocky Brook Road .............
....................
Property Address
lrin,a & Aleksiandr Shneyderman
........... ..........................................................................
Owner Owner's Ramie
information is
North Andover Ma 01845 05-16-2019 J11
required for every ............................ ......
y w" State Zip Code, Date of Inspection
page.
D, System Information
Description:
.......................
............
............. .........
Number of current residents:
Does residence have a garbage grinder? El Yes E No
Is laundry on a separate sewage system? (include laundry system inspection El Yes 0 No
information in this report.)
La,undlry system inspected? El Yes 0 No
Seasonal use? El Yes E No
Water meter readings, if available (last 2, years usa,gle (gpd)),:
Detail:
...........
........... ......
...........
Sump PUMP? El Yes E No
Last date of occupancy: Currently
Occupied,
Commer&ial/Mdustrial Flow Condition,&:
IN/A
Type of Establishment:
Design, flow(based o n 310 C M R 15.2 013) Gallons,per"" "(gpd)
Basis of'design flow i(seats/'persons/sq. t.,, etc.)1. ..........-
Grease,trap present? El Yes [:1 No
Industrial waste holding tank present? ED Yes, E] No
Non-sanitary waste discharged to the Title 5 system.? El Yes No
Water meter readings,, if available*
15ins,doc-rev,6/16 Title 5 Official Inspection,Forn Subsurface Sewage Disposat Systern, Page 7 of'17
U Stewart's Septic Service Ll Andover Septle U Strathain 111"11 Septic U Roto-Rain
(978) 372-7471 (978)4,75,2593 (603) 772,5548, (978) 452-9022
58 South Kimball' Street, Braqford,, MA 01835
Da,tp,,',,of'S,6rvice
PAY FROM THIS BILL
0 r,Name-,
F.3 R 0, Nature of Service
L)
-J. ........ Reg. Maint.
-j -1 NIC
cgee Locatipm
�j E
Day Night
S *eptic Tar Pumping and Clean'
Phone- i,, g
"Done th e Right Way"
Contact:
Billing Address: Not Respons0k, for Covers
tl
or Irrigation Systems
Gity: Zip:
Special Instructions,
UL Gomplete(',i
FJ lnc=pleted Reason.
Per;
...... ......
AM/PM
Services,,nendered
Observations Drain Gleaning
VEAQ11,11UM PUrnping,
C-I Main Line
,L]"' Septic Tank IJ-G o,od Condition
1J" Drywe'll IJ Leectifield Runback Q Toilet Bowl
IJ Lee&Pit/Overflow IJ Riding High IJ Kitchen Sink,
L) D-Box (liquid level) Ll BathtLib/Shower
1.1 Purnp Chamber IJ Full to Covor Q Varlity
L) Grease'Trap f A Excessive Solids F-1 Floor Drab
Vent
L) Catch Basin 11bp/Bottom
IJ Flo,rt I o To i I e t (J Use Nio Powdered 1,-,3'oap 1J, Sewer Jet
f-1 Other Ij 1-1oavy Grease F.3 Other
Qty: Ij Hoots Footage:
Size: IJ Suggest Oectrio,
FJ L.Inder-1000 gallons J 1000 galtonss I,'J, 15100 ga,ll ns f1ootering,
LA 20010 gallons U 30,010 gallons F,-J 4000 gallons FJ Van Called
J 5000 gallons, U Oth-er fJ Other
Plisc,
J Digging Ctiarge F-) Backlioe IJ Inspection
J Location f1jin. IJ Consultion F-) Cerrilification,: P/F
J Service Call L) Estimato Reason..
1.1, Labor Q Port a,ble'"Toflot Rental [A Punip Repair
��J Waiting Time (3 Baffle IJ Repair
Digging Charge,is Per Dri'vor FJ Chemical Treatment
Discretion 01 Other
...............
Description of work, "i"', f
ReconuTrendations lorms of Payment.
parts
WICUL111)Pumping Drain Clo-aning PAYMENT DUE IN FULL
Y'r, Month Yr. Month UPON COMPLETION Tax
Disc ourit
Terms)&Conditions Ui Cash IJ Check U Criedit
To t a I
Not responsible for dan'uago Lmyond cttrb 1410. 1 1.5%for montl'i will be chargacl to accoul"Its Mast due.
2. All complaiiits shall be reported within hours, 4 The purchasor a oes to pay all cosi of cofloction.
r Siginature I,
Commonwealth of Massachusetts
Tlt,le 5 ufficial Inspv%ect"ion Form
Subsurface Sewage Disposal, System Form Not for Voluntary Assessments,
............
106 Rocky Brook Road
Property Address
lrina &Aleksandr Shneyd elf-man
.............................
Owner Owner's Name
information is
North Andover Ma 01845 05-16-2019 ......
req lu ire d'for eve ry ..........
State Zip Gode Date of Inspection,
page-
D. System Information (cont)
Currently Occupied
Last"date of occupancy/use: Date ....................
Other (describe below):
........... .......
General lnformatione
Pumping Records:
Last time pu' was on 18/1 4/ 9
Source of information:
Was system purnped as part of the inspection? El Yes Ej No
If yes, volume pumped:, ......
gallons,
How was quantity plumped determined? ......
Reason for pumping: —------
Type of Syste�m:
Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
E] Privy
Shared system (yes or n if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation, and
maintenance contract(to be obtaine from system owner) and a copy of latest
inspection of the I system by system operator under contract
Tight tank Attach a copy of the DEP approval.
El Other (describe):
............ ......
15ins.doc rev,6/16 Title 5 Official insplectioln Form-Subsurface Sewage Disposal System-Page,B of 17
Commonwealth of Massachusetts
--ect F
.z Itle 5 v icial Insp ion or,m
Subsurface Sewage Disposal System, Form, Not for Voluntary Assessments
106 Rocky Brook, Road
Property Address
Irina & AlieksandrShne"yerr r .................... .......
................
Owner Owner's Name
information is
North Andover Ma 01845 05-16-2019,
requi�red for every
page. 6iyifown State Zip Code Date of Inspection
D, System Information (cont
Approximate age of all componen�ts, date installed (if known) and source of information:
Tank and trenches are approx 23 years of age! Distribution box was in ,2012
Were sewage odoirs detected when arriving at the site? El Yes No
Building Sewer(locate on site plan):
361t
Depth below grade: fee.t.......... ...............
Material of construction:
El cast iron 0 40 PVC, Ej other,(explain):
n
Distance from private�water supply well or su Tow Water
ction line: f6et
Comments (on condition ofJoints, 'venting, evidience of leakage, etc.),
All Good
Septic Tank (locate on site, plan)*
20111
Depth below grade: feet ......................
Material of constructiow
0 concrete El metal Ej fiberglass E] polyethylene El other(explain)
............. ...........
If to is metalt Is ag&- .................. .......
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes 0 No
10 lx5'x6'
Dimensions-,
Sludge depth-.
t5ins.doc rev,6/16 Title 5 Official Inspection Flow Subsurface Sewage Disposal System-Paige 9 of 17
Commonwealth of Massachusetts
I'mi'tie, 5 uo%fficia�l Inspection Form
V .
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
106 Rocky Brook Road
Property Address
bins & Arleksandr Shneydlle, rman
Owner ner's Name
information is North Andlover Ma 01845 05-16-2019,
required for ever�y ........
page,- City/T own State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
3011
Dist an from top of sludge to, bottom of outlet tee or baffle
Scum thickness
Distance from top of'scurn to top of outlet tee or baffle 711, .........
1,61
Distance from bottom of scum to bottom of outlet tee or baffle
Tape and `ludgr Judl9e
How were dimensions determined?
Comments (on, pur ing recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquild levels as related to,outlet invert, ev,ildence of leakage, etc):
We recommend tank be pumpe n a yearlybasis,, baffles were on , structursl integrity a eared to
be good, liquid level was a little high, it appeared to have suer-charged at some point in time there was
a riser that was stained and damp there was no evidence of any leakagle from the tank.
..........
..........
..........
Grease Trap, (locate on site plan):
Depth below grade: N/,A
feet
Material of construction:
El concrete El metal El fiberglass El polyethylene E] other (explain):
Scorn thickne s
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
t5ins.doc rev.6/16 Title 5 Official inspection Form-Subsurface Sewage Disposal Systern-Page 10 of 17
�aim morlwealth of Massachusetts,
on i
icial Insm4ftecto Form
itle, .050 off
Subsurface Sewage Wsposall Systern Form, Not for Voluntary Assessments
1016 Rocky Brook Road
.............................................—""-.......perty Address
Irina & Aleksand'r Shneyderman
....................
Owner Owner's Name
information is North Andover Ma 01845, 05-16-2019
required for even City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or bafflle condition, structur ll integrity,
liquid levels,as related to, outlet invert, evidence ofleakage, etc.):
Tight,or Holding Tarilk (tank must be pumped at time of inspection) (locate on site plan):
N/A
Depth below grade*
Material of construction:
El concrete E] imetal fiberglass Ej polyethylene El other (explain):
.......... ...... ................ ......
Dimensions,"
Capacity* gallons
Dies,ign Flow,: m.. ............
galIons per day
Alarm present: Yes No
Alarm level: Alarmire working order: El Yes No
Date of last pumping: "b a--t-e
Comments (condition of alarm and float switches, etc.)-
................
...........
Attach copy of current pumpi�ng contract (required). Is copy attached? D Yes El No
15ins.doc-rev,6/16 Till 5 Official Inspection Form®Subsurface Sewage Disposal System,-Page 11 of 17
�(tL4 �x Commonwealth of Massachusetts
Tix:l,. 5 UTTICial n c ion Form
Subsurface Sewage D111sposal System L rm Not for Voluntary Assessments
=.......
106 Rocky Brook, Road- .......
Property Address
Irina, & Aleksandr Shneyderman
Owner er's Name
information is North Andover Ma 01845 05-16-2019
required for every
64W
p -Town State Zip Code Date of Inspection
age.
D. System Information (cont)
Distribution Box (if'presient must be opened) (locate on site plan),
1 Triench_pi e had standing water ............
Depth of liquid level above outlet,invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carr ver, any
evi nce of leakage into or out of box, etc.)*,
Box was level both lines had levelers, some solids, no observed leakage in or out of x.The box was
i
replaced in 2012
.................
..............-
Pump Chamber(locate on site plan').,
Pumps in w rking ordier: E] Yes El No*
Alarms, in working order* 0 Yes E] rho*
Comments (note condition of pump chamilber, condition of pumps and appurtenances,, etc,):
..........
If pumps or alarms are not in workingi order, system is a conditional pass,.
Soil Absorption System (SAS) (locate,on site plan, excavation not require
If SAS not, located, explain why#
............ ..............
.............
.......... ----------
t5ins.doe-rev.6/1,6 Titl fficial Insplection Fora:Substirface Sewage Disposal System Page 12 of 17
Commonwealth of Massachusetts
t10 F
I I-le b� QT't'icial Inspec' n lorm
ammm i A
........
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
14 1016 Rocky Brolok Road'
...............
Property Address
Inna & Aleksandr Shneyde rug
an
Owner 6 w e-is s"Name,
information is
r it for every North Andover Ma 01�8,45 05-16-2019
equed
page, it ow State Zip Code Date of Inspection
D, System Information (cont.,)
Type'
leaching pits nu berg
[] leaching chambers, number*
leaching galleries, number* .......
leaching trenches number, len�gth, 2trenches each
4'x9,0`
leaching -filelds number, dimensions:
overflow cesspool number,: .................
El iron ovativetalternative system
Type/Hernia of technology:
ve of ponding,, damp soil, condition of
Comments, (note condition of soil, signs of h�ydraulic failure, le l
,
vegetation, etc.):
......................-
............
.......... ..... ........ ................
Cesspools (,cesspool, must be, pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of sofids, layer
Depth of scums layer
Dimensions of cesspool ....................
Materials of construction
Indication of groundwater inflow 0 Yes [1 N o
t5ins.doc-rev.6,116 Title 5 Official Inspection Form.Subsurface Sewage Disposal'System-Page 13 of 17
Commonwealth of Massachusetts
Uf r
1cla I Inspectin
.A Subsurface Sewage Disposal System Form Not for V luntary Assessments
................
106 Rocky Br k Road
Property Address
Irina & Aleksandr Shneyderman
.............. .......
Owner Owner's Name
inlforma,tion is North Andover Ma 01845 05-16-2019,
required for ever�y
page. �jtyffown State Zip Code Date of[Inspection
D. System Information (cont.)
Comments, (note condition of soil, signs, of hydraulic failure, level of nding, condition of vegetation,
etc.):1
.......................... .......
Privy (locate on site plan)-
N/A
.............1-1-
Materials of construction:
.........
Depth of solids .
Comments, (note condition of soil, signs of hydraulic failure, level of ponding, con diti n of vegetation
etc.):
...............................— ............
........... .......
t5ins,doc-rev.6116 Title 5 Official Inspection Form:Substirface Sewage Disposal System Page 14 of 11
p 0
lon
In
e- dule e D .'stances
of
.F
t t North An do ver, Mcss
A- - -_
R
owing
f
- sh
Sw F.
an c
D'
S
a
Ce 3,.., -__ e .:_' r y - A mot.' . I- f
L t 14A
CCI 4 4.4 Rock v Bro ok R(
LOL A
3 prepered For
s
J7.2
J 7 _ .
i
Leach Trench System 52. *0 CH 48.8 q 0M es,
Ogun U ' t
Fw trenches, 2 L Ong
Sep t emb er
Wide, Deed
Date
JA 12,9. CCje 4
632 1 25.0
6dule of In verts
Cn&,
�
I �
Invert '(9) Found
t Tank , In IJJ.J8
SePLIC
H —50x In l
S 45
D-Box Out lJ2-8j-f
Sep tip Sys tem In, 132-78
In Ver
systemEnd 132.27
-s p lar, h as beer) p ore
"t C 0 t�N 0 fshowing the
System instc
- 549M t0rY dSP - '
jof-emlses- work
f this tYP
!)undct n q 4
Lot 2A
-
e
Neve Assoc
- U.S.
447 Old Hostan.
Sul- �
Commonwealth of'Massachuselfts
...........
I�Iitle 5 Official Insplect"ion Form
S Subsurface Sewage Disposal System Form Not for Voluntary Assessments
106 �ocky Brook Road N Alt
Property Address
Irina & Aleksandr Shneyderman
Owner Owner's Name
information is
Nor�th Andover Ma 011845 05-16-2019
required for every ............. ..........
page. Cityfflown State Zip,Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage IDlisiposal System: Provide a view of the sewage disposal system, including ties to
at I lea st two pe rma n e n t reference I a,n d.m a rk,s o r b e n ch m a rks. Locate a I I wells within 100 feet. Loca is
where public water supply enters the building, Check one of the boxes below:
El hand-sketch in the area below
E] drawing attached separately
fin al -rev,6/16 Title 5 Official Inspection Form:,Subsurface Sewage Disposal Systern Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspect"ion Form
......... Subsurface Sewage Disposal System Forte Not for Voluntary Assessments
106 Rocky Brook Road
Property Address
Irina & Aleksandr Shneyderman
Owner Owner's Name
information is
North Andover Ida 01845 5- 6-
required for every .....
`jiT -a-t-e- Zip Code Da.te of Inspection
page.
D. System Information (co�nt)
Site Exam:
Z Check Slope
EI Surface,water
Z Check cellar
Shallow wells
4+Feet
........................
Estimated depth 'to high ground water: f6et
Please indicate all methods, used to determine the high ground water elevation:
E Obtained from system design plans on record
September 18, 1996
lf'checked, date of design plan reviewed", Date
E] Observed site (abutting property/observation hole within 150 feet of SAS)
EJ Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
El Accessed USES database -explain:
You must describe how you established the high ground water,elevation*
Plan on file done by Neve Assoc. Basement was dry, No,sump purnip.
.............
..........
.......... .............................
Before filing this Inspection Report, please see Report,Completeness Checklist on next page.
15ins,doc rev.6116 Title 5 Official Inspection Form Subsurface Sewage Disposal System Page 16 of 17
Commonwealth of ass e s s
Title 5 Offici�al Inspect"ion Form
Subsurface Sewage [disposal System Form Not for Voluntary Assessments
1, 6 Rocky Brook Road
n.,
Property address
,.,,... ._............... ..
Owner Owners Name
information is
require for fit i n every North Andover "I 1' �� �- ���
� .,.....,..,..
page.. y State Zip Code Date of Inspection
E. Report Completeness
Inspection S,uu uu r ; A, B, C, D, or E, checked
1
Inspection Summary (System Faillure Criteria Applicable to All Systems) co
System Information Estimated depth to high groundwater
Sketch of Sewage Disposal l System either drawn on page 15 or attached in separate tale
i
1
i
1
i
1
I,
t in, .d .rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 17 of 17
Il"i POA
0ORTH
+
Town Of'North Andover
Rd WK a
%1.1 HEALTH DEPAWfMENT
Arlo 015
2
CHECK0#: 91 DATE:
LOCATION:
H/O NAME
CONTRACTOR NAM
Tvve of Permit or License: (Check box)
0 Animal
[3 Body Art E's tab li,shiment $
[J Body Art. ractitioner
0 Dumpster
0 Food Service-Type.- $
$
0 Funeral Directors
• Massage Establishment $
• Massage Practice, $
• Offal(,Septic)Hauler $
El Recreational Camp $
D Sun tanning
[3 swifuming Pool
0 Tobacco
0 TrashlSolid Waste Hauler $
0 well,constn'Iction: $
SEP77C Sys, is,"
0 Septic-Soil Testing
0 Septic-Design Approval
iI
[3 Septic Disposal works Coils tniction(DWC), 1$
S,epti'c Disposal Works Installers(DWI),
0 Title 5 mspector
ell,
Title 5 ReportUy
r.
0 Oh ,(Indicate), $
ONO
N,
90
t
i
,e t
Applicant Yellow-Health Pink-Treasurer 'll