HomeMy WebLinkAbout- Title V Inspection Report - 345 BOSTON STREET 6/5/2019 Commonwealth of Massachusetts
13F'IL,E COPY
TItle 5 Off'ic"ial' Inspecti",on Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
345 boston Street
Property Address
Wu,, is
Owner Owner"s Name ----—-
information is
required for every North Andover MA 01845 5/7/2019
Page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection for may not be altered in any
way. Pl leteness,checklist at the,end of the form.,
Omit I I 1'100 F%
I mporta nt:When A. Inspector Information
filling out forms
on the computer,
use only the tab War 'arce
key to move your Name of Inspector
cursor-do not V),WN, N R11-1 A N Ir)))(,,),V E R
Pearce Construction
use the return
Company Name
key.
1,916 Park St
Company Address
...........
North Reading MA 01864
Ci'ty/Town State Zip Code
foln 978-664-5,264 SI 1
Telephone Number License Number
B. Certification
I certify that; I am a DEP approved system linspector in full;compliance with Section 15340 of Title 6
(310,CIVIR 15.000); I have personally inspected the,sewage disposal system at the property address
listed above- the information reported below is truel accurate,and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of ors-site sewage disposal systems. After conducting this inspection I have determined
that the,system:
1- Passes,
2. EJ Conditionally Passes
1 Ej Needs, her Evaluation, by the,Local ApprovingAuthority
4. Fails
A
Inspector's Signature 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, notel: 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 different conditions of usiol
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r,� Commonwealth ofMassachusetts
...............................................................................................
ion Form ww
Title 5 Official Inspect"
Subsurface,Sewage Disposal System Form Not for Voluntary Assessments
345 boston Street,
Property Ad'dr,ess
Wu, Miao
Owner Owner's Name
information is
required for every North Andover MA 018,45 5/7/2019
........................... .............. ..............................................
Page,. City/Town State Z*tp Code Date of Inspection
C. Inspection Summary
Inspection Summary* Complete 1,1 21 3, or 5 and all of 4 and 6.
1) System Passes:
I have not found any information which indicates that any of the failure criteria,described
in 3 10 CMR 15303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
4
Indicated below,.
Comments*.
2) System Cond'Ilia nally Passes.:
E:1 one or more,system components,as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for f(yes"', "nooll or"not determined" (Y,, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is,structurally
unsound, exhibits substantial infiltration or Wiltration or,tank fa,flure 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 metalseptic tank will pass inspection if it i's structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
Eli Y N El ND (Ex�plain, below):
t5iinsp,doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-'mega 2 of Its
Commonwealth of Massachusetts
T'Itle !sl Off'icial Inspect'ion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments,
345 boston Street
.............Property Address
Wu Mi,ao
Owner ........
information'is OwnerI s,Name
required for every North AndOver MA 01845 5/7/2019
page. City[Town State Zip Code, Date Inspection
C, Inspection Summary (cont)
2") System Conditionally Passes (cont.):
Pump Chamber,pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
Observation of sewage backup or break out or high static water level, in,the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspectilon if(with approval of Board of Health)*
E] broken p1pe(s) are replaced Y E] N ND (Explain below),
olbstruction, is removed Ej Y N E] ND (Explain below)-
Ej distribution box is leveled or replaced E] Y 0 N El ND(Explain below)-
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). 'The
system will pass iris pe�ction 'if(with approval of the Board of Health):
E] broken pipe(s),are replaced 0 Y 0 N, 0 IN D (Explain below),-
E] obstruction is removed E] Y E] N El ND (Explain below)*
3) Further Evalluation is Requilred, by the Board of Health:
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.
a. System will pass unless Bloard of Health determ,"ines, in accordance with 310 CMR
1,5.303(l)(b)that the system is not functioning win,a, manner which w111 protect public health,
safety and the environment:
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Commonwealth of Massachusetts
e T`It,le
ric"ial Inspect'ion, Form
4.
Subsurface
w,
a ,
Sewage Disposal Systern Form - Not,for Voluntary Assessment
345 bos,to,nStreet
Property Address
Owner Wu Micro
i f rrri tion is Owner's Narne
required for ever Forth Andover20
page. City/Town State, Zip Code
Date of ins i"'o
C, Inspection Summary (cont.)
Cesspool or,privy is within 50 feet of a surface r
Cesspool or privy is within 50 feet of a borderingvegetated wetland or a salt marsh
b. System willill faIll unlessr It lip Water,Supplier, if any'),
determines that the sysis functJoningIn a manner that protects, lic health,
safety and ►ir :t;
E:11 The,system has a septic tank and,soil absorption system, (SAS) and,the SASis within
100 feet,of a surface water supply or tributary to a surface water supply.
El, The system has a septic tare and SAS and the SAS is within a Zonef a public water
supply.
[I The system has a septic tank and SAS and the SAS is within 50 feet ofprivate water
supply well,
[] 'The systems has a septic tank and SAS and the,SAS is less than 100 feat but 50 feet,or
more from a private water supply ll .
Method used to determine distance:
This system passes if lea,well water analysis, performed at,a DEP certifiedlaboratory,, for fecal
colif'orm bacteria indicates of n e e annrnn�
' l
to r less than provided r i that n other failure criteria are copy of the analysis must
be attached this form.
cw Other-
4) System FailureCritter l ,All
You must indicate"Yes." r" "'to each of the following for all inspections:
Yes No
Backup sewage into facility r system component due to overloaded or
clogged SAS,or cesspool
Discharge r ponding of effluent to the surfaceof the ground or surface waters
due to an overloadedr clogged SAS or cesspool
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a u
Commonwealth of Massachusetts
TI'tle 5 Officla
I Inspectmion Form
r
Subsurface Sewage isposal System Forte � � ' �l rat r A s ssme
3145, boston Street
Property Address
WU milao
Owner ""........
.
information is
Owner's Name
required for every North Andover 01845
page. City/Town Stag Zip Code Date ofInspection
C. Inspection Summary (cont)
4) System Failure Criteria Applicable to All : (cont.)
Yes No
El' E Static liquid level in the distribution a above outlet invert due to an overloaded
u r clogged SAS or cesspool
0 M i
Liquid depth in cesspool is less than " low invert or available volume is less
than %day flow
Required pmpiu ' more than 4,times in the last year NOT dueto clogged or
obstructedi s w Number of times ur u e W
E] Z Any portion of the SAS,, cesspool or privy is, below high ground water elevation.
And, portion of cesspool or Privy is within 1,00 feet, a surface water supply r
El z
tributary to a surface water supply.
Any portion of a cesspool r privy is within a Zone 1 of a public water supply
well.
0 z Any portion of a cesspool or privy us within 50 feet of a private rater,supply well.
E] 0 Any portion of a cesspool or privy is less than 100 feet but greater than 5 et
from private rater supply well with no acceptablewater quality analysis.
system passes if the well water analysis, performedi led
laboratory,for fecall colill ors bacteria indicates absent and,the pr ce
of ammonlia nitrogen,and nitrate nitrogen is equal to or less t
provided that other faullure,criteria r triggered. copy of the,analysis
and chain of custody must be attached to this formij
The system is a cesspool serving facility with sign flow of 2000 gpd-
10,000
systemEl 0 The it . I have de term inedthat one or more the above failure
rig ri exist as described in 310 CMR 15.303, 'therefore the,system fails. The
system owner should ntact the Board of Health to determine in hat will b
necessary to correct the failure.
Large5) terra considered a large t the system must, erg citify with
designflow of 10,000 gp,d t
For large stria, your must indicate either s" or"no"to each of the following, in addition to the
questions i ■ Section CA.
I
s
Yes" No
E] El the system is within 1400 feet of a surface drinking inn rater supply
El 1:1 the system is within 200 feet tributary to a surfacedrinking water supply
F-1 Elthe system is located in nitrogen sensitive area (interimWellhead Protection
Area �+l PA r a mapped Zone Il of a public rater supply well
t6insp.doc rev.,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systems.Fags 5 of'1'
wm,y
..
F T tie 5 Official
ion
Commonwealth of Massachusetts
Form
M
I r
Subsurface Sewage Dilsposall System Form Not for Voluntary Assessments
42
Property Address
Wu Miao
Owner
information is Owner's Nerve
require'for every North Andover MA 0,1845
page. Cityfrown State Zip Cod's ate of 1n ti
C. Inspection Summary (cont.)
If you have answered"yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes";to,any questionin Section C.4 above the large system has fails ,
owner or operator of any large system con i erect a significant threat under Section C.5r failed
under Section CA ii upgrade the system in accordance with 310 CMR 15,304. The system owner
should contact,theappropirlate regional is f the Department,.
6. You must i d*lcate,"yes"or" "for each of the f,6111lowi I
Yes No
Z 1:1, Pumping information was provided by the owner, occupant, or Board of Health
El Z Were any of the system components pumped out in the previousweeks?
Has the system received normal flows, in the previous two week period
.?
Have large rn f been n introduced t ,the t recently r as part, f
this inspection?
Z El Were as built plans ofthe,system obtained and examined?, (if they were not
available l note as N/A)i
s the facility or dwelling inspected for signs of sewage back
Was the,silte inspected for signs of brash out?
Were all system "n rasp excluding the SAS, located on sit
E] Were true septic teak manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees,, material f constructiont
dire r si ns, depth of liquid, �dept f' Iu '' ,e and' depth of scum?
0 0 facility owner rent from owner) provided with
�the occupants �f �
information on,the proper maintenance of subsurface sewage disposal systems?
size andto 1 Absorption Systemthe site has
been determined based on:
Z EJ Existing information.tion. " r x rn le, a plea atthe Board of Health.
Z 1:1 Deapptermined in t field (if o f the failure criteria related t Part C i t issue
wl
r xi m tion d in n is a merce t l 3 ,� 5.3 2
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Commonwealth of Massachusetts
qu Tlitle 5 Official Inspect'ion Form�
Subsurface Sewage Disposal System Form Note for Voluntary Assessments
345 boston Street
Property Address,
Owner Wu MOO
Owner's Name
[Information is
required for every North Andover MA 01 845 5/7/;-0.1.9-.
page. Cityffown State Zip Code Date of Inspection
D. System Information
1., Resindential to Condoftwions.:
4 4
Number of bedrooms (design),:' Number of bedrooms (actual:
440
D ES I G N 'flow based on 3 10 C,M R 15.203 (for exam ple: 110 g pd x#of roorns)'
Description:
ll
Number of current residents: -3
Does residence have a garbage grinder?, El 'Yes JZ, No
Does residence have a water,treatment unit.? El Yes 0 No
If Yes, discharges to,
Is laundry on a separate sewage system? (Include laundry system inspection F] Yes Z� No
information in this report.)
Laundry system inspected? Yes E] No
Season,aluse? E] Yes Z N o
Water meter readings, if available(last,2 years,usage (gpd)): 41 GPD
Detail*
4/17/2017 to 4/17/21019 29,920 gallons
.............
Sump pump? El Yes Z No
Current
Last date of occupancy, Da 11 t I e 1111111111111111-1-,
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�m
. mm
Commonwealth of Massachusetts
�
. 1, Inspection Form
T't,le 5 Off'icia
Subsurface Sewage Dilsposal System Form Not for Voluntary Assessments
345 boston Street
Property Address
mm...
Wu ia ,
Owner information i w r's Nam
required for every North Andover MA 01845 517/2019
page® Cityffown State Zip Code Date of Inspection
D. System, Information (cont.)
2. Commerciallindustrial FlowConditions:
Type of Establishment,* _n �. ...W .
s 1g,n flow(based o n 310 C M R 15.203) Gallons pe.r, �.�m.. m .....�
day(gird)
Basi's of
esi M MI flow +' ts/person" /sq tµ, etc.),:
Grease trap present? Ej Yes No
'Watertr,eatment unit present? Yes [:1 No
If,yes, discharges ,. ..�. LL ... .mm ,
Industrial waste holding,tank present" El Yes No
Non-sanitary waste discharged to the Title system? Yes, El No
Water raster readings, if available" . ..
Lust,date of occupancy/use* Da
Other(describe, be1w ;
1, Pumping r°ds
t iur ti �..-
., April 2 tie How owner
,Source Was system pumped as part of tie,inspection? El Yes N" N o
lt'yes, volume pumped, . .u.m......., ,. .
gallons
How wasquantity pumped determined?
Reason for pumping M. mm.. .
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Commonwealth of Massachusetts
T"I'tle 5 Off'ic'ial Inspect'ion Form
Subsurface e Disposal System Form Not for V l nt r ssessments
345, Boston Street
i
PropertyAddress
Wu Mi
Owner
Owner's Name
information is
required for every North i t MA 01845 517/21019
page. City[T wrw State ZIP Code, Date of Inspection
D. System Infor ation (cont.)
4. Type of System:
Septic teak, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
EJ Shred system (yes r no) (if yes,, attach previous inspection records,
El Innolvative/Alternative technology. Attach a copy of the current operation n
maintenance contract(to be obtained from system owner) and a copy of latent
inspection, of the I system system operator,under contract
El Tight tank. Attach copy ofthe DEP approval
Other(describe)-
Approximate age of all components, date installed it now and source of*nformation.
2007 Original ste,111111111111111 rB4OH reacords.
Were sewage odors detected when arriving at the site? El Yes E No
tl Building Sewer(locate on site plain):
Material of c r str ti w
El cast iron Z 40 PVC El other(explain): ....., .�. .
Distance from private water supply well r suction line:
100+
'
feet
Comments, n condition, fjoints, venting, evidence of leafage, etc.,):
All appears in good shape inside the house.
t6insp.doc rev.712W2018 TWe 5 Official Inspection Form:Subsurface Sewage Disposal System Page f 18
Commonwealth
icial lbspection Form
Timtl'e 5 Offm
" ,. ce Sewage Dis,posa,l System Form Not for Voluntary Assessments
345 boston Street
mm
Property Address
u �i ,
Owner Owner's Name
information'is
required for very North Andover MA 0 18455/712019
page. City own State ;dip Code Date irlion
D. System Information (cont.)
6. lic Tank (loica,te on site plan):
Depth below r , ......
feet
Material of construction:.
concrete El metal l fiberglass El polyethylene other(explain)
If teak is meta,l, list
'dears
Is age confirmed Certificate C pli (attach a copy of certificate) t> El No
10'6"X 5' "X
Sludge depth: Inches
Distance from top oaf sly tt outlet tee r l 3 Inches
LessScum thickness n one inch:
Distance from tip scum t t outlet r l in i
Distancefrom bottom scum outlet t r I 14
� c
How
were dimensionsdetermined.? ..
Comments n pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet inrt, evidence of leakage, . :
Outlet biter present. Tees are present, L,iqu,id level good. No sign of leakage. n appears
structurally sound.
t 51n p.dOG•rev.712 / 1 Tiff ,Official Inspection Form-'Subsurface Sewage Disposal System*Fags 10 of 18
h
ate, Commonwealth of Mri c e
icia ion,
Totle 5 Offa I Inspect" Form
Subsurface SewaDisposal r Not for Voluntary ss s r rat
345 boston Street
Property Address ...�m
Owner
W ciao
Owner's
information is €
required for every North Andover A 01845
page. mm , ... State Zip Code Date of Inspection
D. System Informatiman (cont.),
Grease7. (locate,on site plea):
Depth ---grade: ,
feet
Material of construction*
El concrete metal El fiberglass El polyethylene other(explain):
Scum thickness
Distance from top of scum to top of outlet tee or baffle . , .w.. ..
Distance from bottom of scum to bottom of outlet tee or baffle ......... . ,... .
Date of last pumping,:" ..
Comme its (on pumping recommendations, inlet and outlet tee o,r baffle condition, structural integrity,
liquid' levels as related to outlet invert, evidence of leakage, etc.
8. Tight r Holding Tank (tank cost be,purnpedt time of inspection), (locate on site plan)':
Depth below grade: . �.....n
Material c nstru tiow
0 concrete El meta l fiberglass El polyethyieneother(explain):
gallons
IIIons.per day
t in p. •rev. 1: / 01 T'itle 5 Official inspection Form:Subsurface Sewage Disposal System.Page 11 of�
m,
Commonwealth of Massachusetts
I Inspect'ion Form
T'Itlb 5 Officia
gym.
Disposal - -Not for Voluntary ntar Assessments
345 boston Street
Property Address
Owner a Miao
i,riformation,is Owner's Name
required for every North,.. Andover �m .., ... ..- eats f Inspectio
.nD. System Information .
111
(cont.)
Tight8. i (cont,)
Alarm r r * El, Yes 0 N'
Alarm level: Alarm in working order: F1 'Yes No
Date of Iasi pumping: Date
Comments (condition of ala, m and float switches, etc.).
Attach copy of current pumping contract(required). Is copy attached? Yes
9, Distribution x (If present must be opened) (locate on, site plan)*
Depth of liquid level above outlet invert, aches
Comments (note if box Is level and distribution outlets equal, any evidence of solids carryover, are
evidence of I a �e Into or out of'box, etc.):
Baffle � . -box is I eI and distribution appears equal. Minimal solids and no evidence of
leaka, The d-box appears to be in
(;do ;p,d,o „rev./26/ 1'18, Title 5 Official inspectio rm,Subsurface Sewage deposal System-Page 12 of 18
%-#ommonwealth of Massachusetts
.............................................
qi
Title 5 Official Inspect'ion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3,45 bost n Street,
Property Address
Wu, Miao
Owner
information is, Owner's Name
required for every North Andover MA 01845 5/712019
'J
page. City/Town State Zip Code Date,of Inspection
D. System Information (cont.)
10., Pump Chamber(Jocate on site,plan).
Pumps in working order: 0 Yes 0 No*
Alarms in working rder: 0 Yes E] N o*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etcj.
Tested pump controls and alarm. All arin good condition and operate properly.
If pumps or a1arms.are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required).,
It SAS not located, explain why:
...........
Type*
El leaching pits numbec ......
El leaching chambers number:
leaching galleries number:
[Z leaching trenches, number, length:
leaching fields number, dimensions,
overflow cesspool number*
innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form,Subsuirface Sewage,Disposal System-Page 13 ref'18
a� Commonwealth of Massachusetts
...
T"tle 5 Off'incial lbspection Form,
e�
Subsurface Sewage Disposal, System FormNot for Voluntary Assessments
345 bostonStreet
Property Address
Wu Miao
Owner Owner's Name
information is
required for eves Andover 018,45
51/7'/2019
page. Cityffown State e Code Date of Inspection
D. System Information (cont-)
11. *II Absorption System, (SAS) ('cont.)
Comments (note condition of soil,I signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.),'.
Everything a rs normal. i ondin ,,,or,_,h,ydraulic failure.
, Cesspools (cesspool must be pumped as pert of inspection) (locate on site plan):
Number and configuration
Depth -top of liquid to inlet invert
Depth of solids layer
Depth of'scum layer m ..... � ....
Dimensions of cesspool
Materials ofconstruction
Indication of groundwaterinflow El Yes N o
Comments n n i i n of soil„ signs of hydraulic failure, levelof' ing, condition of vegetation,
etc.):
(5�,n p„ ' .rev.7/26/2018 Title 5 Oifficial Inspection Forte:Subsurface Sewage Disposal System.Fags 14 of 1
Commonwealth of Massachusetts
TI"tl'e 5 Off'i' I Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
345 boston Street—,—..
Property Address
ner Wu, Mao
Ow
information Is Ownees Name,
requi'red for every North Andover MA 01845 5/7/2019
page., Cfty[Town State Zip Code Date of inspection---'""'-'-"""-"-""'
D. System Information (cont.)
13. Prlivy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids .............
Comments (note condition of soil,, signs,of hydraulic failure, lev�el'of ponding, condition of etc vegetation,
4.),
t5insp.dog-rev.7126/2018 Title 5 Official Inspection Form,Subsurface Sewage Disposal System Page 15 of 18
� .mm
Commonwealth of Massachusetts
Title 5 Official Inspect" Form
ion
I..Al E Ubsurface Sewage,Disposal System Form Not for Voluntary Assessments
A
Aw Street
Property Address
Owner Wu Miao
information Is Owner'sName
required for eves North Andover MA 015/7/2019
age. pity own State Zip CodeDate of Inspection
D, System Information (cone.)
14. Sketch Of Sewage Disposal System:,
Provide view of-the sewage disposal system, including ties to at least two permanentreference,
landmarks, r benchmarks. Locate ail weds within 100 feet. Locate where public water supply eaters
the building. Check one of the boxeslow:
hand-sketch In the areahow
drawing attached separately
L Ills
C)
m
i
,
e
I
f
j
I
15inspAbc•rev.71261 118 Title 5 Official Inspection Farm.Subsurface Sewage Disposal System Page 16 of 18
Commonwealth of Massachusetts
I Inspecti"on Form
T'mitle 5 Offnicia
Subsurface Sewage Disposal System Form ®Not for Voluntary Assessments,
3,45 ston Street
Property Address
Wu Micro
Owner Owiner's Name .......................... ...........
information
required for every North Andover MA 01845 5/7/2019
page. City/Town
State Zip Code Date of inspection
D, System Informati"on (cont.)
15. Solte Exam:
Z Check Slope
Surface water
Check cellarl
Shallow wells
4+
Estimated depth to high ground'water* feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system deign plans on record
If checked, date of design plan reviewed- Date
z Observed site(abutting property/observation hole within 150 feet"of SAS)
Checked with local Board of Health -expla,in-
No,file
11 _p rsrt
E] Checked with local excavators, installers-(attach documentation)
El Accessed USES database -explain*
You must describe how you established the high ground water elevationi.,
The site slopes down on both sides,and to the rear to anelevation well bellow the bottom of the
s, stem. 'The site was built up,requiring"a,,, m p system for proper separation to ground water.,
_,p p,�u
Before filloing too s Inspection Report, please see Report Completeness Checkfilst on next page.
t5insp,doc re,v.7126/2018 Title 5 Official Inspection Form,Subsurface Sewage Disposal System l-Page 17 of 18
mx
Commonwealth of Massachusetts
hs
.�. . T'Itl�e 5 Off"icial lnspect,'ion Form�
Subsurface Sewage Disposal System Form Not for Voluntary Ass ssm ts
35 boston Street
Property Address
Owner Wu Miao
information is Owner's Name
required for every North,Andover5/7/2,019
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all, applicable sections of this form inclusive of:1
A. inspector Information.4 Complete all fields in this section,.
B. Certification- Signed & Dated and 1, 2$ 3, or 4 checked
C. Inspection Summary:
1 , or 5 completed as appropriate
(Failure,Criteria)and (Checklist)lis completed
D. System Information:
For Tight/Holding Tank—Purnping,contract attached
..... - : Sketch tc Sewage Disposial System dr wn on pg. 16 or attached
r * Explanation, ofestimated depth to highra w t r included
t5 I nsp.d' .r .7126/2018 Title l Inspection Fore;SubsurfAce Sewage Disposal System Page 18 of 1 .
S u"mmary Record Card generated on 5 2 19 1,0:31:46 AM by J o6nnaGal Galib Page"I
Town of North And'over
.0
Tax Map # 210-107D-0135-000,0
Parcel Id 22691
345 BDSTON STREET
Since
i
XIA00ING, GUO
345 BOSTONT
NORTH AND
O
Class 101 SingleFamily Property,rt Type 1Residential
Zoning2 1 *
al ZoninO 1 Residential
Size Total Acres
FY 1
UB Mexifing Index
Name/Address: Type Loan Number ti J ct. From U till
WU I��y�q® Juyq'' owner
iXI l A A G U Sri^
45 BOSTON STREET
NOATHANDOVER,MA 018,45
ITCH 'lEL
Previous Customiet Inactive 1 1 2
26 RAY AVENUE
BURLINGTOWMA, 01803
w. UB Account Mai,nt.
Acc'ou'n' t No Cycle Occupant Name Activei1nadive
Bldg I . 22679.0 345 BOSTON STREET t B illing D ate /2 1
1090521 '1 Cycle 01 Active
i
Account No.1090521
Service Code Rate Charge l ultl li ry stirs
ISCF E ADMIN PEE 7. '2
WTR WATER1 ALL METER SIZE 1 .2 , "
UB titer Maintenance
a
I
Account l µ 1 9 21
Bevel No Status Location Bread Type Size YT'D Coma
Water 0.630.63 262
Date Deeding Code Consumption Posted Date Variance
1 W201 9 371 a Actual 5 1
10122112018 3162 a Actual 6 11 19 2 1 -27
V-18/2018 348 a Actual 4 5 1 18
1/1812010 344 a Actual 4 W201 1 8 -21
1 /1 W2017
Actual '1 1 �1
V19/2017 326Actual 6 2/16/2017
7/W2016 316Actual 8 8/16/20161
22/216 308 a Actual 4 W5/201 6 . 3
112212016 304 a Actual 6 21M1 G 1
1 15 290 a Actual 5 11 12, 15 .717*0
2 1 293 a Actual, 17 1 201' 320.E G
4/27)20115 276 a Actual 1 1 1
1/30/2015 272 a Actual /2 1 "'
10)24/2014 268 a Actual 3 11/1 2 1 - 2
7/25/2014 265 a Actual 11 "13?2 1 1
4/24/2014 254 a Actual 5 5/1 5 0,1
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VORT01rr
Ao
0
Town of North over
HEALTH DEPARTMENT
ACH'
DATE.:CHECK#:
ayin..l�fIIII� J'Ju1�N u� N
II
LOCATION: '5 ILI
m Saar it P lbra n
---�70,01 te"
H/0 NAME: O,
"'0"As
Y,
CONTRACTOR NAME: k�A M ,
TV Permit or Licen.se:(Ch.eck box)
• Animal $
• Body Art Establishinent $
• Body Art Practitioner $
0 D ani s ter $
P
0 Food Service-Type: $
11 Funeral Directors,
0 Massage Establishment
'I] Massage Practice
0 Offal(Septic),Hauler $
0 Recreational Camp
IJ Sun tanning $
0 "Iffling of
0 Tobacco $
0 TrasIVSolid Waste Hauler $
11 Well Constniction! $
SEPTICISYSI-ems.-
0 Septic-Soil Testing $
�El Septic-Design Approva I $
0 Septic Disposal Works Cotistruction,(DW0 $
0 Septic Disposal Works Installers(DWI)
0, Title 5 Inspector $
'Title 5 Report
11 Other:Undicate) $
goo
Hia"ith Agent Ini'tials
White-Applicant Yellow-Health Pink-Treasurer
...........
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