HomeMy WebLinkAbout- Title V Inspection Report - 15 SULLIVAN STREET 6/11/2019 Commonwealth Massachusetts
T 1"t 1 e 5, 1 lnsma-ecti'on Form
U TY,i c i'a
Subsurface Sewage Disposal s l System Form ® Not for Voluntary Assessments
15 Sullivan Street
Property Address
Davidlseler
Owner Owner's Name
information is North Aadover Ma 01845 6 5/2 '9
required for eves page. CGt n et t � � dDate _f Insp+ tin
inspection results must be submitted n, this f rrrn. Inspection forms may not be alteredinany
way. Please see completeness hec l st at the end of the form.
owes,NMM%
Imps r rat*When A., Inspector Information
filling out forms
n the ter, s r .
use onlythe tad
key to move your Name of Inspector
cursor-do not Dean �' OF NORTH ANDOVER
1@1�TOW'ff" !rLj ����
use the return .. � ..� f,--Jk�an6t 11 1 uotwtfll 11Company Ir
2 Suntaug Street
tab
-d—ompany Address
Cit F owns State Zip Code
Telephoine Number License Number
B. Certification
I certify that* 1' am a DEP approved system inspector in full compliance,with Section 15.340 of Title
(310 CMR 15. 1 have personally Jinspected the sewage d'isp sal system, atthe property address
listed above; the information reported below is true, accurate and complete as of the time f
inspection; and the inspection was performed rme based on my training and experience in the proper function
and maintenance fon-site sewage disposal systems-After conducting this, inspection I have determined
that the system:
1. 0 Passes
2. , Conditionally Passes
31., Needy Further Evaluation by the Local Approving Authority
4. El, Fa
Fa
actor's Signature Date
The system inspector shall
it � pinspectionthis r+ Approving Authority (Board
ofHealth or P within 30 days of completing this inspection. If the system has a design,flow f'�
10,0100 gpd or greater, the inspector and the system owner shall submit the report t the appropriate
regional office of the CEP. The originall,form should sent t the stern owner and copies sent t
tire,buyer, if appli�c le) and the approving authority.
I
Pleasenote. T .s, report only describes conditions at the time of inspection and under the a
r
conditions f 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.
i in ® ' + -rev.712612018 rifle 6 Official Inspection or Subsurface Sewage Disposal System-Page 1 of 1
Commonwealths of Massachusetts.
T"tle 5
iInspectin�
Subsurface Sewage Dilsp,osall System Form Not for Voluntary Assessments
15 Sullivan Street"
Property Address �...
David Is rer
Owner Owner"s Nerve m,
information is North Andover a 5 615/2019
required for ,,. _
pages City/Town State Zip Gotha Date of Inspection
C. Inspection Summary
Inspection Summary* Complete 121 3 or 5 and all ' and 6.
1) System Fusses:
EJ I have not.found any information,which indicates that any of the failure criteria described
in 310 CMR 15,303 or in 310 CMR 15.3,04exist. Any failure criteria not evaluated are
mate below.
Comments-
System Conditionally Passes
E] One or mor system components as described in t a ,"Conditional Pass"' section need to be
replaced r repaired.! The system, upon,completion of the replacement r repair, as approved' by
the Board of Health, will pass.
Check the box fir"yes", " $$ r"not determined"' (" , N AID) for the following statements„ I "not
determined," please explain..
The septic teak is metal and over 20, years old* or the septic tarp (whether metal or not) is structurally
ally
unsound, exhiblits substantial infiltration or exfiltration or tank failure 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 leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y E] N D (Explain below
t5insp.doc rev.7/2612018 Title 5 Official Inspeld ion Form,Su bsurfa e Sewage Disposal 8ystem M Pale 2 of 18
Commonwealth of Massachusetts
'T"Itle 5
0"irtoici"al Inspection Form
Subsurface Sewage Disposal System Form Not for Vlu ntar sess ents
15 Sullivan Street
Property Address
David Islr
Owner Owner's Name
information is North Andover M 5 6/5/2019
required for every u City/Town City/Town State Zip Code Date Inspection
I tion
C. Inspection Summary (ciont)
2) System Conditionally Passes (court.),
El Pump Chamber pumps/alarms not operational. System will pass with Board!of Health approval if
aumips alarr spare 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. S st r u will
pass inspection if with a appr v ul of Board of'Health):
E] broken pipes) are replaced N 0' Expilain below):
El obstruction is removed Ell l N (Explain below):
distribution box is leveled or replaced N Ej H (Explain below),:
cracked and corroded d box reeds to be replaced
icoriroded outlet baffle in septic tank reeds to be replaced
El The system required pumping more than 4 times a year due to broker or obstructed pipe(s),. 'The.
system will pass inspection if with approval of the Board of Health),-
broken 'pip' s are replaced ! HD (Explain below):
E] obstruction is removed F] Y [j N [71 ND (Explain below)*
3 Further r v al au ut n is Required by the, Board of Health:,
F
aConditions exist which r �qu ire f�.urther evaluation by the Board of Health, in order t determine i
the system is failing t protect public health, safety r the environment.
ent.
. Sly'stemi�will pass a areas Board of Health determines ire accordance w th 310 Cl
1 303(l)(b)thatthe system is not,functioning in a mannerhi ha will protect puMic health,
safety and the environment:
t 1nsp.dloc.rev.71,2612018 Title 5 Offlicial Inspection Formi,Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
T Otle 5 Offm
iciecItion For
Subsurface Sewage Disposal System Form Not,for Voluntary Assessments
15 Sullivan Street
Property Address
David Iseler
Owner Ownerl,s Name
information is North Andover M,a 01845 16/5/2019
required for every City[Town -State Zip Code Date ofinspection
page.
C, Inspection Summary (cont.)
[:1 Cesspool or privy is within 50 feet of a surface water
0 Cesspool or privy is within 50 feet of a bordering vegetated wet la,nd or a salt marsh
b. System:will fail unless the Board of Health (and" Pu blic,Water Supplier, '[if any)
determines that the system is,functioning in a manner that protects the public, health,
safety and enviro=ent:
0 The system has a septic tarek and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surfacie water supply.
F The system has a,septic tank.and SAS,and the SAS is within, a Zone 1 of a pubilic water
supply.
E] The system has a septic tan,k and SAS,and the SAS is within 50,feet of a private water
suppily well.
[:1 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 well".
Method used to determine,distance:
This system passes if the well water analysis,,, performed at a DEP certified laboratory, for fecal
coliform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 pprn,, provided that no other failure,criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"' or"No" to each of the,following for all inspections:
Yes No
El z �Backup,of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El z Discharge or pondinig of effluent to the surface ofthe ground or surface waters
due to an overloaded or clogged SAS or cesspool
t6insp.doc-rev.,7126/2018 Title 5 Officiall Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Tl't,le 5, Official Inspectmilon Form
Subsurface Sewage Disp s l System Form Not for'Volunitary,Assessments
15 Sullivan Street
Property Arsis
David lir
Owner Owner's Name
informa,ti n is North n r lea 01845 6/5/2 9
requ�ired for every City/Town State Zip Cocle DateIns
pection
C,, Inspection Summary (cont.)
4) System Fialilure Criteria Appillicable to All Systems: (coat.)
Yes NEl 2'
Static liquid Pavel in the distribution box above outlet inn rt due to are overloaded
r clogged SAS or cesspool
EJ 0 Liqu�id depth 'in cesspool is less than 6" below invert or available vol m its less
than 1/2day flow
El 0 Required pumping more than 4 times in the last year NOT to clogged or
obstructed i e s . Number of times um
r portion f the SAS, cesspool or privy is below high ground water elevation.
El M Any portion of'cesspool or privy is within 100 feet of , surface water supply r
tributary to a,surface water,supply.
n portion f'a cesspool r privy is within Zone f public water suppi
El well.
El N Any portion wf a,cesspool or privy is within 50 feat of a private water supply wall.
Any portion f a cesspool or,privy is lass than 100 feat but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This,
system passes if the well water anal,yrSIS, performed at,a D P" certified
Laboratory,for fecal coliform bacteria: indicates absent and the presenicle
f amrru n'ia nil"trogen and rmitr ute nitrogen is equal to or lass than 5 ppm,
provided that no other faillure criteria are trii9gered. A,copy of the anallysis
and chain of custody must be attached to this forma.]
The system is s cesspool serving a facility with a design flow of 2000 gpd-
EJ1 gpd.
The system fails. l have determined that one or more ofthe above failure
0 criteria exist as described ire 310 CM R 1'5.3 3, therefore the system fails. The
system owner should contact the Board of health to determine what will be
necessary to correct the failure.
5) Large Systems: a considered a largle,system the system must serve a facility with
s ig in floes'of 1 �000 g,pd to 15 v .
For large systems, youmust indicate either 11, s"' or"no"'to each of the following, in addition to the
questions in Section CM .
Yes N
E] z the system is within 400,feat+ f a surface drinking water supply
El Pq the system, is within 200 feat of a tributary,t,o,a surface drinking water supply"
El N the system is located in a, nitrogen sensitive area (Interim Wellhead Protection
Area—1 r a mapped Zone 11 of a public water supply well
tfin p.do -rev. 1 1 018 Tile 5,Of dat Inspection Form:Subsurface Sewag 9 Disposal System page 5 of 1
Commonwealth of Massachusetts
T"tle ic 5 ia ton Form Off I Ins,pect
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
15 Sullivan Street
Property Address
David Iseler
Owner Owner's Name
information is North Andover Ma 01845 6/5�/2019
required for every b-ateof
page. dii-YrTown State Zip Code Inspection
C. Inspection Summary (cont.,)
Ify1ou have answered "yes" to any question in Section C.5 the system is considered a,significant
threat, or answered U yes"to any question in Section G. above the large system has,failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance,with 310 CM R 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or 11no'f for each of the following for all inspections:
I
Yes N,10
EJ Pumping information was pirovided by the owner, occupant', or Board of Health
E] 0 Were any of the system components pumped out in the previous two weeks?
N El Has,the system received normal flows in the previous two week period?
El N Have large volumes of water been introduced to the system recently or as part of
this inspection'?
Were as built plans,ofthe system obtained and examined? If they were not
available note as N/A)
Was the facility or 'welling inspected for signs of sewage back up?
N El Was,the site inspected for signs of'break out?
Were all systern components,, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of'the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth, of scum?
Was the facility owner(and occupantsif different from owner) provided with
information on the proper maintenance of subsurface,sewage,disposal systems'?
The size,and location of the,Soill Absorption, System (SAS) on the site has
been determined based on:
N El Existing information. For example, a plan at the Board of Health.
I
El 1:1 Determined In the field if any of the failure criteria related to Part C is at issue
approximation of distanc nac
le is uceptable) [310 CIVIR 15.302(5)]
t5insp.doc-(ev.71 12018 Title 6 Offic,ial Inspection Form-Subsurface Sewage Disposal System-Page f 18
uommonwealth of Massachusetts
ic ion Form
Mn
Title 5 uO%ffial Inspect,
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
15 Sullivan Street
Property Address,
David Iseler
Owner Owner's Name
informat"'on is, North Andover Ma 018,45 6/5/2019
required for every City/Town State Zip,Code Date of Inspection
page.
D, System Information
1. Residenflial Fllolw Condlitions:
3 3,
Number of bedrooms (design),: Number of bedrooms(acttlllllial):
DES I G N flow based on 310 CNIR 15.203 for example.- 110 gpd x#of bedrooms) 330
�Description.
3 Bedroom system with 1500 gallon tank and 2, pipe in stone trenches
3
Number of current residents:
Does residence have a garbage grinder? El Yes 0, No
Doles residence have a water treatment unit? Yes No
If yes, discharges to*
Is laundry on a separate sewage system'? (Include laundry system inspection F1 Yes Z No
information in this report,)
Ej Yes El N o
Laundry system Inspected?
Seasonal use? Ej Yes, Z No
Water met ail
aster readings, if avable(last 2 years usag g well water
Detail:
Sump pump? El Yes Z, No
-A.
current
Last date of occupancy: Date
t5fnsp.doc-rev,7126/2018 Title 5 Officialt,Inspection,Form,Subsurface Sewage Dlisiposal Systilem 1,Page 7 of 18
toommonwealth of Massachusetts
ectm Form
1"14
U F Title .5 OTTIcial nsIp ion
Su�bsurface Sewage Disposal System Form �Not for VolunWry Assessments
15 Sullivan Street
Property Address
David Iseler
Owner Owner's Name
information is North Andover Ma 01845 6/5/2019
required for even
page. City/Town State Zip Code Date ofinspection
D. System Information (cont.)
2. Commercial/Industrial Fll=Condfti*onsi:
Type of Establishment*
l s ig n fl ow(based o n 3101 C M R 5.2 03): Gallms per day(gpd)
,Basis ofdesi,gn flow (seats/persons/sqft., etc.)*
Grease trap present?, El Yes El No
Water treatment unit present?. E Yes, No
Is, discharges,to-
Industrial waste, holding tank present? El Yes EJ No
Non-sanitary waste discharged to the Title, 5 system? El Yes [:1 N o
Water meter readings, if available.:
Last date of occupancy/use: Date
Other(describe below)-
3. Pumping Records:
homeowner/ Health Dept
Source ofinformation:
Was system pumped as part of the inspection? El Yes, Z No
If yes, volume purriped: gallons
How was quantity pumped determined
Reason for pumping,-
t51nsp.doc-rev.7/26/2018 'Tille 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth ofMassachusetts
Z T itie 15 Official 1nspection For
Subsurface Swale Ds + sI System '�ot fori Assessments,
5 Sullivan Street
Property Address
David Is l r
Owner O�wner's Name
requ�ired for every
information is North Andover Ma 01845 6/5/2019
City/Town State Zip Code� Date f Inspection
M, System Information (cont)
. hype of System
0 Septic teak, distribution box, soil absorption system
El Single cesspool
Overflow cesspool
El Privy
El Shared system (yes or,n i`yes,, attach previous inspection recordst if any)
Innovative/Alternative technology.r. Attach a copy of the,current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection; the I system by system op+ r t r under,contract
Tight tank. Attach a copy of the DEP approval.
El Other(describe):
pp�r xirn t age all mponents, date inst ll i mown) � s rc rn r ati r�:
9 993 as pier p rrn t on file
Were sewage odors detected,when arriving at the site" Yes 0 No
5. Buillding Sewer(locate on, site plea);
20111
Depth below grade: f6et
Materia,l of construction,
El cyst iron , PV'C other(explain):
Distance from private water supply well or suction lire: fees
Comments(ors condition of"Dints, venting, evidence of'leakage, etc.''.
sewer pipe in good c n iiti n no evidenceleakage
15insp.doc rev.7/26/2018 title 5 Official Inspection Form:Subsurface Sewage Disposal System P g 9 of 1
Commonwealth of Massachusetts
I Inspect'ion Form
T"Itle 5 u'ff"icia
Subsurface S age Disposal System Fbrm� Not for Voluntary Assessments
15 Sullivan Street
Property Address
David Iseler
Owner Owner's Name
information is North Andover Ma 01845 6/51/2019,
required for every
page. City/Town State Zip Code Date of Inspection
System Information, (cont.)
6. Septic Tiank (locate on site pilan),:
30111,
Depth, below gra,de: feet
Material of construction:
0 concrete El metal fiberglass Ej polyethylene other(explal in
1500 gallon septic tank with center cover 8"'to grade
If tank is metal, list age: year
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) E] 'Yes No
101X 51'X 5181"
Dimensions.
1,611
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffie 1901
0-111
Scum thickness
Distance from ,to,p of'scurn to top of outlet tee or baffle 611
1311
Distance from bottom of scum to, bottom of outlet tee or baffle
How were dimensions determined? in field with measure stick and tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid level's as related to outlet invert, evidence of leakage, etc..):
1500 gallon concrete septic tank with concrete baffles and in working order with separation from inlet
'to outlet / no evidence of leakeage
cover to 8"grade
recommend pour niping every two to three years,depending on usage and number of occupants
Inlet baffle fair condition
outlet,baff Ile is compromised, and corroded needs,to be repalc,eld with PVC T see Pic attached
t5iron .doc rev,71 1 18, Ti tie 5 Official inspection Farm:Subsurface Sewa i sposel System-Page 10+f 18
Commonwealth of Massachusetts
T
U F Title 5 vo""TOT'061cial Inspect"ion For
Subsurface Sewage, Disposal System Form Not for Voluntary Assessments
151 Sullivan Street
Property Address
David Iseler
Owner Owner's Name
information is North Andover M 51 6/5/2019
lry required for eve. ClIty/Town State Zip Code Date of Inspection
page
D., System Information (cont.)
7, Grease Trap (locate on site plan),*.
Depth below grade: feet
Material of construction:
E] concrete El me a I El fiberglass polyethylene Ej other(explialn):
Dimensions,
Scum thickness
Distance from top of scum to top,of outlet tee or baffle
Distance from bottom of'scum to bottom of outlet tee or baffle
Date of last pumpi . rate
Comments (ors pumpling recommendations, inlet and outlet tee or baffle condition, str tu'ral integrity,
liquid levels as related to outlet invert, evidence of leakage, etc,.).,
8. Tight or Holding Tank(tank must be pumped at time of'inspection) (locate on site plan)*,
Depth below grade:
Material of construction'.
El concrete El metal El fiberglass E] polyethylene E other(explain)*
Dimensions:
Capacity:
gallons
Design Flow' gallions pier day
t5insp.doc-rev.7126/2018 Title 5 Of Inspection Form.Subsurface Sewage Disposal System-Page 1,1 of 18
Commonwealth of Massachusetts,
f M , Title 5 Official Inspection m
Subsurface Sewage Disposal System Form Not for Volluntary Assessments
15 Sul livan Street
Property Address
David Iseler
Owner Owner's Name
information is, North Andover Ma 01845 6/512019
required for every —
page. City/Town State Zip Code Date of Inspection
Di. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present:, El Yes N o
Alarm le'vel., Alarm in working order. E Yes N o,
Data of last pumping, Date
Comments (condlition of alarm and float switches, etc.)*
Attach copy of current pumping contract(required),. Is copy attached? Yes E] N o
9. DI'stribution Box if present must be opened) (locate on, site plan)*
liquid at Oil above invert
Depth of liquid level'. above outlet invert
I ny n ce er, an
of'solids carryovy
Comments �mote if box is level, and distribution to outlets equalt a evide
evidence of leafage into or out of box,1 etc.):
6 outlet concrete D box level with 2 outlet pipes little evidence of solids carryover
evidence of leakage into or out of box,
D Box cover is 20" below grade
d box in poor conditon heavy corrosion to side walls and cover visible cracks see pies,attached
15insp.ado c-rev,7/26/20,18 Title 5,Official Inspection Form'Su!bs,urface Sewage Disposall System-Page 12 of 18
Commonwealth of Massachusetts
IN
1 Ti
i �' Inspection
M Subsurface Sewage Disposal System Form Not for Voluntary Assessments,
15 Sullivan, Street
Property Address
David Iseler
Owner Owner's Name
,information is North Andover Ma 01845 6/5/2019
req uired for every Ciiyffown state Zip Code gut f Inspection
page.
D. System,, Information (cont.)
10. Pump,Chamber(locate on site plan).
Pumps in working order,: E] Yes F] No*
Alarms in working order. El Yes El li
Commerats (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
11. SoR Absorptilon System (SAS) (locate on site plan, excavation not irequired):
If SAS not located, explain why.-
Type:
11 leaching pits number:
EJ leaching chambers number:
leaching galleries number:
2 L
leaching trenches number, length:
_§O
leaching fields number, dimensions:
overflow cesspool number:
innovative/alternative system
Type/name of technollogy-
t5insp.doe-rev.'7/26120,18 Title 5 Official Inspection Form:Subsurface Sewage Disposal"system-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official s c on Form
Subsurface Sewage Dilsposal System Form Not for Voluntary Assessments
15 Sullivan Street
Property Address
David Iseller
Owner Owner's Name
information is North Andover Ma 01845 6/5/2019
required for every CityrTown State Zip Code Date of Inspection
page.
D, System Information (cont)
1. Soil Absorption System (SAS) (court.),
Comments,(note condition of soil, signs of hydraulle failure, level of ponding, damp soil, condition of
vegetation, etc.)-.
Trenches found in lawn area/ soils in good condition no signs,of hydraulic failure no ponding/ no
damp soil/
trenches constucted of pipe in stone inworking ordler
Hand dug and exposed stone on one trench, stone was clean and dry/see pics
Bottom It trenches 401" +/- below grade
12. Cesspools (cesspool must,be pumped as pa,rt of inspection) (locate on site planed
Number and,configuration
Depthl—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials,of construction
Indication of groundwater inflow El Yes El No
of
Comments (note condition of soil, signs of hydraulic fallu iti on vegetation
re, level of ponding, condi i
P
etc.),
t5insp.doo-rev,7/2,612018 Title 5 Official,Inspection Form,Subsurface Sewage Disposal System-Page 14 of 18
mmonwealth of Massachusetts,
icia ection orm
e
5 1 Insp
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
15 Sullivan Street
Property Adidress
David feeler
,Owner Owner's Name
information is, North Andover Ma 018451 6/5/2019
required for every
page. Cif y/T own State Zip Code Date of Inspection
D. System Information (cont.)
13. Prilvy,(locate on site plan,),:
Materials of construction:
Dimensions
Depth ofsollds
Comments (note condition of soil, signs of hydraulic failure, level of ponding,, condition of vegetationt
etc.),
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Commonwealth Massachusetts
otle 5 Offmici",al Inspect'10,F] Form
TI
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
15 Sullivan Street
Property Address
David Is I u
Dwyer Owner's Name
i
information,requi'red for every No rt ni r Mir 018,45 6 5 2, 19
6 /Town WH State Zip Code Date,of Inspection
D. System Information (cont.),
14. Sketch Sewage ilssl System:
Provide a,view of the swage disposal system, including ties to at least,two permanent referent
landmarks r benchmarks. Locate all wells within 100 feet. Locate where public water suppily enters
the building. Check one of the boxes, below-
hand-sketch in the area below
drawing lung attached, separately
i
t5insp.doc rev.712,6,1,2018 Title 5 Official Inspection Form,,Subsurface Sewage Disposal System Page'16 of 1
Commonwealth Massachusetts
■ 0 � W 001% tUle 5 TT� i Pn Form
�i Subsurface,Sewage Disposal System Form: Not for Voluntary Assessments
ha
Ole
15 Sullivan Street
Property Address
David Islir
OwnerOwner's Name
information is North Andover Ma 0 1845 6/5/2019
required for every
l State Zip Cody Ir� t
D. System Information (coat.)
15, Site Exam.:
PI Check Slope
Z' Surface water
Check cellar
Shallow well's
� 5" s per Ire it
Estimated depth t i r ► wat r� feet
Please, indicate all method's used to determinethe high ground water elevation:
Obtained from system design plans on record
f es plan reviewed: 99
If c , Date
Observed site (abutting r rt se rvatio,n hole within 150 feet of SAS)
Checked with local Board of Health explain:
Checked with local excavators" installers-(attach documentation
Accessed USES database explain'.
You must describe how you established the high h ground water elevation:
Plans on file at BOH' dated 1993 soil test
Previous title five report dated 1997
Checked with abutter 23 Su Ill an St plans on file ground water<60"dated 1993
Before filing this Inspection rt please see Report Completeness Checklist next page.
15in sp.d *rear.7126/2018 Ti1te 5 Officiall Inspection Form Subsurface Sewage Disposal Systern-Pale 17 f 1
L;ommonwealth of Massachusetts
CA T"Itle 5 Off"icial Inspection For
5 Subsurface Sewage Disposal System Fors Not for Voluntary Assessments
15 Sullivan Street
Property Address
David Iseler
Owner Owner's Name
6
information is
required for every North Andover Mla 01845 6/5/21019
page. Tlt�ifo-w n State Zip Code Date of Insplection
E, Report Completeness Checklist
Complete all applicable sections of this form [nclusive of:
A. inspector Information* Complete all fields in this section.
B. Certification: Signed & Dated and 1, 21 3, or 4 checked
Z C. Inspection Summary.,
11 21 3,, or 5 co leted as appropriate
4 (Failure,Criteria) and 6 (Checklist) completed
D. System information-
For 8.' 'Tig lit/Holding,Tank—Pumping contract attached
For 144 Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15* Explanation of estimated depth to high groundwater included
t5fnsp.doco rev.7126/2018 Title 5 Official Inspection Forim.-Subsurface Sewage Disposal System Page 18 of'18
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0' Almitial $
0 Body Art Establishilnent $
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El Dunipster $
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0 Ftineral Directors
0 Massage Estabilishnient $
El Massage Practice $
El Offal(Septic)Hanler
0 -Recreational Camp $
0, Sim tamiing $
0 swimmilig Pool
0 'Tobacco $
G' TrashlSohd Waste Hauler
11 Well Constmictiol,in $
SEPTIC Systems,
EJ Septic-Soil Testing
0 Septic-Delsigni Approval $
11 Septic Disposal Works constmetion WWO $
0 Septic Disposal Works Installers(DWI) $
11 Title 5 Inspector $
Title 5 Report
$
0 Other.-(Indicate) $
N
W 11thi-A" gent Initials
White-Applicant Yellow-Health Pink-Treasurer
........... .......