HomeMy WebLinkAboutPass - Title V Inspection Report - 49 CARLTON LANE 6/13/2019 Commonwealth of Massachusetts,
0
s ec ion
Ti've 5 Ulcial In 'p&% t" Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
49 Carlton Lane
Property Address
Eleanor Lucarini
Owner Owner's Name
Ire form tion,is
North Andover MA 018 5 6-5-2019
requiredfor every dity/Town State Zip Code Date of Inspection
pagie�.
Inspection results. must be submitted on this form. ms Inspection for may not b,
.j, any
way. Please see completeness checklist at the end of the form.,
Important:When
A, Inspector Information
�filling out forms
kl,
on the computer, Neil James Bateson
Q se on ly the,tab
key to move your is of Inspector
cursor-do not Bateson Enterprises Inc.,
use the return Company Name
key.
111 Arg_�Ia, Road
.1-111111............
to Company Address
Andover MA 01810
City/Town State Zip Code:
few
978-475-4786
Telephone Number License Number
B. Certification Al
I certif hat: I am a. DEP approved system inspector Infull compliance with Section .340 of Title 5
(3110 CMR,15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is,true, accurate and compilete 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 on-site sewage d1splosal systems. After conducting, this 'inspection I have determined
that the system,-.
1., Passes
2. El Conditionally Passes
3. Needs Fu er valuation by the Local Approving Authority
'A
4. El Fails
6-5-2019
Inspector's tignvatu' Da,t.e
The system in c,tor shall submit a copy of this inspection report to the Approving Authority (Board
,of Health or within 30 days of completing this inspection. If the system has a design flow of
10 1 0 00 g,pd or ,g reate rt tie inspector and the system owner sh all s,u b m it the report to the a pp roprate
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 notei:, 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 condeltions of use.,
tiros p.doc-rev.7/2612018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page,1 of 18
tl
Commonwealth sacsetts
�RIC Twitle 5 UTTIcial Inspectmion Form
ftj
t Subsurface Swage Dwisposa!System Form Not,for Voluntary Assessments
49 Carlton Lane
Property,Address
Eleanor Lucarini
Owner Owners Name
information is
North Andover MA 01845 6-5-20,19
req,uired for every City/Town State Zip Gode, Date ofinspectiton
page.,
Inspection Summary
inspection Summary Complete 1, 2, 3, or 5 and all of 4 and 6.
11) System asses:
I have not found any Information which indicates that any of the failure criteria, described
e ca not evauaed a
In 310 CMR 15.303 or in 310 CIVIR 15.304 exist. Any fail ur riteri l t re
indicated below.
Comments:
tl
2) System Condftion,allly Rases:
El 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 Hea,lth, will pass.
Check the box for'yes", "no" 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 substant,ial 'Infiltration or exfIltration or tanl.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 N El ND (Explain below .
�J
..........
151nsp.do c-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sy'stern Page 2 of 18
Commonwealth of'Massachusetts
M T t Form 10 t I e 5 Uo""To*tdm'im c mi a n, le c i o n
�i Subsurface Sewage 113"Isposall System Form - Not for Voluntary Assessments
49,Carlton Lane
Property Address
Eleanor Lucarini
Owner Owner's Name
information is, North Andover MA 1845 6-5-2019
required for every
age City/Town State Zip Code Date of Inspection
p .
C., Inspection Summary (cant)
2) System Condlitionally Passes(contl.):
El Pump Chamber pumps./alarms not operational. System will pass with Board of Health approvalif
pumps/allarms are repaired.
El 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 toa broken, settled or uneven distribution box. System will
pass inspection if(with approval,of Board of Health)-
El broken pipe(s) are replaced [I Y [:1 N E] ND (Explain below):
0 obstruction is removed F"I Y 0 N [] ND (Explain below).-
El distribution box is leveled or replaced E] Y N 0 ND (Explain below):
The system required pumping more than 4 times,a year due to broken or,obstructed pipe(s)., The
system will pass inspection if(with approval of the Board oif Health):
Ej broken pipe(s) are replaced Y INI ND (Explain below .
El obstruction, is removed. El Y [:1 N ND (Explain below)-
3), Further Eva luau on is Required by the Board of Health.:
El 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 w11011 pass unless Board of Health determines, iin accordance with 310 CMR
15.303(l that the system iis not functilioniing in a manner which will protect publilic health,
,safety and the erg vaironment,:
15insp.doic-rev.712 1 01 8 Titte 5 Official Inspection Form:Subsurfacai Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
T"tle ,5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �
9 Carport Lane
Property Address
Eleanor Lucarini
Owner nr`s Name ;
information is North Andover MA 01845 6-5-2019
required for eves State Zip Code Date of Inspedion
page.
C, Inspection Summay (cont,.)
E] Cesspool, r privys within 50 feet of a surface water
E] Cesspool, or privy is within 50 feet of a bordering vegetated wetland or a, salt marsh
b. �" any)
Systemwill f �l � �to "�ll� � Supplier,
determines that systems functioning In a manner,t,hat protects the lie health
safety and environment
[:1 The system has a septic teak and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to o surface water supply.
El, The system has a septic teak,and SAS and the SAS is within a Zone a pub,fic water
supply.
e system s a septic tank n SAS and the SAS is within 50 fit a private water
e
supply well. h
The system has a septic teak and SAS and the SAS is, less than 100 feet but 50 feet or
more from a priests water supply well .
Method used to determineistan ,,
"'This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
lif rm bacteria indicates,absent,and the presence of ammonia, nitrogen and nitrate, nitrogen is equal
to or less than 5 p m, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
m
4)
t
u
System Failure Criteria.Applicable to All Systems*.
You mustindicate,"Yes"' or"No P"to each ofthe following for all l s w ct ins,.,1
Yes No
4
Backup f sewage into facility r system component due to overloaded or
cloggedSAS,or cesspool
Discharge or ponding of effluent to the surface of'the ground, r surface waters
1:1 e
due to an overloaded or clogged SAS or cesspooll
ba
t l u .d r r, `ill Official InspectionForm Subsurface Sewage Disposal Systems-Pale 4 f 1 d d
A
Commonwealth of Massachusetts
mitle 5 Olffm
mm
icia,'
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
. 9 Carlton Lang
Property address
El an or L,uc arini
1
Owner Owner's irn ,
information isI rt A 5 6-5-"'
it Town State Zip Cade Date f Inspection required for every
page
C., Inspection Summary (coat.)
0
4)
System Failure Criteria Applicable to All Systems: (cont.)
Yes No
Static liquid level in the distribution boy above outlet invert due to,an,overloaded °a
r clogged SAS or cess1
�Liquid depth in cesspool is less than 6 below invert r available volumeis Mess
than day flow
Re ua�uir �.aarn in moire than times in the last year due t+ 1 g r
1:1 Ellobstructed i e s . Number of tires pumped:
F-1 E] Any portion of'the SAS, cesspool or privy is below high ground water elevation.
E] 0 Any portion of cesspool r privy is within 100,feet of a surface watier supply r
tributary to surface water supply'.
�1:1, Z Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
El 0 Any portion f a cesspool or privy is within, 5,0 feet of a private water supply well.,
El 0 d
Any portion f a cesspool or privy is less than 100,feet but greater than 50 feet
frfromrurate water supply,well with, no,acceptable water quality anal sis�' . [ThIs
system passes if the well water as a ial s*ls,, performed at a DEPcertified
laboratory,for fecal coliform bacterila indicates absent an the presenceI
f ammonlia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,,
r Idled that n other failure are'triggered,. copy f theanalysis,
and chain oficustody rust be attachedto this form.]
El N the s sitern is a cesspool serving a facifity with a design flow of g , _
.
E] Z The system fails. I have determined that,one r more f the above failure
existcriteria described in 310 CM R 15.303, 'therefore the system,fails. The
system owner should contact the Board of Health to determine what will
necessary to correct the failure.,
5 Large Systems: To, be considered a large system the syst m must serve a facility with
design flow of 10,000 gpd,to , gp .
For Margo systems, you must indicate either"Yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
El F] the system is within feet t of a surface drinking,water supply
a
El the system is within 200 feet of as tributary to a,surface drinking,water supply
El El the sysitemis located in a nitrogen sensitive area(interim Wellhead Protection,
Area— ,or a mapped Zone 11 of a public water supply well
tiro p,d •rev.7/26/2018 Title 6 Offidal inspection Form Subsurface Sewage Disposail System,Wage 6 of 1
Commonwealth of Massachusetts
UTTIcIal Inspection Form
T'Otle 5
a e Disposal System Form Not for Voluntary Assessments
Subsurfce Se wag,
49, Carlton Lane
Property Address
Eleanor Lucar ini
Owner Owner's Name
information is North Andover 'MA 6-5-2O 19
required for every
State Zip Code� Date of Inspection
City[Town
page.
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 question in Section CA above the large system has failled. The
owner or operator of'any large system considered a significant,threat,under Section C.5 or failed
under Section CA shall upgrade the s,ystem in accordance with 310 CM,R 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate llyesvpi or,94noll for each of the following for all inspections:,
Yes No
z 1:1 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?
0 z
Has the systern received normal flows in the previous two week period?
Have la,rge'volumes of water been Introduced to the system recently or as part of
El Z this inspection?
z 1:1 Were as built,plans of the system obtained and examined? if they were not
a va ill e note as NIA),
Z E] Was the facility or dwelling "inspected for signs of sewage back up?.
Z E] Was the site inspected for signs of break out?
U EJ Were all system components, excluding the SAS, located on site?
z El 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 occupants if different.from owner) provided with
z 1:1 information on the proper maintenance of surface sewage disposal systerns?
'The size and location of'the Soil Absorption System (SAS) on the site has
belen determined based ow
z El Existing Information. For example, a plan at the Board of Health,.
Determined Inthe field (if any of the failure criteria related to Part C is at issue
approximation of distance is urn acceptablie) [310 Cl R 15.302(5)]
Sbsurface Sewae,Disposal System-Rage 6 of 18
t5inspAoc-rev.,712612M Title 5 Offidal Inspection Form. u g
Commonwealth of Massachusetts
T tie, 51 ial nspectmion Form
Form Not for Voluntary Assessments
�1 Subsu,rface Sewage Disposal System
49 Carlton Lane
Property Address
Eleanor Lucarini
Owner Owner's Name
information is North Andover MA 01845 6-5-2�O 19
required for every —
page. City/Town State Zip Cod I e Date of Inspection
D. System Informatio n
1. Residential Flow Conditions,-.,
Number of bedrooms (design . 4 Number of bedrooms (actual): 4
Y
DESIGN flow based on 310 CMR 15-203 (for example: 110 gpd x#of bedrooms): 6100
Description*
4 ¢'
Number of' rrent residents:
Does residence have a garbage grinder? Yes No
Does residence have a water trleatment unit? El, Yes 2 No
If yes, discharges to:
Is laundry on a separate sewage system?. (include laundry system inspection El Yes Z No
L N
Information in this, report)
Laundry system inspected? El 'Yes N o
Seasonal used El' Yes Z No
Yes
Water meter read,ings,, if'available(last 2 years usage (gpd))-
Detail:
sump pump? El Yes09
Z NO
Last date of occupancy: Current
Date,
t5insp.doc rev.712612018 Title 5 Official Inspection Form,:Subsur-fac,e Sewage Disposal System-Page f 18
Commonwealth of Massachuseft,
Title 5 Offolcl .,I I tion Form
t Subsurface Sewage Disposal System Form Not for Voluntary Assessments,
49 Carlton Lane
Property Address
Eleanor Lucarini
owner Owners Name
information Is MA 0 1846 6-5-2019
I North Andover
req u 1 red fo r eve ry State Zip Code Date of Inspection
yu
CityfTown
page.
D, System Information (cont)
2. Commerc alai/[n d ustrial Flow Conditions:
Type of Establishment*
Design flow(based on 310, CMR 15.203): Gallons per day(gpd)
Basis of des,ign flow(seats,/persons/sq.ft., etc.).:
Grease trap, present? El Yes Ej No
Water treatment unit present.? El Yes
tl
If yes,,, discharges to:
Industrial waste holding tank present? El Yes [j No,
El, Yes [:1 N o
Non-sia nit ary waste discharged to the Title 5 system?
Water meter readings, i'available: ...
Last date of occupancy/use: Date..........
Other(describe bell ow).#
.................
3. Pumping Records:
P 4M, L�d 018, owner
Source of information:
Was system pumped as part of the inspection? Y'e s N o
If yes, volume pumped: 111500
gallons
How was,quantity pumped determined? Measured tank.
Reason for pumping: Inspect,tank&tees.
t5insp.doc-rov.712612018 Title 6 official inspection Form-Subsurface Sewage Disposal System-Page 8 of 18
Gommonwealth ofMassachusetts
OEM
A"bk Am Ir E
F Title b Utticial i n t"orm
Subsu,rface Sewage Disposal System Form Not for Voluntary Assessments
49, Carlton Lane
Property Address
Eleanor Lucanni
Owner Owner's Name
information is MA 01845 6-5-20,19
required for every North,Andover
State Zip Code Date of Inspection
Gityrrown
page.
D. system Information (coat,
4. Type of System:
Septic tank, distribution box,, soil absorption system
z
Single cesspool
E] Overflow cesspool
El Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
E]
El Innovative/Alternative technology. Attach a,copy of the current operation and
maintenance contract(to be obtained from system,owner)and a copy of latest
inspection of the I/A system by system operator unde�r contract
Tight tank. Attach a copy of the DEP approval.
El Other(describle):
Approximate age of all components, date installed if known) and source ofinformation*
Tank&, Pits are 36 years old. 6-15-1983, as built plan. D-boix was, replaced 2012.,
Were sewage odors detected when arriving at,the site? El, Yes No
5. Build*ln,g Sewer(locate on site plan #
2
Depth below grade: feet
Material of construction:
Z, cast iron E 40 PVC El other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition, of joints, venting, evidence of leakage, etc.).
4", Cast Iron through wall, 3" PVC in house, no leaks visible.
t5 ire sp.doo-rev.712612018 Title 5 Official Inspection Farm.Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
ion
I Inspectm Form
T"tle 5 A� fflcia
Subsurface Sewage Dilsposal System Form Not for Voluntary Assessments
49 Carlton La,nel
Property Address
Eleanolr L,ucar'ini
Owner b7w_ner's Name
information is, North Andover MA 01845 6-l5-201 9
required for every of Inspection
page. ItyfTown State Zip Code Date
D. System I nformation (cont.)
6. Sepfic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
Z concrete El metal fiberglass, Ej, polyethylene other(explain,)
If tank is metal, list age:, years
Is age,confirmed by a Certificate of Compliance? (attache a copy of certificate) El Yes Na
Dimensions," 10',x 5',x 4'
311
Sludge depth'.-
3011
Distance from top of sludge to bottom of outlet tee or baffle
3
Score thickness
Distance,from top of scum to top of outlet tee,or baff le 811
Distance from bottom of scum,to bottom, of outlet tee or baffle 12'11
Tape Measure
How were dimensions determined?
Comment's (on, plumping recommendations, inlet and outlet tee or baffle con ditioni, structural integrity,
liquid levels as related to outlet,invert, evidence ofleakage, etc.):
Inlets ar under cement landing for deck stairs, unable-to remove. Outlet tee ok. Depth of liquid at
outlet invert. No evidencle of leakage. Opened up cleanout , flow ok.
t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 18
Commonwealth of Massachusetts
T"tie, 5 Offmici'nal Inspection Form
z
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
49 Carlton Lane
Property Address
Eleanor Lucarpi
Owner Owners Name inf6anation is North Andover MA 011845 6-5-2019
required for every City/Town State Zip Code Date of Inspection
page.
Di, System Information (cont.)
7. Grease Trap (locate on site plan),:
Depth below grade. feet
mm
Material of construction:
0 concrete El metal El fiberglass polyethylene El other(explain):.
Dimensions:
Scum thickness
Distance from top of scum to top,of outlet tee or affle
Distance from bottom of scum to: bottom of outlet,tee or baffle
Date of last pumping- Date
Comments, (on pumping recommendations, inlet and outlet tie or baffle condition! structural l'ntegrity,
liquid levels as related to outlet invert, evidence of leakage, etc. .
8. Ti gtt or Hold1ling Tank(tank must be pumped at time of inspection) (locate on site plan)-
Depth below grade-
Material of construction,."
El concrete El metal I polyethylene
El fiberglass other(explain).
Dimensions:
Capacity* gallons
Design Flow,
gallons,per day
t5lnsp.do c-rev.71261'2018 Title 5 Officiat Inspection Form:Subsurface Sewage Dispo l System-Page 1,1 of 18
Commonwealth asses
T1*t1e 5 utficial lnz-� ection Form
....
Subsurface Sewage Dilsposal System Form Not for Voluntary Assessments,
*� o
49 Carlton Lane
Property Address
Eleanor Lucarini
Owner Owner's Nears
informiation is
MA 01845 6-5-2019__.
r� ir r � lily + �'
City/Town State Zip Code Date of inspection
D, System Information (coat®)
,, Tight or Holdilng Teak (coat.)
larm present: El Yes
[_1 N 0
Alarm level" ._.. Alarm n working ordier: El Yes Ej N o
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc,
9;
I
f
i
Attache copy of current pumping contract(required). Is copy aft ached? E Yes E] No
9* Dist ib of if present must be opened) (locate on site plait):
Depth of liquid level, above outlet invert,
Comments note if box is level and distributionto outlets equal, any evidence of solids carryover, an
evidence of leakage 'Into or out of box, etc.
D-box level & distribution equal, has flees` Ie elers. No evidence of leakage., Evidence of light
carryover. Unable to get measurements off house for id-box,,hasi orange stake& rocks on top �
t„
'c
t lin .d -rev. / 18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System w Page 12 of 1
�y
Commonwealth of Massachusetts
y Twitlie 5 Oifficial Insw%ection Form
Subsurface,Sewage Dilsposal, System Form Not,for Voluntary Assessments
;10
4
4,9 Carlton Lane
Property Address
Eleanor Lucarini
Owner Ownerls,Name
information is North,Andover MA 01845, 6-5-2019
required for every Cttyffown State Zip Code Date of inspection
page.
D. System, do cont.)
1 O�., Pump Chamber(locate on site plan):
Pumps in working order*. Yes No*
Alarms in working order: Yes N o,*'
Comments (note condition of pump,chamber, condition of pumps and appurtenances, u) ddi
If'pumps or alarms are not in working order, system is a conditional pass.,
11. Soill,Absorptions System (SAS) (locate one site plan, excavation not required).-
If SAS, not located, explain why-,
Type:
31
leaching pits number-
El leaching chambers, number:
leaching galleries number.
F� leaching trenches number, length-
E] leaching fields number, dimensions-,
El overflow ces,spool number.-
El unnovative/alternative system
Type/name of technology:
t5l nspdoo rev,7126/2018 Title 5 Official Inspection Foirm,Subsurface Sewage,Disposal System Page 13 of 18
i
i
Commonwealth of Massachusetts
Tiotle
Subsurface Sewage Disposal System Form Not for Volunf r assessments
Y
9 irlt n Lane
Property address
Eleanor carini
Owner Owner's Name
information is MA 01845 6-5-20,19
North Andover
required"for,every City/Town State Zip Code Date,of Inspection
D. System Information (cone.)
11. S will,A'bsorption System (SAS) (cont)
Comments (note condition of soil", signs of � r 11c failure, legal of ponding, damp soll, condition of
vegetation, etc.).:
Soil ok. Vegetation off. No sign, of ponding to surface. Garners inside of pits through outlets in d-boxt
no liquid to inverts of pits.
y
4&
2. Cesspool's (cesspool must umple as part ins ti u) (locate on site lan):
Number and configuration
Depth --top of liquid to nlef invert
Depth of solids layer
Depth of scum layer _.. � .
Dimensions of cesspool
Materials of construction
.. . . .
�r
Indication of groundwater inflow El Yes E3, No
Comments note condition of soil, signs of hydraulic failure, level" of ponding, ennui n of vegetation, �
etc.):
0
It insp. o -rev.712612,018, Tide 5 Official Inspection For :Subsufface Sewage Disposal Sysitem-Fags 14 of 1
N"
Commonwealth of Massachusefts
pection Form
mi a I In s
t Subsurface Sewage D011sposall System Form Not for Voluntary,Assessments
49 Carlton Lane .......
Property Address
Eleanor Lucarini
Owner Owner's Name
information is North,Andover MA 01845 6-5-2019
required for every State Zip Code Date of Inspection
page. &I—ty/—Town
D. System Information (cont)
13. Pflivy(locate on site PlanY
Materials of construiction*
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)-
.....................-------------
t5inspi.doc-rev.7/26 0,18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of'Massachusetts
.900.
T1 5 U
ntle Hicial ns ec o orm
I-
P Su'bsurface Sewage Dilsposall System Form Not for Voluntary Assessments
49 Carlton Lane
...........
Property Address
Eleanor LucaMini
Owner err's Name
information is North Andover MA 0 1845 6-5-20.1-119
required for every
page,. t�FtWfo_wn State Zip Code Date of InspeGtion
System Information (cont.,)
14. Sketch Of Swage Dilisposall System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of thie boxes below:
hand-sketch in the area below
Ej drawing attached separately
ri le Aev
Won
0
4e
OL)4-
CDs V,42'r
aP 1t.
5 &
A�
0 UA-
t6insp.doc-rev.712612018 Title 6 Official Inspection Form,Subsurface Sewage Disposiat System-Page 16 of 18
Commonwealth of Massachuse tts
Titile 5 OTT'Icial Inspectlon Form
Subsurface Sewage Dis, osa,l System Form Not,for Voluntary Assessments
49 Carlton Lane
Property Address
Eleanor Lucarini
Owner Owner's Name
information is
North,Andover MA 01845, 6-5-2019
required for every age. dk-y " State Zip Ge od D n ate of Inspection
pown
D. System Information (cont)
15. Site Exam.'
0 Check Slope
0 Surface water
2 Check cellar
Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation: 1 j6
Obtained from system design plans on record
6-15-1983
If checked, date of des Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Design
E Checked with local excavators, installers,- (attach documentation)
Accesseid' USGS database -explain-
You must describe how you established the high ground,water elevation-
As, per test pit data on design plan
Before fl1linig this lea cti,on Report, please see Report Completeness Checklist on next page.
t5insp.doc rev,7126120118 Title 5 Official Inspection Foam Subsurface Sewage Disposal System-Page 17 of 18
fi
ti
Commonwealth of Massachusefts
a T A.
F IlEle 5 Official Inspection Form
M Subsurface Sewage Disposal System Form Not for Voluntary Assessments
49 Carlton Lane
Property,Address
Eleanor Lucarini
Owner Owner's Name
information is North Andover MA 01,8451 6-5-2019
required for every
. it
State dip Code Date of Inspection
page Cyaown,
Ei., Report, Completeness list
Complete all apipficable sections f this form inclusive of:
* A. Inspector Inn ormatlow Complete all fields in this section.
* B. Certification-. Signed & Dated and 1, 2, 3, or 4 checked
C. Inspection Summary.-
11 21 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
Z D. system information,
For 8: Tight/Holding Tank—Pumpling contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc rev.7126t2M Title 5 Official Inspection Form-Subsurface Sewage Disposal System-Page 1 f 18,
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Board f Health or other approving
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Facility InforMation
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1 Type-of system. El cesspool(s) M,--Sepflc T anik Might Tank
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4. Effluent Tee Filter
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Summary Record Card generated on 5/21/20199:46:59 AM by Karen Hanlon Fags 1
Town of' Nolfth k\ndover
Tax Map if 2101-1 06AGI-009011,-06000610
Parcel ld 17726
49 CARL LANE
LUCARINI, VINCENT
49 CON LANE
d
NORTH ANDOVER, MA
018 1
45 -A
Class 101, Single Family Plroperty Type 1 Residential
Zoning2 1 Residential zonilng,3 1 Residential � f
Size Total 1.1 Acres
FY 2019
LIB Mailin
,-q,lndex
Narne/Address Type Loan Number Active lines ct. From Until
LU'CARINN,VINCENT Payer Active
49 CARLTON ILANE
NORTH ANDOVER,MA
01845
UB Account Mai nt.,
Account No, Cycle Occupant Name, Active/Inactive
Bl,d!lg Id. 13890.0-49 CARLTON LANE Last Billing Date 3/8/2�019
2100,678 02 Cycle 02 Active
UB Services Main't
Account No.2100678
Service,Code Rate Charge Multi pfler/Users
MISCFEE A,DMIN FEE 0.6,35/8 7,82
WTR.WATER Oil ALL METER SIZE 68.40
UB Meter Maintenance
Account No.2100678
Serial No, Status Location Brand Type Size YTD Cons,
13242606 a Active ERT HH METE METE w'"Fester 0.630.63 976
Date Reading Code Consumption Posted Date Variance
5/2/2O 19 1315 a Actual 17 3%
2/4/2019 1298, a Actual 18 3/19/2019 -9%
1'1/1/2018 11280 a Actual 19 12/12/2018 -37%
2018 1261 a Actual 30, 9/201/2018 67%
18 6/201/20,18 -9%
6/3/2018 '1231 a Actual
2/1/2018 1213 a Actual 20 3/28120,18 .38%
11/11/2017 1193 a Actual 32 12129/2017 612%
8/2/2017 1161 aActual 20, 9/2012017' 21%
5/2/2017 1141 a Actual, 16 6/26/20,17 -2%
2/2/2017 1125 a Actual 17 3/14/2017 -52%
11/1/2016 11 to ll 35 12/19/2016 -20%
8/2/2016 107'3 a Actual, 44 9/2112016 159%
5/3/2016 10,29 a Actual 17 6/21/2016 -10%
2/212016 1012 a Actual! 19 �/'2 ' -45%
11/2/2015 993 a Actual 34 12/30/2015 5%
8/4/2015 9159 a Actual 33, 9/14/2015 102%
5/412015 9126 a Actual' 16 6/22/2015 -9%
18 3/'20/2015 -8%
2/3/20115 9101 a Act ul,al
11/3/2014 892 a Actual' 20 12115/2014 -28%
8/1/2014 872 a Actual 26 9/11/2014 66%
5/5/2014 846 a Actual 1 1 2/201 4 -10%
2/4/2014 8310 a Actual 19 3/17/2014 61%
10131/2013 811 a Actual 117 1212 0/2 01� 1%
8/1/2013 794 a Actual 17 9/18/20,131 -10%
5/t/2013 777 a Actual 17 6/18/20,13, 8%,
2/7/20,13 760 a Actual 19 3/13/20,13 -1%
1013,10/2012 741 a Actual 17 12/13/2012 -32%
8/2/2012, 724 a Actual 26 9/26/2012 50%
5/2/20112 6918 a Actual 17 6/201/2012 -2%
ORTst Oil) N1110
0
TownfNorth Andover,
AVID HEA,LTH DEPARTMENT
$SIAC CIO
DATE:
CHECK ff:
LOCATION: L-L
NAME:
C 'rt� u w del w v,w �F,m,,w
ONTI.RACTOR NAME:
T ve of Permit or License: (Check box)
0 Animal
EJ Body Art Establishi,nent $
0 Body Art Practitioner $
El Dumpster 1$
El Food S ervice-Type.,,- $
0 Funeral Directors� $
El Ma,ssage Establlishment $
El Massage Practice $
E] Offal(Septic)Hauler
0 Recreational
0 Situ tanning $
0 Swimming Pool
,LJ Tobacco $
0 TrashlSiolid WasU Hauler $
0 Well Cionstniction $
SEPTIC tems:
0 Sieptic-Soil Testing $
0 Septic-Des Approval $
0 Septic Disposal Works Construction(DWO $
El Septic Disposal Workshistallem(DWI) $
0 Title 51 Inspector
Title 5 Report
0 Other.-(Indicate) $
Health" nitials,
I'M
its-Applicant Yellow-Health Pink-Treasu
.......... ......