HomeMy WebLinkAboutPass - Title V Inspection Report - 132 CRICKET LANE 6/24/2019 a
Commonwealth of Massachusetts
I$ M
Subsurface Sewage Disposal System Form Rot for Voluntary Assessments
Title 5 Official Inspect"ion Form
y
fl 1312 Cricket Lane
Property address
Steven Ce
Owner Owner's
information is
North Andover MA 01845 6-12-2019
required for every
State Zip it Inspection
A
f
lbspecti rn results must be submitted on this fora' Inspection forms may not be altered in any,
may. Please see completeness checklist at the end of the form.
Important:When IK
filling,out forms e
on the qomputer,
Neil James meson
f, Q r,Ir
y
e Dial the tad � 1
y
key to movie your Name of Inspector
wM
cursor not F teson Enterprises Ir7nc.
use the return 1EAE111" DEF,,V\,FUM ENT
key.
111 Arg illy Road
a tab Company Address
Andover MA 0`1810
iitlTrr State Zip Code
Telephone Number License Number
B., Certification
l'certify that:t: l am a. DEP approvedsystem inspector in f ell compliance with Section 1 .3 Title 5
(310 CIVIR 16. w 1 have personally inspected the sewage disposal system atthe property address
lusted above;the information reported below,is tale, accurate and complete as of the time of my
inspection'; and the inspection was performed based on my training n experience in the proper ft ncti rl
and maintenance of n-site sewage disposal systems,After conducting this inspection I have determined
that the system:
I
1. Fusses
2. D Conditionally Passes
d
3. D Needs Further Evaluation bythe Local Approving Authority
Failr , 1
6-1 '_ 11 9
Nnptors ut� r Date
The system inspector shall submit copy of this inspection report rt to the Approving Authority(Board
f Health or EIwithin, 30 days of completing this inspection:. If the system his a design flow of
101000 pd or greeter, the inspector and the system owner shall submit the report two the appropriate
regional office of the DER The original form should be sent to the system owner and copies sent to
the le er, if applicable, and the approving utl rit .
"leas note: This report only describes conditions at the time of'Inspection and under the
conditionsof use at that time.This l' is*Inspection does not address ss how the system will perform
in the future under the same or different,conditions of use.
mnsp.do re,7/26t2018 bills&Offid l,Inspection Form:Subsurface Sewage[lisp s-a'I System•Fags 1 of 1
Commonwealth of Massachusefts
M M
Title 5 icia nspection Form
Off 11
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
132 Cricket Lane
Pro pertyAddress
o
Steven Channen
Owner Ownees Name
information is
re uired for every North Andover MA 01845 6-12-2019
q
spection
City/Town State Zip C,ode Date of]n
page.
C. Ins ec o Summary
Inspection Summary: Com,plete 1, 2,1 3, or 5 and all of 4 and 6.
1) System Passes,
Z� I have not found any information which indicates that,any,of the failure criteria described
�t.Any,failure criteria not evaluated are
In 310 CMR 15.303 or in 310 CMR 15.304 exis
indicated below.,
Comments.-,
...........
...........
2) System Conditionally Passes:
One or more system components as described In the"Conditional Pas�s section need to be
Maned or repaired. The system, upon completion of the replacement or repair, as approved, by
the Board of Health, will pass.
Check the box for no" or"not determined" (Y, N, ND)for the following statements. If" n t
determined,,11 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 exfiltr ratio n or tank fail re 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 m tal,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.
01 Y Ej N 0 ND (Explain below),:
•Pag 2 of 18
t5inup.doe-rev.712012018 Title S Official Inspection Form,Subsurface Sowaga Disposal system,
Commonwealth of Massachusetts
o
T111le 5 vo""ffl'K c mial Inspection Form
to
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
132 Cricket Lane
Property Address
Steven Chann,en
Owner Owner's Name
information is,
North Andover MA 01845 6-12-2019
req uiried for every City/Town ...... state Zip Code Date of Inspection
page.
C. I nspection Summary (cont.)
2) System,Conditionally Passes(cont,):,
El Pump Chamber pumps,/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
ti
El Observation of sewage backup or break out or higlh static water level in the distribution box due
to broken or,obstructed pi )or due to a, broken,, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
[:1 broken pipe(s)are replaced D Y Ej N D ND(Explain below):
obstruction is removed E] Y N 0 ND (Explain below):
F] distribution box is leveled or replaced 0 Y Ej N El ND(Explain below):
[� The system required pumping more than 4 times a year due to broken or obstructed,pipe(s). The
I -of'H,ealth):
system will pass inspection if with( approval of the Board
broken pipe(s)are replaced Y E] N ND (Explain below)
F]
Ej Y 0� N ND (Explain below).obstruction is removed
3), Further Evaluation 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 will pass unless Board of Health determines in accordance with 310 CM,R
15.303(1)(b)that the system 'is not functioning in a manner which will protect public health,
safety and th+ nvironment:
Sewage Disposal System Page 3 of 18
t5 ins p.doo-rev.712612018 Title 5 Official inspection Form,Subsurface
tl:
Commonwealth of Massachusetts
ufficial InspeT V i e5
Cion
Form
,
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
32 Cricket Lane
Property► ddress
Steven Channen
Owner Owner"s Name,
information is
required for eves
North Andover MA 6-���
City/Town State Zip Code Cate of Ins eetieri
C,. Inspectolon, Summary (conit)
E] Cesspool or privy is within 50 feet of a sumacs water
a
E]
Cesspool or privy is within 50 feet of a Ibordering vegetated wetland or a salt marsh
o
h. System Mil fail unless the Board of Health (and Public Water Supplier, if any)
determines,that,the system is function"Ing in a manner that protects the public health
safety and environment:
The system has a s,ept�ic tank soil absorpt,ion system SAS),and the SAS is within
feet of a surface water supply or tributary,to,a surfacewater supply.
the system has a septic tank and SAS and the SAS is within a Zone `"l of a public water
supply.
The system has a septic tank and SAS and the SAS is within 60 feet of a private water
supply well.
El The system has a septic tank and SAS and the SAS is less than 100 feet,but.510 feet or
more from private water supply wel,l**
Method used to determine distance:
qq
b a
This system passes if the well grateranalysis, p rat r ', for 1
� cr�ru+ d t ��" +�iit��d l
t
11 r t+ ri it di s absent and the presence ammonia nitrogen and nitrate nitrogen i
s equal
to or less than 5 ppm,, provided that no other failure criteria are triggered, A copy of the analysis,rust.
be attached to this form.
c. ter
System Failure Cri eria ApplIcable to All Systems:
u must indicate"Yes" or"No" to each of the,following for all *Inspec ions
Yes No
Backup of sewage into facility or system component due to overl a ed or
El 0
cleed SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
ilnp„da -rev.7d1010
Title 5 Officiat Inspection Form:Subsurf age oisposat system Page, of 1
Commonwealth of Massachusetts
TwItle 5 Offictal Inspection Form
_ ;I Subsurface Sewage Disposal System or Not for Volulntary Assessments
132 Cricket Lane
�rrt►address
Steven Ch nnen
Owner Owner's Nam
r
k information is
MA 0845, 61-12-2019
required for 1
, F C t /Ti r� state Zap Codypag t inspection
I
Inspection Summary (coat.
System Failure ►r t rl as Applicable to All Systems: (cont.)
Yes No
Static liquid level Ire the distribution box above outlet invert due to,anoverloaded
or clogged SAS or cesspool
El 0 Liquid depth in cesspool is lass than 60 below invert or available volume is less
than day flow
r
Required uir urmpin more than 4 times in the last year NOT due to,clogged or
obstructed 1 . Number r f times pumped: �
µ
E] Z
Any portion of the 'SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 1 GO feat of a surface avatar supply r
E] 0
tributary to a surface water,supp,ly.
a!
Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
Any portion of a,cesspool or privy is within 50 feet of a private water supply will.
El M Any portion of a cesspool or priory is lean than 100 feet but greater than 50 feat
from a private water siul pply well with no acceptable water quality anal i . hlS
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal conform, bacteria indicates absent and the presence
of g than 5
aar ►r�� a rrrtr�r r�rtrt nitrogen r�equal r 1
r r'i l that other failure aretriggered.A copy of flueanalysis
and chain of custody must be attachedt ►this forma.)
a The system, is a cesspool serving a facility,with, a design flow of 2
1
The system fr l have termined that one or more of the above f ailur
criteria exist as described in,310 CIVI,R 15.3 3, therefore the system fails. The
sterna owner should contact the Board of Health to determine what will be
n necessary to correct the failure.
d
�W
o Faust serve a f a lllt with a
Large Systems, �' considered a lard system the system
design flow of 10,000 gpd to 15,000gpd.,
For large systems, u mustindicate either"yes"'' r"no"'to,each of the f llowing, in,addition to the
questions in Section C. .
Yes No
El E] the system is within feat of a surface drinking water supply
ly
a
El 1:1
the system is within 200 feet f'a tributary to a surface drinking water Sups
the system is located in a nitrogen sensitive area Interim Wellhead Protections
El
Area, I II : r a mapped ,Zone Il of a public water supply wall
I 'Title 5 OfficlaI'Inspection Form.Subsurface w e Disposal SY t P'69e 6 Of 1
t
Commonwealth of Massachusetts
T 0 n F
it,le ,5 tticial Inspw%ectioo
Subsurface wr Disposal System Form Not for Voluntary ssessme s� 132 Cricket L
ane
Property Address
Steven Channen
Owner Owner's Naas
information is
North Andover MA 01845 6-12-2019
required for even
Cit /Tpage,
n State t Zip Code Date f Inspection
C. Inspection Su (cone.)
If you havie answered "'to any question in Section C.5 the,system is considered a significant
threat, or answered "yes to anyquestion in Section G.4 abovethe large system has Boiled.The
owner r r operator ofany large system considered a significant threat under Section C.5 +sir Boiled
under Section C.4 shall upgrade the system in accordance with 310 CMR 151,304. The system owner
n r
should contact the appropriate regioniall office of the Department.
l
. You must indicate "yes" r"no"for each of the folllowi,ng for ail inspections:
,
Yes N
4ED ED Pumping information was provided by t owner, occupant, 'or Board of Health
Were any of the system components pumped out in the previous two weeks?
s' .
M El Has the system received normal flows in the previous two week period?
El M Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and, ;gamin If they were not
v lla la rote as NIA
0 El Was the facility or dwelling inspected for signs of sewage back up?.
W as the site inspected for signs of break outs'
Were all system cornponents, excluding t' e SAS, located n site's
Were the septic tank manholes uncov re , opened, and the interior of the tank
inspected t for the condition of the baffles or tees,, material of construction,
dimensions,ns, a h of liquid, depth of sludgy and depth f'scumi
N n+ ants if different from w nerprovided with
l
!�"" the facility owner w
Z El
information n theproper maintenance f subsurface sewage a disposal systems?
The size and location rf the Soil Absorption System (SAS)on the,site has
been determined based on:
Existing Information. For example,, a plan at the Board f Ha lth.
Determined in the field if any of the failure criteria related to Fart C is at issue
0 EJ
approximation of distance is unacceptable)1310 CMR 15.302(5)]
i
A
{
1
TRW Official Inspection I orm:Subsurface Sewage I i p sat System Begin 6 Of 18
r
Commonwealth, of Massachusetts
.-r-c* m I Inspection Form
Oil Timtle 5 0"M
>
Subsurface Sewage Disposal System Form, Not for Voluntary Assessments
132 Cricket Lane
IProperty Address,
Steven Channen
Owner Owners Name,
information is North Andover MA 01845 6-12�-2019
required for every
page., City/Town State Zip Code Date of Inspection
D. System Information ��
1. Residential Flow Conditions:
4 4
Number of bedrooms (design): Number of bedrooms(actual):
1440
DESIGN flow based on 310 CMR 15.203(for example: 1,10,gip"
x#of bedrooms):
J
Description#
2
Number,of current residents:
Yes No
Does residen�ce have a garbage grinder
El Yes, No
o
Does residence have a water treatment unit,?
If yes, discharges to,*
Yr es No
Is laundry on a separate sewage system?(include laundry system inspection
F
information in this repo
Laundry system inspected? Yes, No
Season,aluse? Yes No
�j
Yes
Water meter r s ingsl if available (last 2 years usage
Detail;
.............
SUMP purnp,( El Yes No,
Current
Last date of occupancy: Date
Titte 5 Official Inspection Form Subsurface Sewage,Disposal System Page' of'18
(151insp.doc-rev.,7/2012018
1 '
u
o
Commonwealth of Massachusetts
Tlll��e tfic' I Insw%ection
Subsurface Sewage Dispos l System Form Not,for Voluntary Assess ent
32 Cricket Lane
i5roperty Address
Steven Channen
OwnerOwner's Nerve
information,
required for every North Andover MA 0.,1845 6-12,-2019
,
page. Cityrr wn State Zip Code Date of Inspection
D. SystemInformation (cone.)
G .
2. CommerciallindustrIal Flow Conditions,.,
Type of Establishment:
llshment:
Design flow(based on 310 CMR 1 5.2 3): Gallons per j
Basis of design flows is persons sgftp etc.)
i
r s trypresent.? Yes N
Water treatment unit present? Yes El Igo
If'yes, discharges to*
Industrial waste holding talk present?
Non-sanitary waste discharged to the Title 5 system? El Yes El Igo
Water,raster readings, if available,,-
Last date of occupancy/use:, _ at
6r(describe below):
Pumped 2017,-owner
Source of information:"
0 Yes Ej No
W
k
� Was sys'em purnped as p"11111111a 0 le inspec i "
IIf s, volume pumped: _
" " " 15,00
gallons
Measure tank.
How was quantitypumped determined?
_ .� .� .
, a
Inspect tiro tees.
Reason for pumping,,*
f
i
t5in p.doc.rear.7/2 1 018 Titla 5 Official Inspection Form.SubsurfaCe Sewage Disposal System-Page, f
Commonwealth of Massachusetts
F
icmial Inspect"ion y T itle 5 O i ff'n Form
1 Subsuffaice,Sewage Disposal System Form -Notfor Voluntary Assessments
132 Cricket Lane
Property Address
Owner Steven Channen
Owner's Name
information is
North Andover MA 018,45 6-12-2019
required for every
Cityffown State Zip Code Date of Inspection
page.
D. System Ind 'i cont)
m:
4, Type of System:
Septic tank, distribution box, soil absorption system
Ell Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) if yes, attach, previous in pectin records, if are
Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner') and a copy of latest
a.
inspection of the I/A system by system operator under contract
Tight tank.Attach a copy of the CEP" approval.
El Other(describe):
Approximate age of all comp nents, date installed if known)and source ofinformation:
19 years old, 3-115-2000, as built plan
El Yes Z o,
Were sewage odors detected when, arriving at the site?, N
5. Budding Sewer(locate on site plan):
3
Depth below grade! feet
Material of construction.
E] cast iron Z 40 PVC. Ej other(explain):
Distance from private water,supply well or suction line: fee I t
Comments (on condition ofJoints, venting, evidence of leakage, etc.):
4" PVC through wall to septic tank. 3"' I in house, no leaks visible.
Subsurface Sewage Disposal System Rage 9 of 18,
Title 5 Omcial Inspection Form.
t5lnspdoc rove,7126/2018
Commonwealth of Massachusetts
ion
Title 5 Official lbspecto Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
132 Cricket Lane
Property Address
Steven Channen
Owner Owner's' ame
information is -12-20,19
North Andover MA 01845 6
required for every
p City[Town State Zip Code it of Inspection
age.
D. tem Informati ct)
6. Septic Tank(locate on site plan).
2,
Depth below grade., feet......,,.......
Material�of construction*.
E concrete El metal fiberglass Ej polyethylene E]other(explainbe
eg
If tank is metalt 11st age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes N o
Dimensions" 10 x 5'x 4'
2
Sludge depth'. -
31
baff
Distance from top of sludge to bottom of outlet tee o r le
Scum thickness 311
811
Distance from top of scum to top of outlet tee or baffle
pkpi ��.1
ri Distance from bottom of scum to bottom of outlet tee or baffle
Tape Measure
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet,invert, evidence of Ileakag,e, etc.,).
Inlet tee ok. Outlet tee olk. Depth of liquid at outlet invert. No evidence of leakage. Pumped septic
tank. Center cover has riser 3"deep.
ou
t6insp.doQ rev.7/26120118 Title 5 Official Inspection Form:Subsurface Sewage Disposal 'stern-Page 10 of 18
Ir
Commonwealth of Massachusefts
jrrr.
tie 5 Official Insnpection Form
Subsurface Sewage Disposal,System Form Not for Voluntary Assessments
CMG
132 Cricket Lane
i5roperty Address,
Steven Can
Owner Owners Name
information is
required for every North Andov r MA 01845 6-12-2019
page. it State Zip Co I de Date of Inspe I ction
D,.,, System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: .111,f I eet
Material of construction,
lain
- :1,o (exp )
El concrete El metal ss fibergla E] polyethylene ther,
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 pumping: Date
Comments (on pumping recommendations inlet and outlet tee or baffle condition, structural integrity,
liquid levels as,related t oultlet invert, evidence of leakage, etc.):
8, T'IAght or Holding Tank(tank must be pumped at fime of inspection) (locate on site plan).
Depth below grade:
ar
Material of construction:
El concrete, E] metal E]fiberglass E] polyethylene El other,(explain):
o
Dimensions:
Capacity* gallons
�.r� . _.w�rrw�mmmmm.r
Design Flow:.
gallons,per day
Title 5 cial inspection Form,Subsurface Sewage Disposal system Page i I of 18
Wnsp.doc•rev.7126/2018 Offi
Commonwealth of Massachusetts
H
Z ion
ial InspectForm
Subsurface Sewage Disposal Systern 'Form-Not for Voluntary Assessments
132 Cricket Lane
Property Address,
Steven Chann,en
Owner
Owner's Name
information is North Andover MA 01845 6-12-20,19
i requiredfor every
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holdoing Tank(cont.)
Alarm present: El Yes 0 fro.
Alarm level-." Alarm,in working order: El Yes No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
N o
Attach copy of current pumping contract r l r d)�. Is,copy attached? Yes
9. Distri',but,ion Box(if present,,must be opened) (locate on site plan):
Depth of liquid level above outlet inn ert
0
Comments (note if box is level and, distribution,to outlets equal, any evidence of solids carryrover, any
evidence of leakage into or out of box, etc.):
D-box level &distribution equal. No evidence ofcarryover. No evidence of'leakage.
Wnspdoc-rev.7126/2018 Title 5 Official Insplection Form.,SUIbSLJrf3C,e Sewage Disposet System-Pag�e 11 of 18
Commonwealth of Massachusetts
u icial Insup%kect' F p i o n orm
Subsurface Sewage Disposal System Form Not,for Voluntary Assessments,
132 Cricket Lane
Property Address
Steven Channen
Owner 6v neP's Name
information is
North Andover MA 01845 6-12-2,019
required for even .. I
page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
10. Pump Chamber(locate on site p�lan):
Pumps in,working order: M Yes 0 No*
Alarms in,working order. Yes No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc):
Pump tank ok. Pump ok. Floats ok,. Alarm has both audible and visual. Riser cover over pump&
floats, 1"deep.
If pumps or alarms are not,in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
lf,SAS not located, explain why'.
'Type:
leaching pits number:
leaching chambers number'.
leaching galleries number:
3 trenches 41'
z leaching trenches number, length'. Long
l ea it ields
number, dimensions:ch f
F] overflow cesspool number:
innovative/alternative system
El
Type/name of technology:
Onsp. Title 6 ofricial Inspoction Form:Subsurface�Sewa ge Disposal system-Pagel 3 of 18
doc-rev.7120/20,18
Commonwealth of Massachusetts
T"Itle 5 V'T'T"'I* I Inspect,"ion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1'32 Cricket Lane
Property Address
Steven Channen
Owner Owners Name
information is
for
North Andover MA Oil 845 6-12-2,0 19
require!d every --
page, CityfTown State, Zip Code Date of inspection
D. System Informat c rat.)
11. Soil Absorption System (SAS,)(coint.),
Comments (note,condition of soil,, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc,.):
Soil ok. Vegetation ok. No sign of ponding to surface.
..........
12. 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 sollids layer
Depth of,scum layer
Dimensions of cesspool
Materials of construction
Indic tion,'old'groundwater inflow E] Yes [j N o
Comments (note,condition ofsoil, signs of hydraulic failure, level of ponding, condition of vegetation,.
etc.)*
..............
Subsurface Sewage Disposal System Page 14 of 18
TRIe 5 OffichAl Inspection Form.
t5insp.dor, rev.7/2612,018,
H
Commonwealth of Massachusetts
icia p ion Title 5 Ott 1 lb s 1&40&e ct" Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
132 Cricket Lane
..........
Property Address,
Steven Channen
Owner Owner's Name
information is
requi,red for every North Andover MA 0,18,45 6-12-2019
plage. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
o
13, Privy (locate on site,plan).
Materials of construction:
Dimensions
Depth of solids
o
Comments(note condition of sold, signs of hydraulic fa ill ure, level of ponding, condition of vegetat"i n
etc.).-
15 in up,doe-rev,.7/26/2018 Title 5 Official Inspection Form,Subs'Lirfa.c awago Disporml Sygbam Pal)A 1S of 18
Commonwealth of Massachusetts
F
Title 5 Official Inspection or,m
a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
132 Cricket Lane
Property Address
Steven Channen
Owner
Ownet's Name
information is
North Andover MA 01845 6-12-2019
required,for every
o
pa, Cityfrown State Zip Code Date of Inspection
D. System Information (,cont.)
14. Sketch Of Sewage Disposal 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 the boxes below,:
hand-sketch in the area,below
E] d,rawing attache separately
..........
(OCA
0 r
A
Is
0
N11-7
t5l n sp,cloc rev.7126/2016 Title 5 Official Inupection Form.Svbsurface Sowage MP0901 SYstOm Page 16 of 18
Commonwealth of Massachusetts
T Ticia T I Insmowect' Form itle o' : ion
Subsurface Sewage Disposal System Form Not for VoluntaryAssessments,
132 Cricket Lane
Property A,ddlress
Steven Channen
Owner Owner's Name
inform,ation is
North Andover MA 01845 6-12-2019,
reqlu�ired for every
page. City/Town State Zip Code Date of Inspectilon
D. System Information (cont.)
1,5., Site Exam:
Check Slope
Surface water
Z Check cellar
Slhallolw wells
4
Estimated depth to high ground water: 6"et
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
8-111-1997
If chieckeld, date of design plan reviewed:
Date
Observed site (abutting pro pert y/observation hole within 150,feet of SAS)
z Checked with local Board of Health -explain:
Design plan
D Checked with local,excavators, installers- (attach documentation)
El Accessed USGS database-ex�plain:
H
You must describe how you established the high ground water elevatiom
As per test pit data on design plan.
Beforie flflln hils, Inspection Report, please see Report Completeness Checklist,on next page.
t6 i nsp,d oo-rev,7126)2018 Title 5,Official inspection Forn Subsurface siewaoe Disposal Systdim•Page 17 of 18
Commonwealth of Massachusetts
T fl
I t,I e !'5 0"T"T'Ic'a n s p e c "ioo
r m
Subsurface Sewage Dis�posal System Form Not for Volluntary Assessments
132 Cricket Lane
P ro p e rty Address
Steven Channen
Owner Owner's Name
information is
North Andover MA 01845 6-12-2019
required for every ...... --
page. City[Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form "Inclusive of:
A. Inspector Information: Complete all fields in this section.
B. Certification Signed & Dated and 1 2$ 3, or 4,checked
Z C. Inspection Summary-
11 21 3, or 51 completed as appropriate
4
ai'lure Criteria) and 6 (Checklist) completed(F
D Sys,-tem Informatiom.
For 8: T ig ht/Hol in 'Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on fig. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
1,51nsp.doc-rev,7/26/2010 Title 5 Official inspection, Farm®Subsurface Sewage Disposal System page 18 Of 18
Town of North, Andover
J
Tax Map # 210-038.0-0328-0000,0
Parcel Id 1121,05
132 CRICKET LANE
CI NEN, STEM
132 CRICKET LANE,
NORTH ANDOVER, MA
101'845
................
Class 101 Single Family Property Type 1 Residential
ZonIng2 1 Residential Zon;ing3 1 Residential
Size T6taI 1 63 Acres
FY 2019
UB Maing Index.
Nlame/Address Type Loan Nu nac U mber Active/It. From, until
CHANNEN, STEVEN Pay or Active
132 CI IICKET LANE
NORTH ANDOVER, MA
01845
UB Account Maint,
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 13879.0-132 CRICKET LANE Last Billing Date 3/8/20119
2100701 02 Cycle 02 Active
UB Services Maint.
Account No.2100701
Service Colde Rate Charge Multiplier/Users
MISCFEE ADM'IN FEE 1 1 9.18 1/
WTR WATER 01ALL METER SIZE 68,40 /1
UB Meter Maintenance
Account No.210,0701
Serial No Status Location Brand Type Size YTD Cons
35077339 a Active ERT HH b Badger w Water 1 1 1082
Date Reading Code Consumption Posted Date Variance,
5/2/2019 1 Actual 16 -4%
2/4/2019 11060 a Actual 18 3/1912019 -39%
11/2/2018 1042 a Actual 29 12112/2018 -28%
8/2/2018 11013 a Actual 40 9/20120118 164%,
5/3/2018 973 a Actual 15 6/20/2018 -10%
2/2/2 1 958 a Actual 17 3/28/2018 -48%0, 8,
1112/2017 941 a Actual 33 12/2912017 50%
8/2/2017 9108 aActUal 22 9/20/2017 42%
5/212017 Actual 15 6/26/2017 -9%
2/2/20,17 871 a Actual 17 3/14/2 0 17 -59%
11/2/2016 8514 a Actual 41 12/19/2016 -37%
8/3/2016 81 a Actual 65 9/21/2016 287%
514/201116 748 a,Actual 17 6/21/20,16 ,6%
2/2/2016 731 a Actual 18 38/2016 -64%
11/'2,/2015 713 a Actual 48 12/30/2015 -2'7%
8/5/2015 665 a Actual 68 9/14/2015 296%
51/6/2015 697 a Actual 17 6/22,/201,5 -5%
2/3/2015 580 a Actual 18 3/20/2015, -49%
11/3/,2014 562 a Actual 35 12115/2014 -29%
81/4/2014 527' a Actual 49 9/111,2014 115%
51/6/2014 478 a Actual 23 6/12/2014 -10%
2/4/ 14 455 a Actual 27 3/17/2014 -31%
10/3112013 428 a Actual 26 12/20/20,13
8/2/,2013, 40 aActual 310 9/18/2013 58%,
5/6/2013 372 aActual' 19 6/18/2013 -2%,
2/7/2013 353, a Actual 22 3/13/201:3,
110/30/2012 331 a Actual 21 12/13/2012 -22%
65%
8/3/2012, 31i0 a Actual 28 9/26/2012
5/3/2012 2 Actual 16 6/2 0/2 0 12 -,6%
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LOCATION:
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CONTRACTOR NAME:
T ve of Permit or License*(Check,von)
13 Aninial
0 Body Art Eistabltsitntent $
0 Body Art Practitioner $
0 Duttipster $
0 Food Senvice-
0 Fun o s $
• Massage Establishittent, $
• Massage Practice $
• Offal(Septic)Hauler
• Recreational Camp
• Sun tatining $
[J swimming Pool $
0 Tobacco $
[I TrasIVSolid Waste Hauler $
0 Well Construction $
SEPTIC Systems:
Septic-Soil Testing $
0 Septic-Des t Approval $
0 Septic Disposal Works Constniction,(DWC)
13 Septic Disposal or Installers
01 Title 5 Inspector $
VNI .. .......
'Title 5 Report
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Other:(Indicate).- $
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White-Applicant Yellow-Health Piqk-Treasurer
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