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HomeMy WebLinkAboutFail - Title V Inspection Report - 250 ABBOTT STREET 7/2/2019 Commonwealth of Massachusetts Uttici" I 1nsp&*Akect0ion Form rt 211) Z 11 01 Subsurface Sewage, Disposal System Form Not for Voluntary Assessments 250 Abbott Street P ro pe rty Address David Soloman Owner Owner's Name information is No. Andover Ma. 018,45 6-26-2019 required for every page. City/Town State Zip Co�de Date of Inspection Inspection results must be,submitted,on this form. Inspection forms may I n any way. Please see completeness checklist at the end of the form., .......... Important:When A. General Cnformationfilling out frmsloot OF WRT",m on the computer', use only,the tab 1. Inspector: 0 key to move your cuirsor I-do not F. Paul Cardone use the return Name of Inspector key. Septic Compliance, Inc. Company Narnie AhQ 1 37 1/2 Baremeadlow Street ... .. .. .. .. —6 m"",--p-"a'n-y.............. .I...................................................-`­.............................................................................................................I...................................................................................................... ............................................... Methuen Ma. 01844 .......... ............ City own, State Zip Code 9781-815-3115 or 97&-681-01726 3294 ............--....... Telephone Number icense Number B. Certification I certify that I have personally inspected the sewage disposal System at this addreIss and that the informatioll reported below s true, accurate and complete as of the time of the in'spection. The inspection was performed based on my training and expeIrience in the, proper f ction and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Tilde 5 (31 CMR 15.000). The system: ®' basses 0 Conditionally Passes Fails, El Needs Further,& lulafil" n b ,l I ApprovingAutho rat y All wolow-o"a "O"Al 11111 11 111111111-1 114:=� I. 7---1;P- natur The system inspector shall submit�,a copy of this inspection report to the Approving Authority (Board,: ofHealth or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The originial should be sent to the system owner and copies sent to the buyer, if applicable, and the approving author,ity. ****ThJis report,on,ly 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 ire, future under the same oIr different condItions of use. ,t5ins.do c rev,6/16 Title 6 Officiat inspection Form-,Subsurface Sewage DispoIsail System-Page I of 17 Commonwealth of Massachusetts it i'ci al Inspect'ion Form LA Subsurface Sewage Chi posaI System Form d Not for Voluntary Assessments 250,Abbott Street P rope rt y Address David Soloman Owner Owner's Name informatilon is No. Andover Ma. 01845 6-26-2019 required for every page. City/Town State Zip Code Date of Inspection B, Certification (cont) Inspection Summary* Check AB CD or E always complete all of Section D A) System Passes: F-1 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: .......... .............. ......... B) System Conditionally Passes: E] 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"'yesIl it, no" or",not determined" (Y, N, ND for the following statements. If"not determined,," please explain. The septic tank is, metal and over 2,0 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits,substantial infiltraflon or xfiltration or tank failure is i'mminent. System mill 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 Certificate of Compliance indicating that the tank is less,than 2,0 year's old is available., E Y ND (Explain below)-, t5ins.doic-rev.6116, Title.5 Official Inspection Form-,Subsurface Sewage Disposal Systerm-Page 2 of 17 Commonwealth of Massachusetts Title 5 %italtaoiciall, Inspec:,tion, Form 01 Subsurface Sewage Disposal System Form Nolt.for Voluntary Assessm ents 250 Abbott Street Property Address David Soloman Owner Owner's Name information is No, Andover Ma. required for every page. CitylTown State Zip Code Date of Inspection B., Certification (cont) [I Plump Chamber pumps/alarms not operational. System will, pass with Board of Health approval if pumps/a,larms are repaired. B) System Conditionally Passes (ciont.): Observation of sewage backup,or break out or Nigh static water level in the distribution box due to broken or obstruct,eld pipe(s) 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 [:] Y N ND(Explain below)� El obstruction is removed 0 Y E] N E] IND (Explain bielow): 0 0 distribution box is leveled or replaced Y N IND (Explain below), .......... E] The system required pumping more than 4 times,a year due to broken or obstructed pipe(s). The system will pass ire spection if with approval,of'the Board of Health)-. E:1 broken pipe(s) are replaced 0 Y E] N ND (Explain below): El obstruction is removed 0 Y N ND (Explain below),- C) Further Evaluation is Required 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, 1. System will pass untess Board of Health, determines in accordance with 310 CMR 15.,303(1 that the system "is not functioning in a manner which will protect public health, safety and the environment: [j Cesspool, or privy is within 50 feet of a surface water Cess,poo,l or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins,dOG rev.6116 Title 5,Official Inspection Form:Subsurface wage Disposal S,ystem-Page 3 of 17 Commonwealth of Massachusetts, nspection For m tierciI I' 1 5 a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2,50 Abbott Street, Property Address David Soloman Owner bw_'n' er's Name, information is No. Andover Ma. 01845 6-26-2019 required for every ...... M.page. tity/Town State ip Code Date of Inspection B. Certific ation (cont.,) 2. System will fail unless ,the Board of Health (sand'' Public,Water S�upppfier, if any) determines that the system iis functioning in a manner that protects the pub�lic health, safety and environment: [:1 The system has,a septic tank and soil absorption systern (SAS)and the SAS is wit,hin 100 feet of a surface water supply or,tributary to a surface water supply. F] The system has,a septic tank and, SAS and the SAS is within a Zone I of a public water supply. E] The system has a septic tank and SAS and the SAS is within 50,feet of a private water supply well. E: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 CEP certified laboratory, for fecal coliform bacteria 'I,ndicaties absent and the presence ofammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no,other failure criteria are triggered. A,copy of the analysis must be attached to this form. 3. Other, D) System Flailure Criteria Applicable to All Systems,-., You must indicate "Yes" or"No" to each of the followin,g for al! 'inspections: Yes No 0 El Backup of'sewage into facility r system component due,to overloaded or clogged SAS or cesspool El E Discharge or pondinn of effluent to the surface of the g!round or surface waters due to an overloaded or clogged SAS or cesspool F] El Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool EJ 0 Liquid depth in cesspool, is less than, 6" below invert or available volumeis less, than. %day flow t5ins.doc-rev. 16 Title 51 Official inspection Form-,Subsurface Sewage Disposal System.gage 4 of 17 141 'Coommonwealth, of Massachusetts 5 utficial ns ec t "ionfop' Form X fill T"tle Subsurface Sewage Disposal System Form Not for Voluntary Assessments 250 bbtttrt Property Address David Soloman Owner d,ter's Name information is No, Andover Ma. 01 845 6-26-2019 required for every page. dity/Town State Zip Code Date ofIns,pection B. Certification (cont.), Yes No Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pi s . Number of times pumped: ❑ Any portion the SASI cesspool or privy is, below high ground water elevation., Any portion of cesspool or privy is within 1 feet ofa. surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. 0 M Any portion of a cesspool or privy is within 50 feet of a, private water supply well. El H Any portion of a cesspool or privy is less than 100 feet but g reater than 50 feet from a private water supply well with no acceptable water quality analysis. [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 ppmi, provided that no other failure criteria are triggered. A copy of the,analysis, and chain,, of custody must be attached to this form.,] 'The system is a cesspool serving a facility with a design flow of 2000gpd- EJ H 101000gpd. 0 E] The system. I hav e determined that one,or more of the above failure c iteria exist as described in 310 CAR 15.303 therefore the system fails. The ri system, owner should contact the Board of Health to diet ermine what will be necessary to correct the fallure. E) Large Systems: To, be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 151,000 gpd. For large systems, you, must indicate either"yes" or"no,"to each of the following, in addition to,the questions, in Section D. Yes No El E] the systemi is within 4,00 feet of a, surface drinking water supply El 1:1 the system is within 200 feet of a tributary to a surface drinking water suppily the system is located in a nitrogen sensitive area (interim Wellhead Protection Area-IWPA,) or a mapped Zone 11 of a, public water supply well If you have answered, "yes" to any question in Section E then system is considered a significant threat, or answered 11yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under,Section, E or failed under Section, D shall upgrade the system in accordance with 310 CM,R 15.304., The system owner should contact,the appropriate regional office of the Department., t6ins.doc rev.6116 Title 5 Official Inspection Forn:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts CAI Title 5 utficiall Inspect"ion orm Subsurface Sewage Disposal System Form Not for Voluntary Assessments eel Af 2,50,Abbott Street Property Address David Soloman ................ ........ Owner Owner's Name, information is r uired for No-Andover Ma. 018,45 6-26-21019 eq every ...... page. City/Town State Zip Code Date of Inspection C, Checklist ate If yes" " " s f the following�- or no a to each o Check if the following have been done. You must,in I ici Yes No El El 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 El Has the system received normal flows in the previous two week per " Have large volumes of water been introduced to the system recently or as, part of 1:1 this inspection? 0 El Were as built plans of the system obtained and examined? (if they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? 0 E] Was the site inspected for signs,of break out? M E] Were all system components, excluding the AS, 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? M El Was the facility owner(and' occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the fiend if any of the failure criteria related to Part C is at issue E] 1:1 approximation of distance is unacceptable 3,1 0 ClVIR 15,302(5)] D. System Information Residential Flow Conditions,*. 4 4 Number of bedrooms (des,ign): Number of bedrooms (actual):, 4,40 D,E S I G N flow based o ri 310 CAI R 1,5.2 0 3 for exam p le", 110,g pid x#of bed r,00 m s)* Mns.doc-rev.6/16 Title 5 Official Inspection Form-,Subsurface S�ewage Disposal Systern-Page 6 of 17 Swinary Remd Card generatod,on 61,2012,019 9:02:11 AM by Karan, Hanlon Page I k I Tow nh of iN,ort ndover Tax Map # 21 0-038VO-01 591,1000040 Parcel Id 12948 260 ABBOTT STREET SOLOMON DAVI D & LISA 260 ABBOTT STREET N. ANDOVER, MA 018,45 1, Residential Class 1,01, Single Family Proplerty'Type I Residential Zon:ing2 I Residential Zontng3 Size:Total 1.92 Acres FY 2019 UB Mall'Inq Name/Address Type Loan Number ctive lira act. From Until SOLOMON DAVID LISA Payor Active 2:60 ABBOTT STREET N.ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Actier e/l,nactive Bldg Id. 13977.,0-250 ABBOTT STREET Last Billing Date 6/612019 Active 2 100561 02 Cy�cle 012 UB Services Maint. Account No.2100561 Service Code Rate Charge MultiplierlUsers r- 7.82 lMISCIFEE ADMIN FEE 0.636/8 WTR WATER 01 ALL METER SIB; UB Meter in ice "WIN Account No.21005,61 D Serial No Status Location Brand Type Size YT Cons 14006309 a Active ERT PIT b Badger w Water 0,630.63, 2122 Date Reading Code Consumption Posted Date, Variance 5/3/2019 29 a Actual, 16 6113/'20:19 -2% 2/512019 13 a Actual 13 3/19/2019 -100% 111281'2018 0 n New Meter 0 12/12/2018 -100% 11/28/2018 8167 s Reset meter 3.2 12/1, / 01 8 35% 8/22/'2018 835 m Manual estimate 27 9/20/2018 -1% MSG 5/21/2018 808 a Actual 21 6/20/2018 -2 2/16/2018 787 a Actual 24 3/28/2018 % 11/312017 763 a Actual 24 12129/2017 -11% 8/3/2017 739 a Actual 27 9/2,0,12,017 4% 5/3/2017' 712 a Actual 215 6/26/2017 -22% 2/'3120,17 687 a,Act u al 33 3/11412017 32% 11/3/2016 654 a Actual 25 12/119/2016 -5% 8/3/2016 629 a Actual 26 9121/2016 38% 5/4/2016 603 a Actual 19 16/21/2016 -18%, 212/2016 584 a Actual 23 3/28/2016 161% 11/312015 561 a Actual 2�O 12/30/2015 -26% 27 9/14/2015 31% �/4/2'01 6 541 a ACtLial 5/4/2015 5,14 a Actual, 201 6/2212016 -10% 2/412015 494 a Actual /2015 .5% 111 120 14 471 a Actual 25 12/16/2,014 -8% 8/l/20 14 4,46 a Actual 25 9/11120 14 -10% 5/6/2014 421 a Actual 28 6/12/2014 -1% 217/2014 393 a Actual 312 3/17/20 14 �29% 10/31'0/2011 3 361 a Actual 40 12120/2013 2% 8/2/2013 321 a,Actual 141 9/1812013 63% 5/1/2013, 280 a Actual 24 6/18/2W 3 -12% 2/1/2013 256 a Actual 30 3/1 3/2013 -20% 101'26/2012 226 a Actual 31 12113/20,12 �27% 00 Commonwealth of Massachusetts 'Titl,e 5 Offmic"ial Inspecti"on Form Not for Voluntary Assessments Subsurface Sewage 101101 spos,al System Form 250 Abbott Street Property Address David Soloman Owner Owner's Name information is No., Andover, Ma. 011845 6-26-20,19 required foir every State Zip Code Date of In on spectiD. Information Description: .......... Number of current residents- Does residence have a garbage grinder? El Yes Fj No Is laundry on a separate,swage system?. (Include laundry system inspection El Yes E No information in this report.) Laundry system inspected? El Yes 0 No Seasonal use? El Yes N No Water teeter readings, if available (last 2 years usage (gpd)): .......... Detail: Sump pump.? El Yes H No Last at of occupancy: Occupied ba"'t"e-- rc Commerciall/Industri,al low Cond*ftions: Type of'Esta,blishment- Design flow (based on 310, CI VIR 15.20,3): ............. Giallons per day(gpd) Basis of design flow(seats/persons/sqft, etc,,)- Grease trap present?,, El Yes E] No Industrial waste holding tank present? El Yes Non-sanitary waste discharged to the'Title 5 system? E Yes El No, Water meter readings I if available: t5ins„do c rev.6/16 Title 5 Official inspection Form Subsurface Sewage Disposal System-Page 7 of'17 Commonwealth of Massachusetts Form izial Inspect"illon ftle 5 Uff rM V Subsurface Sewage Disposal System Form Not for Voluntary Assessments Ar 250 Abbott Street j5i6�' dd,ress David Soloman ............. ... ....... Owner Owner's Name information is .No Andover Ma. 01845 6-26-2019 required for every ................... Dae of'Inspection page. City/Town State Zip Code t D. System Information coat... :. Last date of oiccupancy/use: ................ Date Other(describe below): General information Pumping Record;S: Source of information. According to,the owner tank was pumped, 1 month pri r to i ns"ec run, back-noted Was system pumped as part of the 'Inspection'? El Yes M No If yes, volume pumped- gallons How was quantity pumped determined? Reason for pumping- Type of System: Septic tank, distribution box, soil absorption system Single cesspooll F-1 Overflow cesspool El Privy E] if yes, attach previous, inspection records if any)Share d s ys tem (yes o r no) ('i El Innovativie/Alternative,technology. Attach a copy of the current operation and maintenance contract(to be obtainedfrom system owner),and a copy of latest inspection of the I/A system by system operator under contract 'Tight tank. Attach a copy of the DEP approval. Other(describe)* ............ ........... t5hs.doc rev.6/16 'Title 5 Official Inspection Form-,Subsurface Sewage r Disposal System-Page 8 of 17 �L�' Commonwealth of Massachusetts mm .......... T ns 'I Z F orm"Itle 5' U" t't"ic*ia�l 1pn-111-ect"ion ff Subsurface Sewage Disposal System Form Not for Voluntary Assessments 250 Abbott Street Property Address David Soloman Owner 6�'ner's Nanne information is No AndoIver Ma. 01845 6-26-20 19 required for every page. City/T own, State Zilp Code Date of Inspection D. System I of r t1 cont) Approximate age of all components, date installed (if known) and source of information: Approx 315 years of age ...... Owner Were sewage odors detected when arriving at,the site? Yes No Bullldingi SIewer(locate on site plan),: Depth below grade- feet Material of construction: M cast iron E] 40 PVC other(explain): Distance from private water supply well or suction lune* e"-t Comments (on condition of Joints, venting, evidence of leakage, etc.), Good condition No evidence of any leakage Septic Unk(locate on site plan): 12 Depth below grade,.,, -f 11 eet Material of construction* N concrete Elt�rna I E:1 fiberglass 0 polyethylene El other(explain) If tank is metal, list age: yea-r I s Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes, 1,0'8"Lx5'7"Wx5'8"'H Dimensions* lit Sludg!le depth: t5ins.doc-rov,6116 Ville 5 Official Inspection Form Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts CA Title 5, unicial InsapftecV,on Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 250 Abbott Street Property Address, David Soloman Owner bw­ner's Name information is No. Andover Ma. 018,45 61-26-2019 required for every . ............... Zip Code Date of Inspection page. ty/Town State D, System Information (cont.) Septile Tank(cont.) 231t Distance from top of sludge to bottom of outlet tee or baffle Score thickness ----—---------......................... 411 Distance from top of scum to top of outlet tee or baffle 2211 Distance from bottom of scum to bottom of outlet tee or baffle Sluidge Judge and Tape How were dimensions determined? ........ Comments (ors pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to,outlet invert, evidence of leakage,, etc.,)* We recommend, pumping on a yearly asis inlet was original concrete, both in good' condition, structural integrity appeared to be good, liquid level was h�igh, no evidence of any leakage. Grease Trap (locate on site plan): N/A Depth below grade: �feet Material of clonstructiow El concrete El metal El fiberglass, polyethylene E] other(explain): N/A Dimensi,ons- 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 Data of last pumping* ........... Date t5ins.doc rev.6/16 'Title 5 Offlicial inspection Form:Subsurface Sewage Disposal Sys,te!m Page 1 10 of 1,7 Commonwealth ofWassachusetts T'1",tie 5 ci ns a 'ion Form P Subsurface Sewage Dilsposall System Form Not for Voluntary Assessments 250 Abbott Street Property Address David Soloman .........— Owner 6�rers Name information is No. Andover Ma. 01845 6-26­20,19 required for every ti page. own State Zip Code Date,of Inspection D. System Information (writ.) Comments (on pump,ire g recommendations, inlet and outlet tee o r baffie,condition, structural integrity, f liquid levels as related to outlet invert, evidence of leakage, etc,.). ............. ... ....... Tight or Holding Tank (tank must be pumped at time,of inspection) (locate on site pilian): Depth below grade: N/A Material of construction, 0 concrete El metal fiberglass, E:1 polyethylene E] other(explain)- Dimensions, Capacity: I'll,gallons Design Flow,- gallons per I'll,day ...... Alarm present* El Yes N o ,Alarm level* Alarm in working order. El Yes 0 No, Date of last pumping: ite Comments,(condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract(required). Is copy attached?. 0 Yes 0 No t5inis,dloc-rev.6/16 Title 5 Oifficial inspection Form:;Subsurface Sewage Disposal System Page 11 of 17 Commonwealth of Massachusetts ..................... z -Ultle 5 UTTIcial Insopu'Iftectlon Form rA .............. Not for Voluntary Assessments Subsurface Sewage Disposal System �Form 250,Abbott Street .............. Property Address David Soloman Owner Owner's Name information is No. Andover Ma. 01845 6-26-2019 requ�ired for every page. City/T'own State Zip Code Date f Irrs trr D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments,(note i,f box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of lei into,or out of box, etc.)* Cover was cracked,standing water in all lines, quite a lot,of solids in the box. Pump Chamber(locate on site pilan)- Pumps in working order'- Ej Yes, El No* Alarms in working order* El Yes Comments (note condition of pump chamber, condition of'pum�ps and appurtenances, etc.): N/A If pumps or alarms are not in working order, system is,a conditional pass., Soil Absorpt,101on System (SAS) (,locate on site plan,, excavation not required): IfSAS not located, expl�a,in hy: ............. ........... t5ins.doc rev.61/16 Title fficial Inspectifon Form-,Subsuirf,ace Sewage Dis,pos,al System-Page 12 of 17 Commonwealth of Massachusetts ion ftecto Form Totle 5 ial, In OA s* Subsurface Sewage Disposal System Form Not for Voluntary Assessments 250 Abbott Street Property Address David Soloman .......... Owner 6��Ie"'is Name information is .No Andover Ma. 018,45, 6-26-l201 9 required flor every ....... .111,State Zip Code Da,t,e of Inspection page. own D., System Information (cont.) Type,* El leaching, pits number: 11 leaching chambers number: ........ E leaching galleries number- 4-50'llon 9 leaching trenches number, length* 1:1 leaching fields number, dimensions: EJ overflow cesspool number: innovative/altern tivel systlem Typeltna�me of'technology- ........... Comments (note condition of soil, signs of'hydrauli,c failure, level of ponding, damp soil, condition of vegetration, etc.): Good None None No Grassy i slidel yard area Cesspools (cesspool must be plumped as pert ofinspection), (locate on site plan): Number and configuration Depth —to of liquid to inlet invert Depth of'solids layer Depth, of scum layer Dimensions of cesspooll Materials of construction lire dication of'groundwater inflow El Yes E] No t5ins.docw,rev.61116 Title 5 Official inspection Form,Subsurfa wage Disposal systlem-Page 13 of'17' 10% uommonwealth of Massachusetts Tille 5 uYncia.1 t o orm .......... Subsurface Sewage DiMp,osa! System Form Not fo�r Voluntary Assessments 2,50 Abblott Street Property Adidress David Soloman Owner 6r�-er'-s',Name information is No. Andover Ma. 01845 6-26-�2019 required for every page. Cityff own State Zip Code Date of Inspection D, System Information (cont.) Comments (note condition ofsoill, signs of hydraulic failure, level of poinding, condition of vegetation, etc,): Privy (locate on site plan): Materials of construction- N/A Dimensions Depth, of solids, Commi nts (note condition of soil, signs of hydraulic failure, level,of ponding, condition of'vegetation,, etc,): t5ins.duo c-rev.6116 Title 5 Official Inspection Form, ubsurface Sewage Disposal System-Page 14 of 17 Page 1 " OFFICIAL INSPECTION FORM —NOT w SUBSURFACE VOLUNTARY ASSESSMENTS , G PART C SYSTEM INFORMATION(cmuinued) w SKETCH Provide a sketch of the-s6wage d isposa I system Hi least two-permanent reference-landmaiks or bendunarks.Locate all,wells WithinI 0o feet.Locate where public water supply enters the MUM w ](D _�_ut�"_ 1 I� w N c za 16CM AT ZA- 0 Commonwealth of Massachusetts M Form .7 j I it�le 5� Oifficial Inspection M Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4% 2,50 Abbott Street Property Add res�s David Soloman Owner 6teer's Name information,is No. Andover Ma. 01845 6-26-20 19 req u i red fb r eves .......... page. d Tft� wn State Zip Code Date of Inspection D, System Information (cont.) 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 wel Is within, 100 feet, Locate where public water suppily enters,the building. Check one ofthe boxes below-, hand-sketch in the area below drawing attached separately t5 ire s.dioc rev,61116 Title 5 Officiail Inspection Form:Subsurface Sewage Disposal System,-Page,1 f 17 Commonwealth of Massachusetts 1;21 E t e 5 i im spsft ecti"o n Form al Not for Voluntary Assessments Subsurface Se�wa,ge Dispos System Form 250,Abbott Street Property Address DavidSoloman Owner Owner's Name Information is Ma. 01845 6-26-2019 required for every No�. Andover .M.mm � page. CitylTown State Zip Code Date of Inspection M, System Information (cont.) Site Exam: Check Slope Surface water Check cellar �N Shallow wells Estimated depth to high ground water: 8.5 Feet feet � "leas e indicate all methods used to determine the high ground water eleviation'. Obtained from system dies,ign plans on, record 7-16-199 If checked, date of design plan. reviewed,-. -D"I a 11 te Observed', site (abutting pro,perty/o bservation hole within 150 felet of SAS) Ell Checked with local Board of Health -explain: El Checked with local excavators, installers-(attach documentation) Accessed USGS.database-explaim EJ You must describe how you,established the high ground,water elevation* water level, In brook in front yard 8.5' below system grade. Adjoining property 238 Rea Stet 7-16-99 by Ram Engineer ............ ............... ...... Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Officiat,Inspectilon Form-Subsurface Sewage Disposal System-Page 16 olf 17 Commonwealth of Massachusetts u mio orm tie 5 0""ff' Subsurface Sewagie Disposal System Form Not for Voluntary Assessments 2,50 Abbott Street Property Address David Soloman Owner Owner's Name information is No. Andover Ma.. 01845 6-26-2,019 required for every page. CitylTowin State Zip Code Date of Inspection E, Report Completeness Checklist Inspection Summary* A, B1 C, D, or E,checked Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Z System Informati stimated depth to high groundwatier Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate f'ile t5ins,doc rev.6/16 Title 5 Official inspection Form-,Subsurface Sewage Disposal System,-Page 17 of 17 %40R'T" QJ Town f North Andover HEALTH DEPARTMENT POO'-- C H E C K DATE. 7)"o LOCATION: H/O NAME,. `0 CONTRACTOR NAME: Typ,e of Permit or,License: (Check box), D Animal $ [1, Body Art Establishment 0 Body Art Practitioner $ 0 Dunipster $ 0 FoodSenuce.-Type.-,', 0, Funeral Directors $ 0 Massage Establishment $ El Massage Practice $ U. Offal(Septic),Haulier $ * Recreational Camp $ * Suntanning 0, swims in Pool 0 Tobacco $ �El TiasIVSol*d Waste Hauler 0 Well Constniction $ SEP'RC Sy tems,.-, 11, Septic-Soil Tes-ting [I Septic,-Design Approval $ 0 Septic Disposal works Constniction(DWO $ [:3 Septic Disposal Wore histallers(DW) $ 0 Title 5 Inspector $ "J This 5 Report 0 Other.-(Indicate) $ Wth,-Al'gent hiftials' White-Applicant 'Yellow Health Pink-Treasurer ...................... ............