HomeMy WebLinkAboutPass - Title V Inspection Report - 44 MARIAN DRIVE 7/2/2019 Commonwealth of Massachusetts,
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,
x Title Form
Subsurface Sewage Disposal System Form Not for Voluntary ssess e ts
44 Marian n Drive
Property Address
Joyce Bowan
Owner Owner's Name
f
information is North Andover M 5 6 -201
required forevery ...,,� . , ,. ...
p City/Town State Zip Code Date of Inspection
Inspection, results must be submitted on this form. rspectr rrs any
way., l l' ase see completeness checklist at the end of the form.
Im p o+d nt:When A. Inspector Information
filling out form
on the computer',
use only the tab mail James, Bateson
key to move your Name of Inspector
cursor,do not Blateson Enterprises Inc.
use the return
key. ---
111 mm.� ..
Argilla Road
.
Andover MA 01810
ity T + n State Zip Code
c
Telephone N umbr e r License Number
r
B. Certification l
I certify that*. I am a DES' approved sys inspector i full compliance wit Section 15.340 of Title 5,
(310 C R 15. 1 ) 1 have rson ll lins t d the sewage disposal system t the property address
listed above the information n reported below is,true, accurate and complete as of the time of my
inspection; and the inspection was performed based on ray training and experience��in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
a
0
that the system:
1. Passes
2- El Conditionally Lasses
3, deeds Further Evaluation the LocalApproving Authority
k
Falls
N.
-2 -201
The system inspector shall submit,a copy of this inspection report to the Approving Auth rit Board
f Health or DAP)within.301 days of completing this inspection. If the system has a design flog of
101000 gpd or greater,the inspector,and the system owner shall submit the report to the appropriate
regional office of the ER The original form should be sent to the system owner and copies seat to,
the buyer, if applicable, and the approving authority.
I
Please note: This report,onlydescribes conditions at the time of Inspection and under the
conditions, f use at that time.Thies insp a ti n does not address' how the system ill f rm
ire the future under the game o r different conditions of use.
t In p.d re,v.7,12612018 Title Official'Inspection Form,Subsurface Seaga Disposal System•Page I of 1
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Commonwealth of Massachusefts
ion
Title 5 Ufficial Inswomect" Form
T Subsurface Sewage Disposal System Form Not for Voluntary Assessments
4,4 0
Marian Drive :.
Property Address
�r
dce Bowan
Owner Owner's Name
North Andover
requireq for every �� —
Cit /Town state Zip Code Date of Inspection
C. Inspection Summary (cont)
,r
4' System Failure Criteria Applicable,to All Systems-, art
Yes N
Static liquyid level in the distribution box above outlet invert due to are overloaded
El E r clogged SAS or cesspool
Liquid depth in cesspool is, less than 6" w l w inn rt or available volume is less
than%day flow,
El M Required pumping more than 4 times in the'last year NOT due to clogged or
e
obstructed pipes . Number of tires pumped.,
u
Any portion f the SAS, cesspool,or privy is below high ground water elevation,
Any portion f cesspool r privy is within 100 feet of a surface waiter supply r
El [A
tributary to a surface water soppily. e
Any,portion f a cesspool or privy is within a Zone 1 of a pub�lic water supply
well.
w
Any portion of a,cesspool or priory is within 5 feet f' a private water supply well.
Any portion of;a cesspooll or privyis less than 100 feet but greaterthan 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 + CNf rm bacteria indicates absent and the presence
f ammonia nitrogen,and nitrate nitrogen is equal to or Mess than 5 p pm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to gains form.,]
The system is a cesspoolserving a facility with a design flow of 2,000 gpd-
1010001pd.
�
The system fails. l have determined that onle or more of the above failure
ED E s
criteria, exist as described in 310 CIVIR 15.303, therefore the system fails. The
d
system owner should contact the Board ofHealth to d ter nine' mat will be
necessary to correct the failure.
5Large Systems- To be considered l�r� ; t� n t �system ra �t � a facility it a
design flog of v gd to 15,000 gpd.
For large systems, you must indi gat+ either"yes" or"no"to each olf the following, in addition to the
questions in Section CA
Yes No
El 1:1 the system, is within 400,feet of a surface drinking at r supply
El the system is within 200 feet,of a tributary t a surface drinking rater suppler
a
the system 1s located in a nitrogen sensitive area(Interim Wellhead Protection
tectio
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Area—IWPA r a mapped Zone 11 of,a public water supply well
9
t in p.d .rev.71261 1 8 Title 5 Official Inspection Form:Subsurface Sewage,D isposall System-Page 5 of 1 a
Commonwealth of Massachusetts
T im
M . F itle 5 UTTIcial Inswj%jection For
M Subsurface Sewage Disposal System Form Not for Voluntary Assessments
44
...........Marian Drive
'roe address
Address
.............
Owner Ownees Name
information Is North Andover MA 01845 6-27-2019
required for every
City/Town State Zip.Code Date of inspection
page.
C. Inspection Summary (cont.)
2) System Conditionally Passes, (cont-):..
Ej Pump Chamber pumps/alarms, not operational. System,will pass with Board of Health approval if
pumps/alarms are repaired.
o
El Observation of sewage backup or break out or high st,atic water leve�l in the distribution box due
to broken or obstructed p1pe(s)or due to a broken, settled or uneven distribution holy. System will
pass inspection if(with approval of Board of Health)@
broken pit)are replaced 0 Y [1, N E] ND (Explain below),:
o struction ist removed E Y N Ej ND(Explain below),-
El
E] Y E] N E], ( ow)distribution box is leveled or replaced ND Explain bel :
The stern required purn,ping more than 4 times a,year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the, Board It Health):
E] broken p1pe(s) are replaced Ell Y El N E] ND(Explain below):
Ix
F] obstruction is removed, El Y E] N E] ND(Explain below):
3) Further Evaluation is Required by the rd of Health:
Li 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 Mill pass uniles,s Board of Health determines.in accordance with 310 CMR1
15.303(l)(b)that,the system 'is not functioning in a manner which w*111 protect public healtlh�
safety and the environment:
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System Page 3 of 18
Commonwealth, asscso
Titie, 5 uyy i
icNal Inspection Form
-- A
Subsurface Sewage Disposal,System Form Not for Voluntary Assessments
s
44
Marian Dave
Property Address
Jo
G
OwnerOwner's Name,
information is MA 01845, 6-272019
North Andover .
requireq for every
it � r State ?i Cod Cate Inspection
page. CC. InspectionSummary (cont-)
E] Cesspool or privy is within 50 feet of a surface water tltl
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Cesspool or privyis within 50 feet,of a bordering vegetated wettand or a salt marsh
lb
. System 111 tall unless theBoard of Health (and i ll+ WaterSupplier, if'a,ny
determines thl t the system is functioning i"In a manner that protects the nubillc health,
safety and error lrr mem.
E The system has a septic teak and soil absorption system (SAS)and the SAS is within
100 feet of a,surfacewater supply or tributary to a surface waster supply.
system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply. m
The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
Ej The system has a septic tank and S and the SAS is less than 100 fiat but 510 teat or
more from a private water supply well".
Method used to determine distance:
This systems passes if the well water analysis, at certified laboratory, for fecal
►lit+ r I bacteria indicates bsent and the presence at ammonia nitrogen and nitrate nitrogen is equal
to or less than 6 m, provided that,no other failure criteria are triggered.A copy of the anal is must
t
be attached to tis trig.
m Other:
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, System Failure Criterion AppElicable to All Systems-.1
u mint iin is rt `Yes"'or"Noel'to each of the following for all ins donna:
Yes No
El 0 Backup of sewage into facility or system component,dine to overloaded or r
clogged SAS or cesspool
Discharge or ponding of affluent to the urt I a of the ground or surface watersEJ 0 �
dine to an overloaded,or clogged SAS or cesspool
t5insp. o .rep,7126/2018 Title 5 Official Inspection Fora:Subsurface Sawage Dis,os I System fags 4 of 1
Commonwealth of Massachusetts
Tiotle 5 utticial Inspection Form
I '
Subsurface Sewage Disposal ;system Form Not for Voluntary ntar Assessments
44 Marian Drive
s
Property d d r
Joyce Bowan
Owner Owners Dame °
information is North Andover MA 01845 6-27-2019
required.for err
page. dit—YrFo-
,C. Inspection Summary
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Inspection Summary:,, Complete 1,, 2� 3, or 5 and all of 4 and 6.
a
System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.30,31 or in 310 CIVIR 15.304 exist. Any failure criteria not evaluated are
indicated below.
2 System Conditionally. ''asses:
ire' r more system components as described in,time"Conditional Pass"'section needto,be
replaced or repaired.The,system, upon completion of the replace mie t r repairl as approved by
the Board of Health, will pass.
Check the box for"yes", "no" r"not determined"ined" Y , NID)for the following statements. If"not
determined," please explain�.
the septic teak is metal and,over 2.0 yearsold*or the septic tank(whether metal r not) is structurallyr
sound, exhibits substantial infiltration or exfiltration or tank failure is, imminent. System will pass
inspection if the existing teak is replaced with a complying septic tank as approved by the Board, t'
Health.
A m t ,l septic teak will pass inspection if it is structurally sound, not leaking in and if a Certificate of
Compliance indicating that the teak is lens than 20 years old is available.
EJ Y N 0 ND(Explain below):
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Commonwealth of Massachusetts
w ■�
Tive c ion
UTUCIal Inspe Form
t for Voluntary Assessments
M Subsurface SewageDisposal, System Flota
�'
44 Marian Drive
Property address
Llqy�e wa
Owner Owner's Name
info ,ion i North Andover l' 5 -2 -2 1
r u re for every� ��t�r"r' �rl StateZip d Inspection
pager
C. Inspection
bummary (cont.)
If you have answered s"to any question in Section C.5 the system is consider significant
threat, or answered o
� in � ��� � �the large stem has failed.
The
I � � and question u u
owner or operator ofany large,system considered a significant threat,under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 C,M,R 1,5.304. 'The stern owner
p�,v
should nt act the a ro riate regional office of the Department.
6.. You must indicate"yes" or"no"for each of the following for all inspections.:
Yes No
Pumpinginformation was provided by the caner, occupant, or Board of Health
El 0 Were any of the 'stern components pumped out in the previous two weak?
Has the system, received normal flows,in the ra ►u us two week,period?
Have large volumes of water been introduced to,the system recently or as pat of
El 0 this inspection?
Were as built plans of the system obtained and examined?' if they were not
avall
z El "'fable note as N/A)
was the facility ilit or dwelling inspected for signs f sawa�e back up?
0
Z E]
0
Was the,site ins e tad for signs ofbreak out?
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Were all,system components, excluding the SAS, located n site?
E E] ar"ere the septic tank manholes uncovered, opened, and the interior of the tan
inspected for the condition of the'baffles,or teas, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
z El Was the facility owner(and occupants if different from owner) provided with
information n Chile 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:
z 0 i
Existing information. For example, a plea at the Board ofHealt.h.
Y
Determined iu a in the field if any of the failure criteria related to Part C is at issue
Z F] r,
approximation of distance is unacceptable) [310 CMR 15.302(5,)] 4
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t in p®do -rev.712612018 Title 5 Official inspection r*lm Subsurface Sawage Disposal System Page 1
1
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a
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r Title Off'icial
ubsurfac ,Sewage Disposal System Forte N �VoluntaryAssessments
r
44
Marian Drive
P rope rty Address
e
cage Bowan
Owner Owner's Name
information,'is MA 01845 6-27-2019
requirej for every North Andover
page.
u rn State zip Code Date of inspe tion
D. System Information
1. Residential Floes Conditions:
3
Number oftedrooms (design):
Number ofbedrooms(actual):
440
DESIGN flow,based on 310 C R, 15.203(for example: 110 gpd x#of bedrooms):
j
Number of current residents,-.
Does, residence have a garbage grinder Yes No !
Does residence have a water treatment unit" _ Yes Z No
If yes,, discharges t
Is,laundry rt a separate sewage system? (In lud laundry system inspection 0 'Yes No
information Irk this r port.)
Laundry system inspected? El Yes, Igo
S s rr l use ;, Yes No
Water meter readier s, �f it l (bast years usage gpd s, o
k
'Detail*
i
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e.
Sump,
Last date,of occupancy:
rant
Date
I'
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Commonwealth of Massachus,efts
F Ti*tle 5 UTTIcial Inspection Form
Subsurface Sewage Disposal S st rn Form -Not for Voluntary Asse su rlts,
R4
44
Maran Drive
Property Address
a
o Bowan �
Owner r's Name m.
o
information is North ndoy r MA 01845 -27-2 19 �1
required for every
it r tat Zip Code Alt Inspection
D. System Information (c
y,
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2. Commer a lndu tri !Flow Conditions-. d
of Establishment:
Design flow based on 310 MR 1 5.2 3
.
Gallons per day
Basis of'design flow se ts/p rs s/sqft, etc.):
Grease trap resent D Yes'[-] N
water treatment unit rant es No
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If yes, discharges to.:
Industrial waste holding teak present? Yes N �
Nora-sanitary waste discharged to the Title 5 system? Ej Yes No
Water meter readings, It available:
Last date of occupancy/use: Date T
Other(describe below):
i
P
Source t i�u�t"�rrr� tiou�:: 1 � � �� �r� r e
Was system pumped as part t'the inspection? Yes No
1500
If yes, volume pumped- gallons
k,
How was,quantity pumped determined?
Measured"t ru
Inspect tank ,t
Reason for pumping: �.
a,nd
ees
X
f,insp.dee.rev,712612018 "title 5 Official lei ect eln Fern:Subsurface Sewage Disposal System Page 8 of 1
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Commonwealth of Massachusetts
Title 5 Officmial Inspecti n Form
1
Subsurface Sewage i s Sys r � For
Not for Voluntary �
t
44 Marian Drive
Ire Address
J
Owner owner's dame
information is
North Andover MA 018145 6-27'-2019
re
quired r every � �� �t�� �I Code Date of Inspection
Page.
D. System, Inman (cont.)
.. Type of System: d
,Septic tank, distribution box, soil absorption system
E] Single cesspool
o1
E] Overflow cesspool
El p
Privy
Ej Shared system(yes or no)(if yes, attach, previous inspection records, if any)
d
El Innovative/Alternative-technology.Attach a copy
of'the rrrent operation and
maintenance contract(to be obtained from system,owner)and a copy of latest
a
inspection of the UA system by system operator under contract
Tight"tank. t a li a copy of the E approval.
El Other,(describe):
Approximate age of all components, date install it'known)and source of information-.
19 years old, 9- -2 1 , as built plan*
,d
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Were sewage odors detected when arriving at the site* El Yes l '
5. Building Serer(locate on, site plan):
Depth ' elan ► ri : feet � V
Material of coinst�r ctil n:
s
cast irin 40PVC El, other(explain):
E
Distance from private water supply well or suction line: feet
Comments n condition of joint ,venting, evidence of leakage, eta.):
"Cast Iron through wall, "Cast Iran in house, no leaks visible.
u
" I
I
t5insp.doc, rev,7/2,6,12018 Title 5 Official Inspection Form,:Subsurface Sewage Dispois,al System•Page 9 of 18,
Commonwealth of Massachusetts
TI'tle 5 Off'icial
FA
LL* SubsurfaceSewage,Disposal s System Forte- l r t � ��+ ��
44 Marian Drive
e
Property address
Jo Bowab
Owner Owner's Name
North Andover
required for every
City/Town
;
State
� � ��t Inspection I o
D. System Informationcone.
ro
6: Septic Tank(locate on site plan),.
,
n
Depth
below gads: feet
Mate,ria,l of construction,
concrete metal fiberglass El polyethylene other(explain) r
s
d
It teak'is metal, list age* years
Is age confirmed Certificate of Compliance'? (attach a copy of certificate) 0 Yes N
"w
Sludge,depth:
Distance,from top of sludge ►ttom of outlet tee or baffl
29
7"
Scum thickness
u�r1F
Distance from top scum to t outlet tee or baffle
Distance from bottom of scum to bottorn of outlet tee or baffle
0
r
Tape Measure
How were dimensions determined,?
Comments ors pumping recommendations, inlet and outlet tee,or baffle condition, structural integrity„ �
liquid levels s related to outlet invert, evidence of leafage„ etc..); u
way
Tank level above outlet invert, found outlet filter clogged, clean same,, level back to normal., Inlet tee
o . Outlet tee ok. N vid nce of leakage. camped.septic tank.
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Commonwealth of Massachusetts
ion
Tit,le 5 Official Inspect'm Form
Subsurface,Sewage Disposal System Form Not for Voluntary As essme is
44 Marian Drive
property Address
Joyqe a
Bowan
Owner Owner's Name
information i , North re ar MA 01845 6-7-201
required for
every
page.
�t� r state Zip Code Date inspection''
cowi
D., System Information (cont.)
t
W Grease,Trap (locate on site plea,):
Depth below r feesMaterial of construction"
u
El concrete 0 metal fiberglass pol thylen other(explain)-
Dimensions
Scum thickness
Distancefrom top of scum to top of outlet tee,or baffle a
Distance from bottom of scum to bottom,of,outlet tee or baffle
Late of list pumping4 Date
Comment ion pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as, related to outletinvert, evildence of leakage, etc.):
a
,
p
r
� . Tight or Folding Tank(tank must be pumped at time of inspection), (locate on site plan)
Depth below grade,* �
i
Material of construction*
El concrete El meta,'l El fiberglass 0; polyethylene other(explain),
6
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Dimensions.-
Capacity:
gallops
Y E
1 Design Flow: gallons pier day
151rw p. r J T'itle 5 Sid i inspection Form:Subsurface ear Disposal!System•Page,I I 8
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Commonwealth of Massachusetts
Tiotle 5 (")"Ka"ta'"Imcial
Inspectfion F
Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments
44,Marian Drive
Pr7o_perty Address
Joyt
g�,Bowan
.....
Owner Owner s Name
0
informationis North Andover 9
required for err _tyffown State Zip Code Date of Irispection
._
page
D. SystemInformation coat.)
f
. Tlight or ll il �Tangy cone.
r
Alarm ,present; El Yes [:1 N c
Alarm level: l .rr i working order; Yet i
eDat of last ampi ► ,d
Y
Comments (condition of alarm and',float switches, etc.):
Attach copy of current pumping contract(required). is copy f Ej Yes l
!. Distribution Boy if present,must be opened)(locate on site plan);
i,
Depth of I'liquild level above outlet invert _
Comments note if box is legal and distribution to outlets equal, any evidence of solids carryover, any
evidence of leafage into or out of boar etc.):
-box level &distribution equal. No evidencef leakage. videnc f carryover,
0
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t urn kd -rev,712612018 Title 5 Official Inspection Form,Subsurface Sewage Disposal System.mega 12 of 18, s
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Commonwealth of Massachusetts
U A M .
ion
Form
Tive 5 Ufficia,I Inspect
Subsurface Sewage Wsposall;system Form Not for Voluntary Assessments,
a
44
Maria,n, Drive
Property Address
.ice Bowan
Owner Owner's r''s Name
rr ti is J f North Andover A , 5 6- '- �1
as
required for every
`tat Zip Cod plate f—Inspection
ty/Town D. System Information c . 1
10. Pump Chamber(locate on site plea):
I
Pumps in working in order: N Yes 0
tl
Alarms rms in working order: Yes El No*
Comment (mote condition, f pump chamber, condition of pumps and appurtenances, etc.)*
Pump'T'ank ok. Pump Ok. Floats Off.Alarm ok,. Alarm has both audible &visual. Pump can be
o;
used on auto or hand operation.
If pumps or alarms are not in,working order, system is a,conditional pass.
I., Soil Absorption System SAS), (locate on site plain, excavation not requiredl.
If SAS not located, explainwhy-
Type: n
n�
leaching pits number.
2
leaching chambers nu1m r
leaching galleries number:
El, i
leaching trenches, nu r, lengthy
] leaching fields number, dimensions:
El overflow cesspool number:
El innovative/afternative system
Type/mama of technology:
_mm.
Mnsp.doG*rev,7/261/2018 Title6 Offidal Inspection,Form:Subsurface Sewage Disposal System,Page 13 of 1
t
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Commonwealth of Massachusetts
Tnle !s otticial Insmftection Form
Subsurface Sewage Disposal Sys,tem Form Not for Voluntary Asses n s
ive
44 Marian r
Propedy Address d"
Joyqe qowab
Owner Owner's Name
information is North Andover 018,45 627-2019,
requirej for eves .
State Zip Code Date of Inspection
D, System Information (cont.)
11. Si]Absorptilion System (SAS) (cone®
Comments(note condition,of soil,signs of'hydraulic failure, level 1 re in , damp soil, condition of
vegetation,, etc,):,
,moil ok.Vegetation ok., sin of bonding to surface. 42 Infiltrator chambers. 6 rows with chambers
per row. Opened up,inspection port, no liquid present.
d
b
�m
12. Cesspools (cesspool must urn s part of inspection) (1 at n site elan):
w
Numbler and configuration
Depth top of liquid inlet invert
Depth ofsollds, layer
d�
Q
Depth f scum layer
r
Dimensions of cesspool
n
Materials of construction
0
1 "
Indication of groundwater inflow 0 des El Noa�n
Comments (noes condition of soil, signs of hydra liC failure, level of p nding, condition of vegetation,
etc.)
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Commonwealth of Massachusetts
o
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Tive u icia
Ins&-%ect"I Form
Subsurface rf Sewage Disposal System Forte s � l t s ssments
44 'Irian 'Drive
Joyqe Bowan
�m t
Owner Owner's Name 1
information is North Andover MA 018456-2 -201
required fi forevery
pagCity/Tn State Zip Code Date of Inspection �
D. System Information (ct.
13. Priory,(locate on,site plan):
�A
Materials t' rr tr u ti
Dimensions
Depth of sollids
Comments (note condition of soil, signs�of hydraulicfailure, level of poniding, condition ' eg td tl �
etc.):
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Commonweatth of Massachusetts
ion
lip Tiotle, 5 Official Ins*ftect" Form,
Subsurface Sewage Disposal System Form� fir Il'�r�t r � ssr�a rat
4 ,Maria,n Drive
Property Addreoe Bowan
Owner information is North Andoverf
required ' r everMA 01845 6-217'-2019
y �....
CityTTown State Zip Codle Cate of Inspection
D. System Information (cont.)
. Sketch Of Sewage Disposal System:
Provide iew of he sewage disposal system, including ties to at lust twopermanent reference
landmarks or benchmarks. Locate all well's within 100 feet. Locate where public water supply eaters
the, building. Check one of the boxesbelow.-
EJ
hiand-sketch are thearea below
:A
El drawing attached separately
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Commonwe,alth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal Sys Forte� �t� Voluntary Assessments
44 Marian Drive—_.
Pr+ r y Addres,s
i
Owner Owner's Name,
Information is North Andover MA 0,1845 6-27-2019
required . n
page.
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D, Systemlfr atit t.
16. Silte Exam:
Check Slope
Surface water
Check cellar
Shallow wells B
Estimated depth to high ground water.' feet
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Please indicate all methods used to determine,the high ground water elevation:
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Obtained
from s stern design plans on, record
7-10-2008
It checked, date of design plan reviewed. �
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Observed site(abutting ro rt / ration hole within 15 t of SAS)
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Checked with local Board of Health-explain.
Design plan
El Checked with local xcavat �rs, installers-(attachdocumentation)
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Accessed SGS database-explain:
You must describe how you established the high ground water elevation:
As per test pit data one design,plan.
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Before Filing this Inspection, Report,please see deport Completeneps Checklilst on next page.
it p.' •r D1 "title 5 Official Inspection' Fora,®Subsurface Sewage Disposal System,-Pa 17 f 1
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commonwealth of Massachusettsd
TmItle o Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
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Owner Ownei's Name
information is
requireth Andover
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State Z,ip Code: Date of Inspection
Cityffown
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E. Report Completeness C
Complete all applicable sections of this form 'linclusive of:
0 ., Inspector Information: Complete all fields this section.
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B. Certification: Signed & Dated and 11 1 21 3, or 4,checked
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C. Inspection Summary:
appropriate
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(Failure Criteria) and 6 (Checklist)com lete
D. System Information,:
For :Tight/Holding Tank -Purripling contract attached
For Sketch Sewage Disposal System drawn on pg. 16 or attached
IFor 1 , Explanation sti to depth to high groundwater included
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loci Board of Health to detarmine- the forte they use. The uste!n Pumping Record must be submitteO
the local, Roard of Health or other app"r6ving authority.,
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Tax Map # 210-107.C-0057-0000.0
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Parcel I'd 18341
BOWAB FAMILY IRREVOCABLE UST Sine Nov 2,014
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MARIANDRIVE
NORTH ANDOVER, MA 01845
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Service,Coda Rate, Charge Multiplier/Users
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W'TR WATER 01 ALL METER SIZE 22, 0, 11
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Serial No Status Location, Brand Type Size YID Cons
16336470, a Active 1001 METE METE w Water e' 2
Cate Reading Code Consumption, Posted Date Variance
4/18/2019 1100, a Actual 6 5/15/2 19, -7%
'1116/2,019 1094 a Actual 6 211 ,121 , 12% a�A
1 12212 1 , 1088 a Actual 6 1111 1201 -5% N
711 8121 1 2 a Actual 811 12 1 -1%
4/18/201,8 1076 a Actual 6 51171201 -11%
1/18/2018 1070 a Actua,l 7 212112 1 8 _2 °
10/17/201,7 1063 a,actual 9 1111312 1 2%
11 19/20,17 1054 a Actual 91 /1512 17 24%
411 /2 1 7 1045 a Victual 7 511 "12 1 4 %
1/19/201 17 1038 a Actual 1 211612 1 -2 %
10/18/2016 1033 aActual 6 1111 12+ 1 -12%
71`2121 1 027 aActual' 7 11 121 1 7
4/21/2016 1020 a Actual 6 5/25/2016 -33% I Y
1/21/2016 10 14 a Actual 9 211' 12 1 - % "'
1012112 1 1005 a Actual 1 w 11120 2 15 -2 %
1231201 a Actual 27 11412 15 238%
412 12 15 1959 aVictual 8 5 1 12 15 -11
1/22/2+ 15 951 a Actual 9 2/2 /2 ,15 - e
10123/2014 942 a Actual 2.1 1111412 14 -1
/23/2 14 921 a Actual 2 /1 12 14 1 "2
4/2312 14 898 aActual 611 1201,4 -2 °
1/2 /2 14 890 a Actual 12 211 12014 -10 a
1 124/2 1 a Actual 1 , 1111812 1 - %, e
7/23/2013 8165 a,Actual 29 8/1 1201 22 %
4/25/2013 8,36a,Actual 9 512 12 1 1 5
1/24/2013 827 a Actual 8 211 1201 - % y
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4121212 781 a Actual 9 511212 4%
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