HomeMy WebLinkAboutPass - Title V Inspection Report - 40 PHEASANT BROOK ROAD 7/31/2019 Commonwealth of Massachusefts,
Title 5 Off 1� Inspectm Form icia ion
o
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
40 Pheasant Brook Road
Property Address
Patrick O'Sullivan
Owner Owner's Name
information is
North Andover
i MA 018,45 7-18-20,19
requiredJor every
Inspection results must be submitted on this form�., Inspection forms may not be in a,ny,
way. Please see completeness checklist at the end of the form.
Importantia.When
filling out forms A. Inspector Information
tyk
on the computer,,
Nell James Bateson,
use only the,tab
key to,move your Name of Inspector
cursor-do not
at son Enterprises Inc.
use the,return
Company Name
key. Arill a Road
Company Address
V s j
Andover MA 101,810
City/Town State, Zip Code
978-475-4786 _S11-15
Telephone Number License Number
B. Certification
* cton 540 of 5
I certify, that: I am a DEP appro,ved system inspectorin full compliance with Se i 1 .3 Title
CMR.16.000)1- 1 have personally inspected the sewage disposal',system at the property address
listed above; the information reported below i's true, accurate and complete as of the time of my
inspection; and the inspection 'was performed based on my training and experience in the proper function
and maintenance cif -site sewage disposal systems.After conducting this inspection I have determined
that the system".,
1. Passes
2. E] Conditionally Passes
3., El Needs Further Evaluation by the Local Approving Authority
4 F 'I s
18-2019
11 n s ecto r,s t ig n a,t,,ure:,, Date
The system inspector shall, submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
101000 gpd or greater, the inspector and the system o,w,ner shall submit the rep rt to the appropriate
region office of the DE,P. The original form should be,sent to the system owner a,nd'copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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 conditions of use.,
t5,in .doic rev.7/26/2018 Tile 5 Officiall ire specUon Form:Subsurfate Sewage Disposal System-Page I of 18
uommonwealth ollf Massauselft
0 T A.
.0
I'Lle 5 OTticial Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessment:$
40 Pheasant Brook Road
Property Address
Owner Patrick O'Sullivan
Owner's Name
information is,
required for every North Andover IVIA 01845 7 11 7-2 0 19
page. dityrrown State l Zip Code date 6_f"_1r_s'pection
C. Inspection Summary
Inspection: Summary,- Complete 1, 21 3, or 5 arid'all of 4 and 6.
1) System Passes:
1 have not found any information which indicates that any of the failure criteria described
in 310 CIVIR 15.,303 or in 3,10 CIVIR 15.304 exist., Any failure criteria not evaluated are
indicated below.
Comments:
2) System Cond1litilonally Passes:
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 aPProv.ed by
the Board of Health, willpass.
Check the box for yes", "no," or"not determined" (Y, N, ND,),for the following statements. If not
determined,11 please explain.
Tihe septic tank is metal and over 20 years old* or the septic tank (whether metal,or not) is structurally
unsourlid,F exhibits substantial infiltration or eAltration or tank failure is imminent. System will pass
inspectioilll 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 Kit is structurally sound, not leaking and if a Certificate of
Compfiance indicating that the tank is less than 20 years old is available.
El Y N E] ND (Explain bellow):
fl
Wnsp 2 18 l 5 Offi6all Inspection Form.Subsurface Sewage Disposal Systern-Page 2 of 18
l.doc-rev.716120
Commonwealth of Massachusetts
-lo
�: ctal Ins
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
40 Pheasant Brook Road
Priip-erty Address
Patrick 0"Sulllivian,
Owner, 0 w'',n'er"s Name
information is
North Andover MA 01845 7-18-2019
required for every
Page. City[Town State! Zip Code Date of Inspection
C. Inspection Sum mary (cont.)
2) System Condlitionally Passes (cont.):,
El Pump Chamber pumps/alarms not operational. System will pass with Board'''of Health approval if'
pumps/alarms are repaired.
F Observation of sew e backup or break out or hi I gh static I water level in the distribut ion N due bo I
to broken or obstructed pipe(s) or due to,a broken, settled or uneven distribution box. Systp' m Will
pass inspection if(with approval of Board of Health).-
F] broken plies) are replaced El 'Y El N D ND (Explain below):
EJ obstruction is removed E] Y El N ND (Explain belowY
El fttdbuifion box is leveled or replaced El Y Ej N D ND, (Explain below
e
Thp systm requIr d pi�imping more than 4 times a year due to oroKep or o0str pt 0 p Th
jpe(�),, e
El _Je
system will pass inspection If(with approval of the Boar f Health):
E] broken pipe(s) are replaced E1Y 0 NEI ND (Explain below):
El obstruction is removed El Y [:1 N [j IND (Explain below):
3) Further Evaluation is Required by the Board of'Health-.
[:1 Conditions exill'st which, require further evaluation by,the Board of Health in order to determine if
safety or the environmen
the system, is failing to protect public health
a. System will pass unless Board of Health determ ilneslin accordance with 310 CMR
15,303(1)(b)that the systern its not functiomnq in a manner which will protect puldifle health,,
safety and the environment-.
t5 ins p.doc,rev.,712WO18 Title 5 Official Inspection Form:$ubsurfaco Gowago Disposal System-Page 3 of 18
Commonwealth of Massachusefts
0 OR
Tmtle 5 Official Inspect'lon, Form
SubsurfaceSewage Disposal, System Form Not for V luntary Assessments,
40 Pheasant Brook Road
Property Address
Patrick O'Sullivan
Owner
Owners,Name
R' information is
North Andover MA 0 184 5, 7-18-2019
required for every
pa e. City/Town a—t e— Zip Code Date ofInspection
9
C. Inspection Summary (cont)
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering, vegetated wetland or a salt marsh
b. System will fail unless,the Boar"of Health (and Public Water Supplier, "if any)
d 0 0'etermines that the system is functioning in a manner that protects the public health,
safety and environment:
I
El The system has a septic tank,and soil absorption system (SAS) and the SAS us within,
100 feet of a surface water supply or tributary to a surface water,s ly.
E] The system has a septic tank and SAS and the SAS "is within a Zone 1 of a pubfic water
Ya
supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private,water
supply well'.
E] The system has aseptic tank and SAS and the SAS is less than 100 feet but,50 feet"or
Mofe,frpm, private water suppjy We'll**.
Method used to determi ne distance'.I
This system passes if the well water analysis,, performed at a DEP certified, laboratory, for fecal
colliform, bacteria indicates absent and the pr nce of ammonia 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.
c. Other:
4) System Failure Criteria Applicable to All Systems.
You must indicate"'Yes" or"No"to each of the following for all inspections.
Yes No
Backup,of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponying ofeff Iuent to the surface of the ground or surfacewaters
due to an overloaded or clogged, SAS or cesspool
t5insp.doc rev.71,2612018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 4 of 18
Clommonwea,%Ith of Massa,ch use
tts
Title 5 v c sp, eiction or
Su'bsurface Sewage,Disposal System For Not for Voluntary Assessments
4,0 Pheasant Brook Road
Pfoperty Address,
Patrick O'Sullivan
Owner Owner's Name
ro
information is
7-18-2019
page., City fton
C. Inspection Summary (cont.)
4) Systern Failure Criteria Applicable to All Systems,,,, (cont'.)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El' Z Liquid depth in cesspool is less than 6" below invert or available volurne is, less,
than Y2day flow
Required pumping more than 4,tir + s iin the last year NOT due to clogged, or
obstructed plIpe(s). Number of Urnes pumped:
Any,portion of'the SAS, cesspool or privy is below high ground water elevation.
Any,portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supipl�y.
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 ofa private water supply well.
Any portion of a cesspool or privy is, less than 1 GO feet but greater than 50 feet
from a private water supply well,with no acceptable water quality analysis. (This
system passes, lif the well water analysis, performed at a CEP certified
laboratory,for fecal cioliform bacteria indicates absent,and the presence
of am,monia nitrogen and miltrate nitrogen i's equal to or,less,than 5 ppm,
provided that no other failure criteria are,triggered. A copy of the analysis
and chain of custody must be attached to this form..]
FI M The system is a cesspool serving a facility with a design, flow of 2000 gpd-
101000 gpd.
The system fails. I have determined that one or more of the above failure
El E ciriteria ,exillst as described in 3,10 CMR 15.303, therefore the system falls. The
system owner should contact the Board of'Health to determine what will be
necessary,to correct the failure.
5) Large,Systems: To be,cons,ide ire d a large system the system must serve a facility with a
design flow olf',10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section C.4.
Yes No
1:1 the system is within 400 feet of'a surface drinking water supply
El the system is within 200 feet,of a tributary to a surface drinking water supply
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
151nsp.doc rev..7/26,12018 Title 5 Offi l Inspection Form:Subsvrfac4D Sewage Disposal System-Page 5 Of 18
Commonwealth of Masschse
u icia ionTitle 5 'ff .1 Ins*ftect" Form�
Subsurface Sewage Disposal System Form Not for Voluntary Assessments,
Pheasant Brook Road
Property Address
Patrick O'Sullivan
OwnersOwner
information is
North Arr er 01845 71,1 2 19
s
required for eve
page. City/Town State Zip Code Date of Inspection
C. Inspection mar cone.
It you have answered yes,"to anyquestion in Section G.5 the system is considered a significant
n
threat, or,answered "yes"to any question in Section C.4 above the large system has tailed. The
G owner or operator of any large system considered a significant threat under Section C.5 or tailed'
under Section C.4 shall'upgradel'the system in accordance with 310 CMR 15.304. The system,owner
should contact the appropriate regional office the Department.
Bi
6. You must mindmicate"Yes"' o no"for each of the following for all Inspections:
Yes No
� o
Pumping ing information was provided by the owner, occupant, or Board of Health
E] 0 Were any of the system components pumped out in the previous weeks?
0 El Has the system received normal flows in, the previous two week.period`
Have large volumes,es water been introduced to the system recently or as part of
this, inspection?
Were as,built pleas of the system obtained and exat i ed? It they were,not
i" available,note as N/A)
Was the facility or dwelling inspected for signs of sewage back Lip
El Was the sit inspected for sigma of break outs'
0 El
Were all system r rye ts, excluding the SAS, located on site?
Were the septic teak manholes uncovered erred and the interior of the tank
inspected for the condition of the baffles or tees, material l nstructi n,
q imensi r s, depth of liquid, depth sledge and depth t scum?
s the facility owner(and occupants, if different frorn owner) provided with
01 El informationn the ,proper maintenance of subsurface sewage disposal systems?
The,seize and location of the Soil Absorption System SIRS on the site,has
been determined based on:
0 El Existing information, For example, a plea at the Board of Health.
Determined in the field i 'airy of the t i lure criteria related to hart C is at issue
e approximation ist once us' cce table), [310 CMR 15.302(5)]
u
t5insp.d -rev.7/2612018 Titte 6 Offidal inspection Fora,:Subsurface Sewage Disposai system.page of 1
Commonwealth of Massachusetts
ICE
T 5 1 Inspnection Form
itie urncia
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
40, Pheasant Brook �Road
Property Address
Patrick O'Sullivan
Owner Owneles Name
wired
e for ornover evry
page. Cltyffown State, Zip Code Date of Inspection
Po
D. System Information
1. Residential Flow Condaltlons�:
4 4
Number of bedrooms (design),-, Number of bedrooms, (actual):
440
D ES I G N flow based on 310 C M R 15.2,03 (for example* 110 g pd x#olf'bed roo m s):1
Descriptiontl
:1
Number of current residents:
04 Does residence have a garbage grinder? Yes No
Does residence have a water treatment unit? El Yes Z No
If yes.; discharges,to'.
Is laundry on a,separate sewage systern? (Include laundry system inspection El Yes M No
informationire this report.)
Laundry system inspected? El Yes Z N o
Seasonal use? E] Yes Z N o
Water meter readings, ifavenable (last 2,years, usage
Detail":
Sump plump? E] Yes 0 N o
Current
Last date of occupancy: Date
t5insp.doc rev.712612018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
0%AMA*is a
utticia -'ectimon Form
p I 5, 1 InsmpAh
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
40 Pheasant Brook Road
Property Address
Patrick O'Sullivan
Owner Owner's,Name
inform, ion is
i North Andover MA 01845 7,18-201�9
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information, (c,ont.)
2. Commerciall/Industriall How Conditions:
Type of Establishment,*
Design flow(based on 310 13MR15.2031): Gallons per day(gpd)
Basis ofAesign flow (sets/persons/sq.ft, etc.):
Grease trap present?, El Yes El No
Water treatment unit present? El 'Yes, [:1 No
If yes, discharges to:
Industrial waste holding tank present? 0 Yesfl
El No
Nion-sanitary waste discharged to the Title 5 system? El Yes, E] No
'Water meter readings, if available:
Last date of'occupancy/use: Date
her(describe below):
3. Pumping Records:
Source of inforrnation.,* Pumped M,�y 20181, owner
Was system pumped as part of the ins pection? Z Yes El N o
15010
If yes, volume pumped: gallons
Measured tank
How was,quantity pumped determned i ?
Reason for plumping: Inspect tank &,tees
t5insp.doco rev.7/2612018 Title 5 Offidal Inspection Forl Subsurface Sewage Disposal System-Plage 8 Of 18
Commonwealth, of Massachusetts
..........—$
Title 0 UTti cial Inspection i�or,m
>
Subsurface Sewage,Disposal"System Form, Not for Vol u nta ry'Assesisments,
q's 40 Pheasant Brook Road
Property Address
Patrick O'Sullivan
Owner Ownees,Name
information is
required for every North Andover MA 01845 7-18-2019
Page., City/Town State Zip Code Date of lirtspection'-...................
D. System Information (cont.)
4. Type of System:
Septic tank, distribution box, soil absorption system
El
Single cesspool
Overflow cesspool
Privy
EJ Shared system (yes or no,) (if yes, attach previous inspection records if any)
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 II system by system operator under contract
Tight tank. Attach a copy of the DEP approval.
El Other(describe).*
Approximate age of all complonients, date installed (if'known) and source of information:
20 years,old, 6-2-:19919, as built plan
o Were sewage odors,detected when arriving at the site? El Yes 0 Nip
r v 51., Building Sewer(locate on site plan).',
2.6
Depth below grade:
feet
Materia,l of construction:
cast iron M 40 PVC Ej, other(explain):
Di i n e:stance from private water supply well or suctI on fine.
feet
Comments (ors condition of Joints, venting, eviI n f l ge,, etc.):
4" PVC through wall to,septic tank, 3" PVC in house, no, leafs,vis,ible
t5insp.do rev.712612018 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Pago 9 of 18
uommonwealth of Massachusetts
I Inspect"ion Form
ZI
TI"tle 5 ,u'ffi"cia
Subsurface Sewage disposal System Form Not for Voluntary Assessments
40 Pheasant Brook, Roald
Property Address
Patrick O'Sullivan
Owner dw.ners Name
information is North Andover MA it 845 7-18-2019
required for every
page. CityfTown State Zip Code Date,of Inspection
D. System Information (cont)
6. Septic Tank(locate on site plan):
1.6
Depth below gradle, feet
Material'of construction*,
Z concrete El metal fiberglass, polyethylene, F1 other(explain)
If tank is metal,, list age*
years
Is age,confirmed by a Certificate of Compliance? (attac,h a copy of certificate) 0 Yes, El No
Dimensions.
Sludge depth: 3
3011
Distance:from top of sludge to bottom ofoutlet tee or baffle
311
Scum thickness,
8111
Distance from top of scum to top of outlet tee or baffle
o 1211
Distance from bottom of scum, to bottom of outlet tee or baffle
Tape Measure
How were dimensions determined'?
Comments (ors pumping recommendations 3 inlet and outlet tee or baffle,condition, structural integrity)
liquid levels as related to,outlet invert, evidence of leakage, etc.,)!:
Inlet tee partialy clogged clean, same,. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert,, No
evidence of leakage.,
t5hsp.doc rev.71:26112018, TJUe 5 Offidal Inspection Form",Subsurfaw Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts,
'Otle i n
5 Ar% ,0 It,icia
T Ut I I s p ion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
40 Pheasant Brook Road
Property Address
Patrick "SullivanO
Owner Owners Nam
information ls
required for every NoIrt,h-Andover MA 018451 7-18-2Q19
page. Cutyff own state Zip Code Date of lnsp�crlon
D. semi
7. Grease Trap (locate on site,plan),
o
Depth below grade:
feet
Material of construction,:
E] concrete El metal E:1 fiberglass polyethylene El other(explailn)*
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 pumpling.* Date
Comments (on pumping recommendations, inlet and outlet tee or baffle,condition, structural integrity,
liquid levels as, related to outlet invert, evidence of leakage, etc.):
8. Tight or Holdinlg Tank(tank must,be pumped at time of inspection) (locate on site pJan):
Depth below grade:
Material of construction,:
El concrete El metal iberglass polyethylene
other(explain),*
Dimensions*
Capacity*
gallons
Design Flow'.-
gpiloris per day
t5 ins p.doc rev.7/261,2018 Title 5 Official Imipection Form:SubsurfaceI Sewage Disposal Syslem-Page I 1 of 18
Commonwealth of Massachusetts
Ticia lon Form
T'Itlb 5 .1 nspect'
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
40 Pheasant Brook Road
o Property Address
Patrick Sullivaln
Owner Owners Name
information is
j North Andover MA 018,45 7�,11&2019
required for every I — bie of pec
page., City/Town State Zip Code t— Ins tion
D. System Informatio n (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: El Yes [:j N o
Alarm level, Alarm in working order: El Yes N o,
Date of last pumping:, Date
Comments (condition of alarm and float switches,, etc.),*
Attach copy of current pumping contract(required). Is copy attached".? El Yes El No
9. Distribution Box It present must be opened') (locate on site plan):
0
Depth of liquid: level above outlet invert
Comments (note if box is level and distribution to outlets,equa,l, any evidence of solids carryover,, any
e idence of leakage i vi nto or out of box, etc.):
I
F.
D-box level and distribution equal. No evidence of leakage. Evidence of light carryover, pumped' d-
ti box to clean.
t5 ire sp.doic-rev.7126/2018 Title 5 Official inspection Form Subs,urface Sewage Disposal System Page 120f 18
Commonwealth of Massach�usefts
/........ eicta p ion
Ti 5, Aff I InsijII&ect Form
>1 Subsurface Sewage Disposal System Formw Not for Voluntary Assessmentso
<1
40 Pheasant Brook Road
Vf6perty Address
Patrick O'Sullivan
Owner,
Owner's Name
information is North end MA 01845 718-2019
r�equired for every
Page. t ' Mate Zip Code Date of Inspection
D. System I formation (cont.)
10., Pump Chamber(locate on site plan)#
Pumps in working order: El Yes El N 0,*
Alarms in working order.: Ej Yes, El N6
Comments (note condition 0fpum,p chamber, condition of pumps and appurtenances, etc
If'pumps or alarms are riot ire working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required).
If explain why.,SAS, not located,
4
'Type:
leaching pits number:
leaching chambers number:
leaching galleries number*
leaching trenches number, length.
leaching fields number,, dimensions*
El, overflow cesspool number:
innovati ve/alternativie system
'Type/name of tech,niol ogy
t5insp.doc-rev.,7126/2018 Title 6 Official Insp"tion Form-SubsuffaceSewage Disposal:System-Page 13 of 18
Commonwealth of Massachusetts
sd
IN.L
tic's 1 1nspec
T Ile .5 UA&*N%100&N ia tion Form
W I
S�ubsu�rfac,e Sewage Usplosal System 'Form Not for Voluntary Assessments
40 Pheasant Brook Road
Property Address
Patrick "SullivanO
Owner Owner's Name
information is North!,Andover MA 01845 7-18-2019
i required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
11. Soil Ab,sorptilon System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.).&
Soil ok Ve,getaion ok. No,sign of pon,ding to surface., 12 concrete chambers on bed of stone 65' x
1 Z ". C a
-box to chambers, no liquid at invert.5amer outlet pipe out of d
12. Cesspools ('cesspool must be pumped as,part of inspection) (locate on s,ite plan)
Number and configuration
Depth —top of liquid to inlet invert
Depth of'solids layer
pth of scum, layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow 0 Yes No
i
Comments (note condition of s,o�il, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.).
o
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Commonwealth oflWassachusetts
u ci"a,l Inspect"ion Form"tle 5 'ffi
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
40 Pheasant Brook Road
Property Address
Patric,k O'Sullivan
Owner
.............Owners Name
information is
required,for every North Andover MA 01845, 7-18-20 19
page. CityfTown State Zip Code Date of Inspection
MI
D. System I nformation (cont.ii
13. Privy (locate on site plan)*
Materials of construction:
Dimensions
Depth of solids
Comments (mote condition of soil, signs of hydraulic failure,, level of ponding, condition of vegetation,
etic):
11
ff
IIj
VN
t5iinsp.doc-rev.7126/2018 Title 5 Official Inspection Form,Subsurfaoe Sewage Disposal S�yst,em-Page 15 of 18
Commonwealth of Massachulsefts
T"'Ie 5 "ff I Inspect'i6on icia Form
ssessmen
Not,fo Ats
Subsurface Sewage, D*sp�osall System Form r Voluntary
40 Pheasant Brook Road
Property Address
Patrick O'Sullivan
pi
Owner Owners,Name
information i's
req u i red for every North Andover ...... MA 01 84�5 7-18-2019
page. City[Town State Zip,Code Date of inspection
D. System Information (cont.)
14. Sket0 Of Sewage D111sposal System:
Provide a view of the sewage disposal system, including ti s,to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supplyeaters
the building. Check one of the boxes below.,
El' hand-sketch in the,area below
drawing attached separately
tv L
\0°�)\j evra
.........
ID
Lf j
C)
ON
del
Q
t5insp.doc-rev.7126/2018 Title 5 Official Inspectilon Florm:Subsurface Sewage Dispo�sal System-Page 1:6 of 18
Commonwealth of Massachusetts
K-- T'Itle 5 v'ff'icia1 lnjs*p%ectinon Form
Subsurface Sewage Disposal System Form Not for'Volunta,ry Assessments
40 Pheasant Brook Road
Property Address
Patrick O'Sullivan
Owner Owners Name
Informationis North Andover MA 01845 718-20 19
required f6r -ev,ery
ti
page. Cityff own State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Check Slope
Surface water
Z Check cellar
J
Shallow wells
4
Estimated depth to high ground water* feet
Please indicate all methods used to determine the hi h r1round water elevatiow
Obtained from system design plans on record
6-22-1994
If checked, date of design plan, reviewed: Date
Observed site (ablutting pro perty/observatilon hole within 150 feet of SAS)
Checked with local Board of H lth explain*
Design plan
Checked with local excavators,, installers (attach documentation)
Accessed USES database,-explain.*
You, must describe hiow you established the high ground water elevation:
Test pit data on design plan
Befolre fiRling thils Inspectilon Report, please see Report, Completeness Checklist on next page.
mi
ij
�fj
1,
t5 ire sp.doc ,7126/2018
Title 5 Official Inspection Form,Subsurface Sawago Disposal System-Page 1,7 of 18
-rev
Y y
II
U
E n
a� Commonwealth o�f Massachusetts
oTIT.1e, 5
ICI Insip, ect"ion Form
Subsurface Sewage is s l System Form Not,for Voluntary Assessments
40 Pheasant Brook Road
or
Property Address
atrick 'Sulll r
Owner Owners Name
information is Forth Andover MA 011845 8-2019
required'for every page. it � MIDI
E. Report Completeness Checkli,st
y
Complete all applicable!sectilions of this,form *inclusive sl
i3
0
X Inspector Information*. Complete all fields in this section.
B. Certification Signed & Dated and 1, 2, 3, or 4,checked
C. Inspection SmaryM
1
3 2,1 3, r 5 completeds a r rlate
(,Failure Criteria.) and (Checklist)l list)completed
' . System Information-.
For : Tight/Holding,Tani lug contract the
fd
For : Sketch of Sewage Disposal System !r wn on pg. 16 or attached
0
For 5 Explanation estimated depth t highgroundwater in�cl�r 'e
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t5ln . oc.rev,712612018 Tits �� al In e f un Farm,Subsurface SewageD% 'N t om �1
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Towns of N Andover
'Tax Map # 210-1063-0242-0000.0
Parcel Id 17641
40 PHEASANT BROOK ROAD
0 SULLIVAN, PATRICK Since May 2014
40 PHEASANT BROOD ROAD
NORTH A OVER MA 01845
Class 1,01 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 I Residential
Size Total 1 Acres
FY 2019
UB Mailing Index
Na,me/Address T Y p e Loan Number Active/Inact. From Until
USULLIVAN,PAT RICK Payor Active,
40 PHEASANT BROOK ROAD
NORTH ANDOVER., MA
01845
UB Account Malonti..
Account No cycle Occupant Name Active/Inactive
Bldg Id. 785 .0-40 PHEASANT BROOK ROAD Last Billing Date 4/9/20119
3170517 03 Cycle 03 Active
UB Serviices Maint.
Account No.3,170517
Service Code Rate Charge Multiplier/Users
IVIISCFEE ADMIN FEE 0.6315/8 7.82 1/
WTR,WATER 01 ALL METER SIZE 26.,60 /1
UB Meter Miai'Menancti
Account No.3170517
Serial No Status, Location Brand Type Size YTO Cons
36388118, a Active ERA`HH b,Badger w Water 0.63 0.63, 891
Date ReadIng Code Consumption Posted Date Variance
61/7/2019 897 a Actual 7 -14%
3/7/2019 890 a Actual 8, 4/16/2019 55%,
12/7/2,10,18 882 a Actual 5 1/22/2019 -66%
9/11/20,18, 877 a,Actuail 16 10/15/20,18 98%,
618/2018 861 a,Actual 8 7/2312018 4%
3/6/2018 853 a Actual 8 4/23/2018, 27%
12/6/20 17 845, aActual 15 1/25/20181 -64%
9/11/2017 839, a Actual 19, 10/1812017 78%,
61612017 820, a Actual 10, 7/25/20,17 -11%
3/7/2017 810 a,Actual 11 4/12/2017 2%
121/8/2,016 '799, a,Actual 11 13/2017 -79%
9/8/2016 788, a Actual 53 10124/2016 555%
6/7/2016 735 a,Actual 8 8/2120 16 -45%
3/7/2016 727 a Actual 14 4/22/2016 -44%
12/9/2015 713 a,Actual 26, 1/20/'2016 -71%
9/8/2015 687 a-Actual 911 10/16/201,5 137%,
61/8/2015 596 a Actual 38 7/24/2015 168%,
319/201 5 558 a Actual 14 4128/201 5 -18%
12/9/2014 544 aActual 17 1/151'2015 - 1%
9110/201 27 a Actual 44 10/15/2014 69%
6/10/2,014 483, a,Actual 26 7/16/'2014 51%
3/110/2014 457 a,Actual 17 4/11/2014 -20%,
12/9/2013; 440 a Actual! 21 1/17/2014 -36%
9/10/2013 419 a Actual 33 10/15/2013 6%
6/11/20 13 38,6 a Actual 31 7/24/2013 31%,
3/12/2013 355 a Actual 24 4/22/2013 -5%1
12/10/2012 331 a Actual 2 1/9/2013 -44%
9114/2,011 307 a.Actual 47 10115/2012 27%
6/11/2012 260 a Actual 35 7/16/2 012 54%
3113/2,012 225 a Actual 23 4/14/2012 -19%
lommo
no,f Massachusetts
C 6wn i'ty/T
of
System Pumplong Record
y Form 4
P has provided 's form for use,by Focal Boards ofHealth. Other formt may-be`Used, *
but the
.inform n,must be substintially the.tame as that provided here. Before usingA is forin,check with
10061 Board of Health 6 determine the use. The.System Pumping Recordmust be Submitted to,
Nthe local Board of Health or otherapproving autho ..
t,
A., FactlityInforMation
System Location: Left/RIght,front of hous a R'fgh rearof' house' Left./right side of,house, Left,/13 lap
'fight side of building, Left"Right fr,6nt of bul dinfi , Lei ` gl cif building, under deck
Address 7C
LIV
Cityrrown Stag ZIP Colde
2, System Owner.
u�
a
Name
Address different from location)
City/Towsde
Telephone Number
B. Pumping Record
I. Date of Pumping Diate 2. Q � i l Gallons
3. Type-of s b, C SS 1 1 s) S,,,-eeptiG'TankTight
E] Other(describe).
4. Effluent Tie Fitter present? ED Yes If yes, was it cleaned?' Ej Yes E] No
9G
, d
, . Condition stem:
q 6 system ' e By.,,
Nest.Bates F58,21
Name Vehicle License Number
teen hto razes Ina
Company
here content&were disposed.
Lovett Waste Water
sigi Ohio � fie
�1
Worm,
pE,
0
.. ' co 03 Systems Pumping Record 'Page
v
o�
Town O'North Andover
HEALTH DEPARTMENT
C INN U
CHECK,#': DATE:
lira, 9
LOCATION:
...............
HIO NAME,:
.............
CONTRACTOR NAME: "F!"Le
Of hermit or U (Check box)
jyge icense:
Dj Animal $
0 Body Art Establishinent $
0 doller $
$
0 FoodiService $
1:1 Ftineiral Directors $
11 Massage Establishnient
0 Massage-Practice
0 Offal(Septilic),Hauler
11 RiecreationalCamp,
0 Sun tannitig $
0 Swimniing Pool $
11 Tobacco, $
Ell Trasi/VSolg"d Waste Hauler $
Di Well Construction
SEPTIC Sys,tgns:
11 Septic- of Testing, $
0 Septic-Design Approva I $'
0 Septic Dfisposia lWorks Construction(DWO $
13 Septic Disposal Works Installers(DWI) $
11 Title 5 Inspector
Title 5 Report $
0 Other:(Indicate) $
Healffil"Ag""""'en't Infflals''
i
White-Applicant Yellow-Health Pink-Treasurer,