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HomeMy WebLinkAboutPass - Title V Inspection Report - 60 BEAVER BROOK ROAD 5/12/2020 Commonwealth of Massachusetts Vic , RECEIVED 171 , Title 5 1- OfficialInspectionForm MAY 1 2 2.020Subsurface Sewage Disposal SystemFor Not for Voluntary Assessrt� OF NORTH AND(7vER T�HjEALTH DEPARTMENT Property Address M Owner Own�Name 1 L� U information is required for every ( (�l, — page. City/Town —! 1 l— ' State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any Important:When way. Please see completeness checklist at the end of the form. . Inspector Information filling out forms q on the computer, use only the tab .Q key to move your Nary) of Inspector cursor-do not (`!�� use the return 1 key. Company Name A- $: . 4 pc 42, . t= Company Address CltylTown /� ! State C ZIP Code O � Telephone Number t (� License NSumber B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and 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 of on-site sewage disposal that the system. systems.After conducting this inspection I have determined rmined 1- [Er-'Passes 2. ❑ Conditionally Passes 3• ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the A p of Health 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 re oro ng Authority(Board regional office of the DEP. The original form should be sent to the system owne the appropriate to the buyer, if applicable, and the approving authority. rand he Please note: This report only describes conditions at the time of inspection and under 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. t5insp.doc•rev.7/26/201a Title 5 Official Inspection Forrrr Subsurface sewage Disposal System.page 1 of 18 Commonwealth of Massachusetts != - Title 5 Official Inspection Subsurface Sewage Disposal System on Form or Voluntary Assessments RANI v Property Address Owner -Tom information is Owner's Name required for every �) — Ql..(�� page. Cay/I own State State Zip Code uate of Inspection —�— C. Inspection Summary Inspection Summary: Complete 1,2, 3, or 5 and all of 4 and 6. 1) System Passes: y F S s al 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: 2) System Conditionally 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 approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 2 of 18 `A Commonwealth of Massachusetts ter. Title 5 Official p,��� Subsurface Sewage Disposal SysnSForeCt�fon Form � � Voluntary Assessments PropertyOAddress Owner Owner's Name , information is required for every ► 1 " an ��,��,�.t, _ page. Clty/town �!V'b _� y —15 —a O State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.page 3 of 18 Commonwealth of Massachusetts Title 5 Official 'cial Inspection Form =„ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner. Owner's Name C) information is —� required for every � s� t ^�page. City/I own ---- 1 1/"� V �^ S- @L V State Zip Code Date of Inspection 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 Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ 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 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 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 ponding of effluent to the surface of the ground or surface waters t5insp.doc rev.7/26/2018 due to an overloaded or clogged SAS or cesspool • Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 18 AA Commonwealth of Massachusetts 124 Title 5 Official Inspection Form T -AS J} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Lo �Owner Ton U Owner's Name information is required for every (�(S /\V — Li S v page. City/Town V State Zip Code Date of inspection C. Inspection Summary (cont.) 4) System 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 ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times 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 supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply �.� well. ❑ ET-'- portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Er�'- Any portion of a cesspool or privy is less than 100 feet but greater 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 ppm, 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 2000 gpd- 10,000 gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 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 ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ 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 II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sevrage Disposal System•Page 5 of 18 Commonwealth of Massachusetts f=: Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments F J Property Address 7 0(y-\ — L c� Owner Owners Name information is �_ ���� required for every _ �?�141.!� (q page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section C.4 above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for a//inspections: Yes No D'— ❑ 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? ❑ Has the system received normal flows in the previous two week period? ❑ 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 examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? u ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with 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: lJ ❑ Existing information. For example, a plan at the Board of Health. d ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sevage Disposal System•Page 6 of 18 TOM 60 BEAVER BROOK ROAD NORTH ANDOVER MA Oi 84 _ =r.r r=..r ri•[[ii[[[i i 5 3370 � x- i ilt.l.. tr.li.tll.tt►!..lt,�rl�t. t 1 � SERIAL# READINGS Current USAGE NB OF 3 15 31 8 Type Date DAMS 980 a 03/05/2020 13 87 � f 7}3 1 k SERIAL# READINGS USAGE NB 01= Current Type Date DAYS I 3c'153118 1 954 a 12/09/2019 13 87 36153118 941 a 09/13/2019 13 98 3E153118 924 a 06/07/2019 17 92 36/531/8 908 a 03 07 201/ / 9 16 90 36153118 891 a 12/07/2018 17 87 36153/18 872 a 09/11/2018 19 95 301, 53118 856 a 06/08/2018 16 94 36- �31_9 840 a 03/06/2018 16 90 MESSAGES: RETAIN THIS PORTION FOR YOUR RECORDS. MM *NOTE* PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR r t WATER RATE : FIRST 20 UNITS $3 . 80 OVER 20 UST-1" SEWER RATE : FIRST 20 UNITS $ 5 . 95 OVER 20 UN1 BYPASS METER WATER RATE : ALL UNITS $5 . 55 3 P ease return this portion with your payment to Town of North Andover Commonwealth of Massachusetts , r Title 5 Official Inspection Fora ;7, �r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments perty Address Owner — TOC'� L--c!�Cc!) information is owners Name required for every '�a fA C rnn ,U C( I� Li ^ J l c page. Clty/Town State� b_l.Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Llil Number of bedrooms (design): —=-- Number of bedrooms (actual: DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: N Does residence have a garbage grinder? ❑ Yes Q"'No Does residence have a water treatment unit? ❑ Yes [�No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes [3'�No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ['T'No Water meter readings, if available (last 2 years usage (gpd)): Detail: 4 Sump pump? ❑ Yes ET-No Last date of occupancy: u f(h Date f5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 7 of 18 Stewart's Septic Service ❑ Andover Septic ❑ Stratham Hill Septic ❑ Roto-Ram (978) 372.7471 (978) 475-2593 (603) 772-5548 (978) 452-9022 58 South Kimball Street, Bradford, MA 01835 Date of Service PAY FROM THIS BILL Customer Name: ❑ Reg. Nature of Service ❑ NIC I U Reg.faint. Service Location: a Emergency I Phone: Septic Tank Pumping and Cleaning ❑ Day ❑ Night Contact: "Done the Right Way" Billing Address: Not Responsible for Covers or Irrigation Systems City: zip: Special Instructions U' Completed ❑ Incompleted Reason: Per: AM/P; Servti 7ces Rendered rVn" Vacuum Pumping Observations Drain Cleaning I �_ Septic Tank ❑ Good Condition ❑ Main Line Drywell O Leechfield Runback ❑ Toilet Bowl Leech Pit/Overflow ❑ Riding High ❑ Kitchen Sink D-Box (liquid level) ❑ Bathtub/Shower ❑ Pump Chamber ❑ Full to Cover ❑ Vanity ❑ Grease Trap ❑ Excessive Solids ❑ Floor Drain ❑ Catch Basin Top/Bottom ❑ Vent ❑ Portable Toilet ❑ Use No Powdered Soap ❑ Sewer Jet J Other O Heavy Grease ❑ Other On': ❑ Roots Footage: Size: ❑ Suggest Electric ❑ Under 1000 gallons ❑ 1000 gallons ❑ 1500 gallons Rootering ❑ 2000 gallons ❑ 3000 gallons ❑ 4000 gallons ❑ Van Called ❑ 5000 gallons ❑ Other ❑ Other Misc. `I Digging Charge ❑ Backhoe ❑ Inspection Location 't-l'" ❑ Consultion hrs. ❑ Certification: P/F Service Call ❑ Estimate Reason: Labor ❑ Portable Toilet Rental ❑Pump Repair ❑ Waiting Time ❑ Baffle ❑ Repair * Digging Charge is Per Driver ❑ Chemical Treatment Discretion ❑ Other Description of work r U 0A _I C f� �" 1-{ �� Recommendations Terms of Payment Parts Vacuum Pumping Drain Cleaning PAYMENT DUE IN FULL Yr. Month Yr. Month UPON COMPLETION Tax Terms&Conditions O Cash J Check 0 Credit Discount 1. Not responsible for damage beyond curb line ; o Total �� �t 3. 1.5/o per month will be charged to accounts past due. ; 12. All complaints shall be reported within 48 hours. -=�,�-'..t U 4. The purchaser agrees to pay all cost of collection. 1 3 Customer Signature -- Serviceman /r1 V 0 e- Commonwealth of Massachusetts Title 5 Official In spection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner owners Name information is ^ n required for every ow—( COW page. City/Town � State ZipCode Date of Inspection D. System Information (cont.) 2. CommercialAndustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.).- Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other (describe below): 3. Pumping Records: Source of information: 110 M c cv i �•,�� «� �� Was system pumped as part of the inspection? ElYes a—No If yes, volume pumped: gallons How was quantity pumped determined? .D e S i 4 1-\ ,D let ON, Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 8 of 18 10 Commonwealth of Massachusetts _►� F Title 5 Official Inspection Form s al Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Owner ` V Name M L ners y Ow information is _n _C n�� required for every ' ` ` Q C 11:�(J s L/— I �^�(� page. City/Town State - Zip \J P Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: c / ./ Ea"r Y % 1 I� Were sewage odors detected when arriving at the site? ❑ Yes ErNo 5. Building Sewer(locate on site plan): Depth below grade: 36 feet Material of construction: ❑cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): (�tIL fit` �� ' t5insp.doc•rev.7@8=18 Title 5 Officiaf Inspection Form:Subsurface Sewage Disposal SiYstsm•Page Odle ` Commonwealth of Massachusetts ; Title 5 Official Inspection p Form �; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner T(-,M L c-)s(-0 information is Owners Name required for every 0 —C-L ()>—(` page. Clty/Town I R .� Li-- I State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): y e Depth below grade: feet Material of construction: 21te concrete ❑ metal ❑fiberglass 9 ❑ Polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes '� , X S 6 ,, El No Dimensions: 6 � x' S Sludge depth: < Distance from top of sludge to bottom of outlet tee or baffle '-/U Scum thickness < ' Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 54,"ck Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): C nGlr41G!'1 1 �0 P CIO WWe ccs4le�- �3��'1P t� �►�� � ��c �, Lie 2! t5insp.doc•rev.7/26/2018 Q ' J 'v� u 6' Title 5 official Inspection Form Subsurface Sewage Disposal System•page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection �! Subsurface Sewage Disposal System Form- Not for Voluntary luntary Assessments Prope rty Address t Owner Owner's NamM L� c U information is required for every (-� —C (1 ) )'4L{- page. City/I own � _�—l S-a State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 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 to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 9 El polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: ±Sinsp.doc•rev.7/26/2018 gallons per day Title 6 Official Inspection Form Subsurface Sewage Disposai System•page 11 of 18 ' Commonwealth of Massachusetts ;�� Title H � Subtle 5 Official Inspection Form e Sewage Disposal System Form - Not for Voluntary Assessments coo Property Address Ric) Owner 70 M vS information is Owner's Name required for every ^ O'c page. CRY/I own State Date of Inspection Li- -av D. System Information (cont.) Zip Code 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: El Yes ElNo Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): y e S Depth of liquid level above outlet invert i-1'-ri'r"( 2 ye r Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): l r 'l rS eC4-1a;i_ . t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form Subsurface Sewage Disposal System-page 12 of 18 , .; Commonwealth of Massachusetts =►V�'MINE Title 5 Official Inspection Form 5 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner Owners information is ,/-� required for every I L - Luc page. Clty/Iown State i� - --I' I -11:�- Zip Code D. System Information (cont.) Date of Inspection 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " 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): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: C� leaching trenches number, length: R Ix ❑ teaching fields `/ ' v✓, �i�. number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal system.page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is ,� (► required for every 1 1 �1 �ypl v -1 page. City/Town State U) -` ` f ( 5 Zip Code Date of Inspection 0�� D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): f�C��t .{ �G! C) �' Gt (1 y /T-/ G 7�� 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 solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of etc.): ponding, condition of vegetation, t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form Subsurface Sewage Disposal System•page 14 of 18 11 Commonwealth of Massachusetts Title 5 Official Inspection Form =i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Propertd cress Owner Name"'o ' ` L�\C � o inform wners information is n required for every ' ! r page. City/Town State—�O _ Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 15 of 18 ELEVATIONS of NAs_ SIG -BULL O 4� - � �, INv. OF PIP£OU7 OF HOUSE t36.8d 136.97 a, - � 1NY.yOi'PIPE AT SEPTIC TANK INLET 136.38 IJ6.36 S' INV. OF PIPE AT SEPTIC TANK OUTLET 136.13 M1 �136.IO it INV. OF PIP£AT D-90Y. INLET'+ \ I 135.50 � 135.54 ' --- GRADING EASEMENT ---� / INV• OF PIPE AT D-BOX OUTLET P 135.33� f35.3S. AT END OF DISTRIBUTION PIPE 1 135,00 I35.07 {; r INV. AT ENO OF DISTRIBUTION P/PE 135.00 1 MOO VEfJT- `�92 NOTE: THIS PLAN IS NOT A WARRANTY OF THE SYSTEM. IT IS :•j;�, 44' ' A RECORD OF THE LOCATIONS OF THE-EXISTING STRUCTURES, 1 12' '•,f D--BOX 54' LONG x a' WIDE rp LOT 15A LEACHING TRENCHES Tp_`+6 s-, P-JS 1500 GALLON SEPTIC_TANKEXISTING _U,rU—NDAT10N X l TOP FND �r INTERIM AS BUIL T PLAN L Q T 14 OF = SUBSURFACE DISPOSAL SYSTEM AREA 1.00 ACRES QQ AT 4 �� LOT 14 EVERGREEN ESTATES 1N I NORTH ANDO VER, MASS. PREPARED FOR: � - THOMAS LOSCD SCALE: 1" _ 20' DATE. DECEMBER 3, C14RISTIANSEN I�"'.,SERGI PROFESSIONALLV£ORSCERS 160 SUA1dIFR -T. IIAVERHILL, MA 01830 JEI. 508-:373-03I0 - 1996 9Y CHRISTIANSEN & SERGI INC. DRAWING Not CAn'';An SR Commonwealth of Massachusetts Title 5 Official Inspection Form orm Subsurface Sewage Disposal System Form- Not for Voluntary Assessments rT rY Property Address Owner - V yM LoS�� information is uwners Name � required for every 1^)—CA Zip page. Uty/Town State —1 —1 p 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: ❑ h d-sketch in the area below drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewn a Dis osal g P System•Page 16 of 18 LOCUS MAP SC/LS OATA DESIGN PARAMETERS SEPTI SYSTEM DESIGN LOT 14 EVERGREEN ESTATES qspEcrom. "go, SrAPP NORTH ANDOVER, MASS. 11 M.1.1`11.1 1—'IS' Wnck-'. WMAS LOSCO YWK5RURr, MA 01B.76 gq K K ICHRISTIANSEN SERGI • —4,v swam; 1W.aWA M— 1.0 .W 1W Iry 40 011C jle25lll IM W 11 Vd/j. Ir.fl-1 NO.Is .11. 5""c I'-"to r-j CALCULATIONS v �0'wo TOWN or NokTN ARMEN j 4 L qb -J T' LOT 15A -DZTRflwTm wx LOT 14 n 6 q F4 7, SPIKE.SET M�ttill— A RfA = 1.00 ACPE'- W 14 OAN. �7 iHl 5'AP -------------- IWO GALLON SEPVC TANK V.g FS0.DRAN ?31.0 IS N 7- cIii4iW.-8. 94, -Kc s(l y. IN is,OAK, 115,18 sp, CROSS SEW7001 LOT 13 J PLAN �a �..,. PROMS LONGITUDINAL SECTION rti Commonwealth of Massachusetts �-_► ;�� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ell Property Address Owner Owners�Name information is (� required for every 1 �,/'! f\ Page �.Iry/t own r--�-1 ---L_�! V State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope r�I a ❑ Surface water No ❑ Check cellar D`y ❑ Shallow wells A,,, Estimated depth to high ground water: �— feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: es Q• Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26f2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A00 Property Address o Owner ` L� �U Owner s Name information is n - required for every ` �`+�`• � `y�� — ��O page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 2--A. Inspector Information: Complete all fields in this section. Certification: Signed &Dated and 1, 2, 3, or 4 checked [B-'C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed DID. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Savage Disposal System•page 18 of 18 Of NOMTM M 8 C+ I yy ; O _ s Town of North Andover s •�� ' HEALTH DEPARTMENT S4CHUSE CHECK #: DATE: LOCATION: 6 4 H/O NAME: �O j CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC S�rstems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector /� $ 11 Title 5Report ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Y llow-Health Pink- Treasurer