HomeMy WebLinkAboutPass - Title V Inspection Report - 130 HAY MEADOW ROAD 6/19/2020 Commonwealth of Massachusetts RECET/ED
w Title 5 Official Inspection Form 202n
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments JUN 19
pOVER
__ v U /� �>`' C Gam-✓ ' to
WN OF NORTH AN-TME141
Property Address
"- 5 _
Owner Owner's Nar�+g
information is
required for every
page. City/Tom State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A.,,,Inspector Information
�--.
on the computer,
use only the.t?h r L
key to move your To nape rcursor-do not
use the return Comr Name —--- —
key. (�F2_
Corn Address
C�own State Zip Code
77- V.-Z3 10 � Z;3 t —
Telephone Number License Number
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 systems.After conducting this inspection I have determined
that the system:
1. [ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
169pedors Signat re Date
The system inspector shall Lit 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
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and 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.
t5insp.doc.rev.7262018 Title 5 official Inspection Form:Subsurface Sewage Disposal System.Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
e C�2
Owner owner's Nam
information is
required for every
page. Utyi I own State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
{ 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:
/tea edL"'O L,� /J�t�i —
2) System Conditionally Passes:
❑ One or mores stem components as described in the"Conditional Pass"section need to be
replaced or rep ed. The system, upon completion of the replacement or repair, as approved by
the Board of Healt 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 W`tka 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):
t6insp ooc•rev.7/2612018 Title 5 OOiciM Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Prope1tY Address —'� U
Owner Owner's Nar
pe, - — /
information i �JC11W[ �.�� /1n q s
required for every
very �—LA -
page. City/Town State Zip Code Date of Inspedion
C. Inspection Summary (cunt.)
2) System Conditionally Passes(cunt.):
❑ 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.M642018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 �'1ile. a w
Property Address
Owner Owner's Namp:�2
information is 3
required for every
page. City[Town State Zip Code Date of Inspection
C. Ins action Summary (cunt.)
❑ sspool 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 systehq 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
❑ The system has a septic tank and SAS and the SA 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
due to an overloaded or clogged SAS or cesspool
t5msp doc•rev.7262018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner' —
required fo IS
required for every
page. Cityrrown 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 '/2 day flow
❑ Required pumping more than 4 times in the last year NOT due 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.
❑ �i] Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ `1\ 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.
❑ Q 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 milst indicate either"yes' or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 fe pf a�trib
e drinking water supply
El El the system is within 200 feet of ry 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.72612018 Title 5 Offioal Inspection Form:Subsurtace Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System/Form -Not for Voluntary Assessments
Property Address
Owner Owner'sN
information is ��D`f �L�,� �,
required for every
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 CA 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 CA 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 all inspections:
Yes No
Z) ❑ 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?
Q ❑ 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?
❑ 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:
❑ Existing information. For example, a plan at the Board of Health.
❑ 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.7/26/1018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Q �
Property Address
information is '` 1\c
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
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:
Does residence have a garbage grinder? ❑ Yes 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 ❑ Yes Rr No
information in this report.)
Laundry system inspected? ❑ Yes , No
Seasonal use? ❑ Yes Pq,No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes No
Qtyq�&n
Last date of occupancy: Date
t5insp.doc•rev.70152D18 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System FormA-Not for Voluntary Assessments
Property Address
�e
Owner -
Owner's Name
information is k)G Y L`�� /� — f �� I
required for every ------
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Typt,of Establishment: -
Design flow"(b ed on 310 CM 15203): Gallons per day(gpd)
Basis of design flow(sea ersons/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):
- -- ��� s'�r� Zu2U ,O e✓Z dwN e�
3. Pumping Records: (/
Source of information:
Was system pumped as part of the inspection? ❑ Yes)11� No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev-7/28/2018 Title 5 Offiaal Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
P Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Na ---
information is /\ JV C�_ 64 fY's
required for every y /'_� --
page. City/Town State Zip Code Date of Inspedion
D. System Information (cont.)
4. Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
Shared system (yes al(no)(if yes, attach previous inspection records, if any)
❑ Innovative/Altemative 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:
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: ��
Material of construction:
'IQ ast iron ❑40 PVC ❑ other(explain): -
Distance from private water supply well or suction line: feetT
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form'.Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
cX-S
Owner Owner s Na
information is
required for every
page. City/Tom State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
. CS
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle -9? --
O
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of ouilet tee or baffle Q11)
How were dimensions determined?
Comments (on pumping recommendations, inAet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t K 1%VG0e' i"_
't n c �� �
,—jrjN1j rC_ /` ',�Vk_ L L2
t5insp.doc-rev 7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Na
information is rneN
<Vjfgs' 4(0 3 " Zd
required for every ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
7. Grease p(locate on site plan):
Depth below g e: 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 conditio structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
8. Tight or Holdin Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.MUM Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 78
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
PSubsurface Sewage Disposal System Form - Not for Voluntary Assessments
Properly Address
Owner Owners Na -- -
information is
required for every
page. city/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: — — — Alarm in working order: ❑ Yes ❑ No
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):
Depth of liquid level above outlet invert - -
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.):
�V.,
t5insp doc•rev.7262018 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary
__Assessments
—MTV
Property Address
co-
Owner o -
information is
required for every
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
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:
❑ leaching trenches number, length: -
leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: (� S �`�`
t5insp.doc•rev.728/1018 Title 5 Of oal Inspection Form:Subsurtace Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner X��sNinformation is �� GrF�s
required for every
page. Cityfrown state Zip Code Date of Inspection
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.):
12. Cesspools ( pool must be pumped as part of inspection) (locate on site plan):
Number and config ti
Depth -top of liquid to inlet invert
Depth of solids layer - -
Depth of scum layer _-
Dimensions of cesspool -
Materials of construction
Indicaf.ion of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev 7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner 0
is Na
information is �
required for every
page. City/Town State Tip Code Date of Inspection
D. S stem Information (cont.)
13. Privy to on site plan):
Materials of truction:
Dimensions
Depth of solids
Comments(note condition of soil, sign f hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5lnsp.doc•rev.70=118 Title 5 Of ial Inspection Form:Subsurface sewage Disposal System•page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
P Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments
Property Address -
Owner is N -e U //
information is ✓
required for every
page. City/Tow, State Tip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
4 Lir 7r5
� r
^6Y
POLO—
L4
et- t S
i
�v
t5insp.doc•rev.7QW018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 18
1 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments
tP
Property Address
Owner OwpW'�N�ainformation isLL,`_ f� _ Co
required for every �J l _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
El Check cellar
❑ Shallow wells
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 ou established the high ground water elevation:
[� Cj
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.R282018 Title 6 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form 5I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
, �� _
Owner Oyrt►�r's Na
information is A ► ��( �y
required for every /
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
[� A. Inspector Information: Complete all fields in this section.
'B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
PC. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
D. 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
t5inspAoc•rev.7/2WO18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
Of MORTIS 9 V I
. O
• Town of North Andover
HEALTH DEPARTMENT
�sswcllus�� /
CHECK#: q6.5 DATE: / , ?W
LOCATION:
H/O NAME:
CONTRACTOR NAME: G
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 Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector _ $
Title 5 Report
❑ Other. (Indicate) $
Hedtth Agent Initials
White-Applicant ellow-Health Pink-Treasurer
S�T'[LED l�� •
• Wk.
North Andover Health Department
Community and Economic Development Division
Septic System Pumping Records
Date: May 29, 2020
Address: 130 Hay Meadow
Condition of system: Flooded Tank
Dear Owner:
Please note that a septic system pumping record dated 5/4/2020 and received on 5/18/2020 states
that your septic system FLOODED. This indicates that repairs may need to be performed on your
current septic system. Please have your system inspected by a licensed Title 5 inspector
within 30 days of receiving this letter. Attached is a list of Title 5 septic inspectors that are
permitted through the North Andover Health Department,as well as a best practices pamphlet on
caring for your septic system. If you have any questions or concerns,please contact the Health
Department at the phone number listed below.
Thank you for taking the time to consider the impact this may have on your system as well as the
environment.
Sincerely,
Stephen asey Jr.
Health Inspector
Office: (978)688 9540
Enc: Title 5 inspectors List
Caring for your septic system
Page 1 of 1
North Andover Health Department, 120 Main St.
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
....^ r1 i► '