HomeMy WebLinkAboutPass - Title V Inspection Report - 91 BOSTON STREET 7/13/2020 i
l \ Commonwealth of Massachusetts
Title 5 Official Inspection Form
, n
ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Boston Street
Property Address
I � Ann Manson
Owner Owner's Name
information is required for every North Andover _ MA 01845 7-1-2020
i
page. City/Town 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. sla
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Important:when A. Inspector Information U�- 3Z R
fillip out forms
on the computer,
�I use only the tab
Neil James Bateson �1i PN�VE
key to move your Name of Inspector . o`�NaEpP
Nil—
cursor-do not Bateson Enterprises Inc. N
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key. Company Name
111 Argilla Road
r� Company Address
Andover MA 01810
City/Town State Zip Code
T,
learn 7 -47 -4786 SI-15
9 8 5
Telephone Number License Number
B. Certification
I certifythat: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
Pp Y
(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
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3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
7-1-2020
i, Inspec is ig ature 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
i 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.7/26/2018 Title 5 Official Inspection Form_Subsurface Sewage Disposal System-Page 1 of 18
. Commonwealth
o monwealth of Massachusetts
n p Title 5 Official Inspection Form
0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a�
91 Boston Street _
Property Address
Ann Manson
Owner Owner's Name
information is North Andover MA 01845 7-1-2020 _
required for every _
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
. I
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:
i
2) System Conditionally Passes:
ii
p ❑ 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):
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i
i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Boston Street
Property Address ------ —_---- ----_--
Ann Manson
j Owner Owner's Name
information is
required for every North Andover - MA _ 01845 7-1-2020
page. Cityrrown 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):
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❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
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❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
� Isystem 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):
I
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,
yI 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 Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
i information is North Andover MA 01845 7-1-2020
i required for every
I page CItyTTown 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:
�I
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
d 100 feet of a surface water supply or tributary to a surface water supply.
q ❑ 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
j 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
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be attached to this form.
c. Other:
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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
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 18
�I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ro Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I! � 91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
information is North Andover MA 01845 7-1-2020
required for every
page. City/Town 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 '/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.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
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❑ ® 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
El ® 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 CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
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❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El El Area
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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Boston Street
-
Property Address
Ann Manson
Owner -- - - - ----------- _ --
Owner's Name
information is North Andover MA 01845 7-1-2020
required for every
page. City/Town State Zip Code Date of Inspection
j 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 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
® ❑ 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?
El ® 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
pl 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
information is required for every North Andover MA 01845 7-1-2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
i
Number of bedrooms (design): 4 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: 1
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ® No
I
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Yes
9 ( Y 9 (gP ))�
Detail:
� i
Sump pump? ❑ Yes ® No
Current
Last date of occupancy: Date
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
x Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
„ 91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
information is required for every North Andover MA 01845 7-1-2020
page. City/Town State Zip Code Date of Inspection
I,
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment: —
L Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
l' Grease trap present? ❑ Yes ❑ No
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Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: --
Industrial waste holding tank present? ❑ Yes ❑ No
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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):
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3. Pumping Records:
ii
Source of information: Pumped 2017, owner
Was system pumped as part of the inspection? ® Yes El No
If yes, volume pumped: 1500gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank&tees
1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
information is required for every North Andover MA 01845 7-1-2020
page. Citylrown State Zip Code 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:
6 years old, 11-14-2014, as built plan
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Were sewage odors detected when arriving at the site? ❑ Yes ® No
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5. Building Sewer(locate on site plan):
2
Depth below grade: feet
it
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.):
4" PVC through wall 3" PVC in house, no leaks visible
I
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
i-
p Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
information is required for every North Andover MA 01845 7-1-2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed b a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No
Y
Dimensions: 10' x 5' x 4'
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
29"
3"
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
12"
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
i.
liquid levels as related to outlet invert, evidence of leakage, etc.):
llnlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of lekage.
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t5insp.doc•rev.7/26/2018 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
information is required for every North Andover MA 01845 7-1-2020
page. CityTrown 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:
'I
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
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9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
information is North Andover MA 01845 7-1-2020
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
i
3 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.):
i
Attach copy of current pumping contract(required). Is copy attached? El Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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.):
D-box level &distribution equal, has flow levelers. No evidence of leakage. Evidence of carryover,
pumped d-box to clean. D-box has riser 6" deep.
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t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
�r Title 5 Official Inspection Form
'- I} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I f�
e � 91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
information is required for every North Andover MA 01845 7-1-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. PumpChamber locate on site plan):
( P )
j
Pumps in working order: ❑ Yes ❑ No`
I
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
l,
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 its number: -
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
i 1 field 15' x 30'
® leaching fields number, dimensions:
❑ overflow cesspool number: —
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❑ innovative/alternative system
Type/name of technology:
t51nsp.doc•rev.7/2 6120 1 8 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
L,
91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
information is required for every North Andover MA 01845 7-1-2020
page. City/Town 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.):
Soil ok. Vegetation ok. No sign of ponding to surface.
tl 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
j 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 ponding, condition of vegetation,
etc.):
d
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1
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
i
Commonwealth of Massachusetts
i= p Title 5 Official Inspection Form
I,
i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
information is required for every North Andover MA 01845 7-1-2020
page. Cityrrown State Zip Code Date of Inspection
I
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.):
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t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
I
Commonwealth of Massachusetts
r-
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 P Y rY
. 91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
information is� required for every North Andover MA 01845 7-1-2020
page. aty/Town State Zip 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
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t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
nsp
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Boston Street
Property Address
Ann Manson
Owner Owner's Name
information i s
required for every
North Andover MA 1 45 -1-0 8 7 2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
>4 _
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
L ® Obtained from system design plans on record
If checked, date of design plan reviewed. 3-14-2006
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Design Plan
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database-explain:
You must describe how 9 you established the high round water elevation.-
Test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 17 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i p
Fw Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Boston Street _
Property Address
Ann Manson
Owner - - - --
Owner's Name
information is required for every North Andover MA 01845 7-1-2020
page. Cltyrrown 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.
' I
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. 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
9i
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
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� t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
0 ',
7'
Commonwealth of Massachusetts
City/Town of
um
System Pumping Record
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may be used, but the
information-must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forrim they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town ( State Zip Code
i3
2. System Owner.
�ovv\s�
Name'
Address(if different from location)
d
CiWown State Zi Code
Telephone Number
i
.B. Pumping Record
- t
1. Date of Pumping Date 2. Quantity Pumped: Gallons w
3. Type-of system: ❑ Cesspool(s) �ptic Tank ❑ Tight Tank
❑ Other(describe):
� ICI
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ��
4Z'it/�
6. System Pumped By:
Neil.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contentrw were disposed:
G L Lowell Waste Water 11
Sin a H'`g aul Date
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t5form4.doc•06l03 System Pumping Record•Page 1 of 1
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r�lNwyr'RwCON CMM eww*'Yw)l.*,7(?M'QS 4 17 M 4140-, Fe;o I
Tow of North Andover
Tax Map # 210-107.B-0040-0000.0
Parcel Id 18153
91 BOSTON STREET
ANN G MANSON
91 BOSTON STREET
NORTH ANDOVER MA 01845
Crass 101 SingNfatn4y Prt.•r"rty T!p" 1 Residential
Size Total SAcns
FY —
�I
'I
UB Mailing Index
NamejAddrass Tyrt L^.ar 1`4,11bkr rl�-.I:in,��t From 1M111
ANN G MANSON C,�nnr
91 BOSTON S+REE r
NORI H ANDOVER MA-31 Rd 5
JOHNSTON,DON.ALD F Payor inactrve 4:16)2015
Ct0 91 REALTY LLC
8 NEWELL FARIA DRIVE
WEST NEWBI}RY NW
31985
.FOE FRANCIOSA Previous Custormer Innctly. 5d2a2015 I
8 NEN ELL FARIA ROAD
WEST NEMBIYtY NA C1985
UB Account Maint.
Account Nu Cycu, OCcuparN Name Actrvellnactive
Cfi;g td.136810•91 BOSTON STREET Lost RAing Date 5.1772020
r0305P,1 01 Cycle 01 Act7.e
UB Services Maint.
AccounlNz
Sorme codo Rote Charge MultlpiII&OUsers
IWtSCF EE ADMIN F F 0 63 U8
Vd1 R WATFR 01 Ail NE TER SIZE br) 111
UB Meter Maintenance
Accour,Ne 1C3;:S41
SorlalNo Status Localion 0rand 'ypn Size YTO Cons
AFrt80532 A,-I ERT HH b Badger w Water 0 63 0 63 716
Date Reading Code consumption Fasted Dale Variance
4r24(N20 716 aActuc0 12 5,03,4020 1%
111MOM 104 aActual 11 2rIGY2020 .79%
1061IW2019 693 aActual 50 12'1ar2079 54% Y I'
7f22r2019 943 aActual 35 811312019 319%
Atia20i9 808 aActual 8 5.It512010 24% i
1l1712019 SW aAcl�al 1,0 2)1&J2019 821%
111t!7f?!ftR 540 :e Ariumd 63 17ftAYlO1R Fi^•e.. '1
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Fr• r„ ,• • Of
Town of North Andover
HEALTH DEPARTMENT
,SSACNU+t'S
CHECK#: ,3 O DATE-
LOCATION:
9�S4n/i
H/O NAME: / a,0 sow
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establish»tent $
❑ 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 $
a Title 5 Report �� $
❑ Other. (Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer