HomeMy WebLinkAboutPass - Title V Inspection Report - 46 WHITE BIRCH LANE 9/24/2020 �L\ Commonwealth of Massachusetts
op j? Timtle 5 Offiocuial
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 45 White Birch Ln
Property Address
Matt Ruggiero
Owner owner's Name
information is North Andover
required for every Ma 01845 8/14/20
page. Cityrrown 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 A. Inspector Information
filling out forms
on the computer,
use only the tab Dean Dynan
key to move your Name of Inspector
cursor-do not Dean Pynan
use the return Company Name
key.
2 Suntaug Street
ter, Company Address
L nnfield _ - - Ma 01940
City/Town State Zip Code
508-726-9935 SI12837
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 m
inspection; and the inspection was performed based on y ._ p 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. Ll Fails
? 4� -__ 9 /9
0
nspe4tand,ture 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
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.doe•rev.712512018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
�L\ Commonwealth of Massachusefts
T'tie 1!5 Official n e ' n For
Subsurface Sewage D11sposal System Formi Not for Voluntary Assessments
46 White Birch Ln
Property Address
Matt R u _ " ro
Owner, Owner's Name
information is North Andover Ma 01,845 8/14/20
required for every
page. City/Town, State Zip Code— Date,ofIn --ion
C. Inspection Summary
Inspection Summary: Complete 1, 21 3,, or 5 and' all of 4 and 61.
1) Systemi Passes:
10 1 have, not found any information which indicates that any of the failure,criteria described
in 3110 CMR 15.303, or in 310,CIVIR, 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments-.
4 bedroom single family septic syste with pli'pe in stone dr,ainfield In working order
. ...........
2) System Conditionally Passes:
El 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" orn,ot 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
A pass,
I
unsound, exhibits substantial infiltration or exfiltration or tank failur�e is imminent. System will
inspection if the existing tank is replaced with a complying! septic tank as appro° ed by the Board of
Health.
*A metal septic tank will pass ins pection if it is structurally sound, not leaking, and 1fa Certificate of
Compliance indicating that the tank is less than, 20 years,old is available.
Y,
[D N' Ej, ND (Explain below),
t5insp.doc-rev.7/2,612018 T it le 5 Offic ia I Inspecoon dorm.S ubsurf ace Se wag e D i s posa I S ystem-Page 2 of 18
Commonwealth of Massachusetts
1 iciaInspect'ion Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t
M
48 White Birch Ln
Property Address
Matt Ruggiero
Owner owner's Name
information is North Andover Ma 01845 8114/20
required for every
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
2) System Conditionally Passes (cont.):
El 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):
El broken pipe(s)are replaced El Y El N ❑ ND (Explain below):
❑ obstruction is removed D Y [-] N ❑ ND(Explain below).-
El distribution box is leveled or replaced El Y ❑ N ❑ ND(Explain below):
El The system required pumping more than 4 times a year due to broken or obstructed pipes). The
system will pass inspection if(with approval of the Board of Health):
El broken pipe(s)are replaced El Y El N [:1 ND(Explain below):
❑ obstruction is removed El Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
El 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 Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y
M
' 46 White Birch Ln
Property Address
Matt Ruggiero
Owner Owner's Name
information is North Andover Ma 01845
required for every 8/14/20
page. Cltyfrown State Zip Code Date of Inspection
C. inspection Summary (cont.)
El Cesspool or privy is within 50 feet of a surface water
F-1 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.
El 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 m=indicate"Yes"or"No"to each of the following for all inspections:
Yes No
D z 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
t5fnsp.doe•rev.7M/2418 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
�L
Commonwealth of Massachusetts
fTitle 5 Official Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 White Birch Ln
Property Address
Matt Ruggiero
Owner Owner's Name ._...
information is North Andover Ma 01845 8/14/20
required for every
page. CityfTown State Zip Code Date of inspection
C. Inspection Summary (cunt.)
4) System Failure Criteria Applicable to All Systems: (cost.)
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:
❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ g Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
El ED Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El Z 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.]
El z 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 uno"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
❑ ® 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
t6insp.doc•rev.7126/2018 Title 5 official Inspection Form:Subsurface sewage Disposal system•page 5 of 18
Commonwealth, of Massachusetts
I Inspectmion Form
T'tlie ' ff'icia
ot for u ntry A
Subsurface Sewage Disposal System Form N Vol a ssessments
46,White Birch L,n
Property Address
Matt R.u.g iero,
Owner owner's,Name
information is North Andover, Ma 01845 8/14/20
required for every
page. cityrrown State Zip Code Date of Inspection
C., Inspection Summary (cont)
If you have answered yes" to,any question in Section C. 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 und'er Section C.5 or,fai'led
under Section C.,4 shall upgrade the system in accordance with 310 CIVIR 15.,304. The system owner
should contact the appropriate regional office of the Departm ent,
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
E E 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
El E thisinspection?
Were as it pilans 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?
E EJ Was the site i inspected for signs of'break out? 00
I
Were all system components, excluding the SAS, located on si e?
E El Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the blafflels or tees, material of construction,
dimensions, depth, of liquid,, depth of sludge and depth of scum?
Was the facility owner(and occupants, if'diff area t from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and 11ocatilon of the Soil! Abs orpbbn System (S,AS), on the site has
been determined based on-
E E] 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 15.30,2(5)]
15insp.do c-rev.7/26/2018 TiVe 5 Offidal Inspection Foes:Subsurface Sewage Disposal System-Page 6 of 18
A*%
u,ommonwealth of Massachusetts
A.-
T
TT e icia nspec ion, orm
Subsurface Sewage Disposall'System Form Not for Voluntary Assessments
...........
r4% 46 White Birch Ln
P"r-6i3 aidr—es s
Matt Ru iero,
Owner Ownerm,s Name
info rmation is
North Andover Ma 01845 �8/14/'20
required for everY
pagle. dtyffown State Zip Code Date of Inspection
DO System Information
1 Residential Flow Condoifions:
4
Number ofbeldrooms, (design):, Number of bedrooms (actual),*
600
DESIGN flow based on 310 CMS 15.203 (for example- 110 gpd x#of bedrooms).:
Description,-
4 Bedroom system with 15,00 gallon tank and 1100 sq ft drainfield'
Number of current residents,- 3
Does residence have a garbage grinder? Yes, Fj No
0,
Does residence have a water,treatment unit? D Yes Ei N'
If yes, discharges to-
ts laundry on a separate sewage system? (Include laundry system inspection El Yes 0 No
information in,this report.)
Laundry system inspected El Yes No
Seasonal use? El Yes 0 No
< 150_gpd av,e
'S I
Water meter,reading f available (last 2 years usage(gpd)).
Detail:
Sump pump? El Yes, E No,
Last date of occupancy-, current -
Date,
t5insp.dcc-rev.7/261/2016 Title 5 Official Inspect,ilon Fear mSubsurfam Sewage Disposal System-Page 7 of 18
<L
Commonwealth of Massachusetts
i e ici'aInspect'ionForm
+ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
C
y
,y 45 White Birch Ln
Property Address
Mattt.Ruggiero
Owner Owner's Name
information is North Andover Ma 01845
required for every 8114/2a
page. Cityfrown State Zip Code Date of Inspection
D. system Information (cont.)
2. Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day d
P Y�9P )
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? D Yes F-1 No
Water treatment unit present? El Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? El Yes [:1 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: Homeowner/Board of Health
Pumped last year
Was system pumped as part of the inspection? D Yes Z No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
tSinsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System.Page a of 1a
Commonwealth of Massachusetts
( T'tie 5 Off Forl'11
r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
`~ 45 White Birch Ln
Property Address
Matt Ruggiero
Owner Owner's Name- ---
information is North Andover Ma p1 g
required for every 45 8I14I20
page. CitylTown State Zip Code Date of Inspection
D. System Information (cunt.)
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
El Tight tank. Attach a copy of the DEP approval.
1:1 other(describe):
Approximate age of all components, date installed (if known)and source of information:
system installed 1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1811
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.):
sewer pipe in good condition I no evidence of leakage
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 9 of 18
Commonwealth of Massachusetts
' T"tie 5 1 Official ec ionForm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y
'~ 46 White Birch Ln
Property Address
Matt Ruggiero
Owner owner's Name .._.__...�...
information is North Andover Ma 01845 8/14/20
required far every page, City/Town State Zip Code Date of inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 611feet
Material of construction:
®concrete El metal ❑ fiberglass El polyethylene El other(explain)
1500 gallon concrete septic tank with covers to within 6"
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No
Dimensions:
Sludge depth: 611
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness 0 2"
Distance from top of scum to top of outlet tee or baffle 611
Distance from bottom of scum to bottom of outlet tee or baffle
131'
How were dimensions determined? in field with measure stick and tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
concrete septic tank with inlet and outlet PVC T I Tank in working order with separation from inlet to
outlet 1 no evidence of leakeage f tank in good condition
Liquid at bottom of outlet invert
recommend pumping every two to three years depending on usage and number of occupants
t5insp.doc•rev.7125120/8 TdIe 5 official Inspection Form:Subsurfaoe Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
mm: ... T" dle 5 I Inspect" Form,
ticia
.......
it, ion
i
in Subsurface Sewage Disposal System Forte N a As essment
46,Whig Birch Ln
Property Address
Ott R . 'erg
°owner, _r er rn
Inf rm tion is North Andover a 1 �5 2 0
required for er
page. Stake Zip Code Date of Inspection
D. System Information (cont)
7. Grease Trap (locate on, site plan).
Depth below grade.,,,,
feet
Material of construction.
El concrete El metal fiberglass polyethylene El other explai
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 bafflemm ...
Date of last pumping. �Wt ,.,.,.
Comments on pumping recommendations, inlet and outlet tee or baffle condition,, structural Integrity,
liquid levels as rafted to outlet.invert, evidence ofleakage, etc.):
. Tight or Holding Tank('tank must be pumpedtime f inspec i n), (locate on site plan):
Depthl grad. .. �.... m
Material of construction:
concrete Ej metal El fiberglass polyethylene E:1 other(explain):
Capacity; gallions
Design F1 w. .mm.mm....� ....
gallons per day
t5 in s p,idoc-rev.'7/2612018 Title ufFn u G Inspection Fow Subsurface Sewage Disposal System.Page 11 0f 1
Commonwealth of Massachusetts
@ T'tie 5 I Offi"ci'al Inspect'ion Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
`4 46 White Birch Ln
Property Address
Matt Ruggiero
Owner owner's Name
information is North Andover Ma 01845 8/14/20
required for every
page, CitylTown State Zip code Date of Inspection
D. System Information (cunt.)
8. Tight or Holding Tank(cunt.)
Alarm present: El Yes ❑ No
Alarm level: Alarm in working order: El Yes E-] No
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 ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert liquid at 0"above 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.):
16"X16"concrete D box in good/fair condition
no leakage into or out of box/Little to no solids carryover/D box is level
4 outlet pipes
D box is 10" below grade
tSinsp.doc•rev.712£12018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
10%
uommonwealth of Massachusetts
v 5 Off'icia,l cti"on Form
e
Subsurface e DI'sposall System Form Not for Voluntary Assessments
0
46 White Birch Ln
Property Add s
Mitt ipro
Owner Owner's Name,
information is North Andover Ma 018,45
required for every 8/14/20
page., City own State Zip Code---- Date of Inspection,
D. System Information (cont)
10. Pump Chamber(locate,on site plan):
Pumps in working order,: El Yes, El No*
Alarms in, working order., El Yes E] No
Comments (note condition of pump chamber, condition of pumps,and appurtenances, etc.)-
...........
............ ....
If pumps r alarms are not in working order,, system is a,conditional pass.
11 Soifl Absorption, System (S,AS,) (locate on site plan, excavation not re aired):
SAS, not located, explain why:
.......... .............
......... .....
Type.,,
1:1 leaching pits number-,
El leaching chambers number: -
El leaching galleries number., ................
leaching trenches number,, length-
leachi field's number, dimensions, 1 @ 1180,sq ft
20'X59'
E] overflow cesspool number.
El inn iovative/alternative stern,
t5insp,idoc-rev,7/2'6/20,18, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 018,
Commonwealth of Massachusetts
tip
MW T le 5 Ottic,ial Inspwftection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
46 White, it Ln
Property Address
M���u Piero
Owner Owner's Name
information is North Andover Ma 0,1845, 8/14/20
required for every
State Zip,Code Date of 1nspeEC_i6'n
D. System Information (cont)
1,1., Soll Absorption SysWm ('SAS) (cont.)
Comments ('note condition of soil!,, signs of hydraulic failure, level of poinding, darrip,soil, condition of
vegetation,, etc.):
Drainfield found in green lawn area soils in good condition no,signs of'hydraulic failure no
ponding/ no damp soild/ grass is uniform in good condition
Drain field is 1120 sq ft pvc pipe in stone conventional system,, in working order
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 solid's layer
Depth of scum layer,
Dimensions of cesspool
Materials of construction ..........
Indication of groundwater inflow El Yes El No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t insp,doc-rev.7/26Q01 B Till e 5 Official Inspection Foy:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
T"Itle 5 Offici"al Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y
w
t
4
48 White Birch Ln
Property Address
Matt Ruggiero _
Owner owner's Marne
information is North Andover Ma 01845 8/14/20
required for every
page, Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
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.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
I e ici'alForm
z
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'4 46 White Birch Ln
Property Address
Matt Ruggiero
Owner owner's Name '
information is North Andover Ma 01845
required for every 8114120
page. City/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
Z drawing attached separately
t5insp.doc rev.7/26/2018 Title 5 offlcM Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
r%
%,ommonwealth of Massachusefts
T tI ff
1 le iciai, inspection Form
Subsurf'ace,Sewage Disposal System, Form Not for Voluntary Assessments
46 W'hite Birch Ln
Property Address
M tt Rug i�ro
Owner Owner's Name
information is, INorth Andover Ma 01 184 5, 8/14/20
required for every
Page. Cityffown State Zip,Code Date!of Inspection,
D. System Information (cont.),
15. Site Exam.,
Z Check Slope
Z Surface water
Check cellar,
Z Shallow well's,
361t + as per plan on file
Estimated depth to high ground water, feet
Please indicate gall reset hods, used to,determine,the high ground water elevation-
z Obtained from system design plans on record
If checked, date of design, plan 1994 reviewed- Date
Observed site (abutting property/observation hole,w ithin 150 feet of SAS)
Checked with local Board of Health -explain'.
E] Checked with local excavators, installers-(attach documentation)
El Accessed USGS database -explain"
You must describe how you established the high ground water elevation-
plans on file dated 1994
,System is gravity mound located on ,a slope as per plan on file
The only way to determine high, ground water is with deep '1' le soil testing by soil expert.
Before filing this Inspection Report, please see, Report Completeness Cheicklist on neXt page.
t5fnsp.doc-r .7126/2018 Title 5 Official Inspection Form,Subsurface Sewage Disiposal System-Page 17 of 18
C
ommonwealth of Massachusetts
ici'oal Inspect0ion
Tl"tlie 5 Off" Form
i, Subsurfaice Sewage Disposal System Form Not for Voluntary Assessments
4,6 White Birch Ln
Property Address
Matt Ruggiero
Owner Owner's Name
information is North Andover, Ma 01845 8/14/20
required for every
page. CityfTown, State Zip Code Date of Inspection
Report Completeness, Checklist
Complete all applicable sections of this form inclusive
Z' A. Inspector Information: CornpIete all field's in this section.
Z
' 4 B. Certification* Signied' & Dated and 1, 21, 31 or checked
Z C. inspection Summary-
11 21 3, or 5 completed as appropriate
4, (Failure Criteria) and 6 (Checklist) completed
Z D. s,tem Information:
For 8* Tight/Holding an — Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Expl an ation of estimated depth to high groundwater included
t5insp.doc-rev,7126/20,18 Title 5,Official Inspection For:Subsurface Sewage Disposal System-Page 18 of 18
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DESIGN AS—BVJL T
INV. OF PIPE OUT OF HOUSE 162*57 162.5
INV. OF PIPE AT SEPTIC TANK INLET 162.07 162. 12
INV. OF PIPE AT SEPTIC TANK OUTLET 161.SZ 161.91
INV. OF PIPE AT D- BOX INLET 161.50 161.80 . .
INV. OF PIPE AT D-wBOX CUTLET 161.33 161.G2
INV. AT END GF' DISTRIBUTION PIPE 1 161.00 161.10
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INV. A T 'ND OF DISTRIBUTION PIPIPE2 161.00 161.12 OF HEREBY*CERTIFY THAT HA THIS DISPOSAL SYSTEM AN,
IhIV. A T RNA OF DISTRIBUTION PIPE 3 161.00 1 S 1. 15
FINAL GRADING HAS BEEN 1N �
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Town of North Andover
Tax flap # 21 0=061 44094-0000.0
Parcel Id 12734
48 WHITE BIRCH LANE
MATTHEW RUGGIERO
AMANDA NICKLES
46 WHITE BIRCH LANE
NORTH ANDOVER ILIA 01846
Class 101 Single Family Size Total 0.5 Acres Property Type 1 Residential
FY 2021
5/1112020 447 a Actual 9 6/10/2020 17%
2/10/2020 438 a Actual 8 3/16/2020 11%
11/7/2019 430 a Actual 7 12/23/2019 -25%
817/2019 423 a Actual• 9 9/26/2019 -2%
5/10/2019 414 a Actual 9 6/1312019 11%
2/12/2019 405 a Actual 9 3/19/2019 _god
11/7/2018 396 a Actual 9 12/12/2018 -38%
8/10/2018 387 a Actual 15 9/20/2018 65%
5/10/2018 372 a Actual 9 6/20/2018 2%
2/812018 363 a Actual 9 3/28/2018 -4%
11/712017 354 a Actual 9 12/29/2017 -33%
8/10/2017 345 a Actual 14 9/20/2017 47%
5/9/2017 331 a Actual 9 6/2612017 -13%
2/1012017 322 a Actual 11 3114/2017 -6%
11/8/2016 311 a Actual 11 12/19/2016 -74%
8/12/2016 300 a Actual 44 9/21/2016 378%
5/1212016 256 a Actual 9 6/21/2016 36%
2112/2016 247 a Actual 7 3/2812016 17%
11/9/2015 240 a Actual 6 12/30/2015 -56%
81612016 234 f Final Bill 12 8/6/2015 61%
5/14/2015 222 a Actual 8 6/22/2015 47%
2/13/2016 214 a Actual 6 3/20/2015 4%
11/612014 208 a Actual 5 12115//2014 -73%
8/12/2014 203 a Actual 19 9/11/2014 220%
5/15/2014 184 a Actual 6 6/12/2014 .5%
2/14/2014 178 a Actual 7 3/17/2014 19%
11/6/2013 171 a Actual 5 12120/2013 -24%
8/13/2013 166 a Actual 7 9/18/2013 37%
5/14/2013 159 a Actual 5 6/18/2013 -19%
2/14/2013 154 a Actual 7 3/13/2013 -19%
11/5/2012 147 a Actual 7 12/1312012 -44%
8/15/2012 140 a Actual 14 9/26/2012 15%
5115/2012 126 a Actual 12 6/20/2012 31%
2/14/2012 114 a Actual 10 3/14/2012 -26%
111712011 104 a Actual 12 12/1512011 -56%
8/11/2011 92 a Actual 28 9/14/2011 174%
5/1312011 64 a Actual 10 6/13/2011 _38%
2/14/2011 54 a Actual 18 3/15/2011 131%
11/8/2010 36 a Actual 7 12/13/2010 -48%
8/1212010 29 a Actual 14 9/13/2010 43%
5/13/2010 15 a Actual 10 6/9/2010 12%
2/912010 5 a Actual 5 3/11/2010 -100%
12/19/2009 0 n New Meter - 0 3/11/2010 -100%
1211912009 718 r Replacement 4 3/11/2010 -27%
11/912009 714 a Actual 12 12/11/2009 27%
8/13/2009 702 a Actual 10 9/11/2009 9%
5/12/2009 692 a Actual 9 6116/2009 •68%
2/10/2009 683 a Actual 28 3/1612009 242%
11/10/2008 655 a Actual 8 12/10/2008 -34%
8/12/2008 647 a Actual 11 9/12/2008 22%
5/22/2008 636 a Actual 11 6/18/2008 -4%
2/12/2008 625 a Actual 11 3/14/2008 -46%
11/8/2007 614 a Actual 19 1/15/2008 -38%
8/1012007 595 a Actual 30 9/14/2007 113%
5/14/2007 565 a Actual 12 6/22/2007 201%
2/28/2007 553 m Manual estimate 6 3/23/2007 -34%
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