HomeMy WebLinkAboutConditional Pass - Title V Inspection Report - 235 RALEIGH TAVERN LANE 10/5/2020 Commonwealth of Massachusetts
Title 5 official Inspection Form RFce,�zo
-- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
- OCT
701*0"
235 Raleigh Tavern Lane f/Eq R
Property Address `T R
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
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.
A. Inspector Information c1
1. Inspector: ' / /✓�
Robert Herrick r
Name of Inspector
Wind River Environmental
Company Name
46 Lizotte Drive Suite 1000
Company Address
Marlborough MA 01752
City/Town State Zip Code
(978)833-7924 SI 13769
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:
❑ Passes
Q Conditionally Passes
❑ Needs Further Evaluation by the Local Approving Authority
❑ Fails
September 21, 2020
Inspector's Signature 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
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.
t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 1 of 19
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Commonwealth of Massachusetts
u Title 5 Official Inspection Form
_= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
" 235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
City/Town 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:
2)System Conditionally Passes:
Z 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)
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 2 of 19
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Commonwealth of Massachusetts
rO Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
City/Town State Zip Code Date of Inspection
C. Inspection summary (cont.)
2)System Conditionally Passes(corl
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
Q 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):
Z broken pipe(s)are replaced 0 Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
0 distribution box is leveled or replaced 0 Y ❑ N ❑ ND(Explain below):
The outlet tee is missing and the distribution box is rotted. Both need to be replaced.
❑ 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:
t5ins.doc 0 rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 19
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
9� -- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
City/Town 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
❑ 2 Backup of sewage into facility or system component due to overloaded or clogged SAS
or cesspool
❑ [✓f Discharge or ponding of effluent to the surface of the ground or surface waters due to
an overloaded or clogged SAS or cesspool
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 4 of 19
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Commonwealth of Massachusetts
W Title 5 official Inspection Form
A - _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
City/Town State Zip Code Date of Inspection
C. Inspection summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ Q Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Q Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z
day flow
❑ Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped:_
❑ Q Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary
to a surface water supply.
❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Q Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Q 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.]
❑ Q The system is a cesspool serving a facility with a design flow of 2000gpd-10,000gpd.
❑ 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 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
❑ ❑ 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
t5ins.doc 0 rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 19
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Commonwealth of Massachusetts
�N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
" 235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
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"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
Q ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Q Were any of the system components pumped out in the previous two weeks?
0 ❑ Has the system received normal flows in the previous two week period?
❑ Q 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)
Q ❑ Was the facility or dwelling inspected for signs of sewage back up?
LjJ ❑ Was the site inspected for signs of break out?
0 ❑ Were ail system components, excluding the SAS, located on site?
Q ❑ 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?
Q ❑ 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:
❑ Q Existing information. For example, a plan at the Board of Health.
❑ Q 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))
t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 6 of 19
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
9� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): N/A Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): N/A
Description:
This system consists of a septic tank, a distribution box, and a soil absorption system.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes d No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Q No
information in this report.)
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ Yes Z No
Water meter readings, if available(last 2 years usage(gpd)): 346 GPD
Detail:
Usage: 253,000 gallons=730 days=346.57 --> 346 GPD. Usage data provided by homeowner.
Sump pump? ❑ Yes No
Last date of occupancy: Current
Date
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 19
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f� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial 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):
General Information
3• Pumping Records:
Source of information: Wind River Environmental—see attached.
Was system pumped as part of the inspection? 2 Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Pump Truck Sight Glass
Reason for pumping: Check structural integrity of the tank
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 19
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Commonwealth of Massachusetts
F� Title 5 Official Inspection Form
-- _ - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
[JJ 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:
1981
Were sewage odors detected when arriving at the site? ❑ Yes No
5. Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ❑✓ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town Water
feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
All the joints look solid and there are no signs of leakage. Vented through building sewer.
t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 19
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
_= Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
Q 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: 10'6"x 5'8"x 58"
Sludge depth: 7"
Distance from top of sludge to bottom of outlet tee or baffle 0"
Scum thickness 2"
Distance from top of scum to top of outlet tee or baffle 0"
Distance from bottom of scum to bottom of outlet tee or baffle 0"
How were dimensions determined? Sludge, Rod and Ruler
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
There is no outlet on the tank so measurements could not be obtained. The liquid is at the proper level.
t5ins.doc 9 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 10 of 19
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is Owner's Name
required for every
page. North Andover MA 01845 September 21, 2020
City/Town 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 ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 19
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
-- o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
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 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.):
The distribution box is rotted and needs to be replaced.There is some carryover into the box due to the missing
outlet tee.
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 12 of 19
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Commonwealth of Massachusetts
f� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21,2020
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:
W leaching pits number: 3
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5ins.doc♦rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 13 of 19
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
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.):
The soil is dry and there are no signs of hydraulic failure or ponding.The vegetation is normal for the area.
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 ponding, condition of vegetation,etc.):
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 19
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
- — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
City/Town State 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.):
t5ins.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 19
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Commonwealth of Massachusetts
t= rF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
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:
d hand-sketch in the area below
❑ drawing attached separately
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Q Check Slope
Q Surface water
Q Check cellar
Q Shallow wells
Estimated depth to high ground water: 80"+
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)
21 Accessed USGS database-explain:
Pulled information from web soil survey.
You must describe how you established the high ground water elevation:
Web soil survey puts groundwater at over 80" in this area.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 19
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Commonwealth of Massachusetts
(� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is Owner's Name
required for every
page. North Andover MA 01845 September 21, 2020
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
Q A. Inspection information: Complete all fields in this section.
Q B. Certification: Signed&Dated and 1,2, 3, or 4 checked
Q C. Inspection Summary:
1,2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
Q D. System Information:
For 8:Tight/Holding Tank-Pumping contract attached
For 15: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 16: Explanation of estimated depth to high groundwater included
t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 18 of 19
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Commonwealth of Massachusetts
z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Raleigh Tavern Lane
Property Address
Owner Starrett
information is
required for every Owner's Name
page. North Andover MA 01845 September 21, 2020
City/Town State Zip Code Date of Inspection
Pumpinq Record
workOrdery 0207117655 Custo 1274183 Customer Since:2002 Tax:6.2500
Job Comments Tech Comments
09/21/2020 AN - Title S Inepection (No closing date) SVC Recommended lio Reco sandation.
1SOO gallons; Customer to have Water Consumption Records on Normal water level. Moderate top solids. Moderate bottom
site; WRC has puap Race, signed consent and Coptic plans sludge. Both baffles are intact. Main line Clear. No filter
enA CC on Eile-MD is present on the tank; current tank is not designed to be
used vith a filter. Covert*) secured. Recoorsended Boost
addit ive,CCCS additive.
NorsaL water level. Moderate top solids. Moderate bottom
sludge. Both baffles are intact. Main line Clear.
Recsomended Boost additive, CCLS additive. Cover(o) secured.
(RN)
System Owner System Location
Dave Starrett Primary Rome
235 Raleigh Tavern Lana 215 Raleigh Tavern I—
North Andover, MA 01946 North Andover, MA 01849
(9701 007-2305 Ses—tt (97a) Gal-1089
Service Date: VON 09/21/2020 11.00 AN frequency: Can to Confirm.
Service Type: Standard Previous Service: 09/14/2020
Approx. Gats: ISOO CCLS: 09/27/2010 Location Devils:
Depth Below Grade: Custom Clean:
Cust Home: No Fitter:
Township: Inspection/T5:
County: Baser Build Up:
Description Qty Unit Price Ext Price
Inspection Title S (not including panping) 1.00 a S.39,0000 9 3 .00
Inapection (Labor/Rxposure Dees)per hr. 1.00 a 194.9990 g 195.00
Inspection Title 5 BOR pee■ L.00 a 60.0000 a 90.00
Pamping 1292 - 1900 1.00 a 320.0000 a 320.00
Rnvircamental Compliance - Residential 1.00 $ 3.0000 a 1.1>0
Fuel / Bnergy Recovery 1.00 a 4e.2260 9 64.1)
ausmi: a 1 LS 7.13 tW algKt these 3 IM'Y1 It"to keep your system healthy:
ra a 0.00 •Regubr servicing,additive,ass a 11s7.13 •Useanter
Disposal Site: Dh}tosat Votune: Payment Detalt:
Wage Code: 1900.0000
Nessus anxcxvxvca2044 OS/2022
Sales Rep: NB Repairs Installs CSR: No Liss&Dannelly Due on Receipt
Truck: Tedmkian:Robert Rerrick On Site:02.2e PM P O Humber:
Tech Notes:
System net Operating Fine. Norval water level. Light top solids. Moderate
batons sludge. Inlet baffles are intact. Main line Clear. No filter is present
on the task; carreat task is not designed to be wed with a filter. Cover(ol Customer not on site
secured. Recomkmaded Outlet Tee,Distribution Box/Manifold,
X
Customer Signature
WIND RIVER
ENVIRONMENTAL
t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 19 of 19
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