HomeMy WebLinkAboutPass - Title V Inspection Report - 535 SALEM STREET 12/14/2020 Commonwealth of Massachusetts
1= s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
535 Salem St.
Property Address
Matthew J. Bolduc
Owner --- ---- ------— - ---
Owner's Name
information is required for every North Andover MA_ 01845 12/5/2020
_
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. �Q
Important:When A. Inspector Information
filling out forms 1 4
on the computer, Anthony . Cam ano ��L N�vEFZ
use only the tab Y P _ P
key to move your Name of Inspector OpF D�PP(ZL
cursor-do not Campano Title V Inspections
use the return key. Company Name
Elm Company
Company Address
Pepperell MA 01463
City/Town State Zip Code
» 978-433-2212 _ 12780
Telephone Number License Number
B. Certification
I certify that: 1 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
12/08/20
61nect Ps 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 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.7/2612 01 8 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
535 Salem St. _
Property Address
Matthew J. Bolduc
Owner - -- --.
Owner's Name
information is North Andover MA 01845 12/5/2020
required for every - _
page. Cltyrrown 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:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
�a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
535 Salem St.
Property Address
Matthew J. Bolduc
Owner Owner's Name
information is required for every North Andover MA 01845 12/5/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev 7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/ 535 Salem St.
Property Address
Matthew J. Bolduc
------...------
Owner Owner's Name
information is required for every North Andover MA 01845 12/5/2020
__n_.
page. CitylTow State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
535 Salem St.
tom-- ---- - — _---------_ -- -- -- ---
Property Address
Matthew J. Bolduc
Owner Owner's Name
information is required for every North Andover MA 01845 12/5/2020
- -- ---------------- — - ----
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 '/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.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
535 Salem St.
Property Address
Matthew J. Bolduc
Owner - - - ---- ----
Owner's Name -- - - - -- _---
information is required for every North Andover MA 01845 12/5/2020
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
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
,e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
535 Salem St. _
Property Address
Matthew J. Bolduc
Owner Owner's Name
information is required for every North Andover MA 01845 12/5/2020
___—
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
See attached copy of the as-built dated 10/27/2017 showing a 1500 gallon septic tank with 18ft wide
by 27ft long leaching bed area.
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 ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 013 gpd
Detail:
10 gal./728 days = .013 gpd, usage report is attached.
Sump pump? ® Yes ❑ No
Last date of occupancy: occupiedDate
t5insp.doc-rev.7/26/2018 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 Form - Not for Voluntary Assessments
(P'
535 Salem St.
Property Address
Matthew J. Bolduc
Owner Owner's Name
information is required for every North Andover MA 01845 12/5/2020
- ---
page. Cltyrrown 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):
3. Pumping Records:
Source of information: never per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: - - ---- -- --
gallons
How was quantity pumped determined? -- --- - -
Reason for pumping: --- - ----- - - -- -- ---- --
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
535 Salem St.
t.-
Property Address
Matthew J. Bolduc
Owner Owner's Name
information is required for every North Andover MA 01845 12/5/2020
page. CityTTown 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:
Attached Certificate of Compliance from the Board of Health dated 11/6/2017.
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: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
All exposed joints and pipes are in good condition with no evidence of leakage or venting problems.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
rd Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
535 Salem St.
Property Address -- -- ---- ___- - -_.-_ _-.--
Matthew J. Bolduc
Owner __ -_ _ _-------------
Owner's Name
information is North Andover MA 01845 12/5/2020
required for every _-
page. CItyrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 15 inches
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Both the inlet and outlet tees were in place and composed of PVC. Both were in good condition. The
outlet tee has filter. The tank liquid level was normal at the oulet pipe invert. (See attached photo)
If tank is metal, list age: ----- - - - --- -----
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
101x6Wx5.5'D
Dimensions: -- -- --- ---- --
Sludge depth: 1" — - --- --------
Distance from top of sludge to bottom of outlet tee or baffle 27"— --- - ---- --- —
Scum thickness -- - -
Distance from top of scum to top of outlet tee or baffle 7
Distance from bottom of scum to bottom of outlet tee or baffle 14"
oleraduated dip p
How were dimensions determined? g - ----- --
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank should be pumped every 2 to 3 years. Both inlet and oultet lines have PVC tees. Both were
in place and in good condition. The liquid level was normal and at the outlet pipe invert. The tank did
not appear to be leaking. The outlet tee has a filter. (See attached photos)
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
535 Salem St.
u— —
Property Address
Matthew J. Bolduc
Owner
Owner's Name
information is required for every North Andover MA 01845 12/5/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction.-
0 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M � 535 Salem St.
Property Address
Matthew J. Bolduc
Owner -— - - -
Owner's Name
information is required for every North Andover MA 01845 12/5/2020
_
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 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 d box was level with equal distribution to all three lines. There was no evidence of solids
carryover or leakage into or out of the box. The box was 20 inches below grade with a 12 inch
riser.(See attached photos)
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
_RESP Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
f;
535 Salem St. _
Property Address
Matthew J. Bolduc
Owner -- - - --
Owner's Name ----_..------
information is required for every North Andover MA 01845 12/5/2020
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: one, 18ft wide X
27 ft long.
❑ overflow cesspool number: --
❑ innovative/alternative system
Type/name of technology: - - --- - — --- -- -
t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
535 Salem St.
Property Address
Matthew J. Bolduc
Owner -- ---------
Owner's Name
information is required for every North Andover MA 01845 12/5/2020
_-
page. Cltyrrown 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 was dry with no signs of hydraulic failure, ponding or damp soil. Vegetation above the leaching
bed is mowed lawn.(Photo attached)
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.):
t5insp.doc•rev.7/2 612 0 1 8 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
535 Salem St.
Property Address
Matthew J. Bolduc
Owner —_---
Owner's Name
information is required for every North Andover MA 01845 12/5/2020
page. Cltylrown 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
535 Salem St.
Property Address
Matthew J. Bolduc
Owner Owner's Name
information is required for every North Andover MA 01845 12/5/2020
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
® drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
�y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�`e 535 Salem St.
Property Address
Matthew J. Bolduc
Owner Owner's Name
information is required for every North Andover MA 01845 12/5/2020
—_.
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 5 -
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: 9/1/2017
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Attached is a copy of the original plan showing test hole data dated 09/25/17.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Attached is a copy of the plan showing test hole data for DTH-1 and DTH-2 both showing Mottles at
60".
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,t
535 Salem St.
Property Address
Matthew J. Bolduc
Owner Owner's Name
information is required for every North Andover MA 01845 12/5/2020
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
® 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
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
1b7/202O 535 Salem ST.png
MATHEW BOLDUCK Owner Inactive 11/7,
535 SALEM STREET
NORTH ANDOVER MA 01845
cf 1 UB Account Maint.
Account No Cycle Occupant Name Active/Inac
Bldg Id. 16105.0-535 SALEM STREET Last Billing Date 10/8/2020
3160147 03 Cycle 03 Active
UB Services Maint.
POW
Account No. 3160147
Service Code Rate Charge Multiplim/l.lsers
MISCFEE ADMIN FEE 0.63 5/8 7.82 1/
WTR WATER 01 ALL METER SIZE 7.60 /1
UB Meter Maintenance
Account No. 3160147
Serial No Status Location Brand Type Size
16335843 aActive 00 METE METE wWater 0.6`
Date Reading Code Consumption Posted Date
9/3/2020 593 a Actual 2 10/14/2020
6/1/2020 591 a Actual 0 7/15/2020
3/4/2020 591 a Actual 0 4/8/2020
12/5/2019 591 a Actual 0 1/15/2020
9/12/2019 591 a Actual 0 10/10/2019
615/2019 591 a Actual 0 7/25/2019
3/6/2019 591 a Actual 1 4/16/2019
12/5/2018 590 a Actual 0 1/22/2019
9/6/2018 590 a Actual 5 10/15/2018
6/5/2018 585 a Actual 4 7/23/2018
3/2/2018 581 a Actual 0 4/23/2018
12/4/2017 581 a Actual n 1/25mi S
11/6/2017 581 f Final Bill 1 11/6/2017
9/6/2017 580 a Actual 0 10/18/2017
6/2/2017 580 a Actual 0 7/25/2017
3/3/2017 580 a Actual 3 4/12/2017
12/5/2016 577 a Actual 5 1/23/2017
CA12m A 572 „Arh W 11 1 f V2412n19
;J0 AL gZoNs -- t013 -9F'e
hftps://mail.google.com/mail/u/0/?tab=rm&ogbl#inbox/FMfcgxwKjnXXsKZfGdJbdPgQStnMNvKh?projector-1&messagePartld=0.1 1/1
I CERTIFY THE LOCATIONS, ELEVATIONS, TIES, COVER MATERIAL; EXPOSED COMPONENT
TAX MAP 38 LOT 6 COVERS, ETC., SHOWN ON THIS AS—BUILT SUBSTANTIALLY AGREE WITH THE APPROVED
y547 SALEM STREET PLAN AND HAVE DETERMINED THAT THE BREAK OUT ELEVATIONS HAVE BEEN MET.
N/F DANIEL WINNING EX. 1 1/2 STORY
WOOD FRAME
LOT AREA STRUCTURE Ex. 1
32,487 S.F.t Car HOF
1i Top of Fnd=103.32' Garage
N y535 B 4"" SCH. 40 PVC CIS y
(V SEWER LINE No.411IN
A
SOIL ABSORPTION AREA gss10t1At
LEACHING BED 20' O
18'W x 27'L 56.91 1 1f\`
W/ 3 DISTRIBUTION LINES in Bit. Conc. V 1,500 GALLON CONC. SEPTIC ,IOHN D. SULLIVAN III, PE
a 10 —•—.7. 4 n° TANK (MONOLITHIC)
a — —.— CIV.
yZ.
�a--s Driveway H-20 CONC.
END OF DISTRIBUTION 6, ° TH-1 \' D—BOX — 6 OUTLET
PIPES ARE INTERCONNECTED I Inspection E ffA�A
Pressurized Water I 12• Port V
I
Service (field located)
128.0't
M, OWNER:
Ex. Bit. Conc. Sidewalk BB W
Be W WINNING FAMILY IRREVOCABLE TRUST
W PK NAIL IN SIDEWALK 535 SALEM STREET
GRAPHIC SCALE SALEM STREET ELE✓- 100.00' NORTH ANDOVER, MA 01845
(ASSUMED DATUM)
FEET SCALE:1"=20' ASSESSOR INFORMATION:
20 0 10 20 40 TAX MAP 38 LOT 66
535 SAI" STREET
SCHEDULE OF ELEVATIONS SEPTIC AS-BUILT PLAN OF LAND
DESIGN AS-BUILT LOCATED IN
SEWER INVERT OUT OF HOUSE N 99. ' NORTH ANDOVER, MASSACHUSETTS
SEWER INVERT INTO SEPTIC TANK 99.2.27' 99.2323'
SEWER INVERT OUT OF SEPTIC TANK 99.02' 99.02' SEPTIC SYSTEM TIES BUILDING CORNER (ESSEX COUNTY)
SEWER INVERT INTO D-BOX 98.97' 98.96' SEWER AT FOUNDATION 27.2' N/A PREPARED FOR
SEWER INVERT OUT OF D-BOX 98.80' 98.77' SEWER COVER OVER SEPTIC INLET 30.8' 36.9' WINNING FAMILY IRREVOCABLE TRUST
SEWER INVERT BEGIN LEACHING TRENCH 98.63' 98,61' SEWER COVER OVER SEPTIC OUTLET 37.9' 29.6' SCALE: 1"= 20' DATE: OCT. 27, 2017
SEWER INVERT END LEACHING TRENCH 98.50' 98.50' CENTER OF D-BOX 44.7' 29,2' PREPARED BY
BOTTOM OF LEACHING FIELD 98.00' 98.00, EDGE OF FIELD (C) 23.3' 54.1' SULLIVAN ENGINEERING GROUP, LLC
MAXIMUM SEASONAL GROUNDWATER 95.00' EDGE OF FIELD (D) 43.8' 31.0' P.O. BOX 2004
LOCAL UPGRADE APPROVAL GRANTED: EDGE OF FIELD (E) 54.4' 45.2' WOBURN. LA 01888
i) THE APPLICANT WAS GRANTED A LOCAL UPGRADE APPROVAL FROMTHE EDGE OF FIELD (F) 39.$' 63.3' (781) 854-8644
NORTH ANDOVER BOARD OF HEALTH TO ALLOW A THREE FOOT SEPARATION BETWEEN
THE BOTTOM OF THE LEACHING BED AND THE SEASONAL HIGH GROUNDWATER TABLE. INSPECTION PORT 35.2' 54.0' SHEET No. 1 OF 1
ELEV.(FT) DTH-I DEPTH(IN) ELEV.(FT) DTH-2 DEPTH(IN)
TOP OF PIT-99.76' HOR.A/FILL 00" TOP OF PIT-IOCIff HOR.A/FILL W"
FSL FSL
98.5' 75' 99.2'
10 YR 3/3 10 YR 3/3
8'
HORIZON B. HORIZON B. IDO i CLE3ANUUT COVER -
LS LS
10 YR 6/8 10 YR 6/8
97.Cr 33• 97.0' 36' -
nPROP.Q coVERs TO�,AOE \ \ I s B
C-LAYER C-LAYER
LS LS
2.5 Y 6/4 2.5 Y 6/4 102 ... .._.. _. IPBa.. _...7WRIm�wxo! I -
(CLASS q (CLASS 0
BOT.OF PIT-Ilt7' nusAL�xoW 96" BOT.OF PIT-92.7' RvuBAL wllor� 94'
wlw xtB'W9•NWW w+� FmWW•xDW IDo
MOTnxs•e9.OOev-Bwn9 •eo-(¢EwBBarI 1•TAPER PUN Vsw
TOP N-M
NOTE:SOIL EXAMINATIONS(DTH-I,DTH-2)AND PERCOLATION TESTS(PT-1) p ASTI[ -
WERE PERFORMED BY JOHN D.SULLIVAN III OF SULLIVAN ENGINEERING GROUP,LLC M _ b1^ !XNI PIPE SE
ON JULY 26.2017 AND WITNESSED BY ISSAC ROWS OF MILL RIVER CONSULTING i.L� /•�
wuv
_�.-� � �j /� r9• PwE SEAL
(CONSULTANT FOR THE TOM OF NORTH ANDOVER BON) IL� � Xta `•�'� �->rL A'DM OURET
1 CERIBY-1 IN OCRORER 1905 1 PASSED WE-EVALUATOR EXAMINARdv APPROM;D �( A' i � rW a °fAAM I LI001D LCVEL-
BY THE DEPARTMENT OF ENMROWWNTA PROTECTKW AIID NAT NE ABOVE ANALYSIS WAS ., mpo
PERFORMED BY ME CONSIS TWIN THE REOIXRED FRAINING,EXPER.W,,AND EXPERIEN 1n �M'n
DESLRIBEp RV mo cMR R5.1�.. � � I i }
1 1511) B WA -980
DARE: I . 4'-7' SEE NOTE 6
v. moe I B
SOIL DATA SYSTEM PROFILE I SHEA
NOT TO SCALE SCARC I-2-(W��) L
4• •,
GATE TEST N0. DEPTH ROT.ELEV. RATE
B'CRU9KD SPoNE C(WPACTCG BASE
7/26 7 1 1 36•-58" 95.1' 8 NPI SECTKKR vlEw
PERCOLATION TEST RESULTS (REM W.TK-1500 H-Bo 113J3501a1
- NOTES: 1, •.� � ^
1.CONCRETE:t,000 Ps MIMMMM AFTER 2e w1s. ';igr!
DESIGN ANALYSIS 2.M-C-ORMS WN 310 CUR 1e.W.DEP
lE S REDS.FER SEPTIC LANKS.
ESTIMATED OMLY FLOW'. FINISHED GRADE (2X MIN) 3.ALL REINFORCEMENT PER Asru C122>-B3. SEPTIC TANK(MONOIJTHIC) y,y
3 BEDROOM HOUSE(PEP Bee BOH SEPTIC INSTALLATION RECORDS) 9"MIN.EXCLUDING TOP SOL 2'OF 1/9'TO 1/2' 99.13'. 1500 GALLON W
3 BEDROOMS x I10 GPD/BEDROOM-3J0 GPD(STATE REG) 36"MAX.INCLUDING TOP SOIL WASHED STONE 4• (HIGH FADE)ELEV.
TANK-..E' 99.D0'.
DESIGN ROw-3.GPD d � BREAKOUT ELEV.
ero c�ALO< solo CatW(rm�i a uwwuu) R 4 Yt• 4 {LOW SIDE 3'
4'PERf.P.V.C. fA !A° - O1A O fG° ' O SL o O O ) +� 2¢ ■
W/3/6'-5/8• .o ,b� 'a:oR b°a:oR b�'e: AA b� R oa bo 6' i-5• I tl F
LEACHNG MCA REQUIRED: ORIFICES t D' "a.O a` 4
LTA.R.PERCO At10N FATE-e MPI(CIASS U 3/4'DOUBLE WASHED STONE (ll 4' INLETp
T(6> 4' DIA OUTLET
UAG.-0.,o GPD/SF PLASTIC PIPE SEAL
LEACHING AREA REQUIRED: T
330 GPO/0,70 GPD/SF-47TA2 SF 3' 6' 6' 3' 1'-8' T
LEN_C AREA PROVIDED. i-5, 10'
LEACHING BED:18''WIDE x 27'LONG-48e S.F. I+
Iee K> .11.42 ST REWIRED TO PREVENT BREAKOUT: i8' cl-+- k
DIARY ROW GPACTIY: J LEACHING LINES TO BE PROVIDED 7'O.C. 3
THE FINISHED SIDE SLOPES a THE PROPOSED Sql ADSORPTION SYSTEM WNIN LEACHING BED AS SHOWN d
(06 SF X 0,70 GPD/SF)-340.2 GPO SHALL NOT BE STEEPER THAN 3:1. A MiNIWUN 15 FOOT HORIZONTAL SEPARATION IN SHEET I OF 2 B 1/2'
SMR.2 GPD>330 GPD REQ'O DISTANCE SHALL BE PEOVIDED BETWEEN THE SOIL ABSORPTION AREA AND PLAN VIEW SECTION VIEW
THE ADJACENT SIDE SLOPE. 6 OUTLET H-20 II DRR
LEACHING BED DETAIL Nor6s: REM No.a-eDIN w cQYER s32s� (/1 V
NOT TO SCALE 1.CONCRETE:4.000 PSI MINIMUM AFTER 2H DAYS.
2�DESIGN CONFORMS VITM 310 CMR 15.000 DEP MUM
Lij
TOP OF FND 103.J2' TITLE 5 REGS,FOR DISTRIBUTION BOXES. Q FROMM 6'CRUSHED STONE BASE
SYSTEM PROFILE 2)ALL D-BOX CYOLETS TO BE AT THE SAME ELEVAOON l W O
NOTE:A MINIMUM OF 9.OF COVER - I'
TO BE PROVIDED OVER SEPTIC TANK NOT TO SCALE J)D-BOX TO%WA/ER RCHF
VyJ
Y k DISTRIBUTION BOX. ALL PIPING TO BE A MIN,OF SCHEDULE 40 PVC FILL m SURE�,-/ Q vl V' DO
MIN.FTINLSHED GRADE FIRM BASE. `� (u u• OO p w
�• COVER TD GRADE OVER D-DUX-100.5e' FIRST TIo FEET FINISHED GRADE - _ HEA CONCRETE PRODUCTS
M'pA.CAST MYI L01fla ro BC SCT I£1EL 2%SLOPE MIN. rn / N•E 1
\ �.'! V `U Q W C)7 Ran
(MIN.) oaox soon ers
W,Oi 0-BOx
2'OF t/6'il3 1/2' ..
WASHED STORE J Q {M m Z
•' (101 4'SOLN)PVC SCH.10 MWARTRWTBOx ��
N-ao LonGHT L-VA 9'MIN.EXCLUDING TOP SqL (/)\ (5 O m 1,0
(S-0.02 MIN) J' Jle._Ipj,_'-F (S)4'SCUD PVC 5CH'4p 4"SOLID LIES 36'MAX.INCLUDING TOP SOIL 4'PERF.SCH.40 PIPE JDp 57L1\1{ / Q Z O-GO
EL-9B.4r Tu" J r4'I S.0.01 P�SCH.40 TOP 5 5/0.0 s lir pIFXEs EL-a.Qe
P OPO5E0 EL.M27' DIM la IER 6"CRUSHED / CAP
00-SXNn STONE BASE l 6'OF 3/4' EL• Usp'
(wVTER-T-MoxouTHIc)NH RATED) / DOUBLE WASHED STORE SEPTI TANK B OYAN A ATION: O >J
EL.-gam,
WATERTIGHT "'ClCOMPACT B`RW Lr SEPTM TAMR.02.1 G
.BA02' EL- FILL SASE W RMAL Di MAX SEASONAL GROUNCIMTER TABLE-9e.01(AT TAAW LOCAROIU 4
8"CRUSHED STONE BASE FD-solATO...LEviL/ CRq/NOWA 3'MIN°• CCS
10'MIN.TO BLDG 1 SOO GALLON CONCRETE NOTE:FLOW EOU LIZERs ELEV-95 0 un rr FDRa:+oB'x 6.es x o.n'x e2.4 IBs-1.e13 Lns
WEIGHT OF FAH.(EMP1Y):Tf.930 LB9 NOT TO SCALE
SEPTIC TANK(MONOLITHIC) BE PRONGED AT ALL (BASED ON DTH2�) WEKRIT a SOIL OVCR TANK(9'MW}5,061 Las
_ 20'MIN. TO SLOG OUTLETS
W RE7S FROM 0-BOX LEACHING BED: 18' WIDE%2T LONG rorM.WEIGHT(TANK.80KJ:n,ae1 s.r.>uaurt FORCE(2.e23 Ias)..eK I SEPT. 1, 2017
•LOCAL UPGRADE APPROVAL REQUESTED(4'REQUIRED,3'REQUESTED) vRYN Z Of 2
f
•
I
. I
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community and Economic Development Division
i
CERTIFICATE OF
COMPLIANCE
I
As of: November 6, 2017
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Full Repair of On-Site Sewage Disposal System
By: James Kellett
At: 535 Salem Street
Map 38 Lot 66
North Andover, MA 01845
lich
uance of this cert s ' 11 not be co strued as a guarantee that the system will function satisfactorily.
i
ele E.
Grant
Public Health Inspector
I
i
I
120 Main St.,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov
i
12/6/2020 20201205_123945.jpg
an r
iN
V-,
A0,
F�
h
z
x s
A
Y r✓K
i
r�
r.
f
h �
M -b-
,�i?��.y✓12v� n
https://maiI.google.com/mail/u/0/?tab=rm&ogbl#inbox/FMfcgxwKjnWPhFsNgFHxrSLBWbvjVzMV?projector-1&messagePartld=0.1
i
N
O
J:2
a
a�
rn
�N
Lc�
L
0
U
N
O
vi >
M
M
CO
N J
O C`
N x
O
N LL
Z
LL
>t
r �
Y
3
x
;< LL
0
0
a
0
oa
n
w
o_
E
E
0
U
N
O
O
m
O
N E
o
N N
a
L
12/6,'2020 20201205_131352.jpg
FV�f
O%XA
Y,
r
`tea _ f i 4.y..rkfwA'/�'a�r4
�d y-
e
.z
s:
° gaff
vilk;
"r <*
' Y a
I
u1 ,
3;
i'1f+'
t Ni
3141VA rm
qq
14
u � .�`�"'� ��s .,►AMA � � ��� �'
tads t t. •�.�.. ` yr '=. �.r •'sF.Y'>t '" t.*tF$ f_+*�,rs
r *-.4I t't lE i y�f t'., "sa k s 1 v
f
ip' , ;�
{ f rRX
�.�°
,�. ?„� ��� use # '•�""�'+ �. � � + `-- ,
c, cA Z4
https://mail.google.com/mail/u/0/?tab=rm&ogbl#inbox/FMfcgxwKjnWPhFsNgFHxrSLBWbvjVzMV?projector=l&mesSagePartld=0.3 1/1
12/6/2020 20201205_132949.jpg
.a,
3*:f
'F J
y_ 4�g147t
*b a 7
a 1
a. S
-r
+ f i
4
xi
.s
https://mail.google.com/mail/u/O/?tab=rm&ogbl#inbox?projector-1
12/6/2020 20201205_132942.jpg
r
m
r y
t�
https://mail.google.com/mail/u/O/?tab=rm&ogbl#inbox?projector-1
h �i4
f 4A ,
w �' 1•t: � as I /I � �
a
fi
} r�4 `� a t• .r
a
1
Af
k 1 '
ly
x
3 u
Of MORTM Ati I , 7
O �
3r• ...o; OL
O 9
Town of North Andover
HEALTH DEPARTMENT
,SSACMU k
CHECK#: DATE: Adza
LOCATION: -5s -Arn ZOL
H/O NAME: /% A40 C
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
. Title 5 Report CCU JS` -�v $ 101 3
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer