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HomeMy WebLinkAboutPass - Title V Inspection Report - 93 SHERWOOD DRIVE 3/18/2021 Commonwealth of Massachusetts W Title 5 Official Inspection Form REcEivED Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 202� �,M MAR � oovER 93 Sherwood Drive XrWAOFOf OR TMENT Property Address H�ISR � Owner Lindenstruth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 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 1. Inspector: Robert Herrick 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: 0 Passes ❑ Conditionally Passes ❑ Needs Further Evaluation by the Local Approving Authority ❑ Fails February 26, 2021 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*Page 1 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Sherwood Drive Property Address Owner Lindenstruth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 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: Q I have not found any information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CM 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) t5ins.doc a rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Sherwood Drive Property Address Owner Lindenstruth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 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. ❑ 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: t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 3 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Sherwood Drive Property Address Owner Lindenstruth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 CitylTown 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 ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 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•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 93 Sherwood Drive Property Address Owner Lindenstruth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 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. ❑ Z The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Sherwood Drive Property Address Owner Lindenstruth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 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? Q ❑ 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? Q ❑ 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? Q ❑ Was the site inspected for signs of break out? Q ❑ Were all 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•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Sherwood Drive Property Address Owner Lindenstruth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 GPD Description: Number of current residents: 2 Does residence have a garbage grinder? Q Yes ❑ No Does residence have a water treatment unit? ❑ Yes Q No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes Z No Seasonal use? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): 348 GPD Detail: Usage: 34,000 CF x 7.48 =254,320 gallons/730 days=348 GPD. Usage data provided by the Town of North Andover. Sump pump? Q Yes ❑ No Last date of occupancy: Current Date t5ins.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 7 of 18 Summary Record Card generated on 3/16/2021 9:08:10 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-105.C-0070-0000.0 Parcel Id 16986 93 SHERWOOD DRIVE ROBERT & DONNA LINDENSTRUTH 93 SHERWOOD DRIVE NORTH ANDOVER MA 01846 Class 101 Single Family Property Type 1 Residential Size Total 0.923 Acres FY 2021 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until 05ERT&DONNA LINDENSTRUTH Owner Ai'Jiv^ 3HERWOOD DRIVE 4.TH ANDOVER MA 01845 MOORE, JULIE Previous Customer Inactive 2/21/2012 93 SHERWOOD DR NORTH ANDOVER,MA 01845 RAVI NABAR Previous Customer Inactive 3/3/2017 93 SHERWOOD DRIVE NORTH ANDOVER MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id.17697.0-93 SHERWOOD DRIVE Last Billing Date 1/7/2021 3170368 03 Cycle 03 Active UB Services Maint. Account No.3170368 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE 125.95 /1 UB Meter Maintenance Account No,3170368 Serial No Status Location Brand Type Size YTD Cons 40535330 a Active ERT HH b Badger w Water 0.63 0.63 29 Date Reading Code Consumption Posted Date Variance 12/9/2020 2334 aActual 29 1/13/2021 -54% 9/9/2020 2305 a Actual 67 10/14/2020 20% 6/5/2020 2238 a Actual 51 7/15/2020 91% 3/9/2020 2187 a Actual 27 4/8/2020 -34% 12/11/2019 2160 a Actual 41 1/15/2020 -37% 9/13/2019 2119 aActual 69 10/10/2019 111% 6/11/2019 2050 a Actual 33 7/25/2019 33% 3/8/2019 2017 a Actual 23 4/16/2019 -30% 12/10/2018 1994 a Actual 33 1/22/2019 -52% 9/12/2018 1961 a Actual 72 10/15/2018 210% 6/11/2018 1889 a Actual 24 7/23/2018 -10% 3/7/2018 1865 a Actual 25 4/23/2018 -32% 12/7/2017 1840 aActual 35 1/25/2018 -28% 9/12/2017 1805 a Actual 54 10/18/2017 31% 6/8/2017 1751 a Actual 39 7/25/2017 -2% 3/9/2017 1712 a Actual 7 4/12/2017 -3% 2/21/2017 1705 f Final Bill 34 2/21/2017 -50% 12/8/2016 1671 aActual 81 1/23/2017 -54% 9/9/2016 1590 a Actual 173 10/24/2016 472% 6/13/2016 1417 a Actual 33 8/2/2016 24% 3/9/2016 1384 a Actual 25 4/22/2016 -71% 12/10/2015 1359 aActual 88 1/20/2016 -48% 9/9/2015 1271 a Actual 167 10/16/2015 150% Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�r 93 Sherwood Drive Property Address Owner Lindenstruth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 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 Was system pumped as part of the inspection? 0 Yes ❑ No If yes,volume pumped: 1500 gallons How was quantity pumped determined? Measured by the pump truck Reason for pumping: To check the structural integrity of the tank. t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System o Page 8 of 18 Commonwealth of Massachusetts t;4 City/Town of North Andover -- + System Pumping Record Form 4 a DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information must be substantially the same as that provided here.Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 93 Sherwood Drive Address North Andover MA 01845 City/Town State Zia Code 2. System Owner: Robert Lindenstruth Name 93 Sherwood Drive Address(if different from location) North Andover MA 01845 Clty/Town State Zip Code 4023326917 Telephone Number B. Pumping Record 1. Date of Pumping 02/26/2021 2. Quantity Pumped: 1500.0000 Date Gallons 3. Component: Ej cesspool(s) Septic Tank Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑Yes a No If yes,was it cleaned? Yes No 5. Observed condition of component pumped: Cyctem nP rating Fine NLjrmal roater loc.cl Moderate top —1-ids- Moderate bottorp , current tank is not designed to be used with a tilter. Covers secured. Recommended Boost additive,CCLS additive. 6. System Pumped By: Michael Graham Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA 02/26/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Sherwood Drive Property Address Owner Lindenstruth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 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) El 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: 1995 Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron 0 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.There are no leaks. The system is vented through building sewer. t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p 93 Sherwood Drive Property Address Owner Lindenstruth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 5" feet Wa,:erial of construction: © concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is a0e confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'6"x 58"x 68" Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 2" giftance from top of scum to top of outlet tee or baffle 6" uisiance from bottom of scum to bottom of outlet tee or baffle 14" 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.): Rinccrinmend pumping as needed. The inlet and outlet are solid.The liquid level is normal and there are no signs of ieakage. t5ins.doc rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Sherwood Drive Property Address Owner Lindem,;;ruth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 CityfTown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet N,a'.crial 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 C,).r,.rents(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 'resign Flow: gallons per day t5insdoc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 18 2 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 93 Sherwood Drive Property Address Owner Lindens'-Ah information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 City/Town State Zip Code Date of Inspection D. Sy--tcm Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Ala-rn level:_ Alarm in working order: ❑ Yes ❑ No of last pumping: Date Comments(condition of alarm and float switches, etc.): ;h 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 Cor-1 dents(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leaktige into or out of box, etc.): The distribution box is solid.There are no signs of leakage and there is no carryover in or out. t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 12 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 93 Sherwood Drive Property Address Owner Lindenz;ii.th information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 City/Town State Zip Code Date of Inspection D. Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* AI isms 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: 2 @ 60' r: 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 Page 13 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Sherwood Drive Property Address Owner Lindens.rtlth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 City/Town State Zip Code Date of Inspection D. Sy.zAem Information (cont.) 11. Soil Absorption System (SAS)(Cont.) Cctnments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc __h= so:'was dry during this inspection.The vegetation is normal for the area and there are no signs of hydraulic failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to inlet invert Denth 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 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Sherwood Drive Property Address Owner Lindens,,,th information is Owners Name required for every page. North Andover MA 01845 February 26, 2021 City/Town State Zip Code Date of Inspection D. Sy�3tem Information (cont.) 13. Privy (locate on site plan): Materials of construction: D:ry!ensions 0apxh or solids t Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonvrealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c� 93 Sherwood Drive Property Address Owner Lindens;ruth information is required for every Owner's'tame page. North Andover MA 01845 February 26, 2021 City/Town State Zip Code Date of Inspection D. Sj-�Aem 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 thr poxes below: hard-sketch in the area below L-i drawing attached separately Rmze— DC.,VeAAt s U4 0 SeA4 -c. t Cl r`�4 `ID,l`'.''- t5ins doc 9 rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System.Page 16 of 18 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Sherwood Drive Property Address Owner Lindenst,uth information is required for every Owner's Name page. North Andover MA 01845 February 26, 2021 City/Town State Zip Code Date of Inspection D. Sl-:atem Information (cont.) 15. Site Exam: Q Check Slope Z Su,face water F1 Check cellar U 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: 1995 Date Observed site(abutting property/observation hole within 150 feet of SAS) L, Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: [ad groundwater information from the plans on file with the Board of Health. 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 a Page 17 of 18 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Sherwood Drive Propert dress Owner Linden,3:,,.th information is required for every Owner's N?me page. North Andover MA 01845 February 26, 2021 City/Town State Zip Code Date of Inspection E. R(- )ort Completeness Checklist Complete all applicable sections of this form inclusive of: Q A. Inspection information: Complete all fields in this section. F'1 R. Certifcation- Signed&Dated and 1, 2, 3, or 4 checked F C. !nspection Summary: 1,2, 3,or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed L'! D. System Information: Fr,r 8: Tight/Holding Tank- Pumping contract attached For 15: Sketch of Sewage Disposal System drawn on pg. 16 or attached Fo•16: Explanation of estimated depth to high groundwater included t51ns.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 �gw i Of NORTH,4, O Town of North Andover HEALTH DEPARTMENT ,3•SA�MUSt� CHECK#: 30 66Y DATE: LOCATION: 7.3 '34, H/O NAME: &o eA qpA CONTRACTOR NAME: U� 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 $ i ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ j ❑ Title 5 Inspector $ Title 5 Report C1✓`�, $ 50 1 ❑ Other:(Indicate) $ i Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer