HomeMy WebLinkAboutPass - Title V Inspection Report - 155 LACONIA CIRCLE 5/11/2021 tl l
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
w
a
Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments
155 Laconia Circle
Property.Address _
Ja dish &Suman Gar
Owner owners Name
informrequired
is North Andover Ma 01845 4l8l2021
ra ge, for every c tyfTo n State Zip Code Date of Inspection
page..... p
Inspection results must be submitted on this form.. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form..
Important:When A. Inspector Information
filling out forms
on the computer, Dean
use only the tab Dynan
key to move your Name of Inspector
cursor-do not Dean Dynan
use the return Company Name
key.
2 Suntaug Street
Company Address
L nnfield Ma 01940
City/Town State Zip Code
508-726-9935 S112837
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5
(31!0 CII✓R 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 II have determined)
that the system:
1. Passes
2. Conditionally Passes
3. ® Needs Further Evaluation by the Local Approving i Authority
4. 0 Fails
N'gan�'
ram. t.
pector"s Signature Dot
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 80 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 DER 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.
Mnsp:doc»rev.U25J2t118 Me 5 ofciol Inspection rorro:Stftwfaco Sewage Mspose9 System•Page 1 or 18
Commonwealth of Massachusetts
_ Title 5Official., Inspection :Form
Subsurface.Sewage_Disposal ystemForm--Not.for Voluntary Assessments
155 Laconia Circle
Property Address
Jagdi§h & Su_mah Garg
Owner Owner's Name
Information is; North Andover Ma 61845 4/8/2021
required for every -
Page. cityfrown Slate Zip.Code Date of inspection
C. Inspection 'summary
Inspection Summary: Complete,1, 2,3, or 5 and all of 4 and 6.
7) System Passes:
® 1 have not found any 1ptormation which indicates that any of the failure criteria described
in.310.CMR 15.303 or in 3 1 10 CMR .304.exist.Any'fallute criteria not evaluated are
indicated below.
Comments:
4,Bedroom septic,system in working order
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 repairas approved by
tie Board of Health,'will pass.
,Check the box for"yes", uno°or unot 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(wh er metal or not) is structurally
unsound, exhibits substantial infiltration-or.exfiltration or tank fwiu is imminent.TSystem will Bass
Inspection if the existing tank is replaced with'a complying se tank as approved by ttie Board of
Health.
"'A metal septic;tank will pass inspection if it is stru rally sound. not leaking and if a-Certificate of
Compliance indicating that the tank is less than years old�is available.
❑ Y ❑ N ❑ ND, (Explain below):
A&Mp.doc•rev.7 16=18 Two s airmw tmpecuon Form:subsurface Sewage oispowl Syslem Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage'Disposal System Form-Not for Voluntary Assessments
155 Laconia Circle
Property Address
Jagdish &Suman Garg _
Owner Owner's Name
information is required for every North Andover Ma 01845 4/8/2021
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 s water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, led or uneven distribution box.System will
pass inspection if(with approval of Board of He ):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ' ❑ N ❑ ND (Explain below):
❑ distribution box is eled or replaced ❑ Y - ❑ N ❑ ND(Explain below):
3
❑ The system required pumping more then 4 times a year Clue to broken or obstructed pipe(s).-The
system will pass inspection f(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 Evalua/eqre
quired by t Board of Health:
3
❑ Conditions require rther evaluation by the Board of Health in order to determine if
the system prof public health, safety or the environment.
a. System u ss Board of Health determines in accordance with 370 CMR
15.303(1)(b stem is not functioning in a mianner which will protect public health,
safety and onment:Onsp.doe•rov.7126MS - MM 5 OftieW tnapadJon Form:SubsWaw Sawage Disposal System Pap 3 of IS
I
i
'Comrno usetts!
Tithe, 5 .Off cial lnspectio:n Form
,Subs prfaceSewagbIbIsposal System Form ;Not far Voluntary;Assessments
165 Laconia Circle
PropertyAddress
;Jajdish.&-Suman Garg.
owner Owner's Name. --- .. --
informaUop is.. 'Worth Andover Ma 01845 4/8/2021
required for every
page: Pityrrgwn State Zip.Code Date of Inspeciiok
.C. Inspection ;Summary'(cont)'
❑ Cesspool,or privy is Within 59 feet of a surface,water
❑ Cesspdol or privy is within 50 feet.of:a bordering:vegetated`wetland:ora salt rnarsh,
h. System will fail unless the Board of Health (and Public>Water$u plier, if any}
determines that the system.Is functioning in,a;manner that pro �s the public•heatthi
safety and environment:
❑ The system has;a.septic tank and soil<absorption syst _;(SAS)and_the SAS is within
IDO feetof a surface water'sopoly or tributary to a surf a water supply,
[I The.system has a:septic.tank and SAS:and the S.is within a Zone l;of 6.public;watbt
supply.
❑ The:system'has aseptic tank and SAS:a the SA81s;within 50 feet of a private water-
supp.ly well.
❑ The:system.has'a septic tank e.nd and the:SAS is less than100 feet but 50 feet or
more from.a'prvate water supplyw
Mettiod'used'to_determine distan
*"Thls system passes:,If th ell wateranalysis; performed at.a DEP certified laboratory,for fecal
coOorm bacteria indtcat ".absent and•tfie presence of ammonia nitrogen-and nitrate"r itrogen is`equal
to;or less than 5 pp- ro 46 that no`other#allure criteria are.triggered.A copy i the"analysis:must
be`attached.to'thi orm:, . .. _.
c. Other.
4) 'System Failure Criteria,Appllcable to.AiI's stems:-
You.rrii gs lridicate.IT60 or"No"to each of the foll.owing'for all inspections;
Yes No
® Backup.ofosewage into-facility or-,system camp6hbht,due to,overloaded or
clogged SAS of cesspool'
❑ ® Disd arge or ponding of effluent-to the�surface of the ground or surface-waters
due:to.an overloaded or clogged SAS gr,ce'ss'pool
l5insp_dac•rev'6'2Gl2p18, Title 5 Otra6l InspeaUon Form:Subudaoe Smagebisposal 6ystem-'Page 4 0118
-Commonwealth of Massachusetts:
- Title 5 Official. Inspection Form
- iSubsu:rface Sewage;.Disposal System Nfth-.Not for Voluntary;:Assessments
155 Laconia Cirdle
Property Address
Ja dish B Suman Gar
Owner Owner's Name
information is North•Andover Ma 01846 4/8/2021
required for every.
Page. 'Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont:')
4) System Failure Criteria.Applicable to All.Systems: (cont.)
Yes No
❑ ®• Static liquid level in the distribution box above outlet invert due to an overloaded
Or clogged SAS or cesspool
® Liquid depth in cesspool is.less.than 6"below-invert or available,volume is less
than%!day,flow
❑ ® Required pumping more than 4 times in the last year NOT;due to.clogged or
obstructed pipe(s).. Number of Umes 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 ls.less than 100 feet but greater than 54 feet
frorn:a private water"supply well with no acceptable water quality analysis. [This
system'passes if-the well water analy"sls,.performed ata DEP certified
laboratory,for fecal coliform bacteria-Ifidicates absent and the presence
of amriionia 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 rnUbtbe.attacfted.to'this fdrm.)
❑ M Thesystem,ls 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 ownershould contact the Board of Health to determine what will be
necessary to correct the:failure.
5) l.arge'Systems: To be considered a large system-thesystem must serve a facility-with.a
design flow 4 4Q,t)00 gpd to'l ,000,gpd:
For large systems, you must indicate either"yes"or"no" to.each of the following, in addition to the
questions in Section C.4.
Yes No
❑ ® the system iswithin 400 feet of a surface-drinking water supply
❑ .® the system is'within 200 feet of a tributary to.a surface drinKing water supply
❑ ® fhe system is%located in a nitrogen sensitive area(Interim Wellhead Protection
Area'—IWPA)or.a mapped Zone 11 of a.public_water supply-well
t5lnsp.doc•:rev.7126R01 B Tdle 5 OfGaal lnspod-Form;Subsz#r o;-no Disposal System•Pape 5 of 10
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1555 Laconia Circle
Property Address
Ja dish &Suman Gar
Owner Ownees Name
information is required for every North Andover Ma 01845 4/8/2021
page. Oitf'Rown state Zip Code Date of Inspection
C. Inspection Summary (cont.)
3
If you have answered oyes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section C.4 above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must Indicate"yes"or"no"for each of the following for all Inspections:
Yes No
® ❑ Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® 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 NIA) '
® ❑ Was the facility or dwelling inspected for signs oftewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excludingFthe 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 slutlge 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 Sail 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)]
3
t5inap.doo rov.MOWS Title 5 OtSdW inspection Form:Suaa dme Sewage DtMmsal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Laconia Circle
Property Address
Jagdish &Suman GaM
Owner Owner's Name ---
Information is
required for every North Andover Ma 01845 4/8/2021
require
page. cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Description:
4 Bedroom 1500 gallon tank 2 shallow pits septic system ?
Number of current residents: 2
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 ears usage a 200 GPD ave
9 ( Y 0 (gpd)k
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
3
Mnsp.dec•rev.71MMI a M&5 orri W Inspectian Form:Subswfaee Sewage disposal system•PMa 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Laconia Circle
1?roperty Address
Jagdish &Suman Garg
Owner owner's Name
information Is required for every North Andover Ma 01845 4/8/2021
page. Cityrrawn state Zip Code Date of Inspectlon
D. System Information (cont.)
2. Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons rday(gpd)
Basis of design flow(seatslpersons/sq.fL, etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial w/ffilable:
nk presen ❑ Yes ❑ No
Non-sanitaarge o the Title 5 system? ❑ Yes ❑ No
Water meteailable:Last date ofse: pate
Other(desc
3. Pumping Records:
Source of information: Homeowner,/Board of Health
pumped with in last six months
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5fnsp.doo•rev.712 AIS Tdie s outw Inspection Form:Subsurface sewage DNwse1 system•Page a or to
s Commonwealth of Massachusetts
Title 5 Official ' Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Laconia Circle
Property Address
Jagdish &Suman Garg
Owner owners NameInformrequired tion
Is North Andover Ma 01845 4/8/2021
required for every
page. Citylrown state Zip Code Date of Inspection
D. System Information (cost.)
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/Altemative 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:
1987 as per info on file
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 40°+1-
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.):
sewer pipe in good condition/ no evidence of leakage
t6msp.doc-rev.7l26=1B -nlg s of 4-i t-m-ua7 Famt:8-ft- -Sewage ptsp.1 Syatwa•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Laconia Circle
Property Address
Ja dish &Sumen Gar
Owner Owner's Name
information is North Andover
required for every Ma 011345 41812021
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: set
Material of construction:
®concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain)
1500 gallon septic tank
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
10rX 5'X 518"
Sludge depth:
5"
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
- Distance from bottom of scum to bottom of outlet tee or baffle 13"
How were dimensions determined? in field with measure stick and tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500 gallon concrete septic tank with concrete baffle inlet and outlet PVC T / Tank in working order
with separation from inlet to outlet I no evidence of leakeage
recommend pumping every two to three years depending on usage and number of occupants
center tank cover 12" below grade 1 outlet cover is 15"
t51nsp dac.rea.rrzerml a Tole 5 Offtdal tnspedon Form:SubsdAaco Some Dlspasal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Laconia Circle
Property Address
Jagdish &Suman Gag
Owner Owner's Name
information is required for every North Andover Ma 01845 4/8/2021
page. Cityrrown State Zip Code Date of inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: f t
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other,(explain):
Dimensions:
Scum thickness
Distance from top of sc/boftom
e
Distance from bottom o 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 1 ection)(locate on site plan):
Depth below grade:
Material of construction:
Elconcrete Elmetal fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons pe rday
t5lnspAw•rev.MMM18 ' We 5 Official NspectE M Finn:Subsurrece Sewage Disp=W System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Laconia Circle
Property Address
Jagdish&Sumen Garg
Owner Owner's Name
required
for every
Information is
required f North Andover Ma 01845 4/8/2021
page. City/Town state Zip Code Date of Inspection
D. System Information (cons.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes No
Alarm level: Ala working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float s es, 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 liquid;at 0"above invert
Comments(note if box Is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.): `
6 Outlet concrete D box level with two outlet pipes 1 little evidence of solids carryover 1 no evidence of
leakage into or out of box 1 d box in fair conditoin
D box in working order
D Box located in driveway with cast iron cover to grade
D Box is 12"below grade i
3
i
3i
1
i
t5lnsp.doa•rev.MOWN 'Me5 Off)dal b>spedlon Forth'.Subsurface Sowago 01sposel SysImn•Page 12 of 18
Commonwealth ofMassachusetts
Title 5 -Official alnsp,ection Form
5etbsurtace Sewage Disposal SOtem.F.Oii i" Not•1'orV6166tary Assessments
755`LacvniaCircle.
•Properly,Address - _
,iagdish,&Suman Garg ;
Owner '.Ownef✓.Naine :. -- -- . — -
inforr�ation Is= -
req'yiied foreverji: •,North Andover Me 01845: . 41812021,.
page, Cltyrrowri 'State Ztp Code Date of Inspection
D. System Information ,(coat.)
10. Pump.Chamber`(locate.onaite plan)
Pumps'-i.n working order: Yes, D.
Noy'
Alarms€ri working order, ❑ -Yes ❑ No*
Comments(note:cot�ditiori:of ptiinp'chaFnber;c iflon.of;ptxmps and appurtenances,efc:):
-
If,pumps or:alarms are:not m workmg order,;system rs a corad�trarial;pass:
_ ._
1,1. Soft A.bsorptionsystem-(8A8)'(Iocate on:site.plan,.excavation; 6t'required),
If not located, explain why:
Type:
®
g p. 2 shallow:pits leachIn Its nUrnber. _
[] leaching th..ampers 'number
11. leaching galleries 'ridmbei
i
❑ leactiirig te6hches number, length:
11 leaching fields number;dimensions:
r., ,
❑ overflow'cesspool :numoer:
_ f.
❑ <ihiiavatirielalteriiative:system; ';
T elname of techholo .,
Yp 5Y�
t5insP.doc [ev irz=18 'idle 5 Gmcw 1nspeclion F* .Subsw1ata Sewage Mposal System•Page.l3,0.18
Commonwealth;of Massachusetts
'Title 5 Official Inspection: Form
Subsurface Sewage'Disposal System Form. Not for Votunta v Assessments
155°.Laconia:Circ1e
Property.Address
Jagdish &`Suman'Garg.
Owi gr Ownefs;Name
Infoimafian is Noah Andover Ma; 01845 418/2021
required for every,
Page; <CltylCown _ _ .•_ `Slate_.._ . _ zIA;Code Rate oflnspection°.
D. System InforMation (coat:)
Soil AbsorpttonrSystem{SAS} (cont3
Comments_(noto,cortditiot af'soii,signs-of hydraulicfailure, !dv"el of`por ding,damp.soil,;condition of..
vegetation,,etc;):' _` -
•2'leach pits I3'X16' 6.0d in driveway/gravel_area/ so ls:in goo,condition / no:signs of hydraulic
failure 1 no pending/ no damp=soiV,
12._Cesspools:(cesspool must be,pumped as part of inspection) (locate-on site plan):
Number,and configuration J
Depth—top o€_liquid_6 inlet!hVer#
Depth;of,solids'layer ;
gepth;ofscgm layer
pimensiois'of cesspool
;Materials of construction
Indicatcan of groundwaterinf[ El Yes 0 No
'CoMments.(note conditio . of soil, signs of hydraulic failure; level of pending; condition of vegetation,
l5tn§p doe;•iev,'7f2612018' TM0 5 Official Inspeemn Fam;SuhsWace sewage DispoW Syslem-Pago 14016
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments
155 Laconia Circle
property Address
Jagddish&Suman Garg
Owner Owner's Name
Information is North Andover Ma 01845 4/8/2021
required for every.
page. Cityrr owrr State ZIp Code Date of inspection
D. System Information (cost.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic (lure, level of ponding, condition of vegetation,
etc.): i
1 i
t5tnsp.doc•rev.7126=16 Title 5 orHdar lnspedlon Form.SubsWace Sawa' ge o ispasal System•Page 150E 7B
Commonwealth of Massachusetts
Title -5 -official Inspection Form :
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Laconia Circle
Property Address
Jagdish &Suman Garg
Owner Owner's Name ^'
Information Is
ired for every North Andover Ma 01845 4/8/2021
required Cityrrown State 7J Code Date of Ins ection
page. P A
D. System Information (cons.)
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
Mnsp.dcc•reir.M812818 7419 5 Ofrscial InspecUan Form:Subsutfaee Sewage Disposal 5*W•Page 160710
'Commonwealth of Massachusetts.
Title 5 Official -1-m—.pection Form
5615stiMied.Sewage:Disposal system:Form-Not for Voluntary Assessments
. 155: aconia"Circle
Property Address:
.Ja dish&Suman Gar
owner Qwnees'yame
Inforrn,df is North Andover Ma 01.845 4l8/2021,
required for very.
page. City/Town State Zfd Code Date of Inspection
D. System'Information (Pont:)
15. Site Exam%
® Check Slope
0 surface water
® Check cellar
® Shallow wells
Estimated depth,to.i igh groundwater 4'feet .
Please-indicate all methods uased to:detefmine-the high ground-water elevation:
Obtained from system de'sign,plans on record
If checked, date of-design pfian reviewed: 1987
m - Dale
0 Observed site(abutting.propetty/observation hole- ithin 150 feet of:SAS)'
CheckedEwith local Board.of Health-.explain:
Checked;with_ local excavators, instaillers-('attach documentation)
Accessed USGS database-.explain:
Yo p.m ust describe how you established the high;grcund water elevation:
Plans on Ob at BOH dated 1967 soil testihci
Checked`abutters
'l63,Lacon!a Circle plans on file
471 Laconina Circle,plans on file
Before filing this inspection Report,_please see Report,Completeness Checklist;omne)d page.
t5insp.doe.•r&.,UMMIa Title 5.affiddl lnsp9d ian Form.sutmerece Siovage:Orsposm System-Page t7'of-1 e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
155 Laconia Circle
Property Address
Ja dish &Suman Gar
Owner owner's Name
Information is required for every North Andover Ma 01845 4/8/2021
page. City/rown State Zip Cade 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:TightlHolding 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
Mup.doc•rev.726MI0 Tina 5 QlCidW Inspecibn Form:SLdiadace Sewage blspaser Systam•Page 18 of 18
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Ca in .for youir Septic :SyS elln A 'Reference Guidelor� ' .
Homeowners, ,.
t-ring for Your toot} System„(Gonventidnal'`Septic System,,InnovativelAlfernatirte�Ild)
S stem„or Less .00l
The dddurnula#ed solids 1n- the bottbi'n of the septic tank should be pumped out every:thrt a yeairs to
prolongthe.life of.your system. .Septic systems i>7ust b`E:malr�#sineci, regularly to stay`workng.
Negledt or=abuse of-your system can,cause'it to fail: Failing systems:earl
cause a;serPbs.hea.lth;threat;to;your fpmlly-Landnoighhors
• 0egratle the environment, especially lakes, streams andgroundwater;
reduce:the value OfIyour-pt'aperty,
41 be-very expensive to repair,:
dhdi,put thousand of water supply users at nrislt'if you.lye cn.a;pUblG water supply watersl?ed
acid#ail to-maintain your system.
Be.;alert to these warding signs'ofa failing:system:
..sewage surfacing over the drairifield,(especia.liy after,storms),
• sewage back ups in the lio rse,
lush, green-growth:over the,dminfield;
• slow drain* - to.H is .r drains,
spWago gd,brs
pr4l;Ins�� :::irr
60W ,
da utiod .
Tips to Avoid TfOuble
QO'have your tank p"umped out'and'=system inspedfed.every. 3 to 5'years by a licensed sep#iC
coW6ct6r,'(lNt6d in the.yeIlow pages). .
httpsJlw+lvw.t6wob(rlevib .at ont/4T1
113
i ,
1015=0 Caring for your Sepik Syrab'=A Reference Guide for Homeameis
• DO keep a record of pumping, Inspections, and other maintenance. Use the back page of this
brochure to record maintenance dates.
• DO practice water conservation. Repair dripping faucets and leaking toilets, run washing
machines and dishwashers only when full, avoid long showers, and use water-saving features
In faucets, shower heads and toilets.
• DO learn the location of your septic system and drainfield. Keep a sketch of it handy for
service visits. if your system has a flow diversion valve, learn`its location, and.turn it once a
year. Flow diverters can add many years to the life of your system.
• DO divert roof drains and surface water from driveways and hillsides away from the septic
system. Keep sump pumps and house footing drains away from the septic system as well.
• DO take leftover hazardous household chemicals to your approved hazardous waste
collection center for disposal. Use bleach, disinfectants, and drain and toilet bowl cleaners
sparingly and in accordance with product labels.
• DON T allow anyone to drive or park over any part of the system. The area over the drainfield
should be:left undisturbed with only a mowed grass cover. Roots from nearby trees or shrubs
may clog and damage your drain lines.
• DON'T make or allow repairs to your septic system without obtaining the required health
department permit. Use professional licensed contractors when needed.
• DONT use commercial septic tank additives.These products!usually do not help and some..
may hurt your system in the long run.
• DON'T use your toilet as a trash can by dumping nondegradables down your toilet or drains.
Also, don't poison your septic system and the groundwater by pouring harmful chemicals
down the drain. They can kill the beneficial bacteria that treatjyour wastewater. Keep the
following materials out of your system:
Nondegradables
grease, disposable diapers, plastics, etc.
Poisons
gasoline, oil, paint,.paint thinner, pesticides, antifreeze, etc.
Septic System Explained
Septic systems are individual wastewater treatment systems(conventional septic systems,
innovative/altemative (VA) systems, or cesspools)that use the soll°to treat small wastewater flows,
usually.from individual homes. They are typically used in rural or large lot settings where centralized
wastewater treatment is impractical.
There are many types of septic systems in use today.While all systems are individually designed for .
each site, most systems are based on the same principles.
Your septic-system treats.your household wastewater by temporarily holding it In the septic tank
where heavy solids and lighter,scum are allowed to separate fromlthe wastewater.This separation
process is known as primary treatment.The solids stored In the tank are decomposed by bacteria
and later removed, along with the lighter scum, by a professional septic tank pumper.
After partially treated wastewater leaves the tank, it flows into a distribution box, which separates
this flow evenly into a network of drainfield trenches. Drainage holes at the bottom of each line allow
the wastewater to drain Into gravel trenches far temporary storage. This effluent then slowly seeps
Into the subsurface soil where it is further treated and purified (secondary treatment).A properly
functioning septic system does not pollute the groundwater._
To n o ( North Andover,, MA
z5
via Credit Card endings in 0897'
Thanks for using the Onlinle Service Center
clean dynan
Title 5 Offieiall lns ec;tien Form Submittal#9 17
May 4, 2021
TAle 5 Filing Fee $50.00
Processing Fee 2A9
Total Paid 2,4
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