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HomeMy WebLinkAboutPass - Title V Inspection Report - 141 CARLTON LANE 6/1/2021 Commonwealth of Massachusetts - � Title 5 Official Inspection Form ��w�° o o System ys Disposal Sewage ace sur u I; Subsurface S Dil St Form - Not for Voluntary Assessments JUN O vER 141 Carlton Lane PN� Property Address ADC N�EPPR James Boyle _ __ NFA�-( Owner Owner's Name information is North Andover Ma 01845 5-28-2021 required for every _ -- 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. Important:When A. Inspector Information filling out forms on the computer, use only the tab F. Paul Cardone key to move your Name of Inspector cursor-do not Septic Compliance, Inc. use the return _ Company Name key. 37 1/2 Baremeadow Street VQ _ _ Company Address Methuen Ma 01844 City/Town State Zip Code PrW� 978-815-3115 Or 978-681-0726 #3294 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: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails i C) Inspector's Signature Dat 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i'i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is North Andover Ma 01845 5-28-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: There is an injector pump serviceing the bathroom in the pool house 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 } ;w Title 5 official Inspection Form �T - ........ . } Subsurface Sewage Disposal System Form Not for Voluntary Assessments 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is required for every North Andover Ma 01845 5-28-2021 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 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.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is North Andover Ma 01845 5-28-2021 required for every _. _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 13 4 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is required for every North Andover Ma 01845 5-28-2021 _ 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 Title 5 Official Inspection Form i. ,_ I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ig ,�� 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is required for every North Andover Ma 01845 5-28-2021 _ 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 Summary Record Card generated on 5/24P2021 11:24:25 AM by Sharon Coco Page 1 Town of North Andover Tax Map # 210-106.C-0083-0000.0 Parcel Id 17719 141 CARLTON LANE JAMES & BRONWIN BOYLE 141 CARLTON LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 3.02 Acres FY 2021 UB Mailing Index NamelAddress Type Loan Number Active/Inact. From Until JAMES&BRONWIN BOYLE Owner Active 141 CARLTON LANE NORTH ANDOVER,MA 01845 ALTER,KEITH Previous Customer Inactive 7/29/2005 141 CARLTON LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14165.0-141 CARLTON LANE Last Billing Date 319/2021 2100151 02 Cycle 02 Active UB Services Maint. Account No.2100151 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63 5/8 7,82 11 WTR WATER 01 ALL METER SIZE 130.35 /1 UB Meter Maintenance Account No.2100151 Serial No Status Location Brand Type Size YTD Cons 13242641 a Active ERT HH METE METE w Water 0.63 0.63 30 Date Reading Code Consumption Posted Date Variance 5/4/2021 3722 a Actual 41 44% 2/4/2021 3681 a Actual 30 3/1612021 10% 11/2/2020 3651 aActual 26 12/16/2020 -39% 8/4/2020 3625 a Actual 45 9/9/2020 37% 5/1/2020 3580 a Actual 30 6/10/2020 -1% 2/4/2020 3550 a Actual 32 3/16/2020 -27% 11/4/2019 3518 aActual 45 12/23/2019 -36% 8/112019 3473 a Actual 67 9/26/2019 137% 5/2/2019 3406 a Actual 27 6/13/2019 -60% 214/2019 3379 a Actual 73 3/19/2019 112% 11/1/2018 3306 aActual 33 12/12/2018 -41% 8/2/2018 3273 a Actual 56 9/20/2018 60% 5/3/2018 3217 a Actual 35 6/20/2018 7% 2/1/2018 3182 aActual 33 3/28/2018 -18% 11/1/2017 3149 aActual 40 12/29/2017 -6% 8/2/2017 3109 a Actual 43 9/20/2017 26% 5/212017 3066 aActual 33 6/26/2017 -9% 2/2/2017 3033 a Actual 38 311412017 -43% 11/1/2016 2995 aActual 65 12/19/2016 -43% 8/2/2016 2930 a Actual 115 9/21/2016 248% 5/3/2016 2815 aActual 33 6/21/2016 -17% 212/2016 2782 a Actual 40 3/28/2016 -34% 11/2/2015 2742 aActual 59 12130/2015 -62% 8/4/2015 2683 a Actual 157 9/14/2015 257% 5/4/2015 2526 a Actual 43 6/22/2015 -37% 2/3/2015 2483 a Actual 70 3/20/2015 88% 11/3/2014 2413 a Actual 38 12/15/2014 -73% Commonwealth of Massachusetts Title 5 Official Inspection Form 1''I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments %1 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is required for every North Andover Ma 01845 5-28-2021 :._ page. City/Town 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): 600 Description: __. Number of current residents: 3-- 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 d enclosed 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts City/Town of NORTH AINDOVER, MASSACHUSETTS System Pumping Record Farm 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or otter approving authority. A. Facility Information Important: When fi:ltng out 1. System Location. forms on the / computer,use only the tab key Address to move your Nor.h Andover MA 01845 cursor-do not - — — _. _ use the retum Citylrow:m State Zip Code key. 2 System Owner: Nacre — -- - — � Address(ii different from locatian) v^ity/To1vn State Zip Code Telephone Number B. Pumping Record / 1. Date of Pumping -6-—( 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) [X Septic Tank ❑ Tight Tank Other(describe): - - - 4. Effluent Tee Filter present? [1 Yes [k No if yes,v)as it cleaned? ❑ Yes ❑ No 5. 0"ondition of System: 6. System Pumped By: Name Vehicle Liconsc Number — vVind River Environmental company 7. Location where contents were disposed Sianature o Hauler )ate httpi/h,iww.mass.gcv,'dep/v4ate�ra.oprovals/t5forms.htm#i.ispect Vo'Th �'S� t5form4l.doc•Q8/03 System Plm9l fiord•Page 1 of 1 /' If, Commonwealth of Massachusetts Title 5 Official Inspection Form .r1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is North Andover Ma 01845 5-28-2021 required for every _. page. 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): N/A 3. Pumping Records: Source of information: BOH pump slip 6-21-19 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 Title 5 Official Inspection Form 3. M1I Subsurface Sewage Disposal System Form Not for Voluntary Assessments e is 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is North Andover Ma 01$45 5-28-2021 required for every page. Cltyaown 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: Total upgrade in 2005 7-28-05 Design Plan- Merrimack Engineering Services, Inc. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 13" 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.): Good Good None t5insp.doc•rev.7/2612018 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 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is North Andover Ma 01845 5-28-2021 required for every _ _ page. CltylTown state Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 13"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x5'x4'8" Sludge depth: 4 Distance from top of sludge to bottom of outlet tee or baffle - 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 How were dimensions determined? Sludge Judge 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.): We recommend tank be pumped on a yearly basis, inlet and outlet tee's were in good shape, structural integrity appeared to be good, all liquid levels were good, no evidence of any leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Carlton Lane Property Address James Boyle Owner Owner's Name — _ - information is required for every North Andover Ma- 01845 5-28-2021 _- — _ page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t51nsp.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 i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -t; � T <7 141 Carlton Lane _ Property Address James Boyle Owner Owner's Name information is North Andover Ma 01845 5-28-2021 required for every _ _ page. CltyFrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: NSA 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 Good and even 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.): Box was level distribution was equal, set off pump watched distribution, no solids carryover, no apparent leakage in or out of box, box was in good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is required for every North Andover Ma 01845 5-28-2021 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.): All in good condition, according to the owner pump and all electronics were replaced around 3 years ago. * 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: 1 field 25'x80' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form lA } Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is North Andover Ma 01845 5-28-2021 required for every __ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Good None None No Grassy back yard area. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)- N/A t5insp.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 4;V 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is North Andover Ma 01845 5-28-2021 required for every _ page. CltyFrown 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.)-. N/A t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 UI DI 1 Eh r�� Pµ�l # u�vftGic�.rtri is JvT /IW024*FIXIj, C/SN R 27 A ylaKm/�1TY Of'f�[ 5y4�ntrG.Ga fr rat 9G. (v �,Y,'1tr1• tT Is a tEucc OF fiat l[tKYb�! GAO cf LCHPoNi 1ty, i# ,t orL Lsf 4-S-I (3.A") ,`A11V. rNi~� Fc 4• N I Foe C'XL i N- Pef_ .ci4T. p Tyr- —_I 69i � t / a• t r � � J ( v t I � 1 AS ct1ILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATEDIN Qv p:r}4 A�.4 t7©V EE Q-, t'I�`�, / I,+I G -'rO1J i.atN E AS PREPARED FOR DATE: 7-28-o� ..T�I''� 1�to2L•G � �',� 'l' SCALE: I MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 60 PARK STREET • ANDOVM MASSACNUSETTS 01810 -� TEL(617)475-3545,373•S"l i Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Carlton Lane _ Property Address James Boyle Owner Owner's Name information is required for every North Andover Ma 01845 5-28-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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 t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 i F a: OwncesName-!ttirtnarcei- �,--�. Addrerr~ Installer: Tel N:_44M 01 Dates -'!�fWednadt?Itne --SaU SymbolSoi1 Rarne /#,�c�7vst/ __ Son tlur re. Dap Observation Hole Logs Elevation Depth Soil Hbriztm Sots?came Son Color Son hiottfiq %Gravel,Stoner,etc ti /�,,_11�� �' - � _G, to Yk-41►/,, ---- ., ., 7, 5;f 27��yr G f.L. Z 7Y5,r� Parent Aiateriai. -#''2 U. r . Depth 1e 9tinc{�•�SbftE Weer In the 8ehxgl w Weepiat freailSi Fsa t- 'FSBGSV� F�1 L_u r �? .y l�s LIM aeeria► i •U a�+�sa:w,ter w We 8a,�Weepta�rt as ru FaeeEsxGtY= Dace Percolation Tests Otuerti adoo Hole# Depth of Pere Sort Pre-soils Time at le Time at 9" Time at 6" Time(9"-61— •Rate Miuffach• Performed Bs: Witnessed B�^ Commonwealth of Massachusetts Title 5 Official Inspection Form ;., .... } Subsurface Sewage Disposal System Form Not for Voluntary Assessments 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is required for every North Andover Ma 01845 5-28-2021 1.1111, page. CltytTown 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: 32"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: Soil Logs 4-14-05 Copy enclosed Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: All liquid levels were good, No sump, Soils were dry, Pumped up to a elevated leaching area 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 �e iw Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Carlton Lane Property Address James Boyle Owner Owner's Name information is required for every North Andover Ma 01845 5-28-2021 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 O`,10RTIr,y I 9 et'a 4 "f O O �_ s - Town of North Andover HEALTH DEPARTMENT ,SS�CNU4t4 CHECK#: /748 DATE: l.Off.do-V LOCATION: H/O NAME: _ CONTRACTOR NAME: C ?� 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 ❑ Other:(Indicate) $ )iegith Agent Initials 111' White-Applicant Yellow-Health Pink-Treasurer