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HomeMy WebLinkAboutConditional Pass - Title V Inspection Report - 97 BRADFORD STREET 6/15/2021 Commonwealth of Massachusetts Title 5 Official Inspection Form VE° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments SUN ANppVF� Property Address �� Ur DEPAR L ��a, t � GV Ali f,=�t-�► s H OLI Owner Owner's Name - - information is required for every V_ M A U t 8Q S to -i i- Zr_ZI page- Cilylronrn 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 men A. Inspector Information filling out on the computer, use only the tab c-+E L C t--LC k Lrl_ - key to move your Name of Inspector cursor-do not C'_ O N .: T l tit G e'k <:j;t lei.L.,tr, i f�4 C=— S use the return any Name key. Company Address N__� 0 tz fir:cz�.73>i t-A G t✓c cam, C I g k_1 CilylTowm State Zip Code 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. -A Conditionally Passes e pen,, <''c t o 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector's Sign ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5vW doc-rev 7r?6f"B Title 5 Offckg kupecbon Form:Substrface Sewage Dsposal System.Page 1 of 18 Commonwealth of Massachusetts a ==r= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address -� Owner \J J LS. g a s Ownef s Name information is required for every t�i U tZ k�-' 1�•rv—� .-7—> per- Cityfrown 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 ex t. 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 O"N ❑ ND (Explain below): t5iW doc-rev.7Q612018 Tde 5 Odraal kwpection form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts t = Title 5 official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -71 Property Address -- ------ Owner Owner's Name — --- --- ---- information is required for every _ t�lQ Z E-� '�a��`� �= _ t`^i� ©� - page- Cityfravn State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cunt_): ❑ 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 static water level in the distribution box due to broken or obstructed pipe(s)or due roken, settled or uneven distribution box_ System will pass inspection if(with approval bard of Health): ❑ broken pipe(s a replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstr on 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 a I of the Board of Health): ❑ broken pipe(s)ar placed El El ❑ ND(Explain below): ❑ obstru - n is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further on by the Board of Health in order to determine if the system is failing to prote Ic health, safety or the environment. a. System will unless Board of Health determines in accordance with 310 CMR 15.303(1) at the system is not functioning in a manner which will protect public health, safety nd the environment: t5irsp.doc•rev 706M18 Title 5 Offical 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 Property Address C 1_ Owner Owner's Name --- ----— --—--- information is required for every �1�,Z,—N tJ �„s F� O l z _ �: — 1 l— z C -Z i _ per. Cityrrown 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 v ated wetland or a salt marsh b. System will fail unless the Board of Heal and Public Water Supplier,if any) determines that the system is function' in a manner that protects the public health, safety and environment: ❑ The system has a septic and soil absorption system(SAS)and the SAS is within 100 feet of a surface wat upply or tributary to a surface water supply. ❑ The system has ptic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The syst has a septic tank and SAS and the SAS is within 50 feet of a private water supply w . ❑ 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 t5wW doc-rev 7/26=8 Ue 5 Offaciai hsped,"i Form &tsuface Sewage DGPOsa;System.Page 4 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form r, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 33j (---11 A,.L Owner Owner's Narne — — — -- information is required for every CD Z1 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cost.) 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 ❑ ❑v jA Liquid depth in cesspool is less than S'below invert or available volume is less J than Y2 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. ❑ ❑�.l�� 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.] ❑ ❑ V s The system is a cesspool serving a facility with a design flow of 2000 gpd- /f� 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 withi feet of a surface drinking water supply ❑ ❑ the syst is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ system is located in a nitrogen sensitive area (interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well tNnsp.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 Property Address Owner Owner's Name information is required for every 1 k- ��- _ G l 1c.) page. Cityfrown State Zip Code Date of inspection C. Inspection Summary (cunt.) 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 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 ❑ ji— Pumping information was provided by the owner, occupant, or Board of Health ❑ r--19-1 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? ❑ ❑t�,j/ 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? r ❑ Was the site inspected for signs of break out? ❑ I'Q/ 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, J dimensions, depth of liquid, depth of sludge and depth of scum? Elml Was the facility owner(and occupants if different from owner)provided with ,L� 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: t✓t c _.3> cD35.e*--v =i, ,ate ❑ � Existing information. For example, a plan at the Board of Health_ LCaLP�j ❑ 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.M&2018 Title 5 Official Inspection Form Subsulace,Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Farm F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address - Owner Owner's Name information is _ required for every �.� Z i t-� t��l+��'Lam_ +r�- �- _ _ t - Z v Z.A page- CityPTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): — -- Number of bedrooms(actual): --4 ' DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: Number of current residents: — 7 Does residence have a garbage grinder? ❑ Ye§zd No Does residence have a water treatment unit? ❑ Yes ULM If yes, discharges to: - -- ----Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes V� No information in this report_) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes R- No Water meter readings, if available last 2 ears usage d 9 ( Y g (gP ))� Detail: - r - - - % Sump pump? ❑ Yes`u No Last date of occupancy: Date t5insp.doc•rev 7t2612018 Title 5 Official Inspection Fora:Scrw;Pface Sewage Disposed System-Page 7 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address vt j:\ Owner r7 Owner's Narne — - informatton is required for every 1.. 02 1 1 ���-� r-1 per- dityfrown State Zip Code [late of inspection D. System Information (coat.) 2. Commercialflndustrial Flow Conditions: Type of Establishment: — -- Design flow(based on 310 CMR 15.203): - - — GaRons per day(gpd) Basis of design flow(seats/personsfsq.ft_, etc.): -- -- -- Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, dischar to: -- Industrial waste hol i g tank present? ❑ Yes ❑ No Non-sanitary ste discharged to the Title 5 system? ❑ Yes ❑ No Water er readings, if available: Last date of occupancy/use: pate ---------- -------- Other(describe below): 3. Pumping Records: Source of information: ------- -------- --Was system pumped as part of the inspection? UN--Yes ❑ No If yes, volume pumped: - gallons How was quantity pumped determined? Reason for pumping: i ��� ` e-lt.� 1= 02'At C�k= j 4� 1.� K R s�s � �'c=. r,✓���c J i�1 O k7 i c t✓ t5insp.doc-rev.7/26f2718 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts - Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Nam - - -- — information is y required for every _�-3f Q 7� "1 E Z per- City[Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: uil__ 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 IfA 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: Were sewage odors detected when arriving at the site? ❑ Yes DNo 5. Building Sewer(locate on site plan): Depth below grade: �cc ----- ---- -- feet Material of construction: ❑ cast iron tdA0 PVC ❑ other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.)-. t5insp.doc-rev.7MMI8 Tde 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonweatth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address-- Owner Owner's Name information is required for every _. v--A_t—�-_I�V C�Z q(ZA per- Cityfrown State Zip Code Dade of Inspe� D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: Z Z c►J G> ; feet Material of construction: concrete [-Imetal Elfiberglass Elpolyethylene Elother(explain) 'b— If tank is metal, list age: �� years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ('No Dimensions: -- -�� --- --- Sludge depth: __.-- 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? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t5aW doc•rev-M62018 Title 5 Official knpecbon Form-Skbsulace Sewage Disposal System•Page 10 of 18 , CommonweaM of Massachusetts Title 5 official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary assessments Property Address Owner Owner's Name information is required for every UZ 1-1 iA N ��J page_ Citylrown State Zip Code Date of Inspection D. System information (cunt.) 7. Grease Trap(locate on site plan): Depth below grade: feet -- Material of construction: ❑ concrete ❑ metal ❑ erglass ❑polyethylene ❑other(explain): Dimensions: ---- ----- --- Scum thickness ------- Distance from top of sc to top of outlet tee or baffle ---- Distance from bott of scum to bottom of outlet tee or baffle - -------- — - Date of last p ping: Date - - - Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as relates]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 El metal fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: - gallons Design Flow: gallons per day t5osp 3oc•rer 7t26001 E TdJe 5 OtrsckA kwection Form Sub&xface Sewage Daposad System•Page 11 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form - Subsurface Disposal Sewage Dis g p System Farm Not for Voluntary Assessments Property Address Owner _ Li✓�3*1—P� i Owner's Name information is required for every _ k —'k��- ';L) ��r C)t page- City[Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cant_) Alarm present ❑ Yes ❑ No Alarm level: --- -- --- Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date ---- — Comments(condition farm 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): ©` 1 LF 1 t��E 1 Depth of liquid level above outlet invert (�i �Z- - 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_)-. 2CQ_ E. FJ ( t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments • •operty Address C L C—:V Owner owners Name — infnrmation is required for every page. CityTrown State Zip Code Date of lnsped 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 pun Zamber, tion 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: `- 1= ❑ leaching fields number, dimensions: Ca ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: - -- ------ t5wW doc•rev.7P26t I8 Title 5 Offidal kWeeb n Form:StAnuface Sewae D+sgosai System•Page 13 of 18 ^� Commonwealth of Massachusetts Title 5 Official inspection Form - f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every ti tZii—1 t"�1._)s��;L� c �(t� U t 1p—l 1— Zy page- City/row n State Zip Cade Date of lnspec 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.): tic "i 1'j C - O% I--l--4 Z> a 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 const ion Indicatio groundwater inflow ❑ Yes ❑ No Co ments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5 nsp doc•rev 726/M18 Title 5 Official Inspection Form:sebsuface Sewage System•Page 14 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form j Subsurface Sewage Disposal stem Form -Not for Voluntary Assessments � P � ry Property Address Owner Owner s Name 1 C L i. .j(� t`1 i----_� information is required for every ►� Z�i S7C��l �=� _ to C)i Inge. Cityfrown State Zip Code Date of inspection D. System Information (coat.) 13_ Privy (locate on site plan).- Materials of construction: - - Dimensions --- --------- --- - -- - - Depth of solids --- --- Comments(note condition of signs of hydraulic failure, level of ponding, condition of vegetation, etc_): t5mW doc-rev U26 M 8 TRle 5 Official hispedton Form S4mxface Sewage disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ---- -- — ---- ------ --- Owner _ Owner's Marne - information is _ 1V required for every '") Irk C)tZ; l U i� 'C page- Cityfiown —— -- — State Zip Code Date of Inspection D. System Information (coat.) 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 III e a—) 3 3Z, a > 163 t5insp.doc•rev 7126M18 Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address - --- - -------- ----_..— Owner Ownef's Name -- - infofrnation is required for every i7iQ� per- Citylrown State Zip Code Date of Inspection D. System Information (font.) 15. Site Exam: D/Check Slope Surface water ❑ Check cellar 9/shallow wells Estimated depth to high ground water. - -� ----- ----— feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record t'j C' c �v a t,_.4 a�1✓,5 If checked, date of design plan reviewed: Date ----- U' Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: ©rJ A3sT :JG t�:zo���2 t�S - 1JG GZ�� L91� 11. tom. � z ❑ Checked with local excavators, installers-(attach documentation) titer ���us t�J,a�`.Jai3i..t= 19 Accessed USGS database-explain: \ZJ 1� `, 1z,iY You must describe how you established the high ground water elevation: %-A :) r Cc-,";c Z. 70 c> is\2 :--N P i>;L>y W :��?u` We Before filing this Inspection Report, please see Report Completeness Checklist on next page. 7S\.�_�� Gig �V4G t5w,*p dcc•rev 7l28 18 Title 5 Official kHVecbcn Fes:S tbwaf"- Sewage Disposal System•Pape 17 of 18 L;\tti►Z� H (�`v �, i F-A IE <v l> Commonwealth of Massachusetts ,. Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - Property Address — Owner Owner's Name -- -- ---- — information is required for every �Ij 0 iZ 1-1 ��t�lv�t�11�aZ=_ _�w O t E5 ci z�; page- Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: D A Inspector Information: Complete all fields in this section. Ej,/B. Certification: Signed & Dated and 1, 2, 3, or 4 checked D/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: xplanation of estimated depth to high groundwater included t5rsp dcc-rev 7t2UMI8 Title 5 Official Inspection Form &tsarface Savage Dosprsa!System-Page 18 of 18 Account No Cycle Occupard Nwe Actrre./inactive Bldg ld 154220.97 BRADFORD STREET Last Wig Date 6/9/2021 2120186 02 Cycle 02 Active U8 Services MainL Account No 2120196 ServiceCode Rate Charge Multiplierlusers MISCFEE ADMIN FEE 0.63 5/8 7 82 11 14TR WATER 01 ALL METER SIZE 5320 /1 UB Meter Maintenance 'd Account No 2120186 Serial No Status Location Brand Type Sue Y 35644493 aActive ERTHH bBadger wWatet 0-630-63 Date Reading Code Conswption Posted Date 5A 2/2021 1488 a Actual 14 6/15/2021 2/10/2021 1474 a Actual 14 3/16/2021 11/6/2020 1460 aActual 1z" -1211612020 SA 2/2020 1448 a Actual 28 9/912020 5/11/2020 1420 a Actual 24 6/10/2020 2/10/2020 13% a Actual 25 3/16/2020 11/7/2019 1371 a Actual 23 12/23/2019 8/7/2019 1348 a Actual 24 9/26/2019 5/10/2019 1324 a Actual 19 6/13/2019 2/1212019 1305 a Actual 22 3/19/2019 11/712018 1283 a Actual 18 12/12/2018 8/10/2018 1265 a Actual 22 9/20/2018 5/10/2018 1243 a Actual 22 6/20/2018 2/8/2018 1221 a Actual 21 3/28/2018 11/8/2017 1200 a Actual 18 12/29/2017 8/10/2017 1182 a Actual 26 9/20/2017 5/9/2017 1156 a Actual 21 6/26/2017 211012017 1135 a Actual 27 3/14/2017 11/912016 1108 a Actual 31 12/19/2016 8/12/2016 1077 a Actual 38 9/21/2016 5/12/2016 1039 a Actual 33 6/21/2016 2/12/2016 10% a Actual 37 3/28/2016 11/9/2015 969 a Actual 30 12/30/2015 Part AN Pmt Current Option Refresh Page 1 2 ELat Of No eTq o �? w a Town of North Andover HEALTH DEPARTMENT s�cHuse CHECK#: Jac/6 DATE: 6,�,5, 20AI LOCATION: H/O NAME: CONTRACTOR NAME: 00e-//q P Ty a 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 /-/ 6L $ Title 5 Report (man �rJS $ ,�0 i� ❑ Other:(Indicate) $ i il� Agent Initials White-Applicant Yellow-Health Pink-Treasurer -Ptter of Transmittal Michael G. (YNefl1 P.E. u w tom► C)V7 C>e-" %-A t-A-Tn V Z t' Consutting Engineering Semis p"- 153 Main Street,Suite 204 ( i-cai�� �� L.iVcZs✓�� North heading, MA 01864 cam. zo Dore --- Job No Ze"r 1jF E:,Caw ffi El ChWW Ordw _ { Copies Daft NO. Descr%)don It%l.. SiNGG i l3 r to �s -zl c✓�`Z ��� �,L.;rAr AGE R, N00\4E� s � These are bwxunWed as checked EIRt your use SdxT* des for dsstt EIP*#mUmd aftr 3oen to US pAswonswd Ptmff.� Wccsrechwis E:IpA*m-cmzctedprwft Gt ©Farbidsdm 19_ Remarks _ Cc- TWA Coe ,C 5 Ui C v ni a 3 v a L �a s 1 ZED _'0 copy to G i\,-1 1-1%,J'PO`!G P1 signed Fcmsan.t eir_ 0 ►84�- eerjck�s�crerofcz ed.��r-W