HomeMy WebLinkAboutPass - Title V Inspection Report - 976 TURNPIKE STREET 7/19/2021 c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
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.
y501-
Important:When A. Inspector Information R
filling out forms
on the computer, Neil James Bateson use only the tab J
key to move your Name of Inspector O�NpFt1 �M�NZ
cursor-do not Bateson Enterprises Inc.
use the return Company Name
key. 111 A A Road
� Company Address
Andover MA 01810
Cityr town State Zip Code
978-475-4786 SI-15
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
f310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
[gad 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 determine
that the system:
1. F771Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑Usignatur
7-8-2021
Irl 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 straWsubmit the reporttothL-app op,iate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if-applicable;aiid 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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
°� Commonwealth of Massachusetts
�x Title 5 Official Inspection Form
- 1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
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.
System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
Q 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
jnppection 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
976 Turnpike Street _
Property Address
Majorie Ahumada _
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
required for every
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 wjj�
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑__,_. obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions-exist-which-require further evaluation by the-Board of Health in order to_determine.if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
-, Title 5 Official Inspection Form
r' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
requited for every
State Zip Code Date of Inspection
page. City/Town .
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 o"ystem Gomponent due to,overloaded or
Q clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form.Subsurface Sewage Disposal System•Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada _.
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
required for every —
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 '/Z 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 watersupply-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.iThis
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 designftow-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 whit 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 1Q�od o 1.5,Q00 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
Q__ ❑-' 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
c Commonwealth of Massachusetts
�x Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`.......... 976 Turnpike Street _
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
required for every
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-
El ® 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?
M ❑ Were all system components, excluding the SAS, located-onsife? --
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
® information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owners Name
information is North Andover MA 01810 7-8-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Resiidentiat-Row Comlitions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DEStG T w based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
6
Number of current residents:
Does residence have a garbage grinder? ❑ Yes_® NA
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 ® NQ
information in this report.)
Laundry system inspected? ❑--Fes ❑- M
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Yes
9 ( Y 9 (gp ))�
Detail:
Sump pump? ® Yes ❑ No
Last date of occupancy: Current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�o Title 5 Official Inspection Form
�- 61A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is required for-everq North Andover MA 01810 7-8-2021
page. Cityrrown State Zip Cbde Date of Inspection
D. System Information (cont.)
2. COmmerchilAndustrial Flow Conditions:
Type of Establishment:
10 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:
�qst date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source ofanformation: Pumped 2020, owner
Was system pumped as part of the inspection? ❑ Yes ® No
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
C Fo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
required for every
page. CitylTown 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.
Q Other(describe):
Approximate age of all components, date installed (if known)and source of information:
6 years old, 9-14-2015, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
acast.irQa-.--- Z 40.PVC ❑ other(explain):_-- _-
Distance from private water supply well or suction line: feet
Comments-(on.condition-ofjoints, venting, evidence of leakage, etc.):
4" PVC through floor, 3" Cast Iron in house, 2" PVC in house, No leaks visible.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Repth below grade: feet
Wterial 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'x 5'x 4'
Sludge depth:
V
Distance from top of sludge to bottom of outlet tee or baffle
32"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
8"
"
11 istance from bottom of scum to bottom of outlet tee or baffle"- 1 44-
How were dimensions determined?
Tape Measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
ijquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee ok. Cleaned outlet filter. Depth of liquid at outlet invert. No evidence of
leakage. Inlet&outlet covers have risers to grade.
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
—, Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Q�pth below grade: feet
NateriaLof_constructinn: -
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scumthiekness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Qpte of last pumping: Date
Cpmments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. T must be pumped at time of inspectkm),(Vocate-on-sRe- Far► -.- --
Depth below grade:
Material of construction:
M concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
required for every
page. City/rown State Zip Code Date of Inspecn
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
p,jarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑-No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box level & distribution equal, had flow levelers. No evidence of leakage. No evidence of carryover.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
c Commonwealth of Massachusetts
n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,(P
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber{locate on site plan):
Pimps in working order: ® Yes ❑ No`
ALarms in working order: ® Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump tank ok. Pump ok. Pump cycled on then off. Alarm has both audible&visual. Inlet&outlet
covers have risers to grade.
* 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: 42
❑ _. leaching gatleries number:
leaching trenches number, length:
teaching-fietds number, dimensions: -
❑ overflow cesspool number:
_E1 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
Aim— cam, Commonwealth of Massachusetts
ke Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is required for every North Andover MA 01810 7-8-2021
- —
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
veg�atiot�;-ete}--
Soil ok. Vegetation ok. No sign of ponding to surface. 42 infiltrators, six rows of seven infiltrators per
row.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration -
Depth —top of liquid to inlet invert -
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction --- ---
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
c Commonwealth of Massachusetts
`7 Title 5 Official Inspection Form
L, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c / 976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
required for every
page. Cityffown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Mpterials of construction:
Dimensions
Depth of solids --
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c Commonwealth of Massachusetts
+� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
RFovide a view of the sewage disposal system, including ties to at least two permanent reference
jq�dmarks 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
a 0
w
Nn,e�
D.+21
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 18
c0 Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
976 Turnpike Street _
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
required for eaefy -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site-Exam:
Check Slope
a-Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water:
fef —
et
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: 7-22-2015
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
} Checked with local Board of Health -explain: -
Design plan
❑ Checked with local excavators, installers -(attach documentation)
�] Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
As per test pit data on design plan
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
cam, Commonwealth of Massachusetts
i
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
976 Turnpike Street
Property Address
Majorie Ahumada
Owner Owner's Name
information is North Andover MA 01810 7-8-2021
required for every
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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Town of North Andover
Tax Map # 210-107.G-0044-0000.0
Parcel Id 18328
976 TURNPIKE STREET
NAZIM GOLAURS
976 TURNPIKE STREET
NORTH ANDOVER MA 01845
Class 101 Single Family Property Type 1 Residential
Size Total 1.27 Acres
FY 2021
UB Mailing Index
Name/Address Type Loan Number Activelinact. From Until
NAZIM GOLAURB Owner Active
976 TURNPIKE STREET
NORTH ANDOVER MA 01845
COPELAND,HELEN Previous Customer inactive 10/4/2012
972 TURNPIKE STREET
N.ANDOVER,MA
01845
LISA BALLARD Previous Customer Inactive 516/2015
26 WYOMING AVENUE
HAVERHILL MA 01832
JEM PROPERTY GROUP LLC Owner Inactive 9/30/2015
976 TURNPIKE STREET
NORTH ANDOVER MA 01845
JEM PROPERTY GROUP Previous Customer Inactive 12/712015
1650 ELM STREET;SUITE 400
MANCHESTER NH 03101
EDWARD&LAUREN STOREY Previous Customer Inactive 7118/2019
976 TURNPIKE STREET
NORTH ANDOVER MA 01845
UB Account Maint.
Account No cycle Occupant Name Active/lnactive
Bldg Id.24978.0-976 TURNPIKE STREET Last Billing Date 5/11/2021
1090334 01 Cycle 01 Active
US Services Maint.
Account No.1090334
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.63 5/8 7.82 1/
WTR WATER 01 ALL METER SIZE 109.30 /1
UB Meter Maintenance
Account No.1090334
Serial No status Location Brand Type Size YTD Cons
16465209 a Active 00 b Badger w Water 0.63 0.63 54
Date Reading Code Consumption Posted Date Variance
4/20/2021 1644 a Actual 26 5118/2021 _god
1/21/2021 1518 aActual 28 2/2312021 17%
10/20/2020 1490 a Actual 25 11/12/2020 17%
7/15/2020 1465 aActuai 37 8/12/2020 43%
4124l2020 1428 a Actual 31 5/13/2020 14%
1/16/2020 1397 aActual 25 2/10/2020 6%
10/17/2019 1372 a Actual 24 12/18/2019 53%
7/16/2019 1348 f Final Bill 15 7/16/2019 53%
4118/2019 1333 a Actual 16 6/15/2019 -1%
1116J2019 1317 a Actual 15 2/18/2019 1%
10/2312018 1302 a Actual 17 11/19/2018 14%
O�NORTq,y 11 i
Town of North Andover
HEALTH DEPARTMENT
�ss�cwus°�
CHECK#: 3 DATE: 7. l9 a04,
LOCATION: 9 7 R
H/O NAME:
CONTRACTOR NAME: _1,36-&go
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 $
❑ TrashlSolid 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 $
O\ Title 5 Report
❑ Other. (Indicate) $
gent Initials'
White-Applicant Yellow-Health Pink-Treasurer