HomeMy WebLinkAboutconditional pass - Title V Inspection Report - 21 SOUTH CROSS ROAD 8/16/2021 %ommonweaitn of Massacnuseus
� F Title 5 Official Inspection Form h¢i.lrfn_@ Cnw2nm nicnncnl Quefom Fnrm _Kinf fnr\/nittinfnni Acc mAnfc 21 South Cross Road
Property Address
Carol Moroney
Owner Owner's Name
information is required for every North Andover MA 01845 8-11-2021
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not bred in any
way. Please see completeness checklist at the end of the form. G�`y
n'
Important:when A. Inspector Information �6 "
filling out forms \` ) d0
on the computer, �v F,N�
use only the tab Neil James Bateson i M
key to move your Nai-ne of inspecto ,` ►
cursor-do not Bateson Enterprises Inc.
use the return Company Name
key.
111 Arnilla Road
�..._
VOID
r� Company Address
Andover MA 01810
Citylrown 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
(3 0 CAM 15.000); i have Neisunaiiy inspected the Sewage dispOsai Sysief i ai the PfWeiiy 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
,J 1• f 'i .d' I i A fi .J t•' LF.' i' I ti a A
and II aint-VItancc VI on-JIIG J4tIGgG UIJ�VJGI JyJla�.-.�IIJ. 111 1 VVIIUU-111g UIIJ IIIJpGIitIV11 IIUYG UGlGrmll lt�.-.0
that the system:
1. ❑ Passes
2. NI Conditionaiiy Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
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d
U I I nnn l
V- -GVL 1
Inspectors ignatureV 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonweaitn or massacnusetts
� Title 5 Official Inspection Form
_ i�i C�h¢�rf�ro Cow�na rlicnneal Cvc+am Pnrm _11n4 fnr\/nlilnt`ani Aecacgmente
21 South Cross Road
Property Address
Carol Moroney
Owner Owner's Name
information is required for every North Andover MA 01845 8-11-2021
page. Cityrrown 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:
❑ 1 have not found any information which indicates that any of the failure criteria described
in 310(;MR 15.303 or in 310 UMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
E One or more system components as described in the "Conditionai 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.
/''henL 4he hnv fnr"�mc." unn" nr"nn}r7nhorminoiJ" /V AI Alrl\fnr 4hn fnllnud.,., +nFe...en4e. If"n..i
Vllti V l\.Ills VVA IVI rI , IIV VI IIVt Vti ttil 11111 It.V \I , 1�, 1\V/ IVI tl lAr VIIV YY II It,. Jtf tt/Illt.l ltJ. 11 IIVt
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 subsiantiai infiitration or exnitration or tank faiiure is immineni. System wiii 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
%ommonweaRn oT Massacnuseds
� Title 5 Official Inspection Form
t Clvhclirfara Cauuana nicnneza Cvetiam Fnrm _nlnf fnr Vnhvntani Accmccmantc
V4�
V- 1 � 21 South Cross Road
Property Address
Carol Moroney
ownel Owner's Name
information is North Andover MA 01845 8-11-2021
required for every -
page. City/Town State Zip Code Date of Inspection
G. 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):
❑ Y VD (C111ill UCIVV).distribution 4U1 IJ I@VCI@U UI rCNidccu vLJ
❑ 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):
IJ UIVRCII t.JII.JC(J) are replaced ❑ i ❑� iM ❑ IVhJ (C)I�IQIII UCIVWI.
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
J) FulLhiair CVQIUQIIVII ID RCl.iU11CU UY LIIC OVQIV VI f7CQIL11.
❑ 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
%ommonweann of massacnuseds
Title 5 Official Inspection Form
_ i�t C�hcwrF�rg Cow2no Ilicnn¢al Fnrm _11n4 f-ir\/nli mtan,;1;cceceman4e
21 South Cross Road
Property Address
Carol Moroney
�••••�• viiliii6i S Ndlilc
information is required for every North Andover MA 01845 8-11-2021
page. Citylrown State Zip Code Date of Inspection
�.. in5pec11.w1i 0urnrnary (coni.)
❑ Cesspool or privy is within 50 feet of a surface water
U Cesspool or privy is within bU 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)
J_L_-W.--� hatth- • l___-L_-I!1_ •
UGtC1111111G,that the jy��Clll i� IYIIGLIVIIIt It� iii a 111d9111Ci 111At FJI Vf,CGW t11C FIUUIIG IICdIL11,
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:
**Th'n ��..+ 'F 4k ,....11 f.�.�.....I..n�n ,F..r., —A i— MCA r+41-..1 fn.fnnnl
I his- Jystcm PasscJ 11 inc —,c11. GLGGI G1IG lr JIJ, Vl.IVIIIIGV GL CL LJL-1 N411111{rl� IGVVIGLVIr, IVI IGVGI
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:
Outlet tee, outlet cover, d-box, and pipe to pit#1 needs to be replaced
syst ii-- Failure ^-itere ilc;abi
4f �ystGm ranurG�.n�Gna f►NjnicauiG iv All�yai�iria:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® 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
%ommonweaitn of iviassacnusetts
Title 5 Official Inspection Form
V f CiihctirF=ro 4zaw2no nicnt% ni Cvc+om Fnrm - Dint fnr\/nh inforw Acccccmantc
I fly
WIP
21 South Cross Road
Property Address
Carol Moroney
Owrief Uwners Name
information is
required for every North Andover MA 01845 8-11-2021
page. City/Town State Zip Code Date of Inspection
�.. inspactioli oummary (coni.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Ycs N_
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® "14UI%A UUFUI 111 VGJJpVVI IJ 1G_ Mall V uclvri IIIVGII VI aVa110 VIG YVIu 111G IJ IGJJ
than 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
f1LJ LLI Atly JUIl1U1 V'II the J ,J, CessNuvlI ui Niiv y is Lue_w1__w_.iiyil yivuiuJ wdaC_e1Cv aa.u_._
.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Airy polii io of a cesspool or privy is withi i a Z-Gi is i Gf a NuuiiG wai8r bupNiy
❑ ® well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
LJ Q9 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
J La_r L •-J_. t V_ 1-�J V__ L_-1
oiw C:nau�v� �u5wuy �iiii5►uC aud%nCu iu ima wnn.]
❑ ® 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 41
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 Prot¢ction
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 15
vx � iommonweaRn of nnassacnuseus
Title 5 Official Inspection Form
�• _ I.I C��hc��rf�ro Cowano nicnncal Cv¢tom Fnrm _ 11M fnr 1hnhin42ni Accocemontg
21 South Cross Road
Property Address
Carol Moroney
Owner Owner's Name
information is required for every North Andover MA 01845 8-11-2021
page. Cityrrown State Zip Code Date of Inspection
�.. inspection summary tcont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
thieai, of answered "yes"to any question In Section 0.4 above tilt✓ idfye Systeiil ilds 1 Wit eti. 1 iltr
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 v✓iwn+tahe. appropriate reyivinl office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes IVU
® ❑ 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 largo Volumes of vratcr t,^^- iiMirvuuicd iv 6— ---+-ll �,%A--11 yr-- —+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
® El 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
Commonweaun oT iviassacnuseds
Title 5 Official Inspection Form
1 Cl�hc��rf�no Cnw2no nianncal Cvc+am Fnrm _MM f-ir lfnh,ntan/ Aceaeeman4c
V0 21 South Cross Road
Property Address
Carol Moroney
Owner Owner's Name
information is required for every North Andover MA 01845 8-11-2021
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms (actual): w
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): N/A
Description:
No design plan only as built plan
Number of current residents:
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit! ❑ Yes I�SI No
If yes, discharges to:
is laundry
n a separate se temi? (Include launud-..sys'M.Y UII
IJ IGUIIUIy VII Q JCI./QIQI.0 JCVYGlJG.7yJlCll1! �nwluuC lauuuly JyJLCIII IIIJtJCIiLIVII ❑ Yes ® NO
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Yes
Detail:
Sump pump? ❑ Yes 0 No
Current
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonweann of ivilassacnuseds
� Title 5 Official Inspection Form
is Cnhanrfnra Cnw2no niannaal Cvcfom Fnrm _ Mnf few Vnlnnfnnt Accaccmanfc
kvF21 South Cross Road
Property Address
Carol Moroney
Owner Owner's Name
information is required for every North Andover MA 01845 8-11-2021
page. Cityrrown 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? LJ Yes L_I No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Vvater IIneter reaudings, It available:
Last date of occupancy/use: Date
^44.v&.5 `uGJV1I" vGwrr1.
3. Pumping Records:
Source of information: Pumped 2019, owner
Was system pumped as part of the inspection'! ❑ Yes El No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 ofricial Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
%ommonweaitn of Massachusetts
,p Title 5 Official Inspection Form
i t Ciihci�rf�rg Cawana nicnncm Cvefam Fnrm _MM fnr Vnhinfnni Aceccemantc
21 South Cross Road
VIWO-1
Property Address
Carol Moroney
v rr ilci Owner's Name
information is required for every North Andover MA 01845 8-11-2021
page. Cityrrown State Zip Code Date of Inspection
v. 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:
Original to I Ouse. ii st-GlIed 3-1 IV I JJ I
Were sewage odors detected when arriving at the site? ❑ Yes ® No
V. VYIIN;ng (IVVGI I J IC VIIG PIG.-.,:
1.5
Depth below grade: feet
maiCl lal Of cOil3ii uciivil:
® 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.):
4" Cast iron through wall, 3" PVC in house. No leaks visible.
t5insp.doc•rev.7/26/201 S Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 18
AN-
Commonweaitn of Massachusetts
� Title 5 Official Inspection Form
I _ I.1 Chh¢iiirfnro Cowano nicnncal Cvct}om Fnrm - IUn4 fir\/r%Ilm4an�A¢eaccmantg
1AW/ 21 South Cross Road
Property Address
Carol Moroney
..•:�2r Owner's Name
information is required for every North Andover MA 01845 8-11-2021
page. City/Town State Zip Code Date of Inspection
U. Qy,LG111 1111VIIIIdLIV11 kGUfll.)
6. Septic Tank(locate on site plan):
A IT
Depth below grade:
feet
Material of construction:
I771 I-1 11 r�____�___ ri �.._ii_--i___ I-1 ice__'_.._lain)
� concrete Lai I letal I__I fiberglass I__I F1olyCUlylerie L-f oU1Cl kCXIJIdIII�
If tank is metal, list age: Years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
IUD X��X 4'
Dimensions:
3"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle WA= Outlet tee has hole in it
F
Scum thickness
Distance from top of scum to top of outlet tee or baffle NIA
Distance from bottom of scum to bottom of outlet tee or baffle N/A
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to uuiirrt iilvGit, cviucilc8 of leakage, etc.).,
Inlet tee ok. Outlet tee needs to be replaced, has hole in it. Outlet cover broken, needs to be
rcpjaCCA. vCp+6 of nyui,4 of CU+C1 urci i. 10 cvivcCc Of rca�cyc
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of iviassacnusetts
,i Title 5 Official Inspection Form
l Ciihaiirf2ro Cownno n;imnnc21 Quafam Fn►m _Mnf fnr\/nli in+nni Acccccmanfc
21 South Cross Road
Property Address
Carol Moroney
vwliei Uwners Name
information is required for every North Andover MA 01845 8-11-2021
page. City/Town State Zip Code Date of Inspection
U. System Iiu orati(I on (cunt.)
7. Grease Trap (locate on site plan):
Depth holnu,nro,de-
...,r�„ y,--- 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
Daie or iasi 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:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 18
AN
\ %ommonweaitn of nnassacnusetis
i �
,i Title 5 Official Inspection Form
i t Chcrf�ro Cow2nn nicnncnl Cvcfom Fnrm _MM fnr\/nhlnfnni A ccccmcnfc
y 21 South Cross Road
Property Address
Carol Moroney
Owner Owner's Name
information is required for every North Andover MA 01845 8-11-2021
page. City/Town State Zip Code Date of Inspection
A A I
D. in
formation nformation (cone.)
8. Tight or Holding Tank(cont.)
Alarm present: U Yes t 1 No
Alarm level: Alarm in working order: ❑ Yes ❑ No
rin�n
�� W1 Inn+n
vu iaua r;:I I IpMy^^: 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 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, has flow levelers. Evidence of leakage. Evidence of carryover. D-box
needs to be replaced has bad corrosion. Cover broken, replaced.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 18
Cvommonweaith or"nnassachuseus
rTitle 5 Official Inspection Form
_ C,,ha,,rf2ro Cow2no niannagi Cva+nm Fnrm _ Mnt fnr\/mbintnnw Accaccmantc
21 South Cross Road
Property Address
Carol Moroney
Owner Owner's Name
information is required for every North Andover MA 01845 8-11-2021
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`
V VIIIIIIGIILS k1 IVLG L/LJl IL.IILIWI I V1 FUIIlp%AI ..LJGI, VVIIUILIVII VI '.lU111'jJ GIIU O��UI Lei a scesnances, GL%..,.
" If pumps or alarms are not in working order, system is a conditional pass.
11. Soii Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ 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
%ommonweaun or massacnuseus
� Title 5 Official Inspection Form
Crwhciirf2ra Cow2na nicnncnl Cvcfam Fnrm _ Mnf fnr\/nliiinfnnr Aceneemanfc
4
.� 21 South Cross Road
Property Address
Carol Moroney
Owner Owner's Name
information is North Andover MA 01845 8-11-2021
required for every
page. Cityrrown 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.):
Soil ok. Vegetation ok. No sign of ponding to surface. Camera inside of pits through outlets in d-box,
no liquid to inverts. Outet pipe to pit# 1 is pitched wrong, needs to be replaced.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
All rnnbcr and n n ig lrati..n
I�IAIIpJGI OIIV VVIIIIy IAI GIIVII
Depth—top of liquid to inlet invert
n__1L _L solids
1_..__
Dept 1 ul sonus layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
indication of groundwater inflow U fires U No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
t � %ommonweaitn of iviassacnusetis
,i� Title 5 Official Inspection Form
I.I C�-hci_rfw_p CowanA nicnt% ni Cvcfam Fnrm _Mnt fnr Vnll i n nfat Accaccmanfc
'GE 21 South Cross Road
Property Address
Carol Moroney
owliel Owners Name
information is required for every North Andover MA 01845 8-11-2021
page. Cityrrown State Zip Code Date of Inspection
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n u. System inrvrmatio (cont.)
13. Privy (locate on site plan):
I-IG Le.i 1J o co struction-
Dimensions
vcNu 1 of ovliva
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 Forth:Subsurface Sewage Disposal System•Page 15 of 18
%ommonweaitn of ri iassacnusetts
� Title 5 Official Inspection Form
WIM k Cnhcnrfnrsa Cow2no nicnnc2i Cvcfam IFnrm _ Nnf fnr\/nh infnn1 Accaccmantc
21 South Cross Road
Property Address
Carol Moroney
Owner Owner's Name
information is required for every North Andover MA 01845 8-11-2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 of 18
%ommonweann of Massacnuseds
i-
Title 5 Official Inspection Form
Coihcieerf2rg Cow no nicnncol Ckictom Fe+rm _ Mnf fnr\/nllwnf=nr Aggogcmantc
1C
21 South Cross Road
Property Address
Carol Moroney
vwllef Owners Name
information is required for every North Andover MA 01845 8-11-2021
page. Cityrrown 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:
feet
Please indicate all methods used to determine the high ground water elevation:
LJ Obtained from system design plans on record
If checked, date of design plan reviewed: 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)
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Essex County Soil Map
1/V4 IF:�Mj,dGJ6r11VG IiVVY rVU GJlOU11JI 1GV tl Is iilyii yrvunlu YYQtGI GIGV gIIVII.
Essex County Soil Map, Sheet#36, Canton Soil, Water>6' Deep.
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
%ommonweaith of Massachusetts
r �
,i Title 5 Official Inspection Form
I�I C�rhgiirfaro Cowano Ili¢nncal Cvctom Fnrm _ Nnt fnr\/nli intani Acccc¢mant�
21 South Cross Road
Property Address
Carol Moroney
Owner Owner's Name
information is required for every North Andover MA 01845 8-11-2021
page. Cityrrown 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 o (CItCt,nuai)uviiiNictcu
® D. System Information:
Fcr Q, Tig....duig Tan,',,— Pumping vv ilu-ac attuvii-.d
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
Town of North Andover V
Tax Map # 210-038.0-0180-0000.0
Parcel Id 13250
21 SOUTH CROSS ROAD
MORONEY, MICHAEL J. JR.
21 SOUTH CROSS ROAD
NORTH ANDOVER, MA
01845
FY 2022
UB Mailina Index
Name/Address Type Loan Number Active/Inact. From Until
MORONEY,MICHAEL J.JR. Payor Active
21 SOUTH CROSS ROAD
NORTH ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 13993.0-21 SOUTH CROSS ROAD Last Billing Date 6/9/2021
2100543 02 Cycle 02 Active
UB Services Maint.
Account No.2100543
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.63 5/8 7.82 1/
WTR WATER 01 ALL METER SIZE 38.00 /1
UB Meter Maintenance
Account No.2100543
Serial No Status Location Brand Type Size YTD Cons
36433651 a Active ERT HH b Badger w Water 0.63 0.63 26
Date Reading Code Consumption Posted Date Variance
5/5/2021 1235 a Actual 10 6/15/2021 -35%
2/4/2021 1225 a Actual 16 3/16/2021 -76%
11/3/2020 1209 aActual 64 12/16/2020 -44%
8/5/2020 1145 aActual 116 9/9/2020 877%
5/6/2020 1029 a Actual 12 6/10/2020 32%
2/4/2020 1017 a Actual 9 3/16/2020 -51%
11/5/2019 1008 a Actual 19 12/23/2019 -21%
8/2/2019 989 a Actual 23 9/26/2019 214%
5/3/2019 966 a Actual 7 6/13/2019 -24%
2/5/2019 959 a Actual 10 3/19/2019 -65%
11/2/2018 949 aActual 28 12/12/2018 -56%
8/2/2018 921 a Actual 63 9/20/2018 577%
5/2/2018 858 a Actual 9 6/20/2018 -29%
2/2/2018 849 a Actual 13 3/28/2018 -27%
11/3/2017 836 aActual 18 12/29/2017 -56%
8/3/2017 818 a Actual 41 9/20/2017 183%
5/3/2017 777 a Actual 14 6/26/2017 -4%
2/3/2017 763 a Actual 15 3/14/2017 -45%
11/3/2016 748 aActual 27 12/19/2016 48%
8/4/2016 721 a Actual 18 9/21/2016 67%
5/6/2016 703 a Actual 11 6/21/2016 -14%
2/4/2016 692 a Actual 13 3/28/2016 -63%
11/3/2015 679 aActual 34 12/30/2015 -23%
8/6/2015 645 a Actual 45 9/14/2015 114%
5/7/2015 600 a Actual 21 6/22/2015 3%
2/5/2015 579 a Actual 21 3/20/2015 1%
11/3/2014 558 aActual 20 12/15/2014 3%
8/5/2014 538 aActual 19 9/11/2014 64%
5/9/2014 519 a Actual 12 6/12/2014 -24%
2/7/2014 507 a Actual 17 3/17/2014 2%
11/1/2013 490 aActual 15 12/20/2013 -33%
8/5/2013 475 a Actual 24 9/18/2013 79%
.:
O�NORTp
O
ti 9
Town of North Andover
HEALTH DEPARTMENT
'SS,CMUst�
CHECK#: .3A,13 DATE:
LOCATION: Z/
H/O NAME:
CONTRACTOR NAME:
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 �' $
b Title 5 Report ,�/")(�.�r $
1
i
❑ Other:(Indicate) $
e-alth Agent Initials '
White-A licant Yellow-Health Health Pink-Treasurer Treasurer
PP �