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Home My WebLink AboutPass - Title V Inspection Report - 485 FOREST STREET 9/7/2021 iaommonweaiin of iviassacnuseus Title 5 Official Inspection Form V 1 C:,i1vciirf2rn Cgw2rna nicnnc21 Fnrm _Mr%f fnr Vnhmfarw Accoccmcntc r 485 Forest Street Property Address Michael Ciampa Owner Owner's Name information is required for every North Andover MA 01845 8-25-2021 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be alte` ny way. Please see completeness checklist at the end of the form. ;R imporwni:vvnen A. Inspector Information SEy filling out forms N on the computer, NpFz�N�MEN� use only the tab Neil James Bateson W�F pFpPR key to move your Naune ui h-Ispet;tui cursor-do not Bateson Enterprises Inc. use the return Company Name key. 111 ArniIhn Rnnri 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 /4•IA f%RX0 1G AAA\. 1 ka..e. 11.. in te�.4 Fhn nnc rlie.n.+e.nl e.. - -- !•iGe nrnnorfii el elroe•e. V.V -jr 1 IIGVV p�ruvliully IIIJrVVlV4 u1V u�vruy�. .AIJF.VJUI Jr JL—I1 Ul a11V F1 Vt—ly 4V GIVJJ 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 a.........- -$e... 'a.. ............. el�,.......r.l ......a....... Aia..........d....a-- aL.:.. :.....--4,:.... 1 have. de.a.,.....:ned a11U Ilia I11 LGIIalIl.O VI VII-JILIU OUVVCQyV UIJF/VOGI Ay OlC.111S. 1-%ILV1 %,V11UU\+Ulllj 11110 IIIJFJG%.UVII 111QVV UG10111111IGU that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails I A e1C n//lA .1 ` O-GV-LVL I insp&toVs S nature U 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 %ommonweaith of Massachusetts Title 5 Official Inspection Form Cwrh¢iirfnro Cowano nicrnncn1 Cvc4om Fnrm _Mnt fnr Vnli llntnni Accccemantc 4 485 Forest Street Property Address Michael Ciampa Owner Owner's Name information is required for every North Andover MA 01845 8-25-2021 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 3i u CiviR i 5.303 or in 3i u CMR i 5.304 exist. Any faiiure criteria not evaivated are indicated below. Comments: 2) System Conditionally Passes: r1 n_- L-.Y --�_�.---L- O- %=b :L-J :II LIM nk�UIIU P1_--n ---L.-Il _ZVU L- L- L VI a or more systernn comiporients as '---11UCU III 111G I,VIIUIIIUIIGI r"dJJ JCI.IIVII IICCU lV UC replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. f'kc-1,FMn kox;—".,....n .-i.n II- 4-.I..t•i...r.�n...d" /V wl KIMN ;—6-kc inlli....�nn �n�.+...n nFn Ii"nnrV VI ", LI IC vvn IVI yes , "D 0. I.OL 4G LC1111111C1L ,I , 1\, 1•✓/ IVI allC IVIIV. II Ia, JaU LGIIIC. La I Ilya 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 Massacnuseus Title 5 Official Inspection Form LM�15 Ci�hcr�rfaro Cgwnna Ilienncnl Cvclom Fnrm _Alnt few\/nlitntani Gceceeman4c 4 485 Forest Street Property Address Michael Ciampa Owner Owner's Name information is required for every North Andover MA 01845 8-25-2021 page. Cityfrown State Zip Code Date of Inspection L. 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): Li distribution box Is leveled or replaced LiLI iv ❑ IVU kr-,Kpldlll UCIUW). ❑ 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): j broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): do . 3) FunlieP Evaluation rieyiiifed by uie waPu ui iieaun: ❑ 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 iviassacnuseds Title 5 Official Inspection Form l Ciithaiirfnrn Cownnn nienneni Cvcfom Fnrm _ Mkt fnr Vnitinfani Occcccmentc ,.. NV'N4 485 Forest Street Property Address Michael Ciampa - Owner's Name information is required for every North Andover MA 01845 8-25-2021 — - of I -- page. City/Town State — Zip Code Date Inspection A A G. 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) uGirniiiiies iiiai tilt SysiGiil iS 1uIiciviiiFi9 iii a iiiaiiiirr iiiai Nrviccis iiir Nilotic iirauri, 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: ** TL.;r .. st..m scs if the v II... to-, - ynon ........,.....J ina ,�j.�w�ii pus�..� � un.. v�cu •ruwi w�uiy oiu, N..iiviii.-u u u �.i-i uii..0 owiuwiy, ivi c�.0 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 Appiicabie to Aii Systems: 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 ❑ ® 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.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 iommonweaitn of Massachusetts i- Title 5 Official Inspection Form CIIhelIrF t-g% Cnwann nienncnI Cvcfnm IFnrm _ KIM fnr Vn111nfani Aceacemcntc 485 Forest Street _ Property Address Michael Ciampa win er Owner's Name information is required for evey North Andover MA 01845 8-25-2021 -_ page. City/Town State Zip Code Date of Inspection lr. II I,j.JVULIVII •7UIIIIIIQIy (GO11t) 4) System Failure Criteria Applicable to All Systems: (cont.) V KI Yes IVV ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool I Uquid .1..naL. n c .. 1 In.... LL...n C" L...1..... ' ...�.+. 'I..L.I.. 1��mn 1...... ❑ ® than %day flow�JJN.,�� J �GJJ .��a�� ., .,��.,.. ��,..,, a�o��a.,��vc�,.,,�� J GJJ ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any puiiion ui 1he SAS, ce55p0-u1 ui piivy 15 ueiuw IIiyil yiuuilu wd Ill eie-Vdiiuil. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® rrny Nut uun Oi a uesSNuui ui privy IJ Wltlllll G ZUIIC i of d Nuuliu vVaLCisuNNiy 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 -J -L_:_ _L custody dy _- L L- -LLO-Lied L._ and a,llaln v1 �,iiawuy nliiaa uc aua�,ucv iv uua ❑ ® 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) Laryr Saysteiiia: To be coiisidefed a large sysilaiii the Systein must nerve a iaullity 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 qunntionn in SC-ti..n (` A ,.J.,V„J ,,, VVVI,v,I V.T. 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 10. Commonweaitn of Massachusetts ,p Title 5 Official Inspection Form 1 _Nn4 fnr\/nllin4oni Gccaccmcntc �1 485 Forest Street Property Address Michael Ciampa vwnel owners Name information is required for every North Andover MA 01845 8-25-2021 page. Citylrown State Zip Code Date of Inspection �.. 1r1sPUt;L1 11 Ourn1rriary kconij If you have answered "yes" to any question in Section C.5 the system is considered a significant +h.en+ iJ ° "+n nn.. nc+'nn 'n Cnn+;n r` A hi.\IC+he Ia•ne� +om hnn fn'le.+ The LI II ca L, VI an Jv.,cr cd yVJ LV Gllr L1 V...J LI VII 111 VL/L/LIL/11 V.T GVVYV LIIL. IGIyV Jr JLVI11 IIGJ IGIIV V. I IIV 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 JI IoUld VoiltaVt the apprCipfia v- regional U liCe VI the Depal-tMie it. 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? ❑ ® I IGYG larg's VVIu1nas VI YYq LGI VGGII II ILI VuuVGV LV LI IV Jr JLGIII IU%.Vl 1Llr Vr aJ FGIIL VI 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.7l2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 %ommonweaitn of Massachusetts Title 5 Official Inspection Form ULMV.1 Crwhc_rrfw:o Cow2no nicnnc2l Cvcfom Fnrm _Nnf fnr Vnhinfnni Accoccmonfc 485 Forest Street Property Address Michael Ciampa . Owner Owner's Name information is required for every North Andover MA 01845 8-25-2021 page. Citylrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: A A Number of bedrooms (design): -' Number of bedrooms (actual): -t DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Des vesci iNtiuil: 110 x 3 bedrooms Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? Ej Yes ❑ No If yes, discharges to: is iaundiy on a Separate Sewage System? (Include launuly systernl unspecuull ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes No Water meter readings, if available last 2 ears usage d Yes - Detail: ( Y 9 (gP ))� Detail: Sump pump? [J- Yes I SI No Last date of occupancy: current Date t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 %ommonweaitn of nnassacnusetts ,p� Title 5 Official Inspection Form - i_t Cnhcnrf2ro Cow2no niannamil Citcfam l=nrm _Nnf fnr\/nh infant Accaccmantc _.ate ��.�... . �.... ......... ......... .� 485 Forest Street , ,vrv_v...v•'-v Property Address Michael Ciampa Owner Owner's Name information is required for every North Andover MA 01845 8-25-2021 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? LJ Yes U No If yes, discharges to: industriai waste hoiding tank present? ❑ fires 0 No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Y YGllil 111{:rlCil I VG41111,J, 11 GYGIIG✓16i. Last date of occupancy/use: Date V LII�i1 \V GJVIIVG VGIV VY�. 3. Pumping Records: Source of information: Pumped July 2021 Was system pumped as part of the inspection'? El Yes ICI 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 %ommonweaitn of Massacnusetis �y Title 5 Official Inspection Form ERW`i.l Crwhcrirfw:a Cow2na nicnnc2l Cucfam Fnrm _Mrif fnr Vnh lntnni AccaccmantV I I—Wc V-4- 485 Forest Street Property Address Michael Ciampa vwnt+t owners Name information is required for every North Andover MA 01845 8-25-2021 page. City/Town 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: 22 years old,9-24 1991, u'$ built Yuri Were sewage odors detected when arriving at the site? ❑ Yes ® No a. ounul aCvirer tivcatc vl l anC Nldl l�. 3 Depth below grade: 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.): 4" PVC through floor, 3" 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 iommonweann of nnassacnuserm Title 5 Official Inspection Form [3 1 I Cieh¢nrfnrn Cow=no nicnncnil Awatom Fnrm _IUnt fnr Vnh lnfnni Acecccmcn+c 485 Forest Street Property Address .,..._ Michael Ciampa �••ll�r owner's Name information is required for every North Andover MA 01845 8-25-2021 page. Cityrrown State Zip Code Date of Inspection r% ".._t_.�— 1._r__ _17_� ._ . . U. �1y*LC111 IIIIV1111QLIL n �colll.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: 17-1 LLJI:UII: CIC UIIICIGI UIIUC_g1cJ, PVlyCtLylCnC ULLC_(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No IV'X5'X4� Dimensions: Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle 33.. 0 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 15" How were dimensions determined? tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I I t tnn L C tl t♦ L DI th f li id at tl t: n.+ N ;,d f I L e C ntn� n..q has 111IVt ttiti VI\. VMtI\rt t\rV VI\. V;.pLll VI ly4iV at VYtIVI 111Yt.11. V VYIV l.11V\.r VI VG�1\CI^y.,. VIrI ILtnI VV Y\yl IIGJ riser to grade. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth oT Massacnuseds ,p Title 5 Official Inspection Form _ t Ciihaiirfnro Cowtana nionncnl Cvefam Fnrm - Nnt fnr Vr%hintnni Gcccccmcntc r" -a- -r---• -�-._... 04y ' 485 Forest Street Property Address Michael Ciampa vwtlet Uwners Name information is required for every North Andover MA 01845 8-25-2021 page. City/Town State Zip Code Date of Inspection e% e►- —1— -- —r-----1'— — v. Oysiern rrlrvrrnauon (cont.) 7. Grease Trap (locate on site plan): .....ru. .... 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 Dale of 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 Form:Subsurface Sewage Disposal System•Page 11 of 18 %ommonweaitn of massacnuseus � Title 5 Official Inspection Form lZW-IM 11 Crwhciirfwro Caw2no nianncal Cvafam Fnrm _Nnt fnr Vnh iintnnir Accacemcntc 485 Forest Street Property Address Michael Ciampa Owner Owners Name information is required for every North Andover MA 01845 8-25-2021 page. Cityrrown State Zip Code Date of Inspection u. System information (cone.) 8. Tight or Holding Tank(cont.) Aiarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No n.,+.. .,s Inn♦.. v c,w — IGJI Nun i ping: 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. No evidence of leakage. No evidence of carryover. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of iviassacnuseus Title 5 Official Inspection Form � 1 Ciihaiirfaro Couvanal nicnncal Cvc4am Fnrm _Nnf fnr Vnll lnfani AecoccmenfV V c IN01 485 Forest Street Property Address Michael Ciampa Owner Owner's Name information is required for every North Andover MA 01845 8-25-2021 page. City/Town State Zip Code Date of Inspection D. System information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: Z Yes U No" Alarms in working order: ® Yes ❑ No' .., VA.—X. %Co a ta `I.10ae co u-1t:lV.l.l V1c pu 1 1 I.N C a be , ccnd:al:on oil pumps and appu. G.l.lal.VCa, L%'+ Pump tank ok. Pump ok. Floats ok. Alarm ok. Alarm has both audible &visual. Pump tank has cover to grade over pump&floats " 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): 1C nAG' .-...L 1.......1..J ..L.:.....L... 11 SAS not:ocatCu, Ve Xpialll VVllY. Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 tienc ies ou' long ❑ 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 %ommonweaitn of Massachusetts Title 5 Official Inspection Form _ { Ciihaitrfnra Cow!%no niannani gva4om Fnrm-Nnf fnr\/nllrntnni Accacemantc C, %., � 485 Forest Street Property Address Michael Ciampa Owner Owner's Name information is required for every North Andover MA 01845 8-25-2021 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 vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. 12. Ce5SP006 (Cesspool illust be Hurt Pee as Part Ot a aNectl0i 0 (tcrcace on citt jrtat I). Number and configuration Dent•L. t.... F Hqui/d tG le+ ,,t \..t./all — VF/VI Ia.1 1111J aV Il lllil IIIV VII Depth of solids layer Depth vi sc:;uin 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 %ommonweann of Massachuseus ,p Title 5 Official Inspection Form I Ciihcrirf2rn Cownno nicnncol -Qua tom Fnrm -Mnf fnr\/nhtntnn/ Acececmontc _�_._... �41 485 Forest Street Property Address Michael Ciampa vwrlet Uwners Name information is North Andover MA 01845 8-25-2021 required for every page. City/Town State Zip Code Date of Inspection U. JySICIiI IIITV L1UI1 (cont.) 13. Privy (locate on site plan): IBAIatC.,i4nl1J nVIF V-WVIn IJtrUctirV,nI • 1. Dimensions r ep4l-M Of SOWS I.JGI./LI I Of JVIIVJ 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 Commonweann of massacnuseds � Title 5 Official Inspection Form I.I Ciingivrf2ro Cowann nianncai Cvc4om Fnrm _Mr%f fnr Vr%hiintani Accncemnntc 4 485 Forest Street Property Address Michael Ciampa Owner Owner's Name information is required for every North Andover MA 01845 8-25-2021 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 V � a �px t L a t +o 3 = 3g t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 %ommonweann of Massacnusens � Title 5 Official Inspection Form _ iit Ci�haiiii ro Cownna nianncai Cvctam Fnrm _Nnt fnr Vnlirntnni Accaccmcntc -a- -r--- -�- - 485 Forest Street Property Address Michael Ciampa vwllef Uwners Name information is required for every North Andover MA 01845 8-25-2021 page. City/Town State Zip Code Date of Inspection D. System information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells >4 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: z Obtained from system design plans on record If checked, date of design plan reviewed: 5-23-1996 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design pl. V GgI 11 r./IQ�1 ❑ Checked with local excavators, installers-(attach documentation) IJ /'1la.CJJCU VJVJ UGLd UdJC-CJC pIGII I. 1 VU 4j�%A IVG IIVYY YV{A GJ LGU11QI IGU LI IG IIILJ.11 L,1 V411U YYQ LGI GIGYQLIVII. 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 c � %ommonweaith of Massachusetts Title 5 Official Inspection Form _ i:;l C�h¢:,rfwro Cnw�np ni¢nncal Cvc4om Fnrm _Nnt fnr\/nitintani Aecacemcnte C� 485 Forest Street Property Address Michael Ciampa Owner Owner's Name information is required for every North Andover MA 01845 8-25-2021 page. Citylrown 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 Z C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and o (Chetrnlist) c;oillNlated ® D. System information: For Q• Tighlt LJ..l.din..T.,..I.__ D-�w+n�nn trnnl n4+nnhnrr v� v. iy�w u wwu ig T un n1 i ui i ern�y vvini av�uuuv�wit 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.7/2 612 0 1 8 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 18 Summary Record Card generated on 8/26/2021 4:07:08 PM by Sharon Coco Page 1 Town of North Andover Tax Map # 210-106.B-0218-0000.0 Parcel Id 17616 485 FOREST STREET MICHAEL & MARINA CIAMPA 485 FOREST STREET NORTH ANDOVER MA 01845 FY 2022 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until MICHAEL&MARINA CIAMPA Owner Active 485 FOREST STREET NORTH ANDOVER MA 01845 NIGRO,WILLIAM J Previous Customer Inactive 9/12/2014 485 FOREST STREET NORTH ANDOVER, MA 01845 SUSAN SAULS Previous Customer Inactive 3/30/2017 485 FOREST STREET NORTH ANDOVER MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/inactive Bldg Id. 17597.0-485 FOREST STREET Last Billing Date 2/11/2000 3170268 03 Cycle 03 Inactive From 1/l/2004 Bldg Id. 17597.0-485 FOREST STREET Last Billing Date 7/19/2021 3170267 03 Cycle 03 Active UB Services Maint. Account No. 3170267 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 92.65 /1 UB Meter Maintenance Account No.3170268 Serial No Status Location Brand Type Size YTD Cons 13306717 i Inactive NEPTUNE NEPTUNE w Water 1 1 0 Account No. 3170267 Serial No Status Location Brand Type Size YTD Cons 48966746 a Active ERT HH b Badger w Water 1 1 70 Date Reading Code Consumption Posted Date Variance 6/7/2021 408 a Actual 23 7/27/2021 6% 3/9/2021 385 aActual 22 4/21/2021 -12% 12/8/2020 363 aActual 25 1/13/2021 -63% 9/8/2020 338 a Actual 71 10/14/2020 81% 6/5/2020 267 a Actual 38 7/15/2020 67% 3/5/2020 229 a Actual 21 4/8/2020 -24% 12/11/2019 208 aActual 29 1/15/2020 7% 9/13/2019 179 a Actual 29 10/10/2019 10% 6/10/2019 150 a Actual 26 7/25/2019 87% 3/8/2019 124 a Actual 13 4/16/2019 -7% 12/10/2018 111 a Actual 14 1/22/2019 -29% 9/13/2018 97 a Actual 21 10/15/2018 -14% 6/11/2018 76 aActual 25 7/23/2018 2% 3/7/2018 51 a Actual 23 4/23/2018 -28% 12/7/2017 28 aActual 28 1/25/2018 -100% 9/19/2017 0 n New Meter 0 10/18/2017 -100% 9/19/2017 2648 r Replacement 50 10/18/2017 117% 1 Of MOMT:,y 9 Y 1 O � s Town of North Andover HEALTH DEPARTMENT S4CNUSt CHECK#: 5S5 DATE: I. 7. LOCATION: H/O NAME: Aa , t CONTRACTOR NAME: Z30 .*e SpT_ 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 PO- 0 $ Title 5 Report .�, $Other:(Indicate) $ 1 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer