HomeMy WebLinkAboutPass - Title V Inspection Report - 72 PATTON LANE 4/7/2022 cor%+:&� ir%.. f RECEIVED
Title 5 Inspections - Soil Evaluations APR 72022
TOWN OF NORTH ANDOVER
37 % Baremeadow Street, Methuen, MA 01844 HEALTH DEPARTMENT
978-815-3115
Ti��., C fir.[r.ArF�Ar. DAMAMF
..... .. .....N...,...,.. ....r....
Property Address: 72 Patton Lane, North Andover, MA
Owner: Kristine Uttley
Date of Inspection: 4/4/2022
My renort contained herein does not constitute a euarantee of future usaep and the functionality of the
existing septic system. Such report issued herewith is merely based upon my observations, and I hereby
disclaim any further operation of your current septic system.
aul Cardone
� ��Sepi�icom ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
( Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
:..! 72 Patton Lane
Property Address
Owner Owner's Name
information is required for every North Andover Ma 01845 4-4-2022
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab F. Paul Cardone
key to move your Name of Inspector
cursor-do not Septic Compliance, Inc.
use the return Company Name
key.
37 1/2 Baremeadow Street
_Q Company Address
Methuen Ma 01844
Citv/Town State Zio Code
978-815-3115 or 978-681-0726 #3294
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
j3iu CiiAR i5.uuuj; i have personaiiy inspected the sewage disposai system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
I ctoes Signature ate
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 Owners Namecial Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
�. p Title 5 Official Inspection Form
5 h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Patton Lane
Property Address
Kristine Uttley
Owner --
Owner's Name -
information is North Andover Ma 01845 4-4-2022
required for every __. _
page. Cltyrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This inspection was performed so that the owner could put on an addition to the property per BOH
request. Also there is an existing garbage grinder. I explained that the grinder could possible harm
the system if not designed to accommodate one, she is havivg it removed.
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 leakinq and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Patton Lane
Property Address
Kristine Uttley
Owner Owner's Name
information is Notch Andover Ma 018_45 4-4-2022
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 will
pass inspectiun If(wiiit aNptuvai ui oualu vi
❑ 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).
❑ 1 ne system requlreo pumping more tnan 4 times a year aue to oroKen or oostructeo pipets. 1 ne
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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Patton Lane
Property Address
Ki lA1li11C. ui.i.icy __
Owner Owner's Name
information is required for every North Andover Ma 01845 4-4-2022
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
I-1 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.
n The cvc+em hoc n confirr,+nnle enrl QAQ nnrl+he QAQ is lace+hnn Inn fop+hll+Fn feet nr
— . .._ _�___... ..-_ —
ater 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
IV Vt ICDJ UICI11 5 PPI 11, PIVvIUGU UIGI IIV VU ICI ICII;U11-- LI IICI Id GIC URyyt::IVU. P1 UUE.ly VI LI CII IGIy WZ, IIIUJI
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
t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
,�3 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Patton Lane
Property Address
Kristine Uttley
Owner Owner's Name
information is North Andover_ Ma 01845 4-4-2022
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
Rcni iiriaH ni imninn mnrc thon A timee in thin loct%icor A1r1T Ais to rinnnaA nr
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
LlMM An., nn h;nn of nnnnnnnl nr nr;vy ;r. n Inn inn♦Cf C rf..r........fr.r....nnl., nr
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptame water quality analysis. L i nis
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.]
n The system is a cesspool serving a facility with a design flow of 2000 gpd-
i u,uvU ypd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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
r!w..:..n it n... zf AA AAA ;PC! 1.. AG AAA ..r.r!
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
,- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Patton Lane
Property Address
rV IJU11C UUICy
Owner Owner's Name --------- -------.------___..----
information is required for every North Andover Ma 01845 4-4-2022
—__
page. Cltyrrown 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
tr ct r.rJ ' ' tc cny _t;c Scct!r. (` 1 ctc c Fhc !c ctc h.. F.+11.. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
t—, � Have larae volumes of water been introduced to the system recently or as part of
u L�11 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?
® ❑ vvas the facility owner(ana occupants it ainerent from owner) provicea wan
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Summary Record Card generated on 4I4/2022 8:35:10 AM by Karen Hanlon Page 1
I VvVII VI IVVI III ll11UV vGI
Tax Map # 210-106.A-0090-0000.0
Parcel Id 17235
72 PATTON LANE
KRISTINE UTTLEY
72 PATTON LANE
IYVf\T f IJ l MIVV%V LE I IVIM V 1 V'1'J
FY 2022
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
KRISTINE UTTLEY Owner Active
72 PATTON LANE
NORTH ANDOVER.MA 01845
NEILL, BRIAN&JENNIFER Previous Customer Inactive 10/6/2008
498 JENIFER COURT
SANTA ROSA, CA
95404
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
&uy iu, i i or 5.v 1 c rni i viv LAIZ Lc,.:C.':: y Catz 0,2 22
3170043 03 Cycle 03 Active
UB Services Maint.
Account No.3170043
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.63 5/8 7.82 1/
VV 1 K VVMI ER v;ALL METER JILC C3.03
UB Meter Maintenance
Account No. 3170043
Serial No Status Location Brand Type Size YTD Cons
13242393 a Active ERT HH METE METE w Water 0.63 0.63 138
Date Reading Code Consumption Posted Date Variance
?u12n22 1Fin 12 -22%
12/7/2021 1518 a Actual 16 1/17/2022 -76%
9/7/2021 1502 a Actual 70 10/15/2021 171%
6/4/2021 1432 a Actual 25 7/27/2021 115%
3/4/2021 1407 a Actual 11 4/21/2021 -26%
12/7/2020 1396 aActual 16 1/13/2021 -60%
9/4/2020 1380 a Actual 40 10/14/2020 158%
6/3/2020 1340 a Actual 15 7/15/2020 61%
3/5/2020 1325 a Actual 9 4/8/2020 0%
1 2/9/2019 1316 a Actual 9 1/15/2020 -32%
Summary Record Card generated on 4/4/2022 8:35:10 AM by Karen Hanlon Page 2
I vvvI I v1 I VvI to I VNI 1\4%J v G1
Tax Map # 210-106.A-0090-0000.0
Parcel Id 17235
72 PATTON LANE
KRISTINE UTTLEY
72 PATTON LANE
NURTH ANUUVtK, MA Ul645
FY 2022
9/13/2019 1307 a Actual 15 10/10/2019 41%
6/7/2019 1292 a Actual 10 7/25/2019 -18%
3/7/2019 1282 a Actual 12 4/16/2019 5%
12/7/2018 1270 aActual 11 1/22/2019 -42%
9/11/2018 1259 a Actual 21 10/15/2018 103%
c 7.12C 12 1222 ..n...�,n1 1n 7/71/9n1R _Ze/
3/6/2018 1228 a Actual 10 4/23/2018 6%
12/6/2017 1218 a Actual 9 1/25/2018 -44%
9/11/2017 1209 a Actual 18 10/18/2017 71%
6/6/2017 1191 a Actual 10 7/25/2017 -4%
3/6/2017 1181 a Actual 10 4/12/2017 -13%
12/8/2016 1171 aActual 12 1/23/2017 -52%
9/7/2016 1159 a Actual 25 10/24/2016 127%
6/7/2016 1134 a Actual 11 8/2/2016 20%
2!7! 1C 1122 0 -00/
12/8/2015 1114 aActual 10 1/20/2016 -65%
9/8/2015 1104 a Actual 29 10/16/2015 139%
6/8/2015 1075 a Actual 12 7/24/2015 -9%
3/9/2015 1063 a Actual 13 4/28/2015 18%
12/9/2014 1050 a Actual 11 1/15/2015 -55%
9/10/2014 1039 a Actual 25 10/15/2014 145%
6/9/2014 1014 a Actual 10 7/16/2014 0%
3/10/2014 1004 a Actual 10 4/11/2014 10%
'.nin'nn!n 2n1 ., n„.,,..I 9 1/17MMA -Biro/
9/10/2013 985 a Actual 21 10/15/2013 30%
6/10/2013 964 a Actual 16 7/24/2013 107%
3/11/2013 948 a Actual 8 4/22/2013 -51%
12/7/2012 940 aActual 15 1/9/2013 -70%
9/12/2012 925 a Actual 55 10/15/2012 447%
6/8/2012 870 a Actual 9 7/16/2012 12%
3/14/2012 861 a Actual 9 4/14/2012 -8%
12/9/2011 852 a Actual 9 1/17/2012 -41%
n11212n11 ?A? n..i„n1 17 1n/11117n11 9;A0/
6/6/2011 826 a Actual 10 7/20/2011 9%
3/8/2011 816 a Actual 9 4/13/2011 -32%
12/10/2010 807 a Actual 14 1/12/2011 -20%
9/8/2010 793 a Actual 18 10/15/2010 83%
6/4/2010 775 a Actual 9 7/15/2010 29%
3/8/2010 766 a Actual 7 4/14/2010 -9%
12/10/2009 759 a Actual 8 1/12/2010 -35%
0101,)nna 7F1 .Annicl 11 1n11519nnci 41%
6/4/2009 738 a Actual 8 7/20/2009 -8%
3/12/2009 730 a Actual 10 4/29/2009 -71%
12/5/2008 720 a Actual 21 1/20/2009 -100%
10/6/2008 699 f Final Bill 0 10/6/2008 -100%
9/8/2008 699 a Actual 98 10/10/2008 3%
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Patton Lane
V
Property Address
Kristine utuey
Owner Owner's Name
information is required for every North Andover Ma 01845 44-2022
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: 3
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Enclosed
VVdiCI IIICU:I ICduinys, ii dvdiidUIU kld,i Z yCdlb ubd9U k9PU)).
Detail:
Sump pump? ® Yes ❑ No
Last date of occupancy: CurrentlyOccupied
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
rr%mmnnwa2Ifh of Maeearhiseca#c
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Patton Lane
Property Address
Kristine Uttley
Owner - --- -
Owner's Name
information is required for every North Andover Ma 01845 4-4-2022
_
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease tr2n -resent') n V.. 17 Aln
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: -- ---- --- --- --
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: - -- - -- ---
Last date of occupancy/use: Date
Other(describe below):
N/A
3. Pumping Records:
Source of information: Last time pumped 5/21 no need for pumping at this
time
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: ----- -- ---- - -
gallons
How was quantity pumped determined?
Reason for pumping:
t5insodoc-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
�
11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments h I�
72 Patton Lane
Property Address
Owner __ -- - - - - _ - --
Owner's Name
information is North Andover Ma 01845 4-4-2022
required for every - -
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:
system put in in 7-8-1985,outlet baffle was replaced with sanitary tee and d-box was also replaced
on 3-23-2006
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 20"---- ---
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain): --
Distance from private water supply well or suction line.-
Comments (on condition of joints, venting, evidence of leakage, etc.):
All in good condition
t51nsp.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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, ! 72 Patton Lane
Property Address
Kristine Uttley
Owner Owner's Name
information is required for every North Andover Ma 01845 4-4-2022
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
91,
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age contirmea oy a t;ernticate of uompnance-? (attacn a copy of ceraticate) L_.I Yes ❑ No
Dimensions: 10'x5'x4'
Sludge depth:
3"
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 2-3'
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Sludge Judge and tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
we recommend tank be pumped on a yearly basis, inlet older concrete baffle in place outlet was
replaced with a PVC sanitary tee both in place, liquid level was good, no evidence of any leakage.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth: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
72 Patton Lane
Property Address
Kristine uttie
Owner �-- -- --- —
Owner's Name
information is North Andover.-------- Ma 01845 4-4-2022
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: ---
Scum thickness
Distance from top of scum to top of outlet tee or baffle --
Distance from bottom of scum to bottom of outlet tee or baffle ---
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Patton Lane
Property Address
Kristine umey
Owner Owner's Name
information is required for every North Andover Ma 01845 44-2022
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
U. I gnt or mowing i anK(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: not'.
Comments(condition of alarm and float switches, etc.):
N/A
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Wince
Depth of liquid level above outlet invert 1 cvcl u�oe hc"lnu"r"'"""
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box was level and all 4 lines had speed levelers, ditribution was equal, no solids carryover, no
evidence of any leakage, box has been replaced.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
�y J, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Patton Lane
Property Address
Kristine Uttley
Owner Owner's Name
information is North Andover Ma 01845 4-4-2022
required for every -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
1 Field 20'x45'
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: --- --- - - -- -
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Patton Lane
Property Address
nt IJUI IC uU1Cy
Owner Owner's Name
information is North Andover Ma 01845 4-4-2022
required for every --- ----__---- -- _ -_
page. CltyrTown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorotion Svstem (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Good No None No Grassy
side yard area
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth -top of liquid to inlet invert
Depth of solids layer ---- --- -
Depth of scum layer ---- - - -- -
Dimensions of cesspool -- - - - - -
Materials of construction ------- --
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
N/A
t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Patton Lane
Property Address
Kristine Uttley _
Owner Owner's Name
information is North Andover Ma 01845 4-4-2022
required for every - _ _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: - - --- -- ---- -- -
Dimensions - -- - ------
Depth of solids — --
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
ct ):
N/A
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 18
C� rnmmnnwoalth of Maccarh��aotM
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Patton Lane
Property Address
Kristine Uttley _
Owner Owner's Name
information is required for every North Andover Ma 01845 4-4-2022
page. City(rown State Zip Code Date of Inspection
D. System Information (coat.)
14. Sketch Of Sewage Disposal System:
r'IVVIUC d VICW VI IIIC SCWdUtL-U15NVbdl bybtWII, IIJUIUUIIIY tICJ lU ill ICdbL LWU Pei II Wrier It ICICICIIt C
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
D"k
_��ticptts Turk ------�
NA
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i
i
Warr Meter
i � I F 4 ae!=1R*t• 1 �
i Ato2 21.1*
A to3-U'r
ata>t-1la'
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B to D-B"—33`
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t5insp.doc•rev.7/262018 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
72 Patton Lane
Property Address
►ii5tittC L;U6y
Owner Owner's Name
information is North Andover Ma 01845 4-4-2022
required for every _ __ _ -
page. City[Town 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:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 5-25-1983
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must oescrtoe now you estaatisnea the nign grouna water etevation:
All liquid levels were good,sump pump hole was dry, basement was dry, soil logs available, it is a
raised system
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
rnmmnnwaalth of MaacarhrlcAttc
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Patton Lane
Property Address
Kristine Uttley
Owner Owner's Name
information is required for every North Andover Ma 01845 4-4-2022
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
t51nsp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 18 of 18
Town of North Andover, MA
$50.00 Paid
via Check#1998
Note: 72 Patton Lane
Thanks for using the Online Service Center
Kristine Uttley
Title 5 Official Inspection Form Submittal#65751
April 7, 2022
Title 5 Filing Fee $50.00
Total Paid $50.00
V
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