HomeMy WebLinkAboutConditional Pass - Title V Inspection Report - 195 OLYMPIC LANE 5/3/2022 Septic Compliance, Inc. �G��J�Q
Title 5 Inspections - Soil Evaluations
37 Y: Baremeadow Street, Methuen, MA 01844 p
978-815-3115
Tiffin C Ir%rnnt:t;—% Dnr%^P+
Property Address: 195 Olympic Lane,North Andover,Ma.
Owner: Michael Crepeau
Date of Inspection: 4/22/2022
My report contained herein does not constitute a guarantee of future usage 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.
F. Paul Cardone
Septic Compliance, Inc.
( nmmnn_wnalth of Magcaehiicattc
- .-- , Title 5 Official Inspection Form
8 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Olympic Lane —
Property Address
Owner Owner's Name
information is North Andover Ma. 01845 4-22-2022
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms
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
vv;iiNairy iroiiic
key. 37 1/2 Baremeadow Street _— —
Company Address
Methuen Ma 01844
City/Town State Zip Code
f 978-815-3115 or978-681-0726 #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
(310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ® Conditionally Passes
3. ❑ Needs Further Evaluation b jhe-6q�al Approving Authority
i
4. ❑ Fails
1 ec ors Signature -- a
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•tev.712612018 Titlo 5 Official Inspecbon Form Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
h{ Subsurface Sewage Disposal System Form Not for Voluntary Assessments
^ � 195 Olympic Lane
Property Address
Micnaei Crepeau
Owner Owner's Name
information is North Andover Ma. 01845 4-22-2022
required for every --
page City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
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:
2) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N,ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
uompiiance moicating that the tanK Is iess than zu years oia is avauaoie.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2016 Title 5 Official Inspection Form Subsurface Sewage Disposal System Page 2 of 1a
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� j� 195 Olympic Lane
V
Property Address
Owner Owner's Name
information is North Andover Ma. 01845 4-22-2022
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 oine(s) or due to a broken.settled or uneven distribution box. Svstem 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):
® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
D-Box is beginning to deteriorate, is in need of replacement.
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
I-
--__; Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
- � 195 Olympic Lane _ —
u Property Address
Michael CMpeau
Owner Owner's Name
information is North Andover Ma. 01845 4-22-2022
required for every --
page. CitylTown 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:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
i uu teet of a surface water supply or tnbutary 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
luvic iivil a Niivatz lfvata su NNiy v eV*.
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
l pro v:dvaav y ..wwan [ P ahwi +.. naL.....t..:l..... n.;a...:.. u.c 4.-!G yC.Cd. A�vv.y 3f
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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
61�1a Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Olympic Lane
Property Address
Michael Crepeau —
Owner Owner's Name
information is North Andover Ma. 01845 4-22-2022
required for every -_ State Zip Code Date of Inspection
page. uy Town
C. Inspection Summary (cont.)
4) Svstem Failure Criteria Applicable to All Svstems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
!quid dnn#h in ....nnnl . !C=thnn e', n. nt...n
u z fl
than '/zayow
c ...
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within iuu teet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
trom a private water supply well witn no acceptable 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.]
The stem i nccnnnl cnr+.inn n Fnnilifir u.i#h n r#ociyn flnu,of'ff1A/1 tit,
Li L9 10,000 gpd.'
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ® the system is 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.7t2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
('.nmmnnwpalfh of Maccarthncpf°fc
- --5F, Title 5 Official Inspection Form
�~ ±� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Olympic Lane
Property Address
Michael Crepeau _
Owner Owner's Name
information is required for every North Andover Ma. 01845 4-22-2022
- _
page. CityTrown 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
ilncai, u�aiisvr>riGii 'yGDn W G111y I�VCJ11Vt1 Itt OCtJ11Vt1 V.Y auJvc iiic ieiyo ayaiciii iiaa iatIVJ. 1 uc
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 aN 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?
Hnvn of.un+nr bCCn in!rnd_,,CC l tc tnc system "c-0., nn n n nrt of
r
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?
17 rl Was the facility owner(and occupants if different from owner) provided with
inTormavon on the proper mainienance or suosurrace 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
nnnrnvimn+lnn of i+i n+nnnn in nn nnnnn+n L.I c,\ r44 n /'`611c) •I
t5insp.doc•rev.7/26/2018 Title 5 Dfficial Inspection Form:subsurtace Sewage Disposal System•Page 8 of 18
Summary Record Card generated on 4/19/2022 10:41:35 AM by Sharon Coco Page 1
T...... C AI---LL- A—J—._.-
IUVV11 U1 1vU1L11 /-111UUVGl
Tax Map # 210-1063-0130-0000.0
Parcel Id 17534
195 OLYMPIC LANE
MICHAEL CREPEAU
195 OLYMPIC LANE
v
,.
ivvr�lnilivuvitcrsiritl ia�+6
FY 2022
UB Mailina Index
Name/Address Type Loan Number Active/Inact. From Until
MICHAEL CREPEAU Owner Active
195 OLYMPIC LANE
NORTH ANDOVER MA 01845
KUSEK,D&BORAX,J Previous Customer Inactive 11/15/2013
195 OLYMPIC LANE
NORTH ANDOVER,MA
01845
UB Account Maint.
Account No Cvcle Occunant Name ArtivPtlnarfivP
Bldg Id.17512.0-195 OLYMPIC LANE Last Billing Date 4/7/2022
3170182 03 Cycle 03 Active
UB Services Maint.
Account No.3170182
Service Code Rate Charge Multiplier/Users
MISCFEEADMIN FEE 0.63 5/8 7.82 1/
WTR WATER 01 ALL METER SIZE 64.60 /1
UB Meter Maintenance
Account No.3170182
Serial No Status Location Brand Type Size YTD Cons
32939027 a Active ERT HH b Badger w Water 0.63 0.63 115
Date Reading Code Consumption Posted Date Variance
v/7rriv.22 2512 2 1ztuz' 17 41,'1 2.v22 -IJre
12/8/2021 2496 aActual 20 1/17/2022 -3%
9/8/2021 2476 a Actual 21 10/15/2021 -8%
6/7/2021 2455 a Actual 23 7/27/2021 33%
3/6/2021 2432 a Actual 16 4/21/2021 -7%
12/8/2020 2416 a Actual 18 1/13/2021 -70%
9/8/2020 2398 a Actual 64 10/14/2020 245%
6/3/2020 2334 a Actual 17 7/15/2020 3%
3/6/2020 2317 aActual 16 n/a/2mn inol
12/11/2019 2301 aActual 15 1/15/2020 _75%
9/13/2019 2286 a Actual 65 10/10/2019 162%
6/7/2019 2221 a Actual 23 7/25/2019 71%
3/8/2019 2198 a Actual 13 4/16/2019 -13%
12/10/2018 2185 aActual 15 1/22/2019 -72%
9/13/2018 2170 a Actual 60 10/15/2018 284%
6/8/2018 2110 aActuai 15 7/23/2018 -2%
3/7/2018 2095 a Actual 15 4/23/2018 1%
12/6/2017 2080 a Actual 14 1/25/2018 -5Ao/
9/11/2017 2066 aActual 37 10/18/2017 139%
6/812017 2029 a Actual 15 7/25/2017 4%
3/8/2017 2014 a Actual 14 4/12/2017 -52%
12/9/2016 2000 a Actual 30 1/23/2017 -69%
9/9/2016 1970 a Actual 100 10/24/2016 799%
6/8/2016 1870 a Actual 11 8/2/2016 -17%
3/8/2016 1859 a Actual 13 4/22/2016 -55/o
12/9/2015 1846 aActual 29 1/20/2016 -59%
9/1012015 1817 a Actual 98 10/16/2015 317%
6/9/2015 1719 a Actual 23 7/24/2015 90%
3/10/2015 1696 a Actual 12 4/28/2015 -59%
Commonwealth of Massachusetts
1� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Olympic Lane
Property Address
iviiGilacf viGj�Gdu _
Owner Owner's Name
Information is required for every North Andover Ma. 01845 4-22-2022
--—
page. City/Town 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:
NulIIUCI UI UU1IUl1i ICbidelfiJ 4. - ---
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
t AJnter meter roorii Hive ii n..niln File fleet 2 verve .'sa—C Enclosed
Detail:
Sump pump? ® Yes ❑ No
Currently
Last date of occupancy: Occupied
t5insp.doc•rev.7f28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Invoice
WcWnes Drains
Professional Sewer&Drain Cleaning Date
P.O.Box 298,Wilmington, MA 01887
Office 781-272-3100 Fax 781-272-2999
www.waynesdrains.com
Bill To: Job Name
Job Location
"A
P0#
DESCRIPTION PRICE AMOUNT
J-Irrjr"'i'�
r
Time In Time Out❑
Work El Night/Weekend El Holiday 0 Maintenance I F--
Guarantee (VOID IF ABUSED)
Not Responsible for weak, rotted,broken pipes, drum traps and city sewer back up.
Signature Print
(�n'll Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Olympic Lane
V�
Property Address
Michael Crepeau _
Owner Owner's Name
information is required for every North Andover Ma. 01845 4-22-2022
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.):
ra�cc#r nroconl7 ri Voo
Creasean r—i AID
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: Owner and pump slip
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: No need for pumping at this tank was pumped on12-
2-2021 1500 Gallons by Wayne's Drains _.
t5insp.doc rev.7/26/2018 Trtle 5 Official Inspection Form.Subsurface Sewage Disposal System•Pago 8 of 18
Commonwealth of Massachusetts
-- ---�� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
19.5 Olympic Lane
Property Address
Michael Crepeau ---
Owner Owner's Name
information is North Andover Ma. 01845 4-22-2022
required for every
page City/Town State Zip Code Date of Inspection
D. System Information (cant.)
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 of age- Information on file
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ 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.):
Good Good None
t5insp.doc•rev.7f28f2015 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
195 Olympic Lane
Property Address
IV111.11CiC1 lrl Cl✓'GCIU ___ __._.______
Owner Owner's Name
information is required for every North Andover Ma. 01845 4-22-2022
- --- —
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cant.)
R Sentir Tanis (Innato nn cito nlmnl-
Depth below grade: 8" Brought up to grade with a plastic
riser.
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
We recommend concrete risers and metal covers.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
10'8"Lx57'Wx5'8"H
Dimensions: --
3"
Sludge depth: -
Distance from top of sludge to bottom of outlet tee or baffle —
Scum thickness 1
-
Distance from top of scum to top of outlet tee or baffle -
Distance from bottom of scum to bottom of outlet tee or baffle
T�nc
R_Inrino_ .h lrnc aandHow were dimensions determined? __t
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, both tee's were in good condition, structural
integrity appeared to be good, liquid levels were good, no evdence of any leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface"sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ry 195 Olympic Lane
LJ�
Property Address
Michael Crepeau
Owner Owner's Name
information is North Andover Ma. 01845 4-22-2022
required page.
g . for every City/Town State Zip Code Date of Inspection
D. System Information (cont.)
i. vrease trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
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.):
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):
N/A
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
i- Title 5 Official Inspection Form
- 2�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Olympic Lane
Property Address
Micnaei Grepeau _
Owner Owner's Name
Information is required for every North Andover Ma. 01845 4-22-2022
---- -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: — Alarm in worsting order: ❑ Yes ❑ No
Date of last pumping: gate
Comments (condition of alarm and float switches, etc.):
NIA _
"Attach copy of current pumping contract (required). Is copy attached? ® Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
r-nnrl and F=xt n
Depth of liquid level above outlet invert
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, distribution was equal, No evidence of solids carryover, no leakage at this point, box is
in need of replacement.
t5insp.doc•rev.7/2 012 0 1 8 Titie 5 Official Inspector Form.Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
-, Title 5 Official Inspection Form
iI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4
195 Olympic Lane
u Property Address
Owner Owner's Name
information is North Andover Ma. 01845 4-22-2022
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:
n InNnhinn rhomhoro nrrmhor, -
❑ 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: —
t5insp.doc•rev.72612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�� 195 OI rmpic Lane
Property Address
Michael Crepeau
Owner Owner's Name
information is required for every North Andover Ma. 01845 4-22-2022
- —
page Cityfrown 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.):
Good None 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
11arth of crnm Ivor -----
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.):
N/A
t5insp_doc-rev.7126t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
�tlTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Olympic Lane
u Property Address
fflidlae;Cifijwau
----- --____---------
Uwner Owner's Name
information is North Andover Ma. 01845 4-22-2022
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
t,roviae a view of the sewage atsposai system, mcivaing ties to at teast two permanent reverence
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.7126=18 Tide 5 Official Inspection Form:SU6eUrt ce Sewage Disposal System-Page 10 of 16
Commonwealth of Massachusetts
M. - 50
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Olympic Lane
Property Address
ne:nhnnf crcpcm;
�t�uu
Owner Owner's Name
information is required for every North Andover Ma. 01845 4-22-2022
—
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,
ctc,:
NIA
t5lnsp.doa-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�r
195 Olympic Lane
Property Address
Michael Crepeau_ _
Owner Owner's Name
information is required for every North Andover Ma. 01845 4-22-2022
page. Cfty/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: 7'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: 7-22-99
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
r�l ar`hcr lrorl%Ali h Inrol Rnorri of Wnni h _ovr.l7in•
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
All liquid was good, basement was dry, sump pump hole was dry, soil logs on file
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7126f2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
r'.nmmnnwaalth of Maccarhi�cr�ttc
Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 OI m is Lane
Property Address
Michael Crepeau
Owner Owner's Name
information is North Andover
required for every _ Ma. 01845 4-22-2022
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
t5insp_doc-rev.7rrV2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 18 of 18
t NORTM, I 6
O ` ' •.ti0
o w
p Town of North Andover
�� `• HEALTH DEPARTMENT
�sSacNustt
CHECK#: 7 // DATE:
LOCATION: 195
H/O NAME: c. e,oec u
If
CONTRACTOR NAME: A,,/[
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 $
❑ TrasIVSolid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5Inspector $
Title 5 Report On(OL Grs $✓�0
f�
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer