HomeMy WebLinkAbout- Title V Inspection Report - 53 CEDAR LANE 4/29/2022 W. RECEIVED
Commonwealth of Massachusetts
,I� Title 5 Official Inspection Form APR 2 92022
IIII Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
TOWN OF NORTH ANDOVER
53 CEDAR LANE HEALTH DEPARTMENT
Property Address
CHRIS BOURQUE
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 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 Todd James Bateson
key to move your Name of Inspector
cursor-do not Bateson Enterprises Inc.
use the return Company Name
key.
111 A A Road
r� Company Address
Andover MA 01810
City/Town State Zip Code
•� 978-475-4786 _ SI-16
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 15.000); 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
Q ��ZfZ2
3. ® Needs Further Evaluation by the Local Approving Authority ,v
4. ❑ Fails
4�
Inspecters Signature - 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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 CEDAR LANE _
Property Address
CHRIS BOURQUE
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 2022
page. CitylTown 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
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
r
Commonwealth of Massachusetts
rr ,, Title 5 Official Inspection Form
I) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 53 CEDAR LANE
Property Address
CHRIS BOURQUE
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 2022
— _
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 inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
® Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
a Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 53 CEDAR LANE
u -
Property Address
CHRIS BOURQUE
Owner - ---
Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 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:
❑ 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: TAPE MEASURE
*" his system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
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
t51nsp.doc•rev.7126/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 18
1 Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e� 53 CEDAR LANE
Property Address
CHRIS BOURQUE
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 2022
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private 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
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with 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
t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Forms Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
lip Subsurface Sewage Disposal System Form Not for Voluntary Assessments
53 CEDAR LANE
Property Address
CHRIS BOURQUE
Owner Owner's Name
information is NORTH ANDOVER MA 01845 APRIL 16, 2022
required for every — — — — --
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no" for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
❑ ® this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ 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?
® El information
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.
® El approximation
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)]
t51nsp.doc•rev.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
is Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 CEDAR LANE
Property Address
CHRIS BOURQUE
Owner — - --
Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 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): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD
Description:
4
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ® Yes ❑ No
If yes, discharges to: GROUND
Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d WELL
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: CURRENT
Date
t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�x ,rp Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 CEDAR LANE_
Property Address
CHRIS BOURQUE
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 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 trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: -
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: BATESON ENTERPRISES INC OCTOBER 2020
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined? -
Reason for pumping: -
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l;
53 CEDAR LANE
Property Address
CHRIS BOURQUE
Owner
Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 2022
_
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:
SEPTEMBER 1974 DESIGN PLAN
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
® 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.):
JOINTS AND VENTING OK NO EVIDENCE OF LEAKAGE
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
pia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 CEDAR LANE
Property Address
CHRIS BOURQUE
Owner ------ - __- --
Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 2022
_-- -- __
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8' X 5'
Sludge depth: 6
Distance from top of sludge to bottom of outlet tee or baffle 31'
1"
Scum thickness - -
Distance from top of scum to top of outlet tee or baffle 7
Distance from bottom of scum to bottom of outlet tee or baffle 13"
How were dimensions determined? SLUDGE JUDGE AND
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.):
GOOD MAINTENANCE
INLET BAFFLE OK OUTLET TEE PLASTIC, OK
TANK GOOD
NO EVIDENCE OF LEAKAGE
LIQUID LEVELS GOOD
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
le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 CEDAR LANE
Property Address -- -- _ - _--
CHRIS BOUR_QUE
Owner Owner's Name
information is NORTH ANDOVER MA 01845 APRIL 16, 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.):
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
F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 CEDAR LANE
Property Address
CHRIS BOURQUE
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 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 working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
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 AND DISTRIBUTION EQUAL
SLIGHT EVIDENCE OF SOLIDS CARRYOVER
NO EVIDENCE OF LEAKAGE
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�i'� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 CEDAR LANE
Property Address
CHRIS BOUR_Q_ UE
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 2022
—-- --
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.):
" 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: 2 —
❑ leaching chambers number:
❑ leaching galleries number: - --
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: —- -
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: - -
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 CEDAR LANE
Property Address
CHRIS BOURQUE
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 2022
-- -- —
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 NO EVIDENCE OF HYDRAULIC FAILURE OR PONDING
VEGETATION OK
CAMERA IN LEACH PITS, PITS OK
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction _ --
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
r
Commonwealth of Massachusetts
,,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l;
53 CEDAR LANE
Property Address
CHRIS BOURQUE
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 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,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
r ;a; Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 CEDAR LANE
Property Address
CHRIS BOURQUE
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 2022
-- - --
page. City(rown 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
4
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I
4
E
A
P� 01
B
Pit
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 18
� f
Commonwealth of Massachusetts
Title 5 Official inspection Form
w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 CEDAR LANE
Property Address
CHRIS BOURQUE _
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 APRIL 16, 2022
-- - -
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: 1974
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
PLANS ON FILE
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
AS PER 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
lio Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 CEDAR LANE
Property Address
CHRIS BOURQUE
Owner Owner's Name
information is NORTH ANDOVER MA 01845 APRIL 16, 2022
required for every --
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
l ccu Star Radon in Water
Professional Radon Lab.-.l Services Since 198
NELAC NY 11769 EPA 913.0 SM 20 7500 Rn
NRPP 101193 AL Liquid Scintillation
NRSB ARL0017
Laboratory Report for: Property Tested:
H2O Care Inc. Christopher J. Bourque
18 Lonergan Road 53 Cedar Lane
Middleton MA 01949 North Andover MA 01845
Log Number Device Number Sample Location Result Uncertainty
pCi/L pCVL
8144836 1276052 Kitchen Sink 1500 +/- 110
8144837 1276053 Kitchen Sink 1550 +/- 120
Contact your State Radon Office for information about your radon in water test result. Links to State Radon Offices are
available online at https://geopub.epa.gov/Radon/.
Comment: H2O Care Inc. was e-mailed a copy of this report.
Distributed by: H2O Care Inc.
Sample Collected: 04/19/2022 4:42 pm Date Received: 04/21/2022 Date Analyzed: 04/21/2022
Date Logged: 04/21/2022 Date Reported: 04/22/2022
Report Reviewed By: {.I1fl'll't �t 1 Report Approved By:
Disclaimer: Shawn Pr' e, rector Laboratory Operations,AccuStar Labs
Counting uncertainty is calculated for a 95%confidence level.Factors contributing to uncertainty include statistical variations,daily and seasonal variations in radon
concentrations,sample collection techniques and operation of the dwelling.Interference with test conditions may influence the test results
This report may only be transferred to a third party in its entirety.Laboratory personnel were not involved in the placement or retrieval of the samples.Analytical results
relate to the samples as received by the laboratory.Results shown on this report represent levels of radon gas measured between the dates shown in the room or area of
the site identified above as'Property Tested". Incorrect information will affect results.The results may not be construed as either predictive or supportive of
measurements conducted in any area of this structure at any other time.AccuStar Labs,its employees and agents are not responsible for the consequences of any
action taken or not taken based upon the results reported or any verbal or written interpretation of the results.
Rev2002 2 Saber Way Ward Hill MA 01835 888-480-8812 Page 1 of 1
UNDERSTANDING YOUR RADON TEST RESULTS
GENERAL INFORMATION - Radon is a radioactive gas produced by the natural breakdown of uranium (which is
present in soil and in rock formations throughout this country). Studies have shown that exposure to radon contributes
to the incidence of lung cancer. This relationship between radon exposure and lung cancer is the primary basis for the
EPA's radon policy. The EPA advises you to take action to reduce the level of radon in your air if it exceeds 4.0 pci/L
(picocuries per liter of air) in the lowest lived-in level of your home. The EPA is in the process of setting a national
standard for a maximum recommended radon concentration in water through the Safe Drinking Water Act.
RADON IN YOUR AIR - Radon gas rises through underground rocks and soil and collects around and under the
foundation of your home. Radon enters your home through cracks and/or holes in the foundation. The highest
concentration of radon will be found in the level of the home closest to the ground (usually the basement). The radon
concentration decreases at each successive level above the basement.
RADON IN YOUR WATER - Just as oxygen gas dissolves into lake water, radon gas dissolves into your well water
underground. When radon is present in your water, there are two ways that it can affect your health.
1. Radon escapes into the air when you wash your dishes or laundry, or when you shower or use the kitchen or
bathroom sink. The more water you use, the more radon gas will escape into your air. In this case, radon from your
water contributes to the level of radon in your air.
2. Radon is ingested when you drink your water. The health effects from radon ingestion are currently being studied,
and a federally recommended maximum level of radon in water is expected soon.
HOW SHOULD I REACT TO MY REPORTED RADON AIR CONCENTRATION ?
1. The EPA has advised homeowners to take action to reduce the radon in their home if the concentration in the lowest
LIVED-IN level exceeds 4.0 pci/L. This number was statistically generated based on a lifetime exposure of 18 hours
per day. When considering the risk YOU face from your reported radon concentration, remember to compare the
amount of time you spend in the level of your home where the measurement was made to the 18 hour per day factor.
You may wish to measure the radon in other levels of the home.
2 The statistical risk factor is based on the entire population, but everyone has a different susceptibility to cancer.Your
risk of getting cancer is also based on genetic factors, the environment you live in, and on your general health and
lifestyle. For instance, the EPA and other health agencies have found that people who smoke are especially at risk
from radon exposure.
HOW SHOULD I REACT TO MY REPORTED RADON WATER CONCENTRATION ?
1. The EPA is considering an upper limit of radon in public water supplies. When the level is agreed upon and
finalized, it will provide us with a nationally recommended maximum level for our own water wells.
2. Each New England state currently recommends an action level where private well owners should investigate
water treatment to remove radon. The current action levels (picocuries per liter of water) by state are:
New Hampshire 10,000 Maine 4,000 Connecticut 5,000
Massachusetts 10,000 Vermont 4,000 Rhode Island 4,000
WHAT IF MY REPORTED RADON CONCENTRATION EXCEEDS THE RECOMMENDED LEVELS?
Consider the information above and make a personal 'risk assessment'. You need to consider whether or not you
are comfortable with the radon level you are faced with. If you are not, you should consider making repairs and/or
installing a radon reduction system. You might make your own repairs. There are also companies that specialize in
radon mitigation. We recommend you contact your state radon program for information and advice. You can also
find information at the EPA internet site ( www.epa.gov/radon/index.html ). Two national organization web sites list
accredited radon mitigation companies. Follow the links to radon mitigation. ( www.nrsb.org )(www.radongas.org )
The good news about radon problems is that they can be reduced. If you install a radon reduction system, keep up
with recommended maintenance and occasionally retest for radon to be sure the system is working.
Nashoba Analytical, L,L,C Tel:978-3914428 Fax:978-391-4643 LabNumber: 241533
31 A Willow Road,Ayer MA 01432 Website:http:/hvww.NashnbaAnalytical.com Use this number with all correspondence
Client:
H2O Care Home Mark St.Hilaire ReportDate: 4/25/2022
18 Lonergan Road
Middleton,MA 01949
Certificate of Analysis
Bourque, Christopher, 53 Cedar Lane, N.Andover, MA
Parameter Method Result MCL MRL Date of Analysis Analyst
-S4 Kitchen Sink
Sampled:411912022 4:40:00 PM by V.Silva
Total Coliform Bacteria,/100ml ENZ.SUB.SM9223 Absent Absent Absent 4/20/2022 1:10:00 PM M-MA1118
Arsenic,MG/L EPA 200.9 0.003 0.01 0.001 4/21/2022 M-MA1118
Calcium,MG/L EPA 200.7 ND Not Spec 0.2 4/21/2022 M-MA1118
Copper,MG/L EPA 200.7 ND 1.3 0.004 4/21/2022 M-MA1118
Iron,MG/L EPA 200.7 0.014 0.3 0.004 4/21/2022 M-MA1118
Lead,MG/L EPA 200.9 ND 0.015 0.001 4/21/2022 M-MA1118
Magnesium,MG/L EPA 200.7 ND Not Spec 0.1 4/21/2022 M-MA1118
Manganese,MG/L EPA 200.7 ND 0.05 0.004 4/21/2022 M-MA1118
Potassium,MG/L EPA 200.7 0.7 Not Spec 0.1 4/21/2022 M-MA1118
Silica as Si02,MG/L EPA 200.7 14.6 Not Spec 0.2 4/21/2022 M-MA1118
Sodium,MG/L EPA 200.7 77.7 See Note 0.2 4/21/2022 M-MA1118
Alkalinity,MG/L SM 2320B 79 Not Spec 1 4/20/2022 M-MA1118
Ammonia as N,MG/L SM 4500-NH3 ND Not Spec 0.1 4/22/2022 M-MA1118
Chloride,MG/L EPA 300.0 62.5 250 1 4/20/'2022 M-MA1118
Chlorine,Free Residual,MG/L SM 4500-CL-G ND 4.0 0.02 4/20/2022 M-MA1118
Color Apparent,CU SM 2120E 0 15 0 4/20/2022 M-MA1118
Conductivity,UMHOS/CM SM 2510B 402 Not Spec 1 4/20/2022 M-MA1118
Fluoride,MG/L EPA 300.0 NO 4 0.1 4/20/2022 M-MA1118
Hardness,Total,MG/L SM 2340B ND Not Spec 1 4/21/2022 M-MA1118
Nitrate as N,MG/L EPA 300.0 ND 10 0.05 4/2012022 M-MA1118
Nitrite as N,MG/L EPA 300.0 ND 1 0.02 4/20/2022 M-MA1118
Odor,TON SM 2150B 0 3 0 4/20/2022 AGH
pH,PH AT 25C SM 4500-H-B 7.5 6.5-8.5 NA 4/20/2022 M-MA1118
Phosphorus-ortho as P,MG/L EPA 300.0 ND Not Spec 0.1 4/20/2022 M-MA1118
Sediment,pos/neg -------------- NEG ------ NEG 4/20/2022 AGH
Sulfate,MG/L EPA 300.0 14.9 250 1 4/20/2022 M-MA1118
Turbidity,NTU EPA 180.1 0.45 Not Spec 0.1 4/20/2022 M-MA1118
MCL=Maximum Contaminant Level(EPA Limit),MRL=Minimum Reporting Level
Sodium Guidelines-Mass 20,EPA 250, #=Result Exceeds Limit or Guideline TAX
ND=None Detected( MRL), `=Background Bacteria Noted,J=Estimated Value
Analysis performed according to 310CMR42.00 (�
Massachusetts Certified Peter C.Nevius Page 1 of 1
Laboratory#M-MA1118 Laboratory Director
Water test results 53 Cedar Lane North Andover Ma
i message
Cindy Wooldridge<cwooldridge@h2ocare.com> Wed,Apr 27,2022 at 11:40 AM
To:Chris Bourque<cbourque928@gmail.com>
Good morning Chris,
I have attached your test results for your review. The water samples recently taken from your home indicate that all of
the tested parameters are within both the current EPA Maximum Contaminant Levels and EPA Guidelines.
The EPA Guidelines are for secondary contaminants that are not considered to be a health concern,but may cause
problems with your home's plumbing system,plumbing fixtures,water heaters and appliances.These Secondary
contaminants may cause aesthetics issues and mechanical issues with plumbing and heating systems.
The EPA(MCL)Maximum Contaminant Levels are for most parameters that have known health concerns.
Note:The radon has not exceeded any current guidelines.
Please let me know if you have any questions and if I can't answer them I will find someone who can!
Thank you,
Cindy
Cindy Wooldridge
H2o Care
18 Lonergan Road
Middleton, MA 01949
0:978-777-8330
F:978-777-8385
H20care
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Town of North Andover
HEALTH DEPARTMENT
S�CHUS!
CHECK#: DATE:
LOCATION:
H/ONAME: /41C�clrOU2
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $ _
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ TrashlSolid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
Title 5 Report $ ���
❑ Other. (Indicate) $
Ilea Ith Agent Initials
White-Applicant Yellow-Health Pink-Treasurer