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Home My WebLink AboutPass - Title V Inspection Report - 94 GRANVILLE LANE 8/10/2022 Commonwealth of Massachusetts �tiQ`Lti Title 5 Official Inspection Form P�t�1apNP � � 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40F JA0 Osl �; N �h 2/+ti, Property Addre v�uc Q U'l Owner Owner's Name information is required for every page. Cityrrown 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 I ormation filling out forms on the computer, use only the tab key to move your Name ofof Inspector CT cursor-do not �} '3 a p- "_ use the return Com ny NNa—m�e/��" p key. O Z Ubna!7 ddress � JVc Ci /Town State Zip Code o_l (4 Z 3 96) 4 s t .z / q 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. &1Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9 spector's Si ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -No(for Voluntary Assessments Property Address (Z (,�' 4 '�°' � c'z<CO �C Owner Owner's Name �� ! information is J /►��"' required for every page dtylrown 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 umps/alarms are repaired. ❑ Observatio of sewage backup or break out or high static water level in the distribution box due to broken or o cted pipe(s)or due to a broken, settled or uneven distribution box.System will pass inspection if ' approval of Board of Health): ❑ broken pipe(s)are re ced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ 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): ❑ struction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board ealth: ❑ Conditions exist which require further evaluation by Board of Health in order to determine if the system is failing to protect public health, safety or th nvironment. a. System will pass unless Board of Health determines in cordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner w h will protect public health, safety and the environment: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` `l Vera tid -� Property Address Owner Owner's N information is � �' required for every c I page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0� 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 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. ❑ X 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. C� 5) Large Syste To be considered a large system the system must serve a facility with a design flow of , 00 gpd to 15,000 gpd. For large systems, youln st 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 fe of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tri ry to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensiti area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a publi 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 Property Address Owner Owner's Na TY9i information is J a j � ( ,S � — � — 2 �. required for every �lJ �, page. C Qityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 54 Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes k_No Does residence have a water treatment unit? ❑ Yes 1�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 Seasonaluse? ❑ Yes No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP )): Detail: Sump pump? ❑ Yes K 1-1 No Last date of occupancy: Date t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address C (� Cn U-Ko V t k- Owner Owner's Name information is required for every ��l page Clty/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 o 6njoif 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: �S 1U 1G001 Were sewage sewage odors detected when arriving at the site? ❑ Yes &,,No 5. Building Sewer(locate on site plan): C 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.): ,-k-5 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner ers information is �c'�' 61 required for every 2� to Zip Code Date of Inspection page City/Town State D. System Information (cont.) 7. Grease Trap(locate on site plan): De th below grade: feet Materia f construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or ba 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 condl' ,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 b w grade: Material of cons tion: ❑ concrete ❑em�ta� ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5map.doc•rev.7/26/2018 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal System•Page 11 of 18 S . Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V r Property Address Owner Owners Name /J _ information is required for every "��-- pa9e City/Town State Zip Code Date of Inspection D. System Information (cont.) Pump Chamber(locate on site plan): Pump orking order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump cham 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: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 (/ C414,1Vr Property Address too i Owner Owner's (.-- information is required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Pri (]orate on site plan): Mate 'als of construction: Dimensi s Depth of soli Comments(note dition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/20/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner er's Name required for every — 7 information is fsLX \ __,& (S��q l < "/ 2 c� �� 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: 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 describe how you established the high ground water elevation: I 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 0 :FF I-z, el o Z14 Q f/ f MORTry 3?��•'` '�',y00 4 r� 9 • , Town of North Andover HEALTH DEPARTMENT SA I CHECK#: 15401 DATE: LOCATION: -9 c/� H/O NAME: C CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type. $ C ❑ Funeral Directors $ i ❑ Massage Establishment $ ❑ Massage Practice $ r ❑ Offal(Septic)Hauler $ 4 ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector n $ 1 Title 5 Report ❑ Other:(Indicate) $ f H Agent Initials White-Applicant Yellow-Health Pink- Treasurer