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Home My WebLink AboutConditional Pass - Title V Inspection Report - 54 SUMMER STREET 8/18/2022 + - �C\' Commonwealth of Massachusetts =- Title 5 Official Inspection Form PSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 SUMMER STREET Property Address DONALD ELLARD Owner - - -- — Owner's Name information is NORTH ANDOVER MA 01845 AUGUST 9,2022 required for every ---_ - page. Cdyaown 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, Todd James Bateson 1022 use only the tab - key to move your Name of Inspector N Q cursor-do not Bateson Enterprises Inc.use key the return Company Name jowo CEP �� 111 Argilla Road N NEQ`1.� _— �IC—V Company Address Andover MA 01810 Cityrrown 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 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails --- - - Inspe is SignatureS�_ 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. 15msp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form lIII Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET Property Address DONALD ELLARD _ Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 AUGUST 9, 2022 _ - _ ---- 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 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 r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET Property Address DONALD ELLARD Owner -- -- Owner's Name information is required for every NORTH ANDO_V_E_R MA 01845 _AUGUST 9, 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): LAUNDRY AND BATHROOM SINK GRAY WATER NEED TO BE TIED INTO SEPTIC SYSTEM ❑ 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: l5insp.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 54 SUMMER STREET Property Address DONALD ELLARD Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 AUGUST 9, 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: ** 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 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 ❑ ® 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 Commonwealth of Massachusetts Title 5 Official Inspection Form 13 i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET Property Address DONALD ELLARD Owner -- Owner's Name information is required for every NORTH ANDOVER _ MA 01845 _AUGUST 9, 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 t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 18 3 C Commonwealth of Massachusetts Title 5 Official Inspection Form I1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 54 SUMMER STREET Property Address DONALD ELLARD Owner Owner's Name information is required for every __NORTH ANDOVER MA _01845 AUGUST 9, 2022 _ _. _ 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? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form �i1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�� 54 SUMMER STREET Property Address DONALD ELLARD Owner — — — - — Owner's Name information is required for every NORTH ANDOVER MA 01845 AUGUST 9, 2022 - _ _-_- -- _ --- --- page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): NA — Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA Description: Number of current residents: 2 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 Water meter readings, if available last 2 ears usage d SEE ATTACHED 9 ( Y 9 (gp ))� Detail: LAUNDRY SERVICE AND BATHROOM GRAY WATER NEED TO BE TIED INTO SEPTIC SYSTEM Sump pump? ❑ Yes ® No CURRENT Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 s C Commonwealth of Massachusetts �w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET Property Address DONALD ELLARD Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 AUGUST 9, 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: BOARD OF HEALTH, PUMPED APRIL 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form tip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET Property Address DONALD ELLARD Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 AUGUST 9, 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: AUGUST 1991, AS-BUILT PLAN Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 22 feet Material of construction: ❑ cast iron ❑ 40 PVC BLACK PLASTIC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): JOINTS OK VENTING GOOD NO EVIDENCE OF LEAKAGE t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET Property Address DONALD_ELLARD Owner Owner's Name information is required for every NORTH ANDOVER _ MA _ 01845 AUGUST 9, 2022 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 101, 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' X 5' Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 35" Scum thickness 1 -- Distance from top of scum to top of outlet tee or baffle 6.5" - Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? TAPE MEASURE AND SLUDGE JUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): OLDER SYSTEM RECOMMEND PUMPING YEARLY PVC INLET AND OUTLET TEES GOOD TANK IN GOOD CONDITION NORMAL LIQUID LEVELS t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �u Title 5 Official Inspection Form lio Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET - - Property Address DONALD ELLARD Owner — -- - Owner's Name information is required for every NORTH ANDOVER MA 01845 AUGUST 9, 2022 — 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 FIOW: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET _ Property Address DONALD ELLARD _ Owner _-- -" -- Owner's Name information is required for every NORTH ANDOVER _ MA 01845 AUGUST 9, 2022 _ page. Cityrrown 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 LEVELS NORMAL DISTRIBUTION EQUAL EVIDENCE OF SOLIDS CARRYOVER D-BOX IS ROTTED AND NEEDS REPLACED t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET Property Address DONALD ELLARD Owner Owner's Name information is required for every NORTH ANDOVER MA_ 01845 AUGUST 9, 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: ❑ leaching chambers number: ❑ leaching galleries number: - ❑ leaching trenches number, length: -- ® leaching fields number, dimensions: 1; 46' X 20' ❑ 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 Commonwealth of Massachusetts �u Title 5 Official Inspection Form i 1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET Property Address DONALD ELLARD Owner - Owner's Name information is required for every NORTH ANDOVER _ MA 01845 AUGUST 9, 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 AND VEGETATION GOOD NO EVIDENCE OF HYDRAULIC FAILURE OR PONDING 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 C \ Commonwealth of Massachusetts Title 5 Official Inspection Form '= �i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET - - - -- -- Property Address DONALD ELLARD Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 AUGUST 9, 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 Commonwealth of Massachusetts Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET Property Address DONALD ELLARD Owner _ --- --- — - _--- Owner's Name information is required for every NORTH ANDOVER MA 01845 AUGUST 9, 2022 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A- i Oufld -- A ox 6 5 -- j r, �Qf o e i3 - - Oufle-F �1 ' 5 ' 6 - �- 6ax �2, it t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �r Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET Property Address DONALD ELLARD _ Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 AUGUST 9, 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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: AS -BUILT ONLY PLAN ON FILE ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: ESSEX COUNTY SOIL MA You must describe how you established the high ground water elevation: CANTON FINE LOAMY SAND DEPTH TO WATER TABLE > 80" SEPTIC SYSTEM ABOVE WATER TABLE 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SUMMER STREET Property Address DONALD ELLARD Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 AUGUST 9, 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Summary Record Card generated on 8r7/2022 9:26:36 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-065.0-0040-0000.0 Parcel Id 10727 54 SUMMER STREET ELLARD, PAUL 54 SUMMER STREET N. ANDOVER, MA 01845 FY 2023 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until ELLARD,PAUL Payor Active 54 SUMMER STREET N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 16150.0-54 SUMMER STREET Last Billing Date 7/12/2022 3160194 03 Cycle 03 Active UB Services Maint, Account No.3160194 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE 26.60 /1 UB Meter Maintenance Account No.3160194 Serial No Status Location Brand Type Size YTD Cons 16335676 a Active 00 METE METE w Water 0.63 0.63 59 Date Reading Code Consumption Posted Date Variance 6/3/2022 2732 a Actual 7 7/18/2022 -17% 3/3/2022 2725 a Actual 8 4/13/2022 -14% 12/6/2021 2717 a Actual 10 1/17/2022 22% 9/3/2021 2707 aActual 8 10/15/2021 -11% 6/3/2021 2699 a Actual 9 7/27/2021 -2% 3/3/2021 2690 aActual 9 4/21/2021 14% 12/3/2020 2681 a Actual 8 1/13/2021 -19% 9/3/2020 2673 a Actual 10 10/14/2020 -10% 6/3/2020 2663 a Actual 11 7/15/2020 20% 3/4/2020 2652 a Actual 9 4/8/2020 -4% 12/6/2019 2643 aActual 9 1/15/2020 5% 9/12/2019 2634 aActual 10 10/10/2019 2% 6/5/2019 2624 a Actual 9 7/25/2019 0% ' f Summary Record Card generated on 8/7/2022 9:26:36 AM by Karen Hanlon Page 2 Town of North Andover Tax Map # 210-065.0-0040-0000.0 Parcel Id 10727 54 SUMMER STREET ELLARD, PAUL 54 SUMMER STREET N. ANDOVER, MA 01845 FY 2023 3/612019 2615 a Actual 9 4/16/2019 -1% 12/5/2018 2606 a Actual 9 1122/2019 -58% 9/6/2018 2597 a Actual 22 10/15/2018 -34% 6/5/2018 2575 a Actual 33 7/23/2018 79% 3/5/2018 2542 a Actual 18 4/23/2018 19% 12/512017 2524 aActual 15 1/25/2018 -7% 9/7/2017 2509 a Actual 17 10/18/2017 -74% 6/5/2017 2492 a Actual 65 7/25/2017 -47% 3/3/2017 2427 a Actual 114 4/12/2017 -3% 12/6/2016 2313 aActual 128 1/23/2017 58% 9/2/2016 2185 a Actual 75 10/24/2016 100% 6/6/2016 2110 a Actual 41 8/2/2016 -37% 3/2/2016 2069 a Actual 58 4/22/2016 47% 12/7/2015 2011 a Actual 43 1/20/2016 20% 9/4/2015 1968 a Actual 35 10/16/2015 33% 6/4/2015 1933 a Actual 26 7/2412015 -16% 3/5/2015 1907 a Actual 31 4/28/2015 9% 12/4/2014 1876 a Actual 28 1/1512015 19% 9/5/2014 1848 a Actual 24 10/15/2014 3% 6/5/2014 1824 a Actual 23 7/16/2014 -4% 3/6/2014 1801 aActual 24 4/11/2014 -9% 12/5/2013 1777 a Actual 26 1/17/2014 -2% 9/6/2013 1751 a Actual 26 10/15/2013 1% 6/10/2013 1725 a Actual 28 7/24/2013 -6% 3/6/2013 1697 a Actual 28 4/22/2013 12% 12/6/2012 1669 aActual 25 1/9/2013 -5% 9/7/2012 1644 a Actual 27 10/15/2012 -5% 6/7/2012 1617 a Actual 28 7/16/2012 0% 3/8/2012 1589 a Actual 29 4/14/2012 -1% 12/5/2011 1560 aActual 27 1/17/2012 -7% 9/9/2011 1533 a Actual 33 10/13/2011 -8% 6/2/2011 1500 a Actual 33 7/20/2011 -7% 3/3/2011 1467 a Actual 34 4/13/2011 -2% 12/6/2010 1433 a Actual 36 1/12/2011 4% 9/7/2010 1397 a Actual 37 10/15/2010 -5% 6/3/2010 1360 a Actual 37 7/15/2010 -9% 3/4/2010 1323 a Actual 39 4/14/2010 -5% 12/7/2009 1284 aActual 45 1/12/2010 9% 9/3/2009 1239 a Actual 40 10/15/2009 9% 6/3/2009 1199 a Actual 34 7/20/2009 -15% 3/10/2009 1165 a Actual 45 4/29/2009 32% 12/4/2008 1120 aActual 32 1/20/2009 27% N�eTM 2 af, 9 3"� Town of North Andover HEALTH DEPARTMENT ,JS4CNU°+f'4 CHECK#: '//D DATE: a0-74Z LOCATION: 5Y 5Umr►o L, Sf H/O NAME: (1la-ol-d CONTRACTOR NAME: CL/Cson Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type. $ _ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ _ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector l SS $ Title 5 Report $ 50 T— J_ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink- Treasurer