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Home My WebLink AboutPass - Title V Inspection Report - 166 REA STREET 9/28/2022 �\ rnmmnnwaalth of Maccachi iccsttc Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .0 166 Rea Street Property Address vwva. vvuvu Owner — ----._ --- --- -- --—_ Owner's Name information is No Andover Ma 01845 9-27-2022 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 filling out forms A. Inspector Information on the computer, �� R use only the tab F. Paul Cardone SEQ „�t70`IE key to move your Name of Inspector cursor-do not Septic Compliance, Inc N OF N��PPR�M use the return key. .:....P �r 37 1/2 Baremeadow Street Company Address Methuen Ma 01844 City/'Town State Zip Code 867-815-3115 or 978-681-0726 #3294 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 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 Inspector's Signature e 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 -Not for Voluntary Assessments t ' 166 Rea Street Property Address Jteye Schou Owner --- -- -- Owner's Name information is required for every No Andover Ma 01845 9-27-2022 _ page. Cityrrown 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 followinq 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 uompliance indicating tnat the tanK Is less tnan zu years oia IS avaiiawe. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address Owner -- - Owner's Name information is No Andover Ma 01845 9-27-2022 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 Dir)e(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): ❑ 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: t51nsp.doc•rev 7/262018 Trde 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address Steve Schou Owner Owner's Name information is No Andover Ma 01845 9-27-2022 required for every 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 1 uu teet of a surface water suppiy or tnnutary 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 t__m _ ._...._a_ ..._a___..._._1..we"!** nwrc uvlli Q Nuvaw waicl JuNNry vrcrr 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 I\ . V\IIV-I sG:IrWI.V VII\VIIG aI V, \.0. n VV' r 3f I\"IIoIIValV VI 1VJJ a\I\IG. Vc rP.m.l JIVV:VVV i\L,IG .. .. ....:.. ..... ..a QIICi1�J1J IIIGJ♦ 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 p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address Steve Schou Owner Owner's Name information is required for every No Andover Ma 01845 9-27-2022 page. City/Town State Zip Code Date of Inspection 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 I G .;d dc-th i nl 7n Innn than 5" t.nln.., i n.t nr a ,nilnhln . nl..mn iS !csc 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 wltnln 1 uu 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 from a private water supply well wan 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.] Thn o stnm is a nnrrnnnl = ,inn n fnn8it.....th n A—;- fl—,of )nf)rl 4 Li z 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.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 18 '°- rnmmnnwpalfh of Maccarrthi icpttc -] r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address Steve Schou Owner - -- ------ Owner's Name information is No Andover Ma 01845 9-27-2022 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 UIICQI, ul QI16mol u `yCS" iu afly yuGJlFull 11-1 JCl.11ul-1 0.4 dIJuVC L;iu Icugt; Jyzpir l IIQJ ICIIIGU. I;iu 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? Li Inr.-.... ..I..rv.nn b--cn ;n+�..d.. d+n the r ,e-+nrr, r n+l., n n.i cf 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? 1`5�1 n Was the facility owner(and occupants if different from owner) provided with intormation on the proper maintenance of suosur-race sewage aisposal 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 mn+inn -4:A;,4nnnn is .aPPrCX; .nnnnn n+n hln\ Mon 111AD 4r. 4r17/6\7 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Summary Record Card generated on 9/23/2022 11:20:02 AM by Karen Hanlon Page 1 TniA/n of Ninrfh AmAn%icr Tax Map # 210-098.A-0012-0000.0 Parcel Id 14876 166 REA STREET STEPHEN & CHRISTINE SCHOU 166 REA STREET IvoRT"r%1 n ANDOVER cn )VI v 10 FY 2023 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until STEPHEN&CHRISTINE SCHOU Owner Active: 166 REA STREET NORTH ANDOVER MA 01845 HART,JEFF&CHARLENE Previous Customer Inactive 6/26/2014 166 REA STREET NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive tllog to. 14UJb.0-iou KtA J t kEE 1 La5t 6iiiing Dale JI i J%GVLG 2100498 02 Cycle 02 Active UB Services Maint. Account No.2100498 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63 5/8 7.82 1/ W 1 R WAI tH U1 ALL Mt I tK JILE i u.36 i i UB Meter Maintenance Account No.2100498 Serial No Status Location Brand Type Size YTD Cons 16337058 a Active ERT METE METE w Water 0.63 0.63 227 Date Reading Code Consumption Posted Date Variance a/?!2022 ?')19 aArhiat 37 4/90/2022 31% 5/4/2022 2175 a Actual 28 6/21/2022 3% 2/3/2022 2147 a Actual 28 3/15/2022 -21% 11/2/2021 2119 a Actual 34 12/13/2021 -31% 8/5/2021 2085 a Actual 51 9/21/2021 72% 5/5/2021 2034 a Actual 29 6/15/2021 50% 2/4/2021 2005 a Actual 20 3/16/2021 3% 11/3/2020 1985 a Actual 19 12/16/2020 -40% 8/4/2020 1966 a Actual 32 9/9/2020 55% 5/4/217)2n 1934 a Actual 20 6/10/2020 10% Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address Givvv sk,;IuU Owner Owner's Name information is required for every No Andover Ma 01845 9-27-2022 _ — page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 --- Number of bedrooms (actual): 3- -- — - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Nu111UC1 UI UUllulli IC 2bldullib. - - - --- 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 %Nater motor renrlinnc if nvnilnhln /Inc* 7.rears r.snne /n ell\\• Enclosed____--- ........ ....,.... ..,..... .y.,, .. ........,,..... �...,..� �....... ,.,...a,. \arm- • Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 18 STATEMENT '• w/�A•••14 -- - .. .-. .. 1711MRU UIGI�fC1'tNL .7GKVG.1 PO BOX 271 ._� . WEST BOXFORD, MA 01885 DATE 9 8) fi86-7f. , TERMS: 1''Q 471 PLEASE DETA gryS?..gETUf�J.Vf1TM.Y. _�#.REMITT.r T. _ . - - DATE INVOICE N BALAUCE FORWARD If L, - J, --T-T GIARD GENERAL SERVICES \`- 1�X1 ('t PAY LAST AMOUNT IN THIS COLUMN I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address Steve Schou Owner Owner's Name information is required for every No Andover Ma 01845 9-27-2022 ----- - 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.): Crease tr2p present? i—I V.. r7 Aln Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: - -- Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other (describe below): 3. Pumping Records: Source of information: Owner had tank pumped three weeks prior to the inspection, pump slip enclosed. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Not needed at this time 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 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address Steve Schou Owner - _ ----- -_-- -- --- — ----- Owner's Name information is required for every No Andover Ma 01845 9-27-2022 _-- __-_- 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: 24 years of age Owner 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: —fccl-- ---- - --- - - Comments (on condition of joints, venting, evidence of leakage, etc.): Good Good None t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts i- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments » � 166 Rea Street Property Address OLCVC Olr11VU Owner Owner's Name information is required for every No Andover Ma 01845 9-27-2022 _- _ _ page. CRY/Town State Zip Code Date of Inspection D. System Information (cont.) R Sentir Tonb (Inrci#c nn cifn ninn\- 18" 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: 10'Lx57'Wx5'8H 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 �nrl a Rlnrino Ill�ino How were dimensions determined? s S!u 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.): We recommend tank be pumped on a yearly basis, Tee's in good condition, structural integrity appeared to be good, liquid levels were good, no apparent leakage in or out of tank 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 h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address Steve Schou Owner Owner's Name information is No Andover Ma 01845 9-27-2022 required for every - _ -_ _- - __—- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) t. Grease l rap (locate on site plan): Depth below grade: -fe ---- - -- - - et 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 t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 "Ifitdon'tflush..,callus" 978-828-3654 24 Hour Emergency Services•FREE ESTIMATES { We Unclog... Name', JZ •Toilets,Bathtubs Street A42a •Kitchen/Bathroom Sinks •Main Sewer lines City/State Z0 64- a r�� 1A/n I Iu..1..�v.___.w___• .. _ _ Work Performed at W`e- -- •-••• 2 • -11 arrsnrras nut vuur rt"t!93 ` Remittance:124 Corliss Hill Road,Haverhill,MA 01830 Drains V Us hen propose to ish all the materials and all the labor neeessary for the iromPletion of 1'JrP F P '''n C IIYWIO'=� RAINS R 47 'US is providing a service tee on the terms describe below. MATERIAL , 1.if a box is checked blow,D p g guarantee 1f►Twt rip nAwye`u v v%3zm- r f,Orr 310 11-4 TOILETAUGER 4}lotus rLI-I'MRING REP Ill L7ays _ . 'P\17MA\NG'S?t7e;.F'tAZ'fi-�tt$1�"t L.i-)O Days ..D rt�ttvttssttc R Lwrsi sFarr t Yam,,,, 2.Tt►E'[tgMS ac GONDiTIONS OP"f HL p ToDT L. f/ ROPUSAL WTLI..8C BINDING ON`e`yia:.RALKI`r2S. 3.Osher ' acc=to Eric Conditions w- 2.RELEASE&HOLD HARMI.M.You release its from(arid if wu are a cntrcxsrrcia nUmmer,you will rle,ft d'indmuir &us d bald w harmku rsaiur)all damages claims,demands,settlements.Judgments,liabilities,costs&expenses,including reasonable attorneys feet allegedly arising out of 01)breach of your tapomibilities under paragraph 1,or(B)matters for which we disclaim under paragraph 2. 1 a' ., ♦♦l� ir,�r 1 s�'s' aca.ssuauan atgnXttrre— ritumu ACCFIYEkNCE OF PROPOSA�'/ Customer authorizes the work and::septa the above terms. Date Customerx Si atucr Sn Customer Printed.Name Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address sieve scnou Owner Owner's Name information is No Andover Ma 01845 9-27-2022 required for every _ _ 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.): N/A Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Good and even - 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.): The box was level and distribution equal, no solids carryover, no apparent leakage in or out of box. we set off pump to the dbox to check flow,all line took water with no problem. We noticed some roots at the beginning of the pipe, having a Drain company check the lines as a precautionary measure. Dbox is 8"deep upon a elevated leaching area. t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 12 of 18 y� Commonwealth of Massachusetts -, Title 5 Official Inspection Form i! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street u� Property Address OICye Oudluu Owner - Owner's Name information is required for every No Andover Ma 01845 9-27-2022 -- —_ __ _ page. Clty/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.): Good Good Good " 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: I--I IoorFiinn nhnmhcrc nrrmhcr ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts i� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 166 Rea Street Property Address Steve Schou Owner — -- - - - Owner's Name information is required for every No Andover Ma 01845 9-27-2022 -- __ page. Cdy/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.): Good No None No Grasy leaching 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 ---- -- - - - [)en+h of cram Iwcr 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 <°N, Commonwealth of Massachusetts 1- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address Owner Owner's Name information is required for every No Andover Ma 01845 9-27-2022 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, ctn.): N/A t51nsp doc-rev 7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Iifiassachusetts lip Title 5 Official Inspection Form la, Subsurface Sewage Dh posal System Form-Not for Voluntary Assessments 166 R EA STREET__ Propertti•Address - CHAR_ENE HUNT Owner Owner's Name — —_' `_ —_._ __.+ ——•"—.—•— -- in formation is N.ANDOVER MA _ 01845 05/01/11_ required for every — _•.—.�__—^ _ page. ckyrrorm State Zip Code Date of Inspection— D. System Inforltriation (cont.) _ Sketch Of Sewage Disposal System: Provide a view of the f ewage disposal sy:;tem, including ties to at east two permanel It reference landme rks or benchmarks Locate all wells wi:hin 100 feet. Locate where public water st,pply enters the building. Check one of the zroxes below: ❑ hand-sketch in th,s area below ❑ drawing attached separately 0.0 In 1 i06 Cn:.LON WA1tF: SPINE 'tt 11 TANK Et.Ev 1 N OG (ai.•,•"k!•y ..`` N � b PA MAC � � .�PT i W4 ER LINE ��\ eEk-^HV 3< 11:TOP PO - c' STEP.[LEI tOO.00 Nss I_ K�7 :—..Y7 1 CISTa'.C:S % c � ) ASSE;SORS VA'9K LOI 12 �. LIAI 3T 9Ni�""• IP 7 0 IYi.'e' I I Commonwealth of Massachusetts i Title 5 Official Inspection Form "! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address OlCVO O4,14Vt1 Owner Owner's Name — -- information is No Andover Ma 01845 9-27-2022 required for every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Nroviae a view of the sewage aisposal system, Including ties to at least two permanent reterence 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 t5insp.doc-rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address Steve Schou Owner - - - - ----- - Owner's Name information is required for every No Andover Ma 01845 9-27-2022 - 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: 4' -- -- -- -- - - - 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: 9-2001 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) I--I f hnr-te A.arifh lnnnl Q^nM of I-Jaalfh —a ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: All liquid levels were good,no sump pump,dry basement, Soil logs available. the leaching area is elavated due to GW Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 17 of 18 rnmmnnwaalth of Maccarhi rcattc Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 Rea Street Property Address Steve Schou Owner Owner's Name information is No Andover Ma 01845 9-27-2022 required for every page. Cltylrown 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 NORT" •,y 93 "7 d c F � w a • Town of North Andover HEALTH DEPARTMENT S,CMUSt CHECK#: 35.3 DATE: C� LOCATION: H/O NAME: CONTRACTOR NAME: _ 2./' -d✓)2. Tvve 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 $ Title 5 Report ep PC--55 ❑ Other. (Indicate) #-Agent Initials White-Applicant Yellow-Health Pink-Treasurer