HomeMy WebLinkAboutPass - Title V Inspection Report - 116 SHERWOOD DRIVE 1/9/2022 Septic Compliance, Inc.
Title 5 Inspections — Soil Evaluations
37 Yz Baremeadow Street, Methuen, MA 01844
978-815-3115
Ti+ln C Incr%nr+ir%n Mmn~+
Property Address: 116 Sherwood Drive No Andover, Ma 01845
Owner: Matthew Levis
Date of Inspection: 1-7-2023
My report contained herein does not constitute a guarantee of future usage and the functionality of the
existing septic system. Such report issued herewith is merely based upon my observations,and I hereby
disclaim any further operation of your current septic system.
F. Paul Cardone
Septic Compliance, Inc.
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Sherwood Drive
Property Address
Y14141I1VY. •.V• J
Owner Owner's Name
information is required for every North Andover Ma 01845 1/7/2023
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms
on the computer,
use only the tab F. Paul Cardone
key to move your Name of Inspector
cursor-do not Septic Compliance, Inc
""`I=`c`u"I Company Name
key.
� Baremeadow Street
Company Address
Methuen Ma 01844
City/Town State Zip Code
978-815-3115 or 978-681-0726 #3294
Telephone Number License Number
B. Certification
I r.Prtifv that- I am a nFP annrnved cvstem incnertnr in full romnliance with Section is-adn 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
s actor's 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.
t5insp doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
C � Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
information is required for every North Andover Ma 01845 1/7/2023
—.-- ------ ----
page. City/Town State Zip Code Date of Inspection
C. m5pecuon 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 31 a cMK 1 b.3w or in 31 U umK 1 b.3u4 exist. Any taiiure criteria not evaivatea 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
..............1 ,...\.:�.:a.. ....L.,.a,. 4:-f :..cu..,.a:.... 3-....A la..s:..-, G..'a..J. c-:: .. :,. :.«....:......a [�..,.a...«—M ..---
UIIJVUIIU, V/\I II UI\J JUVJ\G/1\IGI 1111III GlIV11 VI VAlll\I G\IV 11 Vf \GI11\ IGIIUI V IJ 1111111//1 V111. -y-.11 YY III V. ,
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i%
116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
requireded ui.r V1 for e North And Ma 01845 1/7/2023
every ort —over _—_ __—
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):
311 .... A i:........ A.—i.. L-1..... ..t,,.a.....,a...a / \ TL...
�1 111V JyJ\V 111 IGyUIIVU 'JUIII t.J 1 Illy 'Zi Ii 1110111 \11111.J Q YV UUG \V �JI VI\lill VI VIJJl1UVll.0 t./I'.lV�JJ. I/1V
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V 116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
information is North Andover Ma 01845 1/7/2023
required for every --- --- - -- -------
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cost.)
❑ 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:
n The system has a septic tank and soil absorntion 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.
n Tho cwctom hoc n contin tonle onrl QAQ nnrf Oho QA(Z is locc fhnn 100 foot hi if 8;n fro+ nr
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
pp.— .:, ,.. al,.,.a .. ..al.,...t..:l...... ...:�,...:.. .. .,a..:..,........ n —S al.... ,. ..1....:.. .... ..a
\V VI IV JJ 111G11 11, rI V•V IU VU \I I IIV V111V1 IGIIUIV ---a GIV -py VI \IIV GI I-y-1114J\
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
t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
` Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
"} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�.� 116 Sherwood Drive
--
Property Address
Matthew Levis
Owner Owner's Name
information is required for every North Andover Ma 01845 1/7/2023
- - --- --- ----- ---
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
r-1 I17 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
auaa a.uaua vf Cuaivuy mivaa uc wiaacucaa av uua w�mq
❑ ® 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
n nnr,�rn r. inn rcc!the fai!L m
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
Commonwealth of Massachusetts
1.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, a 116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
information is required for every North Andover Ma 01845 1/7/2023
— -----_---- --
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 aH inspections:
Yes No
Z ❑ Humping intormatlon was provlaea by the owner, occupant, or t3oard 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 Introaucea to the system recently or as part or
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 tacutty owner(ana occupants It altterent trom owner) provlaea 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
Summary Record Card generated on 1130023 2:37:23 PM by Karen Hanlon Page 1
I own Ot North Andover
Tax Map # 210-105.C-0066-0000.0
Parcel Id 16982
116 SHERWOOD DRIVE
MATTHEW LEVIS
116 SHERWOOD DRIVE
NORTH ANDOVER MA 0846
FY 2023
UB Mailing Index
Name/Address Type Loan Number Activellnact, From Until
MATTHEW LEVIS Owner Active
116 SHERWOOD DRIVE
NORTH ANDOVER MA 01845
ARMSTRONG,JACK&JANE Previous Customer Inactive 3/18/2021
116 SHERWOOD DRIVE
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
btag ia. I lCb1.U-11b.7r1tKVVVVU UKIVt Last Eiiiing Date ivi i ii2&22
3170526 03 Cycle 03 Active
UB Services Maint.
Account No.3170526
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.63 5/8 7.82 1/
11
1
7
rf C'.ALL
METER S!ZE 22i !2 'i
UB Meter Maintenance
Account No.3170526
Serial No Status Location Brand Type Size YTD Cons
36153057 a Active ERT HH b Badger w Water 0.63 0.63 283
Date Reading Code Consumption Posted Date Variance
19/R/9n99 7A91 a Arhinl 13 -78%
9/13/2022 2508 a Actual 67 10/18/2022 32%
6/9/2022 2441 a Actual 49 7/18/2022 104%
3/8/2022 2392 a Actual 23 4/13/2022 12%
12/9/2021 2369 a Actual 21 1/17/2022 -33%
9/9/2021 2348 aActual 32 10/15/2021 -31%
6/8/2021 2316 a Actual 45 7/27/2021 168%
3/10/2021 2271 f Final Bill 17 3/10/2021 -41%
12/9/2020 2254 a Actual 29 1/13/2021 -77%
Q/Q/9n9n 999.5 a Actual 131 10/14/2020 329%
Summary Record Card generated on 1l3I2023 2:37:23 PM by Karen Hanlon Page 2
i own oT Norm Andover
Tax Map # 210-106.C-0066-0000.0
Parcel Id 16982
116 SHERWOOD DRIVE
MATTHEW LEVIS
116 SHERWOOD DRIVE
IVVR1 n NNNVvcf\ MA v 1U4G
FY 2023
6/5/2020 2094 a Actual 28 7/15/2020 49%
3/9/2020 2066 a Actual 19 4/8/2020 -63%
12/11/2019 2047 aActual 49 1/15/2020 -45%
9/17/2019 1998 a Actual 103 10/10/2019 287%
6/11/2019 1895 a Actual 25 7/25/2019 22%
3/11/2019 1870 aActual 20 4/16/2019 0%
12/11/2018 18W aActual 26 ii22i26ia - 3^,o
9/12/2018 1830 a Actual 95 10/15/2018 292%
6/11/2018 1735 aActual 25 7/23/2018 16%
3/7/2018 1710 a Actual 20 4/23/2018 -2%
12/812017 1690 aActual 20 1/25/2018 -74%
9/12/2017 1670 a Actual 86 10/18/2017 329%
6/8/2017 1584 a Actual 19 7/25/2017 6%
3/9/2017 1565 a Actual 18 4/12/2017 -63%
12/8/2016 1547 aActual 48 1/23/2017 -60%
`J1y/LUl b 14`Jy H/1G ��iudi 3 i 3;21/2v1 7ii9l v ",,
6/13/2016 1381 a Actual 29 8/2/2016 127%
3/9/2016 1352 a Actual 12 4/22/2016 -78%
12/10/2015 1340 a Actual 56 1/20/2016 -54%
9/9/2015 1284 a Actual 120 10/16/2015 230%
6/10/2015 1164 a Actual 36 7/24/2015 89%
3/12/2015 1128 a Actual 19 4/28/2015 -51%
12/12/2014 1109 aActual 40 1/15/2015 -64%
9/11/2014 1069 aActual 112 10/15/2014 326%
�c v 1 e!2011 9Ro/
Dr iVitV i�r aV i a r"�t.ivai �� ,���,��, ,
3/10/2014 931 aActual 20 4/11/2014 -49%
12/11/2013 911 aActual 40 1/17/2014 -58%
9/12/2013 871 a Actual 97 10/15/2013 116%
6/12/2013 774 a Actual 44 7/24/2013 125%
3/14/2013 730 a Actual 20 4/22/2013 -52%
12/12/2012 710 aActual 41 1/9/2013 -52%
9/13/2012 669 a Actual 89 10/15/2012 219%
6/12/2012 580 a Actual 27 7116/2012 25%
1111=12 CCQ .. 94 All A19019 -26%
12/9/2011 530 aActual 28 1/17/2012 -72%
9/13/2011 502 a Actual ill 10/13/2011 236%
6/7/2011 391 a Actual 31 7120/2011 -3%
3/7/2011 360 a Actual 31 4113/2011 -56%
12/8/2010 329 a Actual 71 1/12/2011 -45%
9/9/2010 258 a Actual 134 10/15/2010 297%
6/8/2010 124 a Actual 33 7/15/2010 22%
3/9/2010 91 a Actual 27 4114/2010 -32%
12!F!20n9 Ad a Actual 40 1/12/2010 -60%
9/8/2009 24 a Actual 24 10/15/2009 -100%
8/17/2009 0 n New Meter 0 10/15/2009 -100%
8/17/2009 2281 r Replacement 50 10/15/2009 107%
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
information is required for every North Andover Ma 01845 1/7/2023
— - -_ -_- - - - -_-__ - - -- -
page. Cltyirown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DES;GN ifuw Lmbed wi 3,3 OMR I5.2GS (,ut exa,ujA6. 1 10 ypd x;; 440 ui�cdluuf�laj.
Description:
Number of current residents: 1
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 Enclosed
9 ( Y 9 (gPd))� - ----..__----------
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Currently
Occupied
t5insp.doc-rev.7/28/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 7 of 18
`y,* Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
information is required for every North Andover Ma 01845 1/7/2023
-- ----- --- _ ---- —_
page. CltylTown State Zip Code Date of Inspection
w � �
D. apsierrl IlliVflll�it1U11 �cuni.j
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: nnto - - -- - --_-- --
Other(describe below):
3. Pumping Records:
Source of information: Owner and pumper
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? pump truck tube
Reason for pumping: Owner pumps every year, routine pump
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 18
c�� Commonwealth of Massachusetts
Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
required for every North Andover Ma 01845 1/7/2023
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/Aftemative 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:
23 years of age, 7-26-1999, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.8
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage, etc.):
4" PVC through wall to tank 3"PVC in house no apparent leaks, all in good condition.
t5insp.doc•rev.7Y&M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
information is required for every North Andover Ma 01845 1/7/2023
page. City/Town State Zip Code Date of Inspection
n Ciiafam Infnrmafinn to r%nf N
6. Septic Tank(locate on site plan):
Depth below grade: 0.8
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 x 5'x 4'
Chi inp riPnfh-
1'1
Distance from top of sludge to bottom of outlet tee or baffle
32"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
8'1
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined?
Tape and Dip Stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Ill/.. ....n..............d♦,...I. {... .l..mr...d .... ........rl..L.,...:n T..,.In......-.. :.. ....n.l ,.,...,i:i:.... ..L....,.►......1 :..i......:4..
11YV IVWIIIIIIVIIV 4a.-l-1,C pNl11�J\,V VII .A iVG11� \JGJ/J, 1 VV J .\V\V Ill yVVV WIIV I\IVII, J\l\AVl\II iA\Ill\ry11\�
appeared to be good, liquid levels were good, no evidence of any leakage
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
information is North Andover Ma 01845 1/7/2023
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):
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: -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: - -- - - - --
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions: ------- -- - -
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Sherwood Drive -
Property Address
Matthew Levis _
Owner Owner's Name
information is _._ ._ .____
required for every wurtn r+naovef ivla u i 645 -il I/NL3
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.):
Box was level, distribution was egual, no evidence of any solids carryover, no apparent leakage in or
out of box. There was a new distribution installed two years prior to this inspection.
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
4'
116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
required North Andover Ma 01845 1/7/2023
regwred ed for every — ---- -- --- - --
page. Cityrrown State Zip Code Date of inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2 trenches each
50' long
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: - -- - ----
t5insp.doc-rev 7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�: - 116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
information is required for every North Andover Ma 01845 1/7/2023
— ----------
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.):
Good No None No Grassy
back yard area
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration ---- - -- --- -
Depth-top of liquid to inlet invert -- -- - - -- -
Depth of solids layer --- - - - - --
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.):
N/A
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
i- 03 Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
information is required for every North Andover Ma 01845 1/7/2023
page. Cityrrown 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.):
N/A
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
! n
North Andover, Mass. 2
S h o w i n g
T'-- "A s—Built" Sanitary Disposal System
Lot 9 — 116 Sherwood Drive
Prepared For
bower tteaicy trust.
; Scale: 1" = 20' Dote: July 20, 1999
Zoning District. R-1
Residence 1 District
_ (Planned Residential District)
Assessors Mop: lose
Benchmark: Ponce% +�
No%l In Pole 81541182 $'
E/ev. 126.07' 3
Qo
I-/%A ul VI iJl Vi
Invert Foundation 127.20'
2°
Septic Tank /n = 126.84', Out = 126.45'
N '
D-Box In = 126.18', Out = 126.01'
N
' Open Trench /n = 125.78', End = 125.50'
)pace
I Schedule of Tie Distances
AD = 31.6' AF = 58.8' BH = 45.8'
BD = 26. 1' BF = 54.9' CH = 36.4'
_ AE = 46.P BG = 58.9' Al = 43.5'
BE = 45.9' CG = 51.9' Bl = 39.6'
�o
hereby certify that / hove inspected the construction of this disposal system and that
cnry the construction and final grading has been in accordance with the designer's intent
and that the materials used conform to the plan specifications and 310 CUR 15.0
ri�_ _,__ �--- ..-- 1,.� sl,e ,. ..co of chn-;nn tho "Ac—RIdIt" r:nnd/itions
of the sanitary disposal system
--� installed on the premises. A// work was done in
substantial conformance with the design plans as prepared. All work was done
�,.. within the construction limitations expected for a job of this type.
t� JOHN W
NIO
CIVIL
T/2(ai99 No.WON
esign Engineer P.E. Dote: 9gr'Ia•A����
Tbomes E. Neve Associates, Inc.
Engineers - Surveyors - Land Use Planners
447 Old Boston Rood - U.S. Route 1
Topsfie/d, Massachusetts 01983 887-8586
1 RRn-.S.SnA I
T.n,-77 el Mq n I
ROAD \,
�0 JERAD yQ c \
PLACE A
� ROAD � �
h
14�
m 12 4�, \, `use oles
vres
t -\`
�0 .,�fv Lot 9
°P 39,062 S.F.
y.90 A Cs
44, Upland = J7,911 S.F.
(174 z)
'Q e
44 95`` ` ----- -
� Z
' /3- ------- o-
e �8 _�Septic Tony H
(1500 liadwr5) Leach Trench Sys
O ? Trenches. 50' .
A e C A. T� d, w;,io 17" npo
I
1
C
D 10,, BIliJ�
Tplp r � ..
�✓ofiO'A�r0 lip,
�J15. O
R
4J7' r./1 — (Apo-
T <OC'k• F 1
� E
0 iw
4 gERv1GrC 10\ Tv W
1 �
/
68.00' „y�r�R s R=483. 1' `
--W w Drl Ve
Sh e r w ° ° d
p r i v a t e — 50 , Wide
---T—Note: Property line data taken from o Definitive
Subdivision Plan Of "Jerod Place — Phase IV" By
Thomos E. Neve Associates, Inc., dated September
1. 1995 and revised to March 12. 1996.
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
w� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
information is required for every North Andover Ma 01845 1/7/2023
-
page. Cltyrrown 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
U uiawing aiiauhed sepafaieiy
thinsp.doc•rev.7/26/2016 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page It7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
?� j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Sherwood Drive
Property Address - -- -
Matthew Levis
Owner Owner's Name
"quired for""every North Andover Ma 01845 1/7/2023
re - - ----- - - -----
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
4'
EaiModied dupih iu higgh yiuund waici. 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: -1-1^9-1995
❑ 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:
Test pit on design plan,_all liquid levels were good, no sump pump, basement dry
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'8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Sherwood Drive
Property Address
Matthew Levis
Owner Owner's Name
116quir dfo i' North Andover Ma 01845 1/7/2023
required for every --_ _. —__ -_
page. Cdy/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
111 Argilla Road
Andover, MA 01810 s
Office (978) 475-4786 (978)475-4786
SEPTIC SERVICES
Cell (978) 806-6019
Email: DTineyBatesonSeptic@gmail.com
•
Bill To M lk-(,� z- ob ' DATE
Address / e d 'C', INVOICE No. 674
r
JOB TYPE ❑ Emergency ❑ Maintenance
SERVICE COST
❑ Digging Charge
❑❑C Pump Septic Tank
- -Pump Holding Tank
❑ Pump D-Box
❑ Pump Sewer M.H
❑ Tank Back Flushing
❑ Cleaning Filter
❑ Title Five Inspection
❑ Water Jet Pipes
❑ Snake Main Line
❑ Pump Chamber Installation or Repair
❑ Video Camera Inspection i� ' l �(❑�
❑ Service Call I y;` <<jQ—
❑ Install Riser Cover
❑ Other
Total Billed $ � d
Thank you for your business!
Please mail the payment as this is the invoice.
Payment due at completion of job.
of
• O
dL
• . ,� Town of North Andover
HEALTH DEPARTMENT
SACMUSt q
CHECK#:1103 DATE:
LOCATION: 116
H/O NAME: ✓�-S
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 $
❑ 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 ?0—S 5 $ S� —
❑ Other. (Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer