HomeMy WebLinkAboutPass - Title V Inspection Report - 550 BOXFORD STREET 3/10/2023 commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments i1
550 BOXFORD STREET
Property Address
,TAMES SANTOIANNI
Owner owner's Name
information is ER
page Cit MA 01845_ MARCH 1, 2023
NORTH ANCICJV
required for every _ mm_.__ ._... _ _._._ _....m._..
_._yP...To�.,n...w.......� State Zip Cade pate of Inspection
_ _ .__.._,_._
Inspection results must be submitted on this form.Inspection forme 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 Todd James Bateson
key to move your Name of Inspector
cursor-do not Bateson En_terpnses Inca
use the return Company Name_
key.
___...Arc,�l_Ila load _....__
11
r Company Address
Andover MA d
.._ ________.._......__. ..5�
�O`� Ctry/I own _ State Zip Code
��, 7$-475-4786 1-16
__._.._.Y
Telephone Number License Number
B. Certification
I certify that. I am a DEP approved system Inspector in full compliance with Section '15.340 of Title 6
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above, the information reported below is true, accurate and complete as of the time of my
inspection, and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. Q Conditionally Passes
3. D Needs Further Evaluation by the Local Approving Authority
4. 0 Fails
- - == March 2, 2023
_.__..."._.__ ..w._—__.—_._.__ pate
Inspe s Signature
The system inspector shalt submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater„the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note:.This report only describes conditions at the time of Inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
In the future under the same or different conditions of use.
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$' Commonwealth of Massachusetts
TOtle 5 official Inspection Form
44
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
550 BOXFORD STREET
Property Address
JAMES SANTOIANNI
Owner 6Wners Name ..._.
information Vs NORTH ANDOVER MA 01845 MARCH 1, 2023 required for every Y ..,, . ......._ _....... _.,.
Crt fT own
State Zip Code fate of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2„ 3, or 5 and all of 4 and 6,
1) System Passes:
Z 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:
[l 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 cornplying 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.
El Y D N n ND(Explain below):
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Commonwealth of Massachusetts
w ,��3 Totle 5 Official Inspection Farm
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
550 BOXFORD STREET
Property A idress
,DAMES SANTOIANNI
C7wOwnerC7wrter"s Name___
information is NORTH ANDOVER MA 01845 MARCH 1„ 2023
regflired for every .... _._ ... _...._ ___ . .
page C�tyTown biate Zip Code date of Inspection
C. Inspection Summary (cant.)
2) System Conditionally Passes (cant.):.
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 [__1 Y F-1 N ❑ ND (Explain below):
❑ obstruction is removed ] Y F] N NUJ (Explain below):
distribution box is leveled or replaced [-I Y [] N [,] ND (Explain below):.
The system required pumping more than 4 tunes 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 L-] Y E] N ND (Explain below);
C] obstruction is removed F] 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:
tP nsp¢lame reb,7Q61201 8 Title 5 OfflGial trta{aOGAiM�'CV T17,SuabS uflace Sewage D,SpSosAa Systern-Page 3 of To
Commonwealth of Massachusetts
6r6 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,v
ta `f 550 BOXFORD STREET
Property Address
JAMES SANTOIANNI
Owner
C7wwcler`s 'Name-
information Is NORTH ANDOVER MA 01545 MARCH 1, 2023
required for every _ _.. _. .. . _._._..__ ... ......
page, Cityffow n State Zip Code Late of..Inspection
�
C. Inspection Summary (cunt.) __.. ....___ ______..... .........
[ 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
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
El 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 systern 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
D z Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
D z Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
tl a(nap.dw- rsv.7t261201 H 'N*f�Fbnicwr Iinspaacton Form Subsu"ra ce Se,wage Mspo.'sa, sysle"a-page 4 Of 16
d
Commonwealth of Massachusetts
g i Title 5 Official Inspection For
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
550 BOXFORD STREET
loroperty Address _
JAMES SANTOIANNI
Owner .. .
Owner'_s.Nameinfor
regUireifo is NORTH ANDOVER
req�liredtorevery ,.. w _. MA 01845 MARCH �', 2023
page. Cit !Town _..w __....
Y State Zip Code Gate of Inspection
C. Inspection Summary ( lt.)
4) System Failure Criteria Applicable to All Systems: (cant.)
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 to" below invert or available volume is less
than '/2 day flaw
El 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.
El El Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El Any portion of a cesspool or privy is within a Zone 'I of a public water supply
well.
El Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Ej z 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.]
FA The system is a cesspool serving a facility with a design flow of 2000 gpd-
10„000 gpd.
0 z 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
D 0 the system is within 400 feet of a surface drinking water supply
C] 0 the system is within 200 feet of a tributary to a surface drinking water supply
C] 0 the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area•- IWPA) or a mapped Zone 11 of a public water supply well
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' Commonwealth of Massachusetts
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
- :<r 550 BOXFORD STREET
_ _ ._..
Property Address _ --.-_-
JAMES SANTOIANN1
_. __.. ..
Owner CYwr7er's Ctlame
requir etion as NORTH ANDOVER MA 01845 MARCH 1, 2023
repaired for every _� .. .. _____ -- . ... ....
pscge. City/Town State Lp Code Crete of Inspection
_........._.. _._. __. . ...............
C. Inspection Summary (cant.)
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
l F-1 Pumping information was provided by the owner, occupant, or Board of Health
1-1 Z Were any of the system components pumped out in the previous two weeks?
El 0 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)
0 Was the facility or dwelling inspected for signs of sewage back up?
Z 1:1 Was the site inspected for signs of break out?
E] Were all system components, excluding the SAS, located on site?
Z ❑ 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?
Z 1:1 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;
Z ❑ 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
El approximation of distance is unacceptable) [310 CMR 15.302(5)]
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t
550 BtOXFORD STREET
Property Address
,FAMES SANTOIANNI
Owner
Owner's hYarrte .. __......_,. . _.. . .
informationrequired
is
wire re d for every NORTH AND(OVER MA 01845 MARCH 12 2023 page City/Town State Zip Code Date of Inspection
..
__._... ._ _..._.._.._ _..._.__.,M _..,. .
D. System Information
1, Residential Flow Conditions:
Number of bedrooms (design). 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#f of bedrooms): 440 gpd_
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes Ej No
Does residence have a water treatment unit? ® Yes No
If yes, discharges to: SEPTIC TANK
Is laundry on a separate sewage system? (Include laundry system inspection Yes No
information in this report.)
Laundry system inspected? E Yes El No
Seasonal use? 7 Yes E No
Water meter readings, if available last 2 ears usage d WELL
g C Y g (gp )}
Detail:
Sump pump? [] Yes No
Last date of occupancy: CURRENT _.
Date
tGirosp.ofic-rev ad261nl8 'fi le 5 Official inspection Fomv SULIB euf3+ce Sewage Disposal!SyMem.Page 7 of 18
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
550 BOXFJRD STREET
Property Address
JADES SANTOIANNI
Owner _ _ __.. .,
C)uvner's Name ,
information is repaired for every NORTH ANDOVER MA 01845 MARCH 1, 2023_ _ ..._..... ._ ... �._
page; City/"town State zip Code Date of Inspection,
D. System Information (cont.)
2. CommercialAndustrial 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 trap present? E Yes ❑ No
Water treatment unit present? ❑ Yes El No
If yes, discharges to; _.....
Industrial waste holding tank present? [ Yes El No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: gate
Other(describe below):
. Pumping Records:
Source of information: MARCH 1, 2022 OWNER
Was system pumped as part of the inspection? 0 Yes Z No
If yes, volume pumped: _ ..
gallons
Haw was quantity purnped determined?
Reason for pumping:
t5oras{a,d ac M rev.Tl'l(572018 title 6 Ofriciral Irmpoction Form:Sulnurfacero Sewage oispusml system.page 8 of le
Commonwealth of Massachusetts
`title 5 Official Inspection Form
pity Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
550 BOXFORD STREET
Property Address .
JAMES SANTOIANNI
Owner __ _
C7wner's Name _
information is NORTH ANDOVER MA 01845 MARCH 1, 2023
requiredd for every ... ... _ ..._ _._ _..... _. .,__ __..... ....
page. City91 own State Zip code Date of Inspection
D. System Information (cant.)
4. Type of System:
z Septic tank, distribution box, soil absorption system
0 SingVe cesspool
Overflow cesspool
❑ Privy
El 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
F] Tight tank. Attach a copy of the DEP approval.
[� Other(describe):
Approximate age of all components, date installed (if known) and source of information:.
APPROX 8 YEARS OLD, AS BUILT PLAN 2015.
Were sewage odors detected when arriving at the site? D Yes Z No
5. Building Sewer(locate on site plan).
Depth below grade: 4 ..... .
feet.. . . _..
Material of construction:
[I cast iron Z 40 PVC other(explain):
Distance from private water supply well or suction line; OVER 100'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
JOINTS OK
VENTING OK
NO EVIDENCE OF LEAKAGE
t5 nrfa doc,,.i ev 7f26 r„4))8 '1'mei 5 Officini inwprmca on rnm subsurface Sewage Dizfposal SyMearrl•page 9 of'la
f Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface sewage Disposal System Form - Not for Voluntary Assessments
6 Kw !✓° 550 BOXFORD STREET
Property address
JAMES SANTOIANNI
Owner Jwner s Narne
Itanru for every is
rere�uired for NORTH ANDOVER MA 01845 MARCH 1, 2023
page, City/Town State Zip Code Date of Inspection
D. S�I`Stf'11f1 Information.......__.._________-__ _.........m ..._ .....___. �.._.._._.....w._. .__.._ .,..._._.__�.__ _.........._........__..
(cant.)
6. Septic Tank (locate on site plan):
Depth below grade: 3(
teen
Material of construction:
Z concrete F1 metal F-1 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 E-1 No
Dimensions: 16'X 5'X 4'
Sludge depth; 3,w
Distance from top of sludge to bottom of outlet tee or baffle
2°
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 1 "
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.):
PUMPING RECOMMENDATION: YEARLY FOR OLDER SYSTEM
PLASTIC INLET AND OUTLET TEES OK
TANK IN GOOD CONDITION
LIQUID LEVELS OK
NO EVIDENCE OF LEAKAGE
RISERS ON INLET AND OUTLET COVERS 6" DEEP
t5visp duec;•rev.76"c6/2018 V(110 5 M,Cal hsp tion P;xm SuSsUO3ce Sewage D,sposa0 System•Page 10 rwl 18
Commonwealth of Massachusetts
i . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm Not for Voluntary Assessments
550 BOXFORD STREET
Properly Address
JAMES SANTOIANNI
Owner _.. _._.. _
CJwner's tJarrle
requir required
is NORTH ANDOVER
rewired for every _. MA 01845 MARCH 1, 2023
page. C1ty/Town State Zip Cade bate of Inspection
_. „_,...__...,.. ___....._ _. .
......
....-._._...,,.._ _..........._......._ .... ......._ _.._.
D. System Information (cont.)
T Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
El concrete El metal ❑ fiberglass El 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:
Gate
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.)
& Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
concrete F-1 metal fiberglass polyethylene El other(explain):
_ m
Dimensions: _ _. .. .
Capacity: gallons
Design Flow: gallons per gay
t54ewsp.dor,^inw,7P2612018 "1'iUe 5 OfPiesei Inspection Form:Subsurface Sewage Disposa[System p'aguR 11 or 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
M Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
550 BOXFORD STREET
---._-.. _...- .------
_.... �.
Property_Address
JAMES SANTOIANNI
Owner
Owner"s Larne_
information is NORTH ANDOVER MA 01845 MARCH 1, 2023
required for every _ ...,,.... . _.._. ....
page. CttyfTown State Zip Code Date of Inspection
D. System Information (cant.)
& Tight or Holding Tank(cant.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes El 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 IS LEVEL AND DISTRIBUTION IS EQUAL
LIGHT EVIDENCE OF SOLIDS CARRYOVER
NO EVIDENCE OF LEAKAGE
t5insp,doc-rev,'712612018 Title 5 O f1ckat Inspection Fom Subsurface Sewage DisposM System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
" 550 BQXFORD STREET
I5ropertyAddress
JAMES SANTOIANNI
Owner Owner's Name
information is NORTH ANDOVER MA 01845 MARCH 1, 2023
required for every ..__.._
C1t /Town _..
page. .�... State .. Zip Code rate of Inspection
D. System Information (coat,)
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:
El leaching pits number:
z leaching chambers number: 20
El leaching galleries number:
El leaching trenches number, length:
E] leaching fields number, dimensions:
[._1 overflow cesspool number:
U1 innovative/alternative system
Type/name of technology.
t:Ernsga.a;ac rc,v t`C pdr "Utdi TWe 5 O ficiW Inspeocduon Wotan 5ufusurt ace Sewage Diaposal System-Pap 13 a4'1 u
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�. Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
550 BOXFORD STREET
r o p e r t y Address ......-.-.__.__-
OJAMES SANTOIANNI
_ _ - _
Owner Owners Larne
reinfquired
is NORTH ANDOVER MA 01845 MARCH 1, 2023
required for every _.. _._-.. _.. _._ __... .._. _�._._...,._
page, CItyPTown State Zip Code Date of Inspection
.
_....._.._.....__ ......_._............._,_.....__....,_. _.__. ..__...._._.._. __..�_.--
D. System Information (cant.)
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 OK
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.'712612018 Title 5 official Inspechon Form Subsurface Sewage cisposai system-page f,#of 18
"a Commonwealth of Massachusetts
Title 5 Official Inspection Form
51' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
"r 550 SOXFORD STREET
Oroper4y,Address
JAMES SANTOIANNI
Owner __ _ _ __....... .. _,.._._.......
Owner's Name
required
is NORTH ANDOVER MA 01345 MARCH 2023
required for every ._ .......__. ---. ... _....
page. City/Town State _. Zip Code [late of Inspection
D. System Information (cent.)
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.):
t5nsrr brcra-rev 7FA,tMla TrtRe 5 Official Omos,pewon Fc mb.Subsurface Sewage Disposal System-Page 15 of 15
Commonwealth of Massachusetts
31 Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
550 BOXFORD STREET
Property Address
JAM ES SANTOIANNI
OwnerOwner"s Name
information is
required for every NORTH ANDOVER.. -MA--- ..00 84§_.1____ MARCH 12-202,3
page, Ctryltown 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
Se F-A"i
-T.
/�Ilq
1 0
A atf
Fey
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................ ......
Commonwealth of Massachusetts
lr =, Tide 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
d° 550 BOXFORD STREET
Property Address
JAMES SANTOIANNI
Owner C7wn er's....N_ame_............ .. ..,_..
____..... _ . .._._... ......._ _
information is requVred for every NORTH ANQOVER MA 01845 MARCH 1, 2023
_. .. _ .. __.. .. _ .. ......
page CetyfTovvrr State Zip Code Cate of Inspection..
D. System Information (cent.)
15, site Exam:
Check Slope
Surface water
Check cellar
[..] Shallow wells
Estimated depth to high ground water:
Beet
Please indicate all methods used to determine the high ground water elevation
z Obtained from system design plans on record
If checked, date of design plan reviewed: SEPTEMBER 2015
Cate
[ Observed site (abutting property/observation hole within 150 feet of SAS)
z Checked with local Board of Health -explain:
PLANS ON FILE
Checked with local excavators, installers - (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
DESIGN PLAN ON FILE
SYSTEM IS 4' ABOVE WATER TABLE
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t"1pmp,derc:•resv.7116f:18 1 Vtle 5 Official inspection Form Subswfaace Sewage Disposal System Page 17 of 18
° Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
550 SOXFORD STREET
._ Property Address .
,FAMES SANTOIANNI
Owner bwners I-ame
information is NORTH ANDOVER MA 01845 MARCH 1, 2023
rectvraired for every _ ... _... _ ..,_ ._. ,...... .
page. CityrTown State Zop Code Date of Inspection
_. __. .._._. ..,._ _...w._ .., ...._...,._ ......_._.......__. ..___ _ _..,_ ___w........_...._..
E. Report Completeness Checklist
Complete all applicable sections of this farm Inclusive of:
Z A. Inspector Information: Complete all fields in this section.
Z B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
Z C. Inspection Summary:
1, 2„ 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (,Checklist) completed
Z D. System lnformation;
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
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