HomeMy WebLinkAboutConditional Pass - Title V Inspection Report - 96 LOST POND LANE 4/28/2023 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 96 Lost Pond Lane Property Address Paul James Wolmering&Jacqueline Anne Jacobs Owner Owner's Name information is North Andover MA 01845 Apr 13,2023 required for every City/Town state Zip Code Date of Inspection page. 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. A. Inspector Information 1. Inspector: Timothy Gannon Name of Inspector Wind River Environmental Company Name 46 Lizotte Drive Suite 1000 Company Address Marlborough MA 01752 City/Town State Zip Code 978-702-7420 S114511 Telephone Number License Number B. Certification I certify that: I am a DEP approved system Inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: F1 Passes Conditionally Passes ❑ Needs Further Evaluation by the Local Approving Authority ❑ Fails Apr 13,2023 Inspectors 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 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. t5ins.doc M rev.7lM2018 Title 5 Offloal Inspection Forfn Subsurface sewage Disposal systern o page i of 18 ............ Commonwealth of Massachusetts Title 5 Official Inspection Farm =° Subsurface Sewage Disposal System Form Not for Voluntary Assessments 96 Lost Pond Lane Syr'% Property Address Paul James Wolmering&Jacqueline Anne Jacobs Owner Owner's Name information is North Andover MA 01845 Apr 13,2023 required for every city/Town state Zip Cade Cate of Inspection page. C. Inspection summary Inspection Summary: Complete 1,2„3,or 5 and all of 4 and 6. 1)System Passes: 0 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: Z One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass Check the box for"yes"'„"no"or"not determined"(Y, N„ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y R N ❑ ND(Explain below) tSins.doc rev.7 60018 Me 5 Official Inspection Form:Subsurface Sewage Disposal System o Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y, 96 Lost Pond Lane Property Address Paul James Wolmering&Jacqueline Anne Jacobs Owner Owner's game information is Forth Andover MA 01845 Apr 13,2023 required for every City/Town State Zip Code Date of Inspection page. 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. Z 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 ❑✓C N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ( N ❑ ND(Explain below): C✓1 distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below): Distribution box is heavily corroded and MUST be replaced. Leakage observed.One wall is collapsing in. ❑ 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: t5fns.doc rear..7/26/2018 TIUe 5 Official Inspection Forrmx,Subsurfaces Sewage nisposW Systern.Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Lost Pond Lane Property Address Paul James Wolmering&Jacqueline Anne Jacobs Owner Owner's Name information is North Andover MA 01845 Apr 13,2023 required for every City/Town State Zip Code Date of Inspection page, C. Inspection summary (cont.) 0 Cesspool or privy is within 50 feet of a surface water 0 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b.System will fall 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: 1:1 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. D 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 system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all Inspections: Yes No El 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 t5ins.doc«rev,7/2612018 TiW 5 Oftcdal Inspection Forrn Subsurface Sewage DisposM SysWrn o Page 4 of 18 Commonwealth of Massachusetts B Title 5 Official Inspection Form u Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 96 Lost Pond Lane g Property Address Paul James Wolmering&Jacqueline Anne Jacobs Owner Owner's Name information is North Andover MA 01845 Apr 13,2023 required for every CitylTown State Zip Code Date of Ins page. p action p C. Inspection summary (cant.) 4) System Failure Criteria Applicable to All Systems: (cone.) Yes No ❑ Q Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Q Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ❑ Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped;_ Q Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Q Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes If the well water analysis,performed at a DEP certified laboratory, for fecal coliform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ✓❑ The system is a cesspool serving a facility with a design flow of 2000gpd-10,000gpd.. ❑ Q The system falls. 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 5ns.tloc,r rev.7/26/2018 Title 5 Official Inspe+:bm Form:Subsurface Sewage Disposal System a page 5 of 18 Commonwealth of Massachusetts r µ Title 5Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 96 Lost Pond Lane Property Address Paul Jaynes Wolmering Jacqueline Anne Jacobs Owner Owners Name information is North Andover CIA 01645 Apr 13,2023 regwaired for every page CitydT own State Zip Code Date 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"in Section CA above the Barge 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 C1 © Pumping information was provided by the owner,occupant,or Board of Health ( ® Were any of the system components pumped out In the previous two weeks? [ ® Has the system received normal flows in the previous two week period? [✓ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(if they were not available note as N/A) R 1:1 Was the facility or dwelling inspected for signs of sewage back up? ® D Was the site inspected for signs of break out? [ Were all system components,excluding the SAS, located on site? ] Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge and depth of scum? [] Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems?The size and location of the Soil Absorption System(SAS)on the site has been determined based ow [� 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)] 6";urrrcu.e9a""c a ut.w.'d1"2'Sf"cQ4S I ide 5 Of&.cul tlrearnact on'Fe"ruvr:Suetr^tuir,face sue,age odrvos,ao Sy,.,Awn an P*�"y�.�G of ie Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Lost Pond Lane Property Address Paul James Wolmering&Jacqueline Anne Jacobs Owner Owner's Name information is North Andover MA 01845 Apr 13,2023 required for every City/Town state Zip code Date of Inspection page. D. System Information 1, Residential Flow Conditions; Number of bedrooms(design): Not available Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: Design flow not available on as built, Number of current residents: 3 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 10 No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes w' No Water meter readings, if available(last 2 years usage(gpd)): 268 GPD Detail: Water usage 4/2021-3/2023:26,100 CF x 7.48= 195„228 gallons/730 days=268 GPD.Water use records are attached on Pa e 18, Sump pump? ❑ Yes No Last date of occupancy: Current Date t5ms.aoc•rev.7/26/2018 Title 5 OfficW Inspe0on Forn Subsurface sewage Disposal System•Page 7 of 18 'r Commonwealth of Massachusetts . Title 5 Offit iel Inspection Farm _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Lost Pond lane «'+ Property Address Paul James Wolmering&Jacqueline Anne Jacobs Owner Owner's Marne information is North Andover MA 01845 Apr 13,2023 required for every City/Town State Zip Cade Gate of Inspection page. D. System Information (cont.) 2. Commercial/Industrial Flow Conditions. Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpcd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? El Yes E-l No If yes, discharges to Industrial waste holding tank present? 11 Yes EJ 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): General Information 3. Pumping Records: Source of information: The homeowner and Wind River Environmental are the sources of the information, Was system pumped as part of the inspection? ( Yes F] No If yes,volume pumped: 1500 gallons How was quantity pumped determined? Pump truck sight glass Reason for pumping: Check structural integrity of the tank tTa'ms.doc M rev.7/2&2018 1 r9e 5 o@«oa,Inspechon rarMI sua'suffice Se%,ese Ds„csef System*Pape 8 of 18 Commonwealth of Massachusetts Title 5 ofifiicial Inspection Form p m Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Last Pond Lane Property Address Paul Jaynes Wolmering&Jacqueline Anne Jacobs Owner Owner's fume information is North Andover MA 01845 Apr 13,2023 required for every City/Town State page. Zip Code Gate of Inspection D. System Information (cunt.) d. Type of System: (� Septic tank,distribution box„soil absorption system (� Single cesspool E] Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) [l 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 El Tight tank.Attach a copy of the CDEP approval. Other(describe): Approximate age of all components,date installed(if known)and source of information: 05/23/1 996 Were sewage odors detected when arriving at the site? [] Yes No 5. Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: R cast iron Q 40 PVC (. 1 other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints„ venting,evidence of leakage,etc.): All joints were ok. No leakage observed. R;Strna;,r,4oc•rev,'7r''612018 IX Me 5 Offia M tl nspect n Fo m,@"S6 zsurface timww+ra g*P."Ns posaa9 sysde,0 paaC o 9 W I a r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Lost Pond Lane Property Address x Paul James VWolmering$Jacqueline Anne Jacobs Owner Owner's Name information is North Andover MA 01645 Apr 13„2023 page, required for every City rrown State lip Code date of Inspection D. System Information (cant.) 6. Septic Tank(locate on site plan): Depth below grade: 0.25 feet Material of construction, El concrete E3 metal fiberglass FJ polyethylene C] other(explain) If tank is metal„ list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes d No Dimensions: 1 Q'6-X5'7",X5'8" Sludge depth: 5„ Distance;from top of sludge to bottom of outlet tee or baffle 33", Scum thickness 37 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 1 Oro How were dimensions determined? Tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition„structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was structurally sound and at proper level in relation to the outlet invert.Schedule 40 PVC tees are In place,No leakage was observed.Tank is 4"below grade. Recommend yearly service. 6,5Pns,doc r r" 7rQ6/2016 Flue 5 0fbsaW Inspect on Fwyn subwr acO Sewage fasPosa?Systwr v Pstm 10 0 18 ram. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments gS Lost Pond Lane l1 F roperty Address Paul James Wolmering&Jacqueline Anne Jacobs Owner Owner's Name inforrnatio n is North Andover MA 01845 Apr 13,2C123 required for every City/Town State Zip Code Date of Inspection D. System Information (cant.) 7. Grease Trap(locate on site plan): Depth below grade: feat Material of construction: El concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of Vast 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.): 9. Tight or Molding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: concrete ❑ metal ( fibergkass U polyethylene ❑ other(explain): Dimensions Capacity: gallons Design Flow; gallons per day GuniMO.dDC«feBv.7 16/2016 7'to 5 Ofricw lmm n Fo nrm s.k6s aafacen saaea txura%au sysle,r N'1q,'f 1 0i 18 Commonwealth of Massachusetts K Title 5 01"Ticial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Lost Pond Lane a Property Address Paul James Wolmering Jacqueline Anne Jacobs Owner Owner's blame information is North Andover MA 01845 Apr 13,2023 requipapered for every CityJTown State Zip Cade Date of Inspection D. System Information (cant.) & Tight or Holding Tank(cant.) Alarm present. ) Yes [ No Alarm ieveL— Alarm in working order: D Yes D No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): Attach copy of current pumping contract(required). Is copy attached? C.] Yes No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert p 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.): Distribution box was level with equal flow to three lines, Distribution box is heavily corroded and MUST be replaced.Distribution box is 12"below grade. Light carryover. Leakage observed.One wall is collapsing in. M'ntiocrru,rt5rt: rsv,'7Y2syi/'?P,b�E§ NW"Offioral Iorsgvsaton Form,Saba Haas,e w' 09e DSPOS 4 Syysterr w Flaa,v 12 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Lost Pond Lane Property Address, Paul.Names Wolmering&Jacqueline Anne Jacobs Owner Owner's Name information is North Andover RSA 01845 Apr 13„2023 required for every f,ityl'fowrc page. State Zip Code Date of Inspection D. System Information (cant.) 10. pump Chamber(locate on site plan): Pumps in working order: ) Yes El No' Alarms in working order: El Yes El 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 GonditionaI pass. 11. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type: EI leaching pits number.°. C,..] leaching chambers number: R1 leaching galleries number: 3 El leaching trenches number„ length: E] leaching fields number,dimensions: overflow cesspool number: ] innovative/alternative system Type/name of technology: t"Spns,u9mn.rep;,7„26r�oS rod*5 fydrc dN hr7r'4;w=r;+90n Form,Sutisa dace S3ewage S7m9.araosW System F1,ige 13 0 18 <, Commonwealth of Massachusetts Title 5 01"Ticiel Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Lost Pond Lane Property Address Paul James Wolmiering&Jacqueline Anne Jacobs Owner Owner's Name information is North Andover MA 01845 Apr 13,2023 required for every City/Town Stake Zip Code Date of inspection page. D. System Information (cant.) 11. Soil Absorption System(5AS)(Cont.) Comments(note condition of soil„ signs of hydraulic failure, level of pending,damp soil„condition of vegetation, etc.): Soil was sand and was dry. No signs of hydraulic failure. No pending.Vegetation was normal for the 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 El Yes El No Comments(note condition of soil,signs of hydraulic failure, level of pending,condition of vegetation,etc.). tf'ddns.adoc•rev.'Y126(2018 T'➢Ue 5 fkffwcaW hnsrwm#duiq Foyrn;3ubsudr`a DR SOwagAl M%)OSM SYstem•F'azDO 14 of 18 Commonwealth of Massachusetts w Title 5 On-id"al Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Lost Pond Lane " z Property Address Paul Jaynes WWolmering Jacqueline Anne Jacobs Owner Owner's Name information is North Andover MA 01845 Apr 13,2023 required for every CitydTowro State ?ip bode Date of Inspection D. System Information (cant.) 13, Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil„signs of hydraulic failure, level of pending,condition of vegetation,etc,): tskiaa,rlma;w.oey.'72Ef201 s rpre 5 offirada9 tns;-ct;ovw Forin sub uoa sew-age V'qM1 osali system 0 page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Lost Pond Lane Property Address Paul James Wolmering&Jacqueline Anne Jacobs Owner Owner's Name information is North Andover MA 01845 Apr 13,2023 requi nred for every Cityll,ow page. 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: 0 hand-sketch in the area below El drawing attached separately *NoA Ln 7 aNrrs,doc 0 rev,fa.6r2,018 TIN 5 OffrOM(Mpedorl Forrm SubMt fte Sewage omposal System w Page 16 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Lost Pond Lane Property Address Paul Jaynes Wolmering&Jacqueline Anne Jacobs Owner Owner's Name information is North Andover MA 01845 Apr 13,2023 required for every City/Town State Zip Code gate of Inspection page. D. System Information (cunt.) 15. Site Exam: Check Siope L Surface water Check cellar Shallow wells Estimated depth to high ground water: 81, feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked,date of design plan reviewed: Date Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) El Accessed USES database-explain: You must describe how you established the high ground water elevation: I dug a hole next to the distribution box down to the bottom of the box. Bottom of box was 32"below grade. I then probed down 5".The probe bar came back dry and no signs of groundwater, Before filing this Inspection Report,please see Report Completeness Checklist on next page. G*,'rM 1,10c,0 rev,7Q6r2018 M ste 5 t"JffioW 1nSp4KWn Form &r tB suaftce wS ,rqe r,)t p o sM Syslen,s page''7 0 18 Commonwealth of Massachusetts Title 5 0iclal Inspection Farm y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 Lost Pond Larne ry Property Address Paul James WWolmering&Jacqueline Anne Jacobs Owner Owner's flame information is North Andover MA 01845 Apr 13,2t123 required for every City/Town `Mate Zip Code Date of Inspection page. E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 21 A. Inspection 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 15:Sketch of Sewage Disposal System drawn on pg. 16 or attached For 16: Explanation of estimated depth to high groundwater included Water Use Records 0r„ems".,4Au'AeaWlpo K—H" Newa Town o1 Forth Andover Tax Map#210-104.B,-0213-0000.0 Parcel Id 16635 96 LOBS"POND LANE JACotT a JA QU LI N %LOSI POND LANE NORTH AINDOVER,MA of d21 rnedmt6R1 ProperarTypae ide+ftM SUO 7"aroW 6,d1A,ms FY6 2d�r2'2i II NaaAafAA'd'aasa 'Type Loge iroUMber Arrdd lwnax.A roman tdnatlAd 19WInes,2Ad; 1,d'r'.11W NORTH ANCKWIrA,VA 2W246 up 6"Ou"t at Ada„haurll No C'2elta oceaapod Nam" ACghweAna;cdivo aft w'9.'W'7 '.b.28 LOST POND WANE' t.Ape� d DO*ad"Sa"7,aR�a:YJ �23 21cyca 03 AdlNo Aaa„a,WWR Nana.3t Sorvk,*c000 Raw WtuWM06 mu#wwrrusats iwd aFEE ADMW FEE 0 61 p73 782 1) vaW're wt4MA 21 ALL UVER 62k 19 40 ?1 Atword No,31 5 S oNd No statue Lavation einrotl 'Pw,pww sk" Yro com 1,9tl�'.WdGSd1' w AcOve d2 ERT KI b emadpen ra www 060063 27'e 00* wee C*d* crnanaa ptWnan PO VW oche vea'W ae 14 .2 2044 *Aa"mW 3 WR 2,7* .ram Q*21222 waW41 aAaAw e Wrrd7�a a 4 &RIV,202�2 33 stead tf% Wdu"1iiA2'G" 312% ktiWI022 1"r #Acdeel 31 7MV27022 9131'"6 111bp',N22 18616 SAchaap 3 W11' 22 WIMP 1234 aA40W 57 18S84d,„,,V32t 2 4% P202A P' 8 eArMsa 16 MO MI 1dW"MY% tSlrts.drx 0 rev,712V2018 1"Velum 5&"2Nt'da„'Wal Inspection F'ou n:Sub$urka~a2e Sewage D7 spasal SysWrn r Pagta 18 of IS