HomeMy WebLinkAboutPass - Title V Inspection Report - 43 MILL ROAD 6/29/2023 a
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
� Subsurface Sewage disposal System Form - Not for Voluntary Ass ��tlhits
43 Gill Rd _
Property Address
Bobbie Wilson
Owner Owner's Name
information ie N Andover Ma 01345 3/2,1/202,
required for every ... .. _ __. ..
page. City/Town state Zip wade Clete 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 farm.
Important:when _....... _._.. .._......
filling out forms A. Inspector Information
on the computer,
use only the tab David Chandler
key to move your Dame of Inspector
cursor.do not Sewer Works
use the return
key. Company Name
26 Hillside Ave
Company Address
_
Westford Ma 01886
�OL City/T ow.n... state ,dip Code
97 a92-4410 s137
Telephone Number License Number
_._. ....... _ ...... _.............._ ... ..__.w._ _.._.. ....... __.. m..._. ._, .....__.._,.... .... __....._ .._...... .... ..... ........ ........_.. _ ,....._..
B. Certification
I certify that; I am a D P approved system Inspector In full compliance with Section 15.340 of"Title
( 10 CMR 15.000); I 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 tratining 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. Z Passes
2. Conditionally Passes
3. Needs Further Evaluation by the local Approving Authority
4. ❑ pails
3/21/2023
I spect0� ' re late
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or EP) within 39 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 farm 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
oTitle 5 Official Inspection Form
r
So bsu�rface Sewage 1i posal system Form- Not for Voluntary Assessments
4 43 Mill Rd
Property Address
Bobbie Wilson
Owner Owner's' Name _
information is
N Andover Ma 01845 3d21d2023
required for every __. .. . .. ....
page. 6ityfrown State Zip Code Date of Inspection
G. Ir�ip�eGticart �um���
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 5.
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.
aystrn consists of a MioroF.ast treatment unit
2) System Conditionally Passes:
Cj 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, NCB)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metai or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent, System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health,
*A metal septic tank will pass Inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N r NCB (Explain below):
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°R Commonwealth of Massachusetts
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
f 43 Mill lid
Property Address
Bobbie Wilson
Owner Owner's Name
information information Isor every And Id
ftrRirer�re N over a 0184 3/21/20,2311,
....
page. C;ityfTown Mate Zip Code 'Date of Inspe fion
... ....,.a_, _...... . ..............._ _.... .........._......_ __ W._._.._, .w ._._...... ...
C. Inspection Summary (coat)
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 brew 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):
El broken pipe(s) are replaced [I Y FF N [I NCB (Explain below):
obstruction is removed Ej- Y F-1 N El NCB(Explain below).
distribution box is leveled or replaced El Y F-1 N E] ND(Explain below):
E] 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 El N El ND (Explain below):
obstruction is removed El Y [I N F] ND (Explain below).
3) Further Evaluation is Required by the Board of Health:
E} 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:.
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hewn t ornmonwe lth of Massachusefts
Title 5 0" ici l Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
;. 43 Mill Rd
Property Address
Bobbie W lson
Owner r wner°s Name
information is Andover Ma 01845 /21/202
required for every
page, City'rrown State Zip Code Date of inspection
C. Inspection Summary (cant.)
Cesspool or privy is within 50 feet of a surface water
F1 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:
E] The system has a septic tank and sail absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
F1 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 frorn a private water supply wells"*.
Method used to determine distance:
*This system passes if the well water analysis„ performed at a DFP 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.
) 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
El 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
t15ddnap ckwc«rntw.71:G121W8 Trtio 5<.aY1'ooal lnspectt'xsw Fonnr.Subsurface bsurfaacee Sewage 11srsarssl Syslem-Page 4 Ut 18
Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form . Not for Voluntary Assessments
43 Mill Rd
Property Address
Bobbie Wilson
Owner Owner's Name _
urtieuire for
Ns N Andover Ma 0184 /21/202
required rar every _. .. _
page. ptyr,rown State by Cade Date of Inspection
C. Inspection Summary (coat)
4) System Failure Criteria Applicable to All Systems: (cant.)
Yes No
N Static liquid level in the distribution boat above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than S" below invert or available volume is less
than 'f2 day flow
El El Required pumping more than 4 times in the last year NOTclue to clogged or
obstructed pipe(s). Number of times pumped:
El E 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.
El Z Any portion of a cesspool or privy is within a Lone 1 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.
1:1 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 collform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or less than S ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this forma
The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,0 l0 gpd.
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 flaw of 10,000 gpd to 16,000 gpd.
For large systems„ you must indicate either"yes" or"no"to each of the fallowing, in addition to the
questions in Section C.4.
Yes No
11 11 the system is within 400 feet of a surface drinking water supply
El 0 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 Lone 11 of a public water supply well
W nsp dw-rerw.712612018 nue 5 o fieaa fiaawa;aaecto r r'oann Subsurtacax sewage Dsp osaaa8 sysler,o Pages 5 to 18
a W. Commonwealth of Massachusetts
I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm _ Not for Voluntary Assessments
43 Mill Rd
Property Address
Bobbie Wilson
Owner owoner° 'dame
requiredtion
ie Andover Ma ¢�1545 3/21/2023
rewired for every _
page. Cityf"rown State Zip Cade Date of Inspection
C. �l�s{�t�cticarl SulrnmalWy �cont.)
If you have answered "yes," to any question in Section C.5 the system is considered a significant
threat, or answered"yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15,304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
0 S Pumping information was provided by the owner, occupant„ or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
13 El 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 NIA)
Z El Was the facility or dwelling inspected for signs of sewage back up?
Z 1:1 Was the site inspected for signs of break out?
Z El 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"?
Z 11 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 Sail Absorption System (SAS) on the site has
been determined based on:
M ❑ Existing information. For example, a plan at the Board of Health.
" El 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))
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Commonwealth of Massachusetts
µ . Title 5 Official Inspection Form
Subsurface Sewage disposal System Farm - Not for Voluntary Assessments
43 Mill Ned
Oroperty Address'
Bobbie Wilson
Owner Owner's fume
Mquiredufo is NCI Andover Ma 0134 3/2112023
required for every .. ... _ _ ... _
page. rtyf`rowwn State �p Code Crate Iof Inspection
.. __..............M.,. _w..._ ,_.ww.. _.. _...._....... __.w. __...... ......._.
D!. System Information
1. Residential Flow Conditions:
Number of bedrooms(design). 3 _ _ Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
Description:
Number of current residents:
Does residence have a garbage grinder" ❑ Yes El No
Goes residence have a water treatment unit? El Yes E No
If yes, discharges to:
Is laundry on a separate sewage system' (Include laundry system inspection F-1 Yes E No
information in this report.)
Laundry system inspected? El Yes E No
Seasonal use? R Yes No
Water meter readings, if available (Nast 2 years usage (gpd)): �gpd
Detail:
property vacant two.years _
Sump pump"? Yes No
Last date of occupancy: vacant two years
Crate
t5inrp,dor w rov.7/26/2018 T6tle 5 offioal 8nspoction Pony) Subsurface"S4maage N-4, al SYMOM-Page 7 Of W
Commonwealth of Massachusetts
Title 5 Offolcolal Inspection Form
Subsurface Sewage Disposal system Form -Not for Voluntary Assessments
4 _Pulill Rd
Property Address
Bobbie Wilson
Owner owruer Nan1e
information is N Andover Ca 01545 3/2�1/2023
required for every _
page, Cuty("rcrwn State Zip Code Clete of Inspection
_ .__..... ....., _...m..., _.._ ..._, _._. ....,._, ____..__......._........, _ .. ...,_...,._
D. System Information (cont.)
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15. 03):
etIons per day(9pdb
Basis of design flow(seas/persons/sq.ft., etc.): _ ........
Grease trap present? El Yes ❑ No
Water treatment unit present? [I Yes Ej No
If yes„ discharges to:
Industrial waste holding tank present? 0 Yes E] No
Non-sanitary waste discharged to the Title 5 system? Yes [l No
Water meter readings, if available.
Last date of occupancy/use: Date
Other(describe below):
3, Pumping Records:
Source of information: Sewer Works 78-5 -4410
Was system pumped as part of the inspection? El Yes ] No
If yes„ volume, pumped: tt _
a�r��
How was quantity pumped determined? _ _ .......
Reason for pumping:
k5insg,drw.,•rapv.'7P26/2018 'TRW 5 Offioal 6nspea~t&r n rracrw Sutrosurfaace Sewage Disposal Syrswfn•Page 8 0 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
w rw Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Mill it'd
Property Address
Bobbie Wilson
Owner Owner's Name
�rlforifn ds N Andover Ma 01845 3/21/2023
pager
ftsr every _
city[Town State Zip Cote Date of Inspection
D. System Information (cant.)
4. Type of System:
❑ Septic tank, distribution boat, sail 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
E, Tight tank. Attach a copy of the DID approval.
z Other(deschbe):
MicroFast with Infiltrators
Approximate age of all components, date installed (if known)and source of information:
installed 2004
Were sewage odors detected when arriving at the situ El Yes Z No
5, Building Sewer(locate on site plan):
Depth below grade: 2 " _
feet
Material of construction
El cast iron Z 40 PVC other (explain): _
Distance from private water supply well or suction line: n
feet
Comments (on condition of joints, venting, evidence of leakage, etc.)
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Commonwealth of Massachusetts
Title 5 Offlocloal Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
f 43 Mill Rd
I roperty Address _
Bobbie Wilson Owner owner's Name
requirwdfo is
N Andover Ma, 1�1�4 3/ 1/2C7�3 required for every . ... _
page, City/Town state Zip Code Date of Inspection
D. System Information (cant.)
. Septic Tarok (locate on site plan):
Depth below grade: 1 „
feet
Material of construction:
0 concrete El metal [I fiberglass [I polyethylene [ other(explain)
If tank is metal„ list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) E Yes [I No
Dimensions: 5.5'x10.5' ..
Sludge depth: Primary 1 "; aerobic 10"
Distance from top of sludge to bottom of outlet tee or baffle n011
...
Scum thickness
Distance from top of scum to top of outlet tee or baffle nq-
Distance from bottom of scum to bottom of outlet tee or baffle n'a
How were dimensions determined?'
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
pump when system sludge levels are elevated, baffles intact, liquid levels of Micropast are approprate
levels, no signs of any leaks cracks
t5m%p doc•v ev.'V26)2018 TIft 5 offoal b'gw lckxon f'¢wrw.Subsurface o wa ge Dvsposa Systern•Page 10 of 95
r;
Commonwealth of Massachusetts
._,,. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
..
43 Mill lid
Properly address
Bobbie Wilson
Owner" Owner's Name
information is N Andover Ma 01845 3/ 1/20 3
required for every ._ _
page. Crtyfrown State Zip Code Gate of Inspection
D. Systems Information (cone.)
7. Grease Trap (locate on site plan):
Depth below grade;
yet
Material of construction:
�] concrete metal fiberglass polyethylene other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottorn 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:
0 concrete El metal 0 fiberglass El polyethylene El other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gaRorrs per day
a.Nnsp.doc•rev 7126=16 'i"file 5 Offiaad 4nspoetion r'cm.Subsurface Sewage Disposal System•Page r I of 18
o, Commonwealth of Massachusetts
Title 5 ►f oci l Inspection Form
w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y, 43 Mill Rd
Property Address
Bobbie Wilson
Owner
Owner's Name
information Is N Andover Ma 01 45 3/, 1/ 0 3
required for every ... _ _
page, cityifown State Zip Code Date of Inspection
...... ......._ . .m. _._. .......
D. System Information (coat.)
. Tight or Holding Tank (cant.)
Alarm present: D Yes Ej No
Alarm level; alarm in working carder: Yes ❑ No
[late of last pumping; Date
Comments (condition of alarm and float switches,. etc.).
Attach copy of current pumping contract(required). Is copy attached? Yes No
g. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.)
No CDbox pressure dose system
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° Commonwealth of Massachusetts
:i Title 5 Official Inspection Form
P. Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
na . 43 Mill Rd _
Property Address
Bobbie Wilson
Owner Owners Name _
requir etlon is N A dloyer Ma 01845 3l 11/ 0 3
required far every _ . . . _ _. _
page. cityf'own State Zip Rode Date of Inspection
......... _. .... _..._. _w.w._.................
D. System Information (cant)
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.):
observed system operate cycle, pump and alarms in working order
If pumps or alarms are not in working order, system is a conditional pass.
11. Sail Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
......_..
Type:
leaching pits number:
leaching chambers number: 16°x `
[-1 leaching galleries number;
leaching trenches number, length:
[ ] leaching fields number, dimensions; _
overflow cesspool number:
El innovative/alternative system
Type/name of technology: Microast with Infiltrators
m5ans3r.dm«rev_'7PM2018 Title 5 fJ13'mal Inspection Form,Subsurface Sewage Disposal S1asl,em.paw 13 of 18
Commonwealth of Massachusetts
" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 bill Rd
Property Address
Bobbie Wilson
Owner Owner's game
information is N Andover Ma 01845 3/21/20 3
required for every ... . .. _
page, city/"town State Zip code Date of 8nspection
w_v.._ __w.... ....,_., .. __..M._..., .. ._.,.......__.. _..
D. ,System Information (cont.)
11. Soil Absorption System (SAS) (cant.)
Comments (note condition of soil,: signs of hydraulic failure,. Level of ponding, damp soil, condition of
vegetation, etc.):
gras_over leaching area, no signs of hydraulic failure, no damp soils, sandy soils(septic sands)
1 . 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 n Yes E3 No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation„
etc.):
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q Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Mill Rd
Property Address _
Bobbie Wflson
Owner owner's Name _
return fionrequired
as N Andover Ma 01845 3/21/2023
recpuareed for every .. ..._........_ .. ._ �.... ....
page Cntyfrown Mete Zip Code Date of Inspection
.w.... _w.__..... .......... . ..._... .._. _._. ..._. n...._ ..w..... __ ... ..
D. System Information (cont.)
13, Privy (locate can site plan)„
Materials of construction:
Da mensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of pondin , condition of vegetation,
etc.):
_ ._..---
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Commonwealth wealth of Massachuseft
Subsurface Sewage Disposal System Forma-Not for Voa untary Assessments
43 Mill Rd
Property Address
Bobbie Wilson
Owner Owners Name
Wtrrrnstan is
N Andover Ma 01845 3/21/202
required for every
page. City own State Zip Cade Date of I nspection
D. System Information (cant.)
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:
El hand-sketch in the area below
drawing attached separately
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.......... w. .__. __.__... --------- ..... ---... _ ..... ..... _..... -......_...
Commonwealth of Massachusetts
_ ._ Titfl 5 UO"Micial Inspection Form
m` Subsurface Sewage Disposal System Form - Not for"Voluntary Assessments
;. 43 Mill Rd
Property address
Bobbie Wilson
Owner Owner's dame
required
rs N ,Andover Ma 01845 121/202
requNred tsar every _.. _ ..... __ ...
page City/Town State Zip Cede Date of inspection
..... _._........._..._.__._..._.._._.____.. ._. __.... _....... . ...._.
D. System Information (cant,)
15. Site Exam:
Check Slope
Surface water
Check cellar
El Shallow wells
Estimated depth to high around waiter:
Z
Beet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans can record
If checked, date of design plan reviewed. /04
Date
[ Observed site(abutting property/observation hale within 150 feet of SAS)
( Checked with local Board of Health -explain:.
❑ Checked with local excavators„ installers-(attach documentation)
[� Accessed USOS database -explain:
You must describe how you established the high ground water elevation:
Leach field area was designed by N,E.Fngineering utilizing a 2` offset to ground water. System was
designed, approved and construted utilizing 2'_ground water offset.
Before filing this Inspection Report, please see Deport Completeness Checklist on next page.
t5msp.dac rev'7/26/2.118 Tltka 63 Offi del Inspection W'orrrr,Sub scarf ra,,trwage Disposal System-Page 17 of 18
Ewa Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�,.
43 Mill Rd _. ..
Property Address
Bobbie Wilson
Owner owner's Name
information is N Andover lea 01845 3/21/2023
required for every _..
page CityrTown State by Code Gate of inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
0 A. Inspector information. Complete all fields in this section.
B. Certification: Signed & Dated and 1, 2, 8, 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
15'irlysp doc-mv."tld6=18 Td%5 OPrbraaml fnsS�raasion Forrw Subsi face S"ages DisposM",System•F age 18 of 18
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Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
............... ....... -------- ........
A. Installation
important:When Bobbie Wilson
filling out forms Owner
on the computer,
use only the tab 43 Mill Rd
key to move your E a'cilfty street Address
'
cursor-do not N Andover 01845
use the return
key. City Zip
IMailing address of owner, if different:
Street Address/PO Pox�
City State Zip
ext.
Telephone Number
............
B. Authorized Service Provider
Sewer Works
6�M Firm'
26 Hillside Ave
street Address
Westford Ma 01886
City State Zip
(978)692 -4410 ext.
Telephone Number
David Chandler
Certified' 61ne'rator-N-a--m-e Ce I rt I M I ca I t I ion-Number
............ ........... ......
C. Facility/System Information
24.4.280.
DEPID Manufacturer ID Model Number
4/2005 4/2005
Installation Date Start of Operation
Approval Type: E General El Provisional Ej Piloting Remedial
Seasonal Residence—used less than 6 mo./year: E] Yes E-1 No
D. Operating Information
11/05/2020
inspection Date Previous Inspection Date
12" Primary, 10""-aerobic Pumping Recommended El Yes El No
Sludge Depth(to be checked yearly)
t5amom cloc-rev, 04-11-13 Page 1 of 3
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
L i DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
E. Field Testing
Field Inspection:
Color: El gray El brown E deer El turbid
Ej Other(specify):
Odor, E musty El earthy El moldy El offensive 0 turbid
Effluent Solids: Z no El some
8,87 SU 3.0 rngJL 1 6 NTU
pH 604 DO 2 or greater Turbidity 40 or le,ss
Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected
per Standard Methods and analyzed for BOIL and TSS.
F. Sampling Information
Samples Taken: El Influent Z, Effluent
Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use
nitrogen reducing systems�
gpd
Parameters sampled-, [:1 pH El BOCK [:1 CBOD ❑ TSS 0 TN [] Other(list below)
'Other I Other 2 Other 3
............. _--------
G. Inspection and Maintenance
Description of any maintenance performed since previous inspection & during this inspection:
Blower amps 3.1,1.,clean filter-,
Notes and Comments:
t5aiom doc rev,04-11-13 Page 2 of 3
Massachusetts Department of Environmental Protection
Bureau of Resource Protection -Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
--------_........... --------------
H. Certification
l certify: l have inspected the sewage treatment and disposal system at the address above, have
conducted the required Field Testing and/or sample collection in accordance with Standard Methods,
have completed this report and the attached technology operation and maintenance checklist, and
the information reported is true, accurate, and complete as of the time of the inspection. I am a
or in accordance with 257 CMR 2.00
3/21/2023
Date
System owner must submit this report, technology O&M checklist, and any required sampling results
to the local board of health as follows for each inspection performed:
Remedial Use—by January 315'of each year for the previous calendar year
Piloting Use-within 45 days of inspection date
Provisional Use—by March 31 1h of each year for the previous 12 months
General Use—by September 30�h of each year for the previous 12 months
Send to:
Department of Environmental Protection
Attention: Title 5 Program
One Winter Street, 5' Floor
Boston, MA 02108
t5aiom.doc-rev.04-11-13 Page 3 of 3
NASHOBA ANALYTICAL
DIVISlOtq OF GRANITE STATE ANIALY'rICAL SERVICES , LLC
31 ,"+Willow Road yei,Massarhusett 01432
Phone:978-:391-4428 websit :vvv wnashobaanalytical.corn
CERTIFICATE OF ANALYSIS
DATE PRINTED: 03/23/2023 RECEIPT TEMPERATURE: NA
CLIENT NAME; Sewer Works
CLIENT ADDRESS: 26 Hillside Ave.
Westford„MA 01886
SAMPLE ID 2303.03439-001 DATE AND TIME COLLECTED: 03/21/2023 12:00PM
SAMPLED BY: D.Chandler DATE AND TIME RECEIVED 03/21/2023 02:15PM
SAMPLE SITE: Wilson
SAMPLE LOCATION: Pump Chamber
43 Mull Rd CLIENT JOB#:
N.Andover MA
Test Description Results Units DO MOL LOO(RL) OF Method Analyst Dale&Time
Flog Analyzed
Turbidity 1.6 NTU 0.1 0.1 1 EPA 180.1 AH-MA 03/21/2023 02:55PM1
Peter C. Nevius
Laboratory Director
Page 2 of 2
CON r RACT/E STI MATE
Sewer Wot*s
,26 Hillside Ave.,
Westford, Ma 01886
978-6924410
www.sewerwork's.net
E'mai net
Date: 3/28/2023
Narne: Bobbic Wilson Address:43 Mill Rd
City,State,Zip,N Andover, Ma 01845 Job location: same
phone: Property owner: same
. ......... - -----
Work to be performed:
1. Contract is for one visit per year, Inspection to include testing unit for ph; DO(dissolved oxygen)and for turbidy. Includes filing
of required DET forms with copies to stale,N Andover Ilealth Dept.,- and customer. Inspect filters and control unit. Cost is�dilm?er
jmjwj
visit., includes lab fees. "I"otal flIM. Price does not include any repairs that May be required.
2. Should the unit fail the above field testis of ph; DO and tUrbidy. Then the following tests will need to be performed: BOD
(Biological oxygen demand); ; I'SS(total suspended solids). Fhe costs lor the above tests is$375.00 which includes all lab fees. "this
information to be placed on filed reports.
3. Should additional site visits be required, additional charges will apply.
4. Servicing and inspecting the Fast unit is no guarantee the Unit Will function properly as manufacturer states.
The total contract SLIM fior the work specified above is......:$AM
Payments are to be made as hollows:
Deposit amount; Due:
Balance due at billing,.:$cost pet visit
All payments are due when customer is billed. An account balance after 30 days from billing date is subject to monthly finance
charges of] 1/2%if Linder$500, 1%ifover$500. IfTustorner indebtedness is not paid in full according to the terms of this
contract,then all guarantees are null and void.
Signed:...Davaid B Chandler(electronically)......... ........ .............
David B.Chandler.
Sewer Works
Date,-.__3/28/2023 .........._... .... .........
AcceTul. ce o ' 110 osal: The prices, speci ficat ions and conditions set forth in this contract are sat islactory and are hereby
accept e Y' iare authorized to do the work as specific(] ayment will be made as outlined above,
Date:.. .. ........ ... .................................... Sig---.....___..........._....... ......... ........