HomeMy WebLinkAboutPass - Title V Inspection Report - 190 GRANVILLE LANE 7/28/2023 FILE#-L.ALt
TITLE V INSPECTION
can G. Luscomb 11 & Sons
288 Maple, Street
Middleton, MA 019491
978-774-4065
Title V License # S1848
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTVON FORM
PROPERTY OWNERS NAME 0 1 rA r C
PROPERTY ADDRESS
41 —LLA—
DATE OFINSPECTION J L'c I v
NAM�E OF INSPECTOR
Commonwealffi of
Title 5 " i it For
p Subsurface Sewage Disposal System Form INot for VoWntary Assessments
1� .�ranvlllie Lane
_
Property Address
Finlaselr
Owner .
uar s NUrrrne
information is.
req uBred fforevery North Andover A,..... 0184 July 19, 2023 d _
page. mt / own State Zip Code Date of Inspect on
Inspection results must besubmitted can this form. inspection terms may not be altered in any
way. Please see completeness chocklist at the end of the for m
_...._. _._._......w.......... ......_. .... . .. .. _ ....... ....
Important!When
filkng out forms A. InspectorInformation
on the computer„
use o,nty the taus Gleam G Lus nrnb ill .............. .........
key to miove your Name of Inspector
cursor,:do not Dean G. Lus irnb Ili �: Sons
Me�the return
mmee,m, m.,_e
key. Company Narne
288 Maple street
to .......................
crnprnywddres
Middleton MA 01949
a m,.a.. ,_ �.
_... State Zip Co. de
� nt �p ern 1 4
4- Na
elephrane Number License Number
B. Certification
I certffy that; i am a IDEA approved system inspector in,full compliance with Section 15.340 of Title
( ' 1 U have personally inspected the sewage disposal system at the property address
listed above, the information reported below its true„ accurate and complete as of the tiime of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of onl-site sewerage disposal systems. After conducting this i nspe tion i have deterrritned
that the system:
1. E Passes
2. 0 Coniditionaily Passes
Needs Further Evaluation by the vocal Approving Authority
4. Fails,
r n �t
inalctcr's signature Bete
The system inspector shall submit a cop 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
1 p pd or greater„ the inspector and the system owner shall submit the report to thle appropriate
regional office of the DER The original form shouicii be sent to the system owner and copies sent t
the buyer, if applicable, and the appirovtng authority,
Please note: This report only describes conditions at the time of iinspection and under the
conditions of use at that time.This"his Inspection does not address how the system will perform
in the future under the same or different conditions of use..
t&nsp Bloc•rev 05f,"P18 nue 5 orp a1 Rispocnlcon Folm:Santrscur aw Sewage MnpcSW system.Pa go 1 of 18
fin,°aCommonwealth of Massachuseft
nTitle 5 Off"Icial Inspection Form
Saraoa Sewage Disposal System Form® l"~'alot for Voluntary Assessments
a 190 Granville lane
......... _
V irop,erry Address
Holasek
Owner � nar"a a�ta Na
information is
required for aver Forth Andover 011845 July 1 x 62
�w+ ... m _ ,.P_ ._........ ..e _..e.......... m . _.. e
fags, CftyPTown state Zip Cods Date of Urns acllon
C. Inspection Summary
InspectionSummary: Complete 1 2, 3, or 5 and all of 4 and 6.
11 System Passes:
I have nlot found any information which indicates that any of the fanllu ire criteria described
in 310 CMR 15.3103 or in 310 C P 15,304 exist„ Any failure criteria not evaluated are
W indicated below.
Cor°nrnents.
Inu
System Conditionally Passes:
El 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 Heakh, will pass.
Check the box for "yes , "no- or"not determined" (Y, N, NDt )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 e filtration or tank failure is imminent, ;System will pass
inspection if the existing tank'ls replaced with, a complying septic tank as approved by the Board o
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 Goes than 210 years old is available.
® Y N ND (Explain below):
t a nspr, •rev MEW20118 Me 5 Official h5praubon Fort n.Suil'asualfaoe;sm We mP sposal System®r'age 2 om"Ids
Commonwealthchug
Title 5 Official Inspection �Form
I ,l Subsurface a s e Disposal sal yste Form Not for,Voiurrt ry Assessments
190 Granville Lane _. .. . .
Prrapely dedi-ess
H lese
..e, ,,, _ ........ _......_
V rr',r wner" Naale
irdfforVr'abort is
quked for every North Andover ..a_,.. _ .._... A 01845___ July 19,
2023
pa le. ity�Tow n State Zap Cads Date of Ord p c liars
.
C.
Inspecti (cont.)
System Conditionally masses (cont):
Pd.rrrtp,Charnber plrarytp'sialarms Ir7 t operational. System will pass w rath bard of Health approval it
pumps ier s are repaired.
' Observation of sewage backup or Ibreak out or hii h static water level in the distribution, box due
a� to broken or obstructed pipe(s)or due to a brq err, settled or uneven distribution box, Systern will
pass inspection if(with approval of Board of Health):
El broken pipe(s) are replaced E] Y El N El NI (Explain bellrm ):
obstruction is removed N NI (Explain below)v
distribution box is iewreied or ireplfeoed Y N ND (Explain below):
'The system required pulrnpinq more than 4 times s year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Heslthl):
broken pipe(s)are replaced Y E] N Ej Nib (Explain 'beiowd :
El obstruction is removed ® N LI ND (Explain below):
Further Evaluation is Required by the Board of health:
Ej Conditions exist which require further evaluation by the Board of Health in order to deteirmiirne it
d � the system is failing to protect publlc health„ safety or the envy ron ent.
so System will pass unless Board of Health determines in accordainice with
"t ( )(b)that the system is in t functioning in s manner which will protect public health,
safety and the environment:
t5rV'Ip.d oc•rev.72502018 TRte 5 Odrrsfs]hspecW ForrN'h.SubsurftCro SeMip Disposal System IIpage 3 of'18
Commonwealth chusefts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System � Not for Voluntary Assessments
'igg GranOlte Letts
F�roperny F�driras
lsS . . .,..„, ,e.
OwnerSara °r� a
irwtormatiran is
regWr d for every North Andover m® . 01 Jus 19, 2
page. City/Town state Zp Coda Date of IInspection
C. Inspection, cone.
El Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering ring vegetated wefiand or a salt marsh
b.. System will fail) unless the Board of Health jand Public Water Supplier, if any
w 'r` determines that the system Its 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 wwuthin
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.
0 The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply wlll.
0 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 deterrnnne distancew
w This system passes if the well water analysis, performed at a DEP certified laboiratcr , for fecal
colifdrrn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is epUal
to or less than 5 pprn, provided that no anther failure criteria are triggered, A ccp'y of the analysis unrest
be attached to this form.
c. Other;
System Failure Criteria Applicable to AllSystems:
You must indicate "Yes"' r"No"to each of the following for all inspections.
U "es Nlca
No Backup w'f s gre into,facility or system component du to overloaded or
El clogged SAS or cesspool
Discharge or pending lof effluent to the surface of the ground or surface wawat r'
due to an overloaded or clogged SAS or cesspool
I.NnSp. r-rev.7126r2018 Tba 60ffickg Insperton Form Srabsueaca Sewage DmI.N M SyVm a P&QVv 4 W I O
` Commonwealth of Massachusetts;
Title 5... . Off"Icial Inspection
Subsurface Sewage Disposal System Fora Not for"voluntary Assessments
190 Granvulle Lane
_.
r��errhy a� dr�s�
Rolasek
t^ ,1 — 11, a,,—. ,
Ownei0orrmation us
w wwrnsrr r irne
required for every North Andover _ __.....__ _A ..._...._ 134 duly 19, 023
page. it 6 u l9u S a4e 1p- o Date of Gn peOW1
.__..._............ ... _.. ....
C. Inspection Summary (cont.)
y System Fallure Criteria Applicable to,All Systems: (cont.)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded
or ciogged SAS or cesspool
� Uquid depth in cesspool is less than �" Wow Ilnver"t or available volume is lass
than 1/2 day flow
required pluurnpirig more than 4 times in the last year NOT due to clogged or
, obstructed pipe(s). Plumber of times pumiped: _,_•
fEl Z Any portion of the SAS, cesspool or privy is below high ground water elevation.
El M 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 n a:done 1 of a public water supply
weli.
Any portion of a cesspool or privy is within 60 feet of a private water supply well,
Any portion of a cesspool or privy is less than 100 feet but treater than 50 feat
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 cloliform bacteria indicates absent aiupd the presence
of ammonia nitrogain and nitrate nitrogen is equal to or less than 6 pprrn,
provided that no other failure criteria are triggered..A copy of the analysis
and challin of custody rust be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,0100 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 Mil be
necessary to correct the failure.
Large Systems: To be considered a large system the system must serve a facility with, a.
de ign flow of 10,000 ggpd to 15,000 gpdµ
For large y^stems, you must indicate either"yes"or"no"to each of the following, in addition to the
gluestioins in Se tiop 4.
1
,ry � "es No
El Elthe system n is w 'ittnin 0 feet of ,„ u `ace drinking w ateir supply
El the systern is w It i feet "f s `lbutary to a surface drinking grater supply
the,5yst6m is located in a nitrogen sen ive, rea(I nterim Wellhead i rote tlorn
El El Ar�e•a_ IW A)or a mapped Zone 11 of a publi c Water supply Yvell
t5insp,dDQ rev,712U2015 'Title 5 offC6al m m ian V--o rro Subsurface Sewage Msja !Al,.,.'yvernr Page 5 of 1 B
5
Commonwealth e a lMassachusetts
Official For
Subsurface Sewage Disposal System Formm Not for Voluntary Assessments
f gg ranwrille t..arre
Property Address
Holasek
ermaon
Owner _._._ _.—...—._ _.._...
rat"uire4rfo - -- � 11g, 0 lorllh
�trni�r �r
rp��ir�d��r e„ro�err;y� e,..,downer t � �o��y ®e..,
page, state Zip Core ruts of Inspection
C. Inspection (coftm
if you have answered"yes"to any quuestlon in Section C.5 the system is considered a significant
threat, or answered"yes"to an question in Section CA abovethe large system has tailed. 1"h
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 accordiance with 10 CMR 15.304. 'The system;owner
should contact the appropriate regional office of the Department,
. You must iindicate "yes"or"no"for each of the following for all inspections:
"es No
0 El 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?
l Has the system received normal flowers in the previous two,week period?
�i Have large volumes of water been introduced to the systeirn recently or as part;of
this inspection?
Were as built pNsns of the system obtained and examined' (lf they were riot
mailable note as NIA)
)
Was the facility or dwelling inspected for signs of sewage back p?
E] Was the site inspected for signs of break out?
Were all system components, excluding the SAS, (located on site?
Were the septic tarok manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
irnensions„ depth of liquid, depth of sludge and depth of scum?
Z El Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewerage disposal systems?
The size and location of the Soil Absorption System ( our the site has
been determined based on:
E] EAsting information, For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Dart C is at issue
approximation of distance is unacceptable) (310 CMR15.302(5)]
t5osia sic-rev FU6t G16 r"itle 5 offmw rnspaction frarr subaa,rr ,e&wwage DisposM Sysiem Page;15 0 18
Commonwealth a rr e
Title 5 Official Inspection Formi
'i
subsurface Sawaige Dis l System FormNot for Voluntary Assiessmerats,
190 y �r
ne
�.,a "A ------- - _ _. �... .
ra�ap��ri�7 d�t�dr�� "
Holasak
Owner Owner's,I Irequired for every North Andover MA 01845 Jug 1 , 2023
page. C ii;� III State Ziip Cade Date of Inspection
InformationD. System ,
1, Residential Flow Conditions:
4
Nura°rlb �r of � i brooms (design)- Number mb r of b dlroarrus(a tual):
DESIGN as based on "Eta 15.203 (tor example: 11 pd of b drorums): 44 pd
Description:
Town and owner.
N urr-rabsr of current residents:
Does residence have,a garbage griindeO' `has No
Does residence have a water treatment a nq El Yes IZ No
If yes„ discharges to:
Is laundry on a separate swan system? (include laundry s stern inspection Yes
Z No
information in this report.)
Laundry system inspected? Z "des El No
as rrai use? El Yes Z No
Water,r aster readings,, if a abbla last ears usage d ,0
( (gyp ���
�r
Detail:
Sump pump? Yes N
,current
Last date of oocupancy� bits.
8ainsp¢aac irav t B.r.64!0&B TKO 5 OfYiidall Inspooflon'•o Form:Subsufface Sewage DispsW System,PNe 7 Hof'V'S
Commonwealth of Massachusetts
�r Title 5 ial Inspection Foy Subsurface Sewage Disposal System Form Not for Volluntary Assessments
""o f 190 GranvMetaros
Properly Address
Own N .
Owner _. Na
information is
required for every North Landover 01 Jury � ,
.___..... _._.._.. _... ._.._.._ _._ __....
page. wtty�rr� Pm State Lp Code Chi of 1mp'e' ion
_.. _ _....... .__ _ .._.._...............W _........___ .. . ....._.. _ ..
D. System Information (cont.)
Z Commerclal/lindustrial Flow Conditions.
"w Type of Establishment:
Design fl
ow based on 310 CMR 1 , 0, )�
Gaflons per day, pd)
au of dirty flow ( tlprornlp,,ft., etc,). '
Grease trap present? / // Yes, No
i
Water treatment ent unit present? ,, � Yes, No
Df yes, discharges t .�
Irwdua trW waste hMing trek present? El Yes
Non-sanitary w t discharged tip;the Title 5 system? El Yes o,
Water ureter readings,, if available:
Last data of occiijp n&y/us � �.... .
Other(desciribe bellow):
pumping .
Source 5f information'. u�rr p r Last ppr d /t /23_
1 .1
Was system purnpled as part of the inspection? El Yes 0 N
Vw ;uii
If yes, volume pumped:
f� alions
dHow was quantity purrup ld determined? w,.. ..
No mead at
ea r for puua�mpirU thin time. to .. re� h du lle
U3insp.doc rev,712612018 Tba 5 Gffici l inspedim Form-Subsurfaro Sewage M9r*8,M Syfftarr P^R90 8 Of E8
Commonwealth f Massachusetts,
Title 5 Official Inspection Form
iZ Subsurface Sewage Disposal 'System Form _Not for VOlUnt ry Assessments
190, Grenville Lane
Property,address
rtolesek
Owner - ... ......... ............ .,.... ... ,....................._.
Owner's N
me
inf
rmation�s
required for every North Andover MA 015 July 19, 2023 _
page. Cony/Town State Zip Code mate of�nspsctlon
D. System Information (cant)
Type of Sys,tem-
ED
Septic t nik, distribution box, soil absorption system
l Ingle cesspool
Overflow cesspool
w„J Pril y
El Shared system (yes or no) (if yes, attach prey ous inspection records, if any)
El Innovative/Alternative technology. Attach e copy of the current operation and
maintenance contract(to be obtained from system ow i ner) and a copy of latest
inspection of the l/A system by system operator under contract
El TG ght tank. Attach a copy of the DEP approval.
Other(describe);
Approximate age of all components, date unstalled (if known) and source of information:
§ystern is frorn 19 -44 yrs older . ...
Were. sewage odors detected when arriving at the site" El "he's 0 No
d, Building Sewer(locate on slte plan).
„"
Depth below grade:
Material of construction:
#i, _.
r oast iron PVC other(explain):
Distance fronn private water supply well or suction line: feet my.
,Comments (on oondhtion of joints„ venting, evidence of leakage, etc.),
N aln lone and joints are In good condition, no signs of any problems,
u5in,%).&x,*rep a6,16J''S!01b 1'We 5 offi'iw 6rapec'tion r-crn;'subsrsudace Skrmamge ticposgi Syste'r m Page 9 Of 18
Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments,
d
"f 190 Granville Lane
Property Address
o l k.
Owner _..... _ ........
uGmt� mr ri ra w ner's Name
r prmired to�r every North Andover MA 011845 Jul'y...1 , 2023
page. Atyr"ram'rn State Zip Code Date of irm�p mion
.. .._....._. _.....___ .._.._...._.._W....._...__._ .. ._._.._..�_ ._ ....
D. System Information (cont)
. Septic Tank (locate on site plan):
Depth below grade: If I eet
. ..,., -
� Material of construction:
concrete P mi t l F-3 fiberglass El polyethylene El other i in)
"10 0 gallons
If tank t m,etal,,UALp
is 40,66, r f fic" t o',f hornpliI ric attach a co f certificate) No
urra n �r n ' "- 1000, allon 7
YY
Sludge depth: -
Distance from trap of sludge to bottom of outlet tea or baffle 4Pa
Scum ticknaaa
as
Distance from top of scum to top of outlast tee or baffle _
"1 Epp
Dstance from bottom of scurn to butt rrm of outlet tee or baffle
How were admen lion determined? by measurements,
Comments (ors pumping recommendations, inlet and outlet tee or baffle counidltloan, structural Integrity,
llqumlid levels as related to outlet invert, evidence of leakage„ etc.):
The tank and baffles are In goad general l conidltlu n.. The tank is running at lit" correct working Ih ight,
R5nn5p drx,.rev 7126U01'a 'rWe 5 Offio�,)]hisp c6an Form,Subftiesfm sewagp Disposal'System^Page I'D of 18
Commooiwealth of Mass,achusefts
1d31�iTitle 5 Official Inspection For
Fti: xb Subsurface a 'Sewage Disposal System Form Not for" oiuntary Assessments
19 raroAla Lane
cdpr�ty ddrsn
i-ilasak
inforrroattrnrn is
required for every rth ndover '..m.. 01845 _ JW 19„ 9
page, City/Town tmte Zip Code rate of Inspection
D. System Information (writ.)
7. Grease"gate (locate on site plan):
i9ttt below grade: _feet
liMaterial of construchom
concrete El metal fiberglass [ Iprutysth0e nother(explain):
tirrle nsio ns:
Scum ttnickniass _ _m. e.e.._. ,.......e,e..,a
Distance from top of scurry to top of o uti t"t ' boftl m..� ,..
Distance from blottom of.1,scurri't'al
.b ttorn of cutlet tee� r-.,affle
Date of last,pat pin : _ —
iists
Comments (on purnping recommendations, lrnlat and outlet tea or°"betit omditioni„ structural integrity,
liquid levels as related to outlet invert„ evidence of leakage, etc.):
9. Fight or Ilh olding Tank(tank must ba pur"rnpad at time of inspection) (locate on site ptan-n),:
Depth belowgrade:
at&: al of constructiom
El concrete EJ metal [I fiberglass [pelybifhylenecnther a plalirn):
alpatty. °
q�u��rn
Design Flow�
a,
gallrnns per day
t5nsp.doc-rev,'103,12018 7utnm 5 MUM 141SP mWW Forrro Subsjjeai uu Sewage IC bsposa Syaterrr,Pag 11 Of I S
Commonwealth of Massachut
Title 5 Official
"q Subsurface Sewage Disposal System Fortes Not for Voluntary Assessments
un
190 Granville pane
�..e�.
Property Address
Holase
a� _ ..__.
information�
required for every Northn.. .. ip_.. g
23
page. Ciit Jrow�ffn t'aft'e Z' 'Conde Date of lie pertmon
�D. System Information (cant.)
Tight or Holding Tan (cont,,)
Muth
Alarm pre t El 'Yes El No
Alarm leoreV; o Alarm in working order ,.,,Yas ..,., 'o
Date of Vasa pumping: _
Cornments (condition of alarm and tPpat„gwit hes, etc.
Attach copy of current pumping contract(required). Is copy attached? "Yes No
9. Distribution, Box (if present Irnust be opened) (locate on site plan).
Depth, of liquiiud level above outlet invert hero
9
Comments,(note if box is level and distributions to outlets equal, any evidence of solids carryover, any
evidence of iea age into or out of box, etc ):
The d--box is 1 " beiow grade and is 17"" x 20". The d-box is in good working condition and shows no
� signs of any problems,
t5hrsp.idicc-rev 712612015 Bdd+e 5 pGfucral nnspabctrrrorn Forum subsurface Sewage om}rortsmW 3ywv r*Page 920f.ftw
Commonwealth
w
^lSubsurface Sewage Disposal System Poem Not for Voluntary Assessments
ram^
g
10 Gra�rrulls Laren
r�r�p�lP�w�!'��m9rr�
H das k
Owner
brnr"s Name
in formostIon is
required for every North Andover MA ...... 01845 July I ,.202
..........
psgie. cityrrawwn state Zip code Date or Inspection
D. System Information (col t.
10. Pump Chamber(locate on site plan):
Pumps in wor,king order: `as No*
r� Alarms is working order: ... Yes 01No*
pQ°r Comments(rants condition of pump charrib r, ccrr rtic'tn cf p'tumps and appurtenances, etc.):
" of pumps or alarms are not in working order, system is a ccrrditionall pass.
11 Sad@ Absorption System (SAS) (locate on site pdarr, excavation not required):
df SAS not located, e pWiru rf�m�y:
0
'rhe SAS was located by asbuilt drawings, previous title v from 1996 and rt-box to ie ei area of yard.
o,
Type
El leaching pits number:
leaching chambers rnurnber:
leaching galleries numbleir: _. .�..-.. . _.
ieachMg trenches number, length:
leaching fields number, dimensions:
overflow cesspool number:
D rrrrmcvati /alternati e system
Type/narne of technrscicgy�
n59np,43 rev,7r2612{) 8 noP5 mrrccniaw Ins,Funuclio n Fermn °Subsiuoiece O'Na e Dspo5W System^Page 13,o.'I8
Commonwealth ofMassachusetts
Totle 5 Official Inspection Form
fl, Subsurface Sewage Disposal System Dorm Not for Voluntary Assessments
19 Gir n ill Lane
Property Address
lolsu
Owner ..-. _ ...... _. _. ,. e......a.. _._ _._.. .,.m...e...
information m
Own&s Name
required for every North Andover MA 01845 July 19, 2023
Page. Gftyffown State Zip ode mate of Inspection
U. t Information on,t �.......... _.w _�,m..._saW.._ ..we........._
11. Soil Msorption System (SAS) (cant.)
Comments(note condition of soil, signs of hydrauk failure„ level of p nding, damp soil„ condifion of
vegetaflon, etc.):
The SAS is in good general ondition, Thus area is covered with well maintained green grass,.
. ............ . ..........
12. Cesspools (cesspool must plumped as part of insp tlorn), (locate on site plan):
Number and configuration n _
Depth top of lnpuud to, inlet invert
Depth of solids layer
' Depth of scum layer
Dirnensnons of cesspool
Materials f construcflon
LR,
Indication of'groundwater inflow 0 Yes El No
omrni ruts(not condition f s ��, signs of hydraulic failure,, l l,pf porndirng„ condition of vegetation,
etc
C;srsp.rdon°rev 7rWZ018 TWe 5 Official hspeC4f l Form Subsurfarp;Sevag�p Dispo:9 al Sygtwm•Page 14 of 16
Commonwealth of Massachusetts
10
? r I i ace Sewage Disposal sty �or°u Not fair Voluntarya e r� rst
,... a me.....ro
P'ro-ir�y Adreaa
Holasek
Owneir Own7iarn a _..........
inforrilation is
_
required for every Nqrth Andover MA 01845 July 19, � 3
a �. flit t�'�w�� � _.. _.- — —
g hate Zip Code Date of inspection
D. Siystem Information i(coint.)
13. Pr (Iorate on site l n)
Materials o con,"",uutlru, - __......_ _
Dimensions
Depith of' 11ds ,. .. _
Comments (note cordifl ru of soil, signS of r, nnNu ,t ilt,r level of g�t�rdin ra6tio n of vegetation,
etc.):
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Commonwealth f Massachusetts
Title Official i
q
Subsurface Sewage Disposal r Form Not for Voluntary Assessmen
19 ranvnli Leas
Property ddme'
Holasek
Owner NkneG'u Name
nr orma.tnon is
required fair ever 1_....... ,n._k �J,
pegs. i �"r� rnd� r �u��ode �„
pection
System Information (co nt,
14, Sketch Of Sewage Disposal System:
Provide ien of the,sewage disposal systeim, irn iuding ties to at feast two permanent reference
landmarks r benchmarks. Locate Ali weds within 1010 feet. Locate where public water suppi " enters
the building. Crack inns of the boxes below:
im7
hand-sketch in the area below 1
D dravving attached separately
rim,
n rrrr
II
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Commonwealth
Title 5 Official Inspection Form
, - Subsurface Sewage Disposal System IF rm Not for Voluntary Assessments
nts
. 1':90 Granville Lane
Holsk.
_... .... ...� ........w. ...... ..,�... ... ...... .... .. ®®
Owner wrmer`s�rrm�
information'is
required for every North Andover MA 01845 July 19, 21023
page, w4y/Town state Zip Codd e I t 4 1n' p o-
D., System (cont.)
15. Site Exam:
Check Slop
Surface water
I
Check cellar
Shallow well
Estimated depth to hlgh ground water: 9 7 r" m�
t�,sa
Please indicate all methods used to deterrnne the high ground wager elevation:
Obtained from system design pin s on record
rd
1g7
If checked, date f design plain reviewed: m .te
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health- plain:
--Permit, pr_o proposed, uut s`mprvious title...v�rom mug .
...�.�—
Checked wlth kcal excavators, installl rs W (attach documentation)
El Accessed USGS database -a pWin:
You must describe how you established the high ground water lsysticn:
deep hole test dcmms in 19,78 showed ground water at 117 or 9a'7 % The basement is 7° bellow grade
with no suimp pump. Driveway wwa and Granville sit apprc 7"- " below grade of the back yard where the
system is located with no sign of wester.
Before il'i'n this Inspection Report, please see Report Completeness Checklist on next page.
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Commonwealth
6 f"Icial Inspection, For
011 Subsurface Sewage Disposal to Form m Not for Voluntary Assessments
190 r nvlll mane
_ ,,, ............
prop rty Address _.
l-Ilk
Owner Owner's
Name
irnforrrtatw n ps
required!for every North Andover r �..®. : ..... .., 01845 Sul 19, 3
_._ _..
page. cityrrown state ZP Cads Date or hispection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of.
. Inspector Inform tiom Complete Compiete all fiIelds in this section.
B. Certificatiom &gn d Dated and 1 , or 4 checked
C. Inspection Surnrnar :
1, 2, 3, or 6 com letedappropriate
t
4 (FaRure Criteria)and 6 (Checklist) mpl t d
D. System information:
For : Tigh l-l016ng Tanik- Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 1 : Explanation of estimated depth to high groundwater included
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