HomeMy WebLinkAboutPass - Title V Inspection Report - 42 OLD CART WAY 7/28/2023 FILE#.,LL,,' LL,71
TITLE V INSPECTION
can . L II1 & Sons
288 Maple Street
Kddleton, MA 01949
978-774-4065
Title V License # S1848
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNERS NAME
PROPERTY ADDRESS f" Vs!0,
DATE OF INSPECTION
NAME OF INSPECTOR 1, r
Commonwealth itMassachusefts
rT't1e 5, Offic"al Inspecton Form
Subsurface Sewage Disposal l ystem Form,_ Not for Voltuntary,Assessments
ssments
µ 421 Old Cart Way
Property Address
snnd
Owner ner s Name
information Is
u q ulir d for every North Andover MAI 1 011845 JWy 17, 2023
page, State Zip u'de Date of Insper on
Inspection results must be submitted on, this fora. Inspection formers may not be altered in any
way. Please see completeness checklist at the end of'tfts form.
important;When Inspector Information
f fin out forms A.
on:the computer,
use only the tab been G. Lus nr b 111
Trey to move your Name of Imsperlor
cursor-do not Dean G. Liusc mb Il & Sons
se the return
key. Cornperny Nerve
88 Heppe Street
company Address
Middleton. MA 01949
Crty 6w''rn state ziip Code
r g -`f it-4065 1' 48
..__...._
q"eIephorre N urrnber._._ .. License Number
B. Certification
i certify that: I am s DEP approved system inspector in full compliance with Section 15.340 of Title
(310 CMi I . sd)l I have personally inspected the sewage disposal systern at the property address
lusted above" the inform tiion reported (below is true, accurate and complete as of the tirne of my
Inspection; end the Inspection was performed based on guy training and experience in the proper funictic�n
and maintenance of en-site sewage dispes ll systems. After ter conducting this inspection I have determined
that the system:
1 messes
2.
Conditionally Passes
. D Needs Further Evaluation by the Local Approving Authority
4. Faiis
.
N
Jule 17 0
i u"
lr�spec o6 s rcgrrstoire „ I" fete The system inspector shell submit a copy of this inspection report to the Approving Authority (Board
of(Health or I P"P)within 30 days of completing this Inspection. If the system has a design flow f
10,01010 gpd or greeter, the inspector and the system owner shall submit the report to the appropriate
regional office of the DER The original form should be sent two the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please . ..
note. "G'"Ihrs report only describes conditions at the time of inspection and under the
conditions f use at that time.This Inspection does not address how the system will perform
in the ftrtr.rre under the same or different conditions of use.
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Commonwealth u
Title 5 Official Inspection Form
Subsurface Sewage I it l System Form Not for Voluntary Assessments
42 Old Cart Way
Property Address
Kennedy
Owner mw _ _ .�.n......., „ .,
required
y nu r" i am .. ... 0111 4 July 17, 0
r uu�r 't��i� wr
�information u� ��Andover Ili.. _—
page l y ate n.. Zip Code Date of Inspection
. Inspection
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1 System Passes.
I have not fo� and any information which indlcates that any of the f ilUre criteria described
in 310 CMR 15�.303 or in 310 CMR 15.304 exist. Any failure crfterla not evaluated are
indicated b,eiow.
System Conditionally Passes.
One or more system components as,described in the"Conditional Pass" section need to b
replaced or repaired. The system, upon completion of the replacement or rep ur, as approved by
the Board of Health, will pass.
Check k the box for "yes", "no"or'not determined" (Y, f , NiD)for the following statements, If°"not
determined," please explain.
r
The septic tank is mtl and over 20 years old* or the ptl tank(whether metal or not) is trutrrrlBy
unsound, exhibits substantial infiltration or rexfiltr° tion or tank failuire is urrirnin nt. Systern will pass
is inspection if the existing tank is replaced with, a complyingSeptic tank as approved by the Board of
kaalthr.
nnatal septic tank will pass inspection of it is stru Ctruirally sound, not;leakling and if a Certificate of
Compflance indicating that the tank is less than 20 years old is veil bl .
Y N ND (Explain below):
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YMr✓b�
Commonwealth t
Title 5 Official Inspection For
�A Subsurface Sewage Disposal System Form Not for Voluntary Assessments
YJ 42 old Cart' ay
Propea,y Address
Kennedy
Owner Owner's Name
gw for
is r e �uuredf�rsvery forth Andover e _ MA 01845July 17, 20,23
In, cf.o.
n
e. _.........
C. Inspection r (coat.)
System Conditionally passes (cont):
i u"urnp Chamber PUMps/alarrins not operational. System will pass with Board I'w'nf l...leallth approval if
p mpsialarrns are repaired.
Observation of sewage backup or break out or hii h 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 wfll
pass inspection if(with approval of Board of Health):
El broken pipe(s) are replaced E] N 0 NC" (Explain bekow):
El obstruction is removed I Y 0 IN El NCB (Explains below)„
distribution box is leveled or replaced El "Y El N E.1 ND (Explain below):
The system required pumping more than 4 tir nes a year due to broken or obstructed pipe(s),. 'rhe
system mill pass inspection if(with approvai of the Board of Health):
Ej broken pipe(s) are replaced ® Y r ND (Explain below);
obstruction is removed 'Y hi (Explain below)l:
Further Evaluation is Required by the (Board of Health'.
El 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 'f',,tb CMR
f w 1 f Ib that the system is not functioning in a manner which will protect public health,
safety and the environment:
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, Commonwealth, Massachusetts
Title 5 Official Inspection Form
, Subsurface Sewage Ills sal System Form Not for Voluntary Assessments
r �rr
g 42 Old Cart Way
Property A 6,ess
KennedyOwner .
Owner's Narrwe - -
information u Northor every Andover MIA 01 45 July 17, 202
pages. ity/Town state zip o'd dare of rnspe r�uo
,_ ._ a.� .....
C. Inspection Summary (cont)
El 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
nl . System will fall awnless the Board of Health a ublic Water Supplier, if any)
determines that the system is functioning In a manner that protects the pubilic health,
safety and environment
El The system has a septic tank and soil:absorption system twt and the SAS is within
1'0 feet of a surface water supply or tributary to a surface water swrppi .
The system has a septic tank and SAS and the SAS is within a Zone 1 of a pubillic water
supply.
El The system has a septic tank and SAS and the SAS is w ,ithin 60 feet of a private water
supply well.
El The system has a septic tank and SAS and the SEAS is less than 100 feet but 50,feet or
more fr rn,a private water supply well".
Method used to determine distance:
This system passes if the well water analysis„ performed at a DEFT certified taboratory, for fecal
oli,f r n bacteria indicates absent and the presence of ammonia nitrogen and initrate nitrogen is equal
to or,less than 5 piprn, provided that no other failure criteria are triggered. A copy of the analysis rnr.ust
be attached to this form.
c. Other:
f System Falluire Criteria Applicable to AllSystems:
wr must,Indicate"Yes"' or"No"'to each of the following for all inspections:
Yes No
,Ww Backup of sewage into facility or system component due to overloaded or
dogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
El 0 due to an overloaded or dogged SAS or cesspool
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° Commonwealth of Massachusetts
x� TWe 5 Official Inspection Form
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,s 42 Old Cart Way___
Property Addreas
Kennedy .......
Owner _
6ner"s�a,me
untarrrtatiorn A
required fired for every North Ai ndover.., m... ,_.. M.A 011845July 17„ 023
page. Cityl-row n state Zip code Date of Inspection
C. Inspection summary (cont.)
System (Failure Criteria Applicable to All Systems: (cont.)
'yes No
® static liquid level in the distribution box above outlet invert due to an overloaded
or clogged ss or cesspool
Liquid depth In cesspool is less than s"° below invert or available volume is less
than 1/2 day flow
Required puumpirng more than 4 firnes in the last year Tdue to clogged or
obstructed pi Number of times purnpe&
11 z Any port&i 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,
z Any portion of a cesspool or privy is within a Zione I of a public water supply
well,
E] M Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is lens than 1 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 DE,P certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 plum,
provided l that no ether fai'llu re 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 2000 gpol-
o the system fails. I have determined that one or more of the above failure
criteria exist as descrilbed in 310 CMR 15.303, therefore the system falls. The
system owrner should contact the Board of Health to determine what will be
necessary to correct the failure.
), Large Systems; To be considered a lame system the system,must serve a facility wltha
g y y y on addition
design flow of 10,000 gpd to 1 ,0ga gpd.
�uestions�nsectiorn 'ust indicate either"yes" tlow„ mng°., ltiorm to the.
or"no"to each of the fol
q
"yes No
El 1:1 the system is wn thin tl°feet of-111 surface drinking water supply
0 the,$yst6 is w,viftrn 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (interim wellhead Protection
Area—Iwl' ) or a mapped Forme 11 of a public water supply well
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„ Commonweal efis
Title 5 Official
Subsurface Sewage Disposal System Forum Not for Voluntary Assessments
s n y�
4.2 dd Cart Way
r''ropp rty Address _
Kennedy
Owner
Hens Namxwe
Mnfforr abon m
spared for every North Andover MA11111 01 4 ,Badly 17, 2023
page. Cityr o n state Zip bode Crate of Inspection
_ _._......�... _.... _u._.._.�___. _........_ _ _.... - -----
C. ..
Inspection r (cont.)
If you have answered"yes”to any question dry 'Section C.5 the system is considered a significant
threat, or answered ered "yes"to any question iin Section CA above the large system has failed. The
owner or operator of any Dirge system considered a significant threat under Section C,a or,failed
under Section CA shadi upgrade the system in accordance with 310 CMR 15.304. The systern owner
should contact the appropihate regional office of the Department.
. You must Indicate"yes" or pan, "for each of the following for all inspections:
"yes No
0 El Pumping 'information was provided by the owner, occuupanit, or Board of(Health
El E Were any of the system components pumped out in the previous two weeps?
Has the system received rna rmal'flows in the previous two week period"?
El E
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 mote as NIA)
Was the facility or dwelling inspected for signs of sewage back up?
Ej Was the,site inspected for signs of brew out"?
0 were ail systern~n components„ excluding the SAS, located on site?
Z El Were the septic tank manholes uuincovered„ 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 scrum
Was the facility owner(arid occupants if different from owner) provlded with
E El information on the proper maintenance of subsurface sewage disposal systems?
The ei a and location of the Soil Absorption System(SAS) on the site has
been determined based om
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 tunacceptabie) [310 CMR "D . ( )
m5ftp doo•raw 712&018 'raw@e 5 offic,,ja9 11m3pecton(Form SiLijbsurface Sq awago la„spidlnd P ago 6 of Is
Commonwealth � of Massachusetts
� Title 5 Offic"lal Inspection Form,
Subsurface Sewage Disposal al stern Form -IN t for Voluntary Assessments
42 a old Cart .air
Property Address
Kennedy.
���n, r rear ���
information A
required for every North Andover M 2023
A 01845_ -------- ----- a . u , Jul 17,
il ronn Statei
_.,..
Code Data of unspec on
D. System Infarmation
1. Residential Flow Conditions:
Number ref bedrooms (design): 4 Number of bedrooms (actual):
DESIGN flow based on 310 CMR1 . 0 for example: 110 gpd x#of bedrooms), pd
Description:Town and owner,
6
Number of current residents:
Doan residence have a garbagegrinder? E] 'Yes Z No
Does residence have a water treatment unit? 0 "Yes Z No
If Yes, discharges to: __..._._ .........e, .. _..ee..._.. m.__.
Is laundry on a separate sewage s stern? (Include laundry system inspection n El Yes 0 No
information n In this report.)
Laundry system inspected? 'Yea E No
Seasonal use7 El "Yes 0 No
'water meter readings, if available (last 2 Years usage(gpd)� : 4"O g 'o �d ---
Iatail:
m ._.
Sump pump? Z Yes El No
urrernt.
Last date of occupancy:
t;&nsp.dirao^my 712RI201 8
Commonwealthdross
.... .n. Y Subsurface Sewage Disposall SystemForm Not for' lurnt cy Assessments
Property A, dress
Kennedy
Owrmr information ns
w nee m required fired r every North Andover ,. ... ., .. ... ,_ ,........ 01 4 J i �� e„
page, '�t�lrrww' staff ... Zip Code Date or inspection
................... Information
D. System nit.
. Commerciallindustrial Flow Condifions:
Type t Establishment: _ _.._.. --
f,
Design flow(based on 310 GIVIR 1 203): per ray iqq i
� i ,of dire flow (sealsrsocn / p,.tt. eto.): .. ,, ...�..® . _
Grease trap Ipr ntEl Yes 0 No
Water treatment unit present? Yes N
It yes, d1ischarges to- _.... .. ..___ _ .. ....._
Indu tri l waste holding tank pr rt?1/', Yes No
,f
Non-sanitary waste t dischar , 10 the Tube 5 system? El Yes No
"water meter r readings ff' vail bl � ._ �. .. .......
Last date of p n y/u w Date a-_- _.
Otheir(describe bl i ^):
,Pinups ever . ...yr . Last u.ple,
Sour of inf rrrn bon: _
Was system pumped as part of the i p tilon? El Yea
If yes,, volume pur p d�: Mons
How was quantity pumped determined? �.�.� ...
Reasorh t er ur i o reed t this tnrru Staff s B� 'dole
__ _
p p
r'rfln4 p,doG mcu.712=016 Tdje 5 OfficW MspecCion For Subsurraca Sewage G isposW ystclrvw Page 8 of 18
Commonwealth of Massachusetts
:. 7
lTitle 5 Off"IcIal Inspection Form
SubsurfaceDisposal i lSystem Fora �- t for Voluntary Assessment
:, 420 Id Cart Way
---
Property Address
lnlndy
Owner 66IFnIe11 area
information u
required for every, North Andover_-.. m _.,... MA .-.._ 01845 July 17, 02
page. ity/Town State Zip Codle Date of inspection_ .. _.._ ... w. ... ..
Di. WsW I Information (corut,
Type of System.
Septic tank, distribution Ibox, soul absorption system
Single cesspool
u �
El Overflow cessg ll
Privy
El Shred system(yes,oir no) (if yes, attach previous inspection records, ifany)
Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system wave r) and a copy of latest
inspection of the I/A system by system operator under contract
Tight tank Attach a copy of the DEP approval.
Other(describe),,,
Approximate age of ail components, date installed(if known)and source of information:
ystrn us frame Jgg -3.5-
Weresewage Tudors detected when arriving at the site? ® '
Building Serer(Facets on site plan):
.ry ]YB
Depth below grade:
Material of construction:
^r, cast iron Lq 40 PVCother(,explain): --- -------
Distance from private water supply well or satin ling: feet
Comments (ran condition of joints„ vending, evidence of leakage„ etc. :.
Main Iine and joints are in good condition, no signs of any problems.
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Commonwealth of Mlassachuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluunt r w e uent
, '" 4 Cold Cart d ---_ __
Property Address
Owner enn0y--......m... rs ... m� �n..... .
Owner's Name
Worrrtl0on 6s
required for every North Andover MiA . ..,, 01 4 �. J u ly 1T" �
page. tiff l-rowwn State Zip Cade Date of inspection
D. System r t nt.
. Septic Tarok (locate on site plan):
UP
Depth below grade.
ffeet.
teteriel of construictiom
concrete D metal fiberglass polyethylene other(explain)
K �
If tank'I et 7, ii t age:
i age ( d"6 " eirtifi t�e ofCompliance? (attach copy of certificate) .Ye -,-No
TBur �enl " ° 1 10 eiloin , -
1
lurd e depth:
Distance from top of sludge to b ttoirn of outlet tee or bete
1"o
Scum thickness
Distance from top of sclurn to top of outlet tee or baffle
1 ""
Distance from bottom of scum to bottom f u,rtlet tee or baffle
Flow were dimension determined? b measurements
Comments (en pumping re ornirmend bon , iinliet and ouatfet tee or,belle condition" structural Integrity"
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank and baffles are in good general condition, The terry is running t its correct workft height.
lln.&'�.C�M °f'�Y c;f2�' 1. "roja 5 OffimaM MSpecfion Form ��L�'f.T'S"hAr$e ce Sewage Di ar?,DaW y stDM,f'sga 10'caf"f'F,
Commonwealth of MassachuseM
Tftle 5 Offic"al Inspection Form
Subsurface Sewage Disposal System Form-Cot for Voluntary Assessments
42 Old Cart Way
Property Address
Kennedy ......................
Owner' Owner.'s.IName ......------
information is
reqWred for every North Andover, MA Oil Jul 17, 2023
page. City/Town state Zip i Code Date of InspeLlion
D. System Information (coint.)
7, Grease Trap (loc,ate on site plan):
Depth Ibeiow grade: ..fee.t. .....
IJ
I Matedal of construction:
0 concrete F_] metal El fhb ass E] polyethyl �Ie other(explasn),,
............. ....................
Dimension
Scum thickness
Distance from top of scurn to top of outlet tee orbe(i
//' ,...............
Distance from bottom of scum to bottom 011166flet tee or'bafte
IDate of It pumping: .............
Comments(on pumping recomr4ndations, inlet and outlet tee or baMecondition, structural integrity,
liquid levels as related t it invert, evidence of leakage, etc.):
----
..... .....
................ ..........
8. Tight or IHolding Tank(tank must be pumped at time of inspecbon� (locate on site plan):
Depth below grade, ."
................
.........
kol Material of construction:
0 concrete D metal ........ED,fibergil E] plo[yethylem-, E] other(expWn):
Dimensions:
Capacity-
Diesigni Flow: na per day
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Commonwealth of Massachusetts
Title 5 Official Inspection
I�
�i Subsurface Sewage Disposal System Form mm Not forVoluntary Assessments
2 Old Cart Way
Property Address
Kenned
Owner Ken�s, .w. ., , �m
- w..
Information is
µ0184 Ji ui 17 202
M� �,.b�C�"d for every
page.
Ilty/ own .__ tat
il.C..."d ._ „ .
�' �d Vet of Vinsp �^twran
�D. System Information (cont.)
Tight or Holding Tank(cant.)
®�m
Alarm present. "des N
Alarm rrn leveL ..m.. Aiarrn in orlon,. rdd r:
a m.
y �
Cute of lent pu mpIn : -
Comments (condition of a,larm and float swatch's, etc
.® ��_........ .. ... -
Attach copy of current pumping contract(required),, Is op attached* Yes El No
. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level b e o utl t invert far
.,. „_..._. �w�. _...
Comments(note if box is level and distribution to,outlets qual, any evidence f solids, carryover, any
evidence of Ieakagie into or out of box, etc.),:
The d-box is 12°" blur grade and is 118"x f °". The d-box is in good working condition and shows n
signs of any problems,
t&nsp dac�ram.712C470 kd T o-t "a officW hapedlon FoRna sut*uvr ne Sewage Ctlmsr1cusal Sys.pr r Page'12 Cd 18
Commonwealth of Massachusetts
Official Inspection For
ubsur a e Sewage Disp' sal System Form Not for Voluntary Assessments
R
„ .. Id-Cart Wa
..
— .w... .,.,.. _ .. .-- ®.�..n. _ _.......
Property Address
Kenr"ed r
Owner Owner's _
We
o required frair every North Andoverrrdover _ State.- 1� Code Date 17, 2 '
of Inspection
Systemr' (cont)
10. Pom hamber(locate on site plan):
Pumps in working, rder, e
Alarms in working order. "des o*
Comments(nuke condition of p'u inp chaimbr�s �lrudltloru of pumps and appurtenances, eta.):
.w. . ..
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):
`p If SAS not io ated, explain why:
The SAS was located by as built drawin s„ d-box to level area of yard and prevl us title v from 2013.
.........
Type.:
E] leaching pits inumber
leaching chambers number:
� leaching galleries number; m._
� leaching trenches number, length:
1 - x 5 w
leachlng fields number, dimensions,
El overflow cesspool number;
E] innovative/alternative system
Type/n�arne of technology,
V&nsp.cbc rep."M25+2015 'Tilde 5 Offi i,sr lirnspacA'on Forrmn Mspos al WAWn.Page is ear"�8
Commonwealth f Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forte Not for Voluntary Assessments
2 'id art' " ._..._._
Property Address
on,nady
Owner _,m,., . __._..__ _....__.. �m. . .. .......... „ .
untarmatiorl d
required for every North Andover �.� 01 duly 17, 2
�.
..__ ... _.W� .
page. µratµ y/Town 'State a CD ode t of rrtlsprcurrrn
........
D. System
Information (cont.)
11. Sit Absorption System (SAS) (conQ
Comments (note condition of soil„ signs of hydraulic failure, level of ponding, darnp Soil, condition of
vegetation, eta
n general_ _ ...._maintained green grass
" SAS 1,� in d ral �r�dutu�� ��a�area is Ord with^ �Bl r� ir�'t.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plant):
Number and configivarstuc'n
Gpth—trap of liquid to inlet invert
T
Depth of solids layer
l ..
,
,e
Depth of scurn layer
Dimensions of cesspool _ ,� . _ _ �.
Materials of construction
Indication of groundwater inflow ''as 'c
Comments (mote condition f soH, sighs of hydraulic fail"Ur level of p riding, c nd ticn of vegetation,
etc.);
Oi nsp OM; nway."r dZ gbfl 'rnt'6e 6 OfrciN Inspecwn FW tiadlbsurrc"ce Se+awage rTinp,r saI Sysvirr, Page 14 W 18
Comirnonwealth of Massachusefts
i-
Title 5 Official Inspection Form
.. ) Subsurface Sewage Disposal System Form Not for Voluntary Assessments
rY�
42 Old Cart
-_ A.._.,.r'o erg Addr ss
Kennedy
Owner near's Name information is,
required for every North Andover MA 01845 'July 17, 2023
State Lip Code� Dare of
.. ..� ......�.
System,D. f rm t (cont.)
1& Privy (locate onsite plain):
sa
Materials of construction" �.....a.. _ �. _
Dlmensions
Depth of s,olids
Comments(mote condition of evil, Ign 6f�r r ic failure, ll v 11 f ponding, condiiflon of t tlanp
etc,):
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Commonwealthsc
Twtle 5 Off 01colal Inspectmon
l Subsurface Sewage Disposal System Form Not for Voluntary Assessments
t,
42 Old Cart
Property Address
Kennedy.-_.--,._-_
Owner Owner's 11Narne
for ever
an�tsrn ils uu�i Sara _ _...__. July 17, p
023
n»+In RHO WIII r ne fi i Cod le gnaw ....... ,..,,_
requiredoath rvd¢nwer _ I�
p cuff Il�roau tncgro
Di. System Info (coat.),
14, Sketch Of Sewage Disposal System:
to
Provide e view of the sewage disposal system, including ties to at least two pernrn nwernt reference
landmarks or benchmarks. ILoo to all r elll wfthlrn 100 feet. Locate where public water supply enters
the bufldn"rn . Check one of the boxes below:
hand-sketch in the area below
drawing tt ched separately
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Comimonwealth of Massachusetts
Title 5 i l Inspection Formi
r Subsurface Sewage Disposal System Form °. Not for �rlurwt Assessments
., l' art
Property 66r'ews
Owner & ernrned
r n r's Name
information its
requ v d for every �.....,. _..e.._, .. .e — - DateJul taro,
page. Aty)Tow n rotate &p d wa Dat 1 ,-
�t�zrthw ,rwdaver I g1
pacruoin
D,. System Information (con�t.)
15. Site Exam:
Check Slope a rd$161/
°r
Surface water j0 ° Pe.
Check cellar
h llow wr,,reli's
'
Estimated depth t h hi ground water: f"
Meese indicate all methods used to determine the high ground vaster elevation!
Obtained fr non system design plans on record
if checked, date f desigin� plan reviewed: / /
88 m.e..e_, _.._.._._ . _ _ �.,.._.
ante
Observed site (abutting Iproperty/observation hole with irn 1510 feet of Vie )
Checked with tocal I waerdl of Health-explain:
errnnt'___prqp sed, esbuilt and previous title v from 7/1/131
Checked with local excavators, installers- (attach documentation),
Ej Accessed USG USGS database -expla n
u must des,ciribe how you estebiished the high ground water elevation:
Basement is 7° below grade w;vuth a sump pump. Original i design from 1988 showed I SHWT at "
below grade. The back yard was raised Tat the time the system was installed for e depth of ESHVTF
of 1' belt grade.
Before til'W9 this Inspection Report, please see Report Completeness Checklist on next page.
t xa .��d ^raw B t 'k S .a"itPa 6 d th'; i R du e� c&hprr Forcm.Su,JbAlArfaire&,rova� ICF7Y��pos71 System°��tkge't7 art vr°7
ommonwealth of Massachusetts
Title 5 Official Inspecittion, Form
1-4"V
J
Subsurface Sewage Disposal to a Form -' oit for Voluntary a e arnenta
"" 4 Old Cart Wad
Owne Kennedy"'',
unfrarrn tarn} n r'a Na
me
required for every NorthAndover .. -- _. ..,,.ee. 0184 ®e., JWy_"t , q23
page. i, & w'n ;state Zip fade biiie of lnsp tiara
E. Report Completeness, Checklist
Complete al9 appil le sections of th Is form Inclusive f:
A, Inspector information: Cornplete all fields in this section.
El . Cerdficafiom Signed & Gated and t, 2, 3, or cheicked
C. ans,pection S urnlrrnalr :
t, 2, 3, or d completed as appropriate
4(Failure Criteria)and 6(Checklist) cornpteted
D. System Information:
For : 7u htlHoldln l Tank— Pumping contract attached
For 14: Sketch of Sewage Msposal Snyatern drawn on p . 16 or attached
Fair 15: Explanation of eatlrrtated depth to high groundwater lrn luded
rev 7126a2012 'rjVe 5 Official Nipedii sys win Page rrt a f 18