HomeMy WebLinkAboutFail - Title V Inspection Report - 40 DUNCAN DRIVE 8/10/2023 Commonwealth of Massachusetts
d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assess r e t5
40 DUNCAN DRIVE "
Property Adorers
_........ ................... _..... _ _ . ...
KAREN MELLO
Owner ner"s Narne
reqiefinformation Is NORTH ANDOVER P41A 01845 AUGUST 10, 2023
required tear every ,. �_.. ..._. ... _. _ _ ...._._ �..� ....... .
page. Crtyffowvn State Zip Code Crate 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 form.
lmperrtant When A. Inspector Information
fOng out forms
on the computer, Todd James Bateson
use only thus tab __.
key to move your Name of Inspector
cursor-do not Bateson Enterprises Inc.
use the return _._.. _.___ __
key. company Name
_ 111 Argilla Road
t Company Address _
Andover MA 01810
1 p CrtyfTown State Zip Code
� 78 7 -4786 SI-15
"retlephone Number Ucense Number
____.__..._._._ _ ...._... .......... .. .......... __.._._......_,. _.. _ _w.w....,.,_ .,.,_,_.,... .. . .... ..... ........ ......_..,_ . _..._.
B. Certification
I certify that: I arm a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personaiiy inspected the sewage disposal system at the property address
listed above„ the information reported below is true accurate and complete as of the time of my
inspection„ and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. 0 Passes
2. n Conditionally Passes
. Needs Further Evaluation by the Local Approving Authority
4. Fails
AUGUST 10, 2023
dnspe r`s Slgnatur mate
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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use,
u5insp oic*aev.AP kv"e'M TOW 5 OffwiaaR hsfx,,dxri rsam:Subsufa^ ice Sewage ffispasas System-Page 1 0 18
_....... ......... . . ......... ..............._._...........................,_....._.....____W..,....._..................
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
A40 DUNCAN DRIVE
Propeny Address
KAREN MELLCO
Owner Owwaaer"s Name
information is
requor�;.d for every NORTH ANDOVER MA 01845 AUGUST 10, 2023
aer„Tu _ __
raage, City(T' wrr State Lap o 4 code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 0.
1) System Passes:
[�] Y have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CNIR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
[ . 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.
`l [ N ] ND (Explain below):
V,mn pdoc-fev 712ti/2018 rice 4',f roftfc"a l 6r'rssrruufr n orm ;auk'mufface Sewage Disposal System-Page 2 0 6
ammonwealth of Massachusetts
`title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm Not for Voluntary Assessments
40 DU CAN DRIVE
Property Address
KAREN f ELLO
Owner Owner's Name
&8 f required
u�r NORTH ANDOVER MA 01545 AUGUST' 10, 2023
te��riredect for every
page. City/Town State Zip Code fate of lnspectgrn
C. Inspection Summary (cant.)
2) System Conditionally Passes (cant.):
Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
�.....� Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
broken pipe(s) are replaced �....._� Y N ND (Explain below)
„m obstruction is removed E N ND (ExpVain below)'
distributiion box is leveled or replaced (_._� YEj N 0 ND (Explain below):
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 F7 N ED ND (Explain below)
3) 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 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment;
tl xmr„p doc•rev 7f2612018 160 5 O fw ins 1r°4„aS7edfoir r omin suhswface Sevvtege Disposal system-Page 30't6
NN" Commonwealth of Massachusetts
l(p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
40 DUNCAN DRIVE
Property Address
KAREN MELLO
Owner Owners N arne
information,'ws.
required for every NORTH ANDOVER MA 01545 AUGUST 10, 2023
page. atyrf own Mete Lp Code Date of urlspeobon
C. Inspection Summary (cant.)
. 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
i System will fail unless the Board of Health (and public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
The system has a septic tank and soil absorption system (SAS) and the SAS is within
1.00 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.
._ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply weld.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
fnore from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a CEP certified iaboratoryr, for fecal
coliforrrvn 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 criterua 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
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
0due to an overloaded or clogged SAS or cesspool
t„'+mrxp doc-rev 71260018 1ale 5 cmicai fnww,,tion 6-orrri ,�uGA;�t,ovi�¢.w�"�wK���a l)js,o al nystfin•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
M Subsurface Sewage Disposal System Form - Not for Voluntary Assessrrients
40 DUNCAN DRIVE
Property Address
KAREN MELLO
Owner Owner's Name
information is NORTH ANDOVER MA 01845 AUGUST 10, 2023
required for every .... _
page Cityrfown State Zip Cade Date of Inspection
_.......,w.._._..��. _._.
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cant.)
Yes No
Static liquid level in the distribution box above outiet invert due to an overloaded
or clogged SAS or cesspool
El z Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
z ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
E ® 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 a Zone 1 of a public water supply
well.
CJ z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
z The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
z E] The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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
0 [_] the system is within 400 feet of a surface drinking water supply
❑ El the system is within 200 feet of a tributary to a surface drinking water supply
7 ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone 11 of a public water supply well
t5 nsp doc^rerou.MW2018 t ikVe 5 OfficiM Inspa¢„ction r+t„em.Su„8asuffacee Sewage Dspusza4 System^Page 5 of 18
Commonwealth of Massachusetts
x , : Title 5 Official Inspection Form
�nV Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 DUNCAN DRIVE
-- . .. ...
Property Address
KAREN MELLO
Owner
Owner's Name
information is required for every NORTH ANDOVER MA 01845 AUGUST 10, 2023
page. City/Town State Zip Code Date of Inspection
............_...._...........w.w__..... _........_._ _.
C. Inspection Summary (cant.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15,304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no" for each of the following for all inspections;
Yes No
F� 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?
Z U Has the system received normal 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?
El Z Were as built plans of the system obtained and examined? (If they were not
available note a N/A
* 0 Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ Were all system components, excluding the SAS, located on site?
Z F-1 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 scurn?
Z 1:1 Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Z ❑ Existing information. For example„ a plan at the Board of Health.
Z EJ 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)]
t5insp doe-rew..7126f2018 Twee 5 Offiicial Vr•ispeo*n roan'.Subsurface Sewage D, sposFM System•Page 6 of 18
Commonwealth of Massachusetts
i� r�z Title 5 official Inspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
40 DUNCAN DRIVE
Property Address
KAREN MELLO
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 AUGUST 10, 2023
..
page City/Town State Zip Cade Crate of Inspection
D. System information
1. Residential Flow Conditions:
Number of bedrooms (design): NA Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA
Description:
Number of current residents: 1
Does residence have a garbage grinder? [l Yes Z No
Does residence have a water treatment unit? Z Yes ❑ No
If yes, discharges to: LAWN
.............
Is laundry on a separate sewage system? (Include laundry system inspection El Yes Z No
information in this report.)
Laundry system inspected? El Yes Z No
Seasonal use? ❑ Yes Z No
Water meter readings, if available last 2 ears usage d WELL
g ( Y g (gp ))
Detail.
Sump pump? 0 Yes Z No
Last date of occupancy: CURRENT
p Y rate
t5rsp.¢Iac-rev 1P26Q01 S l`flYe 5 Official InspeacWn Farm.Sutasurt'a ce Sewage Disposal Systern•Page 7 d 18
Commonwealth of Massachusetts
m °Ti°tle 5 Official Inspection Form
ptr, Subsurface Sewage disposal System Farm - Not for Voluntary Assessments
40 DUNCAN DRIVE
Property Address
Owner Owner's Name
inforequrr dfor Ps NORTH ANDOVER MA 01845 AUGUST 10, 2023
reyu6red far every _.. ..
page. CMtyf own Skate Lpa Cade bate of InspaeaftEan
_,._, ...._... .... . ..... _._.. .. _........_.... .. ... ......... _. _...
D. System Information (cent.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
6aBperns per day(gprcp)
Basis of design flaw (seats/persons/sq.ft., etc.): _
Grease trap present? [_] "Yes [_� No
'Dater treatment unit present? El Yes No
If yes, discharges to:
Industrial waste holding tank present? [ Yes No
Non-sanitary waste discharged to the Title 0 system? El Yes Fj No
'''Dater meter readings, if avaiVable
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information SPRING 2022, OWNER
Was system pumped as part of the inspection? [_� Yes ����� No
If yes, volurne pumped gaIIIons
How was quantity pumped determined? _
Beason for pumping:
t,)in p a90 c•iev.7Q6t2018 tl u o 5 offucwe Bnygltu.Kc¢ n room.Subsurface Sewage GJv%m al Syma.n-f'w9ge 8 0 t8
Commonw ealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
a, 40 DUNCAN DRIVE
Property,address
KAREN MELLO
Owner Owner's Dante
oequiredfo NORTH ANDOVER MA 01€345 AUGUST 10 202;3
oec,�ur0�'ed far every _
page CO/town Mate zip code Cate of Inspectoon
D. System Information (cant.)
4. Type of System.
z Septic tank., distribution Sax, sail absorption system
Single cesspool
E_1 Overflow cesspool
El Privy
._. Shared systern (yes or no) (if yes, attach previous inspection records, if any)
El 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
�_,I Tight tank. Attach a copy of the DEP approval.
,..._] Other(describe):
Approximate age of all components, date installed (if known) and source of information:
39 YEARS„ INSTALLED 1984, EXISTING TITLE 5 ON FILE
Were sewage odors detected when arriving at the site? E_1 Yes Z No
5. Building Sewer(locate on site plan'):
Depth below grade: fed
Material of construction
Z cast iron C � 40 PVC f,.....m other(explain):
Distance frorn private water sr,rpply well or suction line: feet
Cornments (on condition of joints, venting, evidence of leakage, etc.):
JOINTS AND VENTING OK
NO EVIDENCE OF LEAKAGE
G"'kdv&p 9tl.c rev.712Ep/2016 T uVIi.5 r)f'{f°11 fnspflclawl Fwrl SoNa"p Disposal S"Ier'1'^age 9(A'I pl
.... .................................._........_............._..................._ ,...,,,..., ...... ........,...,.., ............... _
�'ON' Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
t
40 DUNCAN DRIVE
Property Address
KAREN MELLO
Owner owner's Name
requiredrro fo is
irrtortorevery NORTH ANDOVER MA 01845 AUGUST 10, 202
Page C 4y/ own State Zips Code Date of Inspection
D. System Information (cant.)
Septic Tank (locate on site plan):
Depth below grade:
feet
Material of construction:
concrete 0 metal El fiberglass polyethylene other(explain)
If tank is metal, list age years _
Is age confirmed by a Certificate of Compliance? (attach a copy of Certificate) [ Yes [ No
Dimensions: 4 _
Sludge depth: 8"
Distance from top of SILidge to bottom of outlet tee or baffle 0 _
Scum thickness
Distance from top of scram to top of outlet tee or baffle
Distance from bottorn of scorn to bottom of outlet tee or baffle
'6?"
Now were dimensions determined? TAKE MEASURE AND SLUDGE
,FUDGE_
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
SYSTEM IN FAILURE
CONCRETE INLET BALFFLE OK
CONCRETE OUTLET BAFFLE DETERIORATING
TANK OK
NO EVIDENCE OF LEAKAGE
INLET RISER COLLAPSING
LIQUID LEVELS OK
t5irrtrg>,doc,rev T11W201 t1 'h0o 5 Official inspection F ov'rri Subsurface Sewage Disposal System•Page 100 18
Commonwealth of Massachusetts
Title 5 Offid l InsplecUon Form
( r: } Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Gw 40 DUNCAN DRIVE
Property 4ddress
IAREN MELLC
Owner Owner's Name
required
as NORTH ANDOVER MA 51845 AUGUST 15, 2I028
pr�ureei far every
ape y p e of Inspecfion
CIt fTcwaror .. .............. .._. _._....... ......._.. .. ....�.. State _....._.,..�g .bode . . C)at......._..._.. _.�_ ....._....._. . .._ _.
D. System Information (cant.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction
concrete Ej metal 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 last pumping:
Jute
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:
[1 concrete [.-1 metal 0 fiberglass polyethylene Ej other (expla'in)�
Dhniensions: _
Capacity:
gallons
Design Flow: gallons per day ..
ISwiw.{a dor•rev 7126 C'a 6 Py1e 5 0 ffi.^.opal Vn 5peca tor a Form.Sarhs+ua,I ace So ,age D,sp<ImaI Sy'slenn-Pa,rge 11 of'f B
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 DUNCAN DRIVE
Property Address
KAREN ME._... LLO
_.. .. ._......
_.
Owner Owner's Name
information is NORTH ANDOVER MA 01845 AUGUST 10, 2023
required for every .. ..
page City/Towc7 —_-State Lap Cade Date of Inspection
_...._.a .... .......... ... ....... ___._
D. System Information (coat.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes E No
Alarm level: _ _ -- Alarm in working order: Q Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
_ _.... .
.-
Attach copy of current pumping contract (required). Is copy attached? Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan).
Depth of liquid level above outlet invert 1,
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-BOX HAD HEAVY SLUDGE BLOCKING FLOW LINES
PIPES CLEANED OUT AND RAN CAMERA DOWN:
FIRST PIT FLOODED
SECOND PIT 6" FROM FLOW LINE
THIRD PIT LINE HAD ROOTS, COULDN'T GET TO PIT
DISTRIBUTION NOT EQUAL IN D-BOX
EVIDENCE OF LEAKAGE
D-BOX DETERIORATING
INSTALLED NEW D-BOX COVER
15insp-doc rev,7I2892018 T4sle 5 C7ffh.W Inspection Foram SUbsurlaco Sewage Dsp sai Sys€e m-Papa 12 of'18
Commonwealth of Massachusetts
rta ,4µ Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
40 DUNCAN DRIVE
Property Address
KAREN MELLO
Owner (7wrler's Name
Information is required for every NORTH ANDOVER MA 01545 A U G ST 10 2023
page. City/Town State Zip Code Date of Inspection
__..._........_.....
....___.__
D. System Information (cant,)
10. Pump Chamber(locate on site plan):
Pumps in working order: [,_] Yes 0 No*
Alarms in working order: [] Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11, Soil Absorption System (SAS) (locate on site plan„ excavation not required):
If SAS not located, explain why:
Type:
z leaching pits number: 3
F] leaching chambers number:
F] leaching galleries number:
[� leaching trenches number, length:
[� leaching fields number, dimensions:
El overflow cesspool number: _
E] innovative/alternative system
Type/name of technology:
t!l,ilrisp doc rev.712'612018 1 Me 5 Official Inspect on rkrmr Subsurface Sewage DispusW System•Page'13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
f Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
. 40 DUNCAN DRIVE
F'ccrperky Address _
KAREN MELLO
Owner Owner's Name: _ .......
_
Vr1f r'rYtatf on ds
required for every NORTH ANDOVER MA 01545 AUGUST 10, 2023
pane, cstyrrowrl State Mp Code [late of Inspection
_. .......... _ _. ...
D. System Information (cont.)
11. Sail Absorption System (SAS) (cant,)
Comments (note condition of sail, signs of hydraulic failure, level of ponding„ darnp sail, condition of
vegetation, etc,):
SOIL WAS WET AND wA-rER FROM WETLAND WAS ENCROACHING IN LAWN
EVIDENCE OF HYDRAULIC FAILURE
NO EVIDENCE OF PONDING
12. Cesspools (cesspool rnust be pumped as part of inspection) (locate on site plan);
Number and configuration
Depth .-top of liquid to inlet invert
Depth of solids layer
Depth of SCUM layer
Dimensions of cesspool
Materials of construction
Indication of groundwater Inflow � � Yes No
Cornments (note condition of soil, signs of hydraulic failure, level of pond'ing, condition cf vegetation,
etc.)
f5or spr.dn r,-rev 7Y:?CroA2016 .6..kt'f5 s rYlir,1k Or^nr8yarr.Poia.err 6r ulrue7 xuE:9:dY.N"fa'S'kb"a"au*rrrllr r.YRts�aessan 9!;yC:a rrr &'"aq,}a 1"1 a'+r`rift
` Commonwealth of Massachusetts
fi Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 DUNCAN DRIVE
Property Address
KAREN MELLO
Owner
Owner's Name
information is NORTH ANDOVER MA 01845 AUGUST 10 2023
required for every _...- .. ----_.
page. City/down State Lip Code Date of Inspection
_..v.._.. ....,_ _._._._._. __...,_._
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 ponding, condition of vegetation,
etc.)
t5'msp.doc-rev h2612016 Title 5 Offio6el inspection Fufm S ubsew laces Sewage Dsposal System-Page 15 of 18
Commonwealth of Massachusetts
I Title 5 Offoici l Inspection Form
Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
ti
40 DUNCAN DRIVE
_.__ ......w_ ._._w_...W _...v..._..___ ..__._....__._... __.._........ ..........__ _.._._.._.._.w__..._ __ _ .... .. ._..w.__._.__._._.
f�raperty Address
KAREN MELLO
Owner Owner's Name
�na6requiredrrfo is NORTH ANDOVER MA 01845 AUGUST 10, 2023
orevery ......._ __...w,_..__ __..._......�...__...___..__ ....._. ___.... .w......_____ m............... ,......_....._... _.........._ _.._...___....__ _........_....._....
page.
Gty/Town State Zp Cade mate of Inspection
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:
Z hand-sketch in the area below
drawing attached separately
W,r n
A
1rrc -1-
_. cjpl
31
t
A - J4(d 2. � r
(AVQ,4 551 3 03
At1 p
C 4-7 a
o
____ ._.__._____ ______......_ -- ..���.___ _.
t?,4nspa.rbw� o my '7126/2018 `�ue 5 CbM6'kiai 4)sp ectc on Form:Subsurface ace Sewage r)Gr��+sM System•Page 16 of 18
,tom , Commonwealth of Massachusetts
r �r Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� r
40 DUNCAN DRIVE
l5r0perty Adrtress
AREN MELLO
Owner Owner's Name
inforequired
as NORTH ANDOVER MA 01845 AUGUST 10, 2523
requireei for every _ _
page City/Town state Tip Code Efate at fnspectnon
D. System Information (cont.)
15. Site Exam:
Check Slope
W Surface water
Check cellar
[ , Shallow wells
Estimated depth to high ground water: 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: . _
t7ate
w] Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
PREVIOUS TITLE 5 ONLY
E. Checked with local excavators, installers - (attach documentation)
Accessed USES database -explain:
ESSEX COUNTY SOIL MAP
You must describe how you established the high ground water elevation
BOTTOM OF LEACH PIT ESTIMATED TO BE 4, ' IN GROUND
WETLAND WATER 30' AWAY ENCROACHING ON SURFACE OF LAWN
LEACH PIT CLOSEST TO WETLANDS IN WATER TABLE
PIT FLOODED
Before tiling this Inspection Report, please see Report Completeness Checklist on next page.
t5fnsp doc:•rev,712W2016 1410�Offrco� Inspection 6'eaan.S ubsurlace";,ku,wrage d7o,up=0 S"teo-m•Pagel/of 16
Commonwealth of Massachusetts
Iw T I -le 5 tlffiial Inspection Form
Subsurface Sewage Disposal Systern Form - Not for Voluntary Assessments
40 DUNCAN DIVE
Property Address
KAREN ME1.,L
Owner Owner's Name
information is
required for every NORTH-1-AN DOVER MA 01845 1 AUGUST" 10, 20,2
page C ity/'town Estate Zip Code Date of Inspection
............ ............w....._... ...... .....__............ ..._....._ .. _..,. . ....,._.__._..._. .,., .. _....... ._....._....,. ........ ......._ ......_, _.....___..... .........,_.,....�......_..._...._._..,,........m,_,.......
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
Z A. Inspector Information: Complete all fields in this section.
Z S. 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
Z 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
f5arsp doc-rev l/26y�)18 r itCk',,", Official Irispeec h nt&orri .ac bsii Sewage Disaos av Syst ern•Page'f 8 of 16