HomeMy WebLinkAboutPass - Title V Inspection Report - 72 PHEASANT BROOK ROAD 10/16/2023 FILE #
TITLE V INSPECTION
Dean G. Lius 11 & Sons
288 Maple Street
Middleton, MA 01949
978-774-4065
Title V License # S18,48
SUBSURFACE SEWAGE DISPOSAL sys,rEM INSPECTION FORM
PROPE,RTYOW'NERS NAME
PROPERTY ADDRESS
f
DATE OF INSPECTION
.................
jr,",
NAME OF INSPECTOR
Commonwealth ssachusetts
Inspection
7,lSubsurface
r
Sewage Disposal System, Form Not for Voluntary ss ssm nts
72 pheasant Brook Road �..._
property/Wduess
uell tt
Owner Owner's rrne
e. . . ....
Warrnation is
required for every North Andover MA 1 October r
, 2023
..
page, Ciiyffown up Code Date of Inspection
Inspection results(must be submitted on this form. Inspection forms may not be altered in any
way. please see completeness ss checklist at the end of the form.
knipormarmt.VVh rrA. Inspector Information
fuhmnrmg out forms
on Uie computer,
use only the tat Dean G. kuscom�rmb lii
marry�t�c irmiowe your NW 11 smr of mnsp C6'
cursor-do runt Dean 0. Lmascr rn'd li &Sans
use the r t rug
key. Company Name
m Maple Street
Company Address
Middleton A. m Mew _ 01
949,
dityrr
_.owwmu�.. _ sty _. - Zip ortus
-_
7 ..7'7 - 5 ty ,,..
telephone mWuirnm' r License Number
CertificationB.
l certify that; l am s DEP approved system inspector in full compliance with Section 15.340 of Title
(310 CMIR115. ; l have personally inspected the sewage disposal system at the property address
listed al ms„ the information reported below is true, accurate and complete as ofth tirn of rrm
inspection; and the inspectionmss perform based on my training and xp ri nce mn the prop r furmc'ti�n
and maintenance of on-site sewage disposal systems. After conducting this inspection, EI have determined
that the systrrm.
1. [,xl Passes
Conditionally Passes
. P Needs Further Evaluation by the Local Approving Authority
Falls
2u u u m m' Vsr t
r Octo00
bersr
m pCtoYsSigirIarrre
Date
The systems inspector shell submit s 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 s assign flaw of
10,000 gpid or greater, the inspector and the system owner shall submit the report to the appropriate
r guc nW office of the DER The originW form should be sent to the syst rn omm r and copies sent to
the buyer, if applicable, and the sppovMg authority,
Please note This report only describes conditions at the time of inspection and under the
conditions f use at that time.This Inspection dies not address how the system will perform
m
i the future under the same or different conditions of use.
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sw Commonwealth of Massachusefts
Title 5 Official Inspection Form
* Subsurface Sewage Disposal System, Form Not for Voluntary Assessments
J
�., 72 Pheasant Break lead _
Property �tr�ire�s
Ouellette
Owner ownersNai-me-'
Mormetion i
required for eveiy North Andover �..ae w, _ de... MA-1-11 01845 October 31,12023
page. RY/T wri p
State �ii ode Date of Inspection
C. Inspection Sum r
Inspection Summary: Complete 1:1, 2, 3, or 5 and ali of 4 and 6.
1) System IPassesm
l have not found any information wMch indicates that any of the failure criteria described
in 310 CMR 15.303 or in 3110 CMR 15.304 e lst, Any failure criteria not evaWated are
indicated below.
Comments:
a
tr�
� ) S,ystem Conditionally Passes;
one or more system components as described in the "Conditional Pass" section Sneed to be
replaced or repaired. The systTern, upon completion of the replacement,or repair, as approved by
the Board of health" will pass.
C�heck the box for"yes", "no"' r"runt determined" (Y, N, IND)for the fallowing statements, if",not
determlined,"r please explain,
The septic tank is metal and over 20 yearsold* or the sepfic tank(whether metall or not) is strtuatUally
unsound, e hOits substantial infiltration or e filtratueun or tank failure is imirminemt. Systernwill[ pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
omplianiae 40catlngi that the tank is less than 210 years old is available,
E] Y [I N E] ND (Explain below):
�qinap drac,uaw W&201 T3
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Commonwealth of Massachusefts
.w yTitle 5 OfficialFor
Y;
9l Subsurface Sewage Disposal sal System Form - Not for Volurnt ryAssessme nts
,.
72 Pheasant Brook Ind
Property Address
Ouellette
Owner Owier's Name
informaboin is
required for every
North,Andover --
page _ trine pup Code Date of Mspecglon
C. Inspection Summary (co nit.)
System Conditionally Passes (writ,):
Pump Chamber pumps/alarms riot operational, System will pass with Board of Health approval if
purnnps4srms are repaired.
* Observatron of sewage backup or break out or high static water level in the dlstributio n bore due
to broken or obstructed POW,or due to s broken, s ttl d or uneven distribution biox. System will
pass inspection if(with approval of C and of Health):
„ bunker, pip (s), are r pisrn d Y El N El fit' (Explain below):
obstruction is removed
j Y ® t (Explain bel w '�):
distribution box is leveled r replaced Y El N 0 ND (Explain bellow):
The system required pumping more than 4 times s year due to broken or obstructed pips(s). The
system Mll pass inspection if(With approval of the Board of ' slth,)i
broken pipe(s)are replaced [:1 Y' E N F� N (Explain below):
obstruction is removed Y N ND (Expiain below):.
Further Evaluation is Required by the Board of Health:
t ondintlo ns exist which require further evaluation by the Board of Health in order,try d t rmr n�n if
the system is failing to protect public health, safety or the environment.
s, System will pass unisss Board of Health determines in accordance with 31 M
15.303(1)(b)that the system is not functioning In s manner which will protect public hiealth,
safety and the environment,
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Commonwealth of Massachusetts
a l Subsurface Disposal System, Form
®bleat for Voluntary Assessments
72 pheasant Brook c d
Property Address,
Ouellette
Owner _ .
Owner's 'erne
Wormation as
r quitlred for,every North ndp r _®.. ...._. _ e. 011845 October , 20 .
page. Ch'y"IT,-o' n state Zip Code Date of Inspection
Inspection Summary i(cont.)
Cesspool or privy is within 50 feet of s surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wefland or a salt marsh
bm System will fall unless ft'm Board of Health fared public Water Supplier, if arty)
n determines that the system is functioning in a manner that protects the Ipubil he lth,
a safety and environment:
The system has s septic tank and stall absorption system (SAS) and the SAS is Mthin
1 O�O feet of su rfse water su�ply or tribu tary to a surface ter su ppi
y
The system has a septic tank and SAS and the 'SAS is within a Zonle 1 of s public water
supply.
E3 The system has s septic tank and SAS and the SAS is within 50 feet of s 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
moire from a private water supplywell".
Method used to determine distance:
This systertt passes if the well grater analysis, performed at s IDEP certified laboratory, for fecal
coliftarm (bacteria iindmcstes absent and the presence of ammonia nitrogen and nitrate maitro en is equal
to or less than d ppirn, provided that no other failure criteria are triggered. A copy of the analysis,must.
he attached to this form,
c. Other:
System Failure Criteria applicable to All Systems'
You Mug indicate"Yes" or"No" to each of the followingfor all inspections:
pr+
J
l Yes No
Backup of sere into facility,or system component dine to ovierloaded or
clogged Saga or cessplooil
Discharge or ponOng of effluent to the surface of the igrouniid or surface waters
due to an overloaded or clogged SAS or cesspool
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Commonwealth of �Massachusetts
6 MIS ace l s For
rubs urfa sagie Disposal Systeni IForm - Not for Voluntary Assessments
712 Pheasant Br-Road
Property Address
dual latta
Owner owner's n is Naive
hfarmabrequired o r every is North Andover 0.1 8,45 O tirab r , 202
f m .row"n"', State Zip Code Date of ecfiaarry -_ —
Inspection Siummary (Cont,)
System Failure Criteria Applicable to All Systems: (anent.)
" ups No
l E Static liquid levee in the distribution box above outlet invert rt due to an overloaded
r clogged SAS or cesspool
Liquid depth in cesspool is less than " below invert or available VOlUme is less
than 1 z day flow
Required pumping more than 4 times in the last year NOT dine to clogged or.
lbtruucta,d pip ( ). Nurrubr of times pumped:
Any portion n of the SAS, cesspool or privy is below high ground water elevation,
5
1/
.any portion of cesspool or privy is within 10 feat of a surface water supply or
tributary to a surface water supply.
niy portion of a cesspo6 or privy is within a Zone I of a pUblic water supply
well.
... Any portion of a cesspool or privy is within dg feet of a private water supply well.
niy portion of a cesspool or privy is lass than 100,feat but greater than bti feat.
from a private water suppiy well with no acceptable°water qualiity analysis. (Timis
systems passes if the well water analysis, performed at a DEP certified
laboratory„ for fecal collform bacteria indicates absent and the presence
of amrrmo,nila nitrogen and nitrate nitrogen Is weal to or leas than 5 pprrr,
provided d that no other r failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this f' rm
l The syst rn is a cesspool serving a facility wtth a design flow of 2000,gpd®
"10,000,gpd.
The system falls. 1 have determined that one or miore of the above failure
criteria exist as described in 31 MR15.303, therefore the system fails, The
system ownl r should contact the Board of Health to determine what will b
necessary to correct the failure.
') 'Large Systems., To be considered a large system the system must t serve a°facility with a
design flow of 110,000 gpd to 15,000 gp a
For la rge systems, you rmu t indicate either"yes"„ r"no"to each of the'f l l a ing in addition to the
questions in Section tom. .
"yes N
i f „ the system is within -g ifs t f a surface drinking water supply
f,
the systrn is w�vithin a featf us tributary to a surface drinking water supply
t locatednitrogen sensitive area(Int� rlr Wellhead
Area—IWP )or apped inns 11 of a public water $Upply well
25jnsp,d re 7t,�"�ia'2016
Titk-;5 rPrrijaaa Inspe"ton Foamub5i+jftce^sawAge oivt 1�aa�n�Sysy Rm.P21,e;5 vat 18
° Commonwealth, o ' � use
Title �li l Inspection For
lSubsurface I isposal stem Farm Not for oluuntar Assessments
w: 2 pheasant Brook Road
Pr pen AA idre s
Ouellette
Owner - �, .... _._... m e _
Owner's Name
information is
reg,rclrsd for every North Andover �66 l,ill, October ,. d .
page, City/Tow n
Inspection
s.. ecti o �Sum 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 Marge system considered a significant threat under Section C,5 or failed
under Section CA shall i upgrade the system in accordance with 310 CMR 15,304, The system o°wwrneir
should contact the appropriate regional office of the Department.
6. You must indicate "yes"or"no" for each of the following for afl inspections,,
Yes No
Pumping information was provided!, by the owner, occupant, or Board of Flealth
Were any of the system components pumped out in the previous two weeks?
Has the s stern received normal flows in the previous two week period?
Have large volumes of water been introduced to the systern recently or as part of
thiis inspection"?
D Were as built plans of the system obtained and examined? (If they were not
available note as NIA)
VA El Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out?
Were ail 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, delpth of liquid, depth of sludge and depth of scvduM?
Was the facility owner(and occupants if different from owner) provided Mth
information oirn the proper maintenance of subsurface sewage disposall systems?
'rhe size and location of the'Soil Absorption System (SAS,) on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health,
9 etermilned in the field (if any Of the failure criteria related to Part C is at issue
approximation of distance its unacceptable) [310 CMR1 • ( )]
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Commonwealth of Massachusetts
T"fle 5 Official Inspection Form
9y i� r
1 Subsurface SewageDisposal st rn Form
Not Voluntary
72 Pheasant Brook Baud e e.
Pirop,c�i'y address
Ouellette
Owner Omers'�_am'e
hforrrw nur n is
required d for, weary forth Andover g1 October , 2023
m._ m _
page. it �Towns f to rb
. ......_ _�..._�..... ..._... State Zip oade mists n rpw, —_. ....... _
SystemD. Information
1. Residential Flow Conditions:
Number of bedrooms (design), 51 _ Number of bed,roorns(actual):
:
DESIGN flow based on 3101 1 . g (for xarn"npl : 11 10 gpd x of b dro rrns):
gpd
Description:
Town and owner.
Number,of current residents: m...
Does residence have s garbage grinder? Yes No
Does residence have a water treatment unit? "
es No
If yes, discharges to:
Is laundry on s separate sewage system? (Iniclude laundry system iinsp cdon Yes `" N
information In this report.)
Laundry system inspected? "Yes
El No
ss nal rasa? El Yes Z No
0111,
Water master readings, if av amlabl last 2 years usage(gpd)), _
Detail:
Sump purrnp? E] "Yes 0 No
current
Last date f occupancy:
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e
Commonwealth of Massachusofts
TMe 5 Official Inspection Form
r w �
J. Suibsurface Sewage Disposal System " ri m Not for Voluntary Assessments
72 Pheasant Brook Road
Property Address
uulitt
_.._. a .......... ....
Owner ner Owner's Narne
rifalr o is
required for very North Andover MA 01845 October 2023
r� do cr �� IDate specfion
_._._
rr If i .
u rm r t iJindustrial Flow Conditions:
Type of Establishment: _
De
sign flow(based on 1 I 15. 0113): anurlr"s per day
Basis of design flow(seats/p irs ns/sq,ft., etc.):
Grease s trap present?,,, Yes
El No
Water treatment unit pr s 0, Yes Igo
ifies, discharges t
industrial wastle holding tank prasamt�,; � Yes � No
o
lion-sanitary waste dis har sd to the Title d systamt',,,,,,,,. El Yes N
Water meter readings uf�a sulabla:
Last data 9f occupancyluse, ate _
Other(describe below):
. Pumping Records:
Last pu pad 5 yr
Source f information; _ ego.
w�
Was system pumped as part of theinspection? has �' A
f �
if yes, vo urnie pumpeda bans_ _
How was quantity pumped determined
No need at tfuis tirme. Stay_on s i�nadu�l
Reason for p i
pg,l n _ ... ®m.. _
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k�arbs«hro�„xr,•raw 7(260,018
Comminnwealth of Massachusetts
Title 5 Official Inspection Form
.. j Subsurface Sewage isp sal System ponce72 �Not for Voluntary Assessments
r
Pheasant Brook Road
Property Address
Ouellette
Owner Own IrI's Name
hforrrr toraa"n is MA 01845 October 3 2023
req uured for every Npirth ndov r
page. Ciity�Town State zip Code IDate of�nspecfion
D. .stem~ Informationgat,)
. Type of System;
Septic tank, distribution box, soul absorption systalrn
V�'rrr
El Single,cesspool
o is�
Overflow cesspool
El Privy
.. Shared systarrn(yes or no) (if yes, attach previous inspection records, if any),
Innovative/Aliternative technology. Attach a copy of the current operation and
maintenance contract(tin be,obtained from system owner)and a copy of latest
inspection of thin I/A system by system oparat lr under contract,
'right tank, Attach a copy of the DEP approval.
Other(describe):
Approximate age of all components, data lnstalllad (ifknown) and source of information:
s!em is fr
om 25 ors old, ... _.....
Were sewage oldors detected n he°l arriving at the site? El Yens 0 No
, Building Sewer(locate on site plan):
Depth belcw grade:
feet
Material of construction:
past iron 0 PVC other(e
xplain):
Distance fr rn p h ate water suppler well or uu tion line. feet
Comments(on condffion of joints, venting, evidence of leakage, etc.):
plain Mina and joints are in good condatit n„ no signs of any problerns.
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Commonwealth of Massachusetts
on Form
� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
4
w 72 Pheasant Brook Road
Propeky Address
ueH tt
Owner Owner's Name
oirularruiatioru I
r quir d for ve ry Niorth Andover MA 0184 October 3, 2023 _.
page. city/Town _. .._ .__ ....._ State fop Code rate of ns pe c blori
D. System Information (cont)
Septic Tank(iocate on site plain):
"
Depth below grade. — —
(Maternal of construction:
0 concrete El rn t: i E:11 fiberglass poi eth l rne other(explain)
1500 gallons 1 1 o ,
"6
00
ifItar$k-is ' t ljist.a gl" .. ,.r.
�r _
� � ��,e
a e
is c tfffff � Certificate of Compliance? (attach a copy of certificate) ,...
" x 51 xy1011 - 1500 gallons
Dimensions:
--
lip
Sludge depth:
4 fl"
istice from top of sludge to bottorn of outlet tee or bay �. m...
t"P
Scum thickness
"m
l lstanca from top of scum to top of cutlet tea or Ibaffl
Distance from bottom of scrum to bottom of outlet tee or bafflePe
_
Howe were&rrn nsicrns determined?
.y nsurrrnrnts
orn m nts(on pumping r cornmrn rnd tir ns, inlet and outlet tee or baffle e condition, structural integrity,
llquid levels as related to outlet invert, evidence of ieakage, etc.):
The tank and baffies are in glood general condition. The tank is running at it"s correct working height.
...... ..........
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s�
Commonwealth of Massachusetts
dTitle 5 Official Inspection Form
r SubsurfaceSewage Disposal System I ' r � Not for Voluntary Assessments
w gar
,. ,. 2 Pheasant nt Brock Road
Orf'roerty Address
uulltt
Owner Owner's ar'rn .
Woru titian i
required for every Worth Andover, MA 0.1 i cttub r p '02
page,' ' _ ... w_. ......_._.State _.. Zip t°ode__. _ Gate of inspection �.
atem Information (writ.)
7, Grease Trap (pocate on sfte plan):
Depth below grade:
IN»aI Material of construction:
h�
concrete fiberglass poly th W other(explain)'.
7
__.
w
Scum thickness
Distance from top of sckjim to top sole outlet tee r 6 ff1€11
Distance from bottorn of scum to bottom,dfoutlet tee or baffle
Date of last p rnpin : t
Comments (on, pumping repornmendations, inlet and cutlet tee or baffle condition, structural mtegrfty,
liquild levels as related t�'utlot pnvart, evidence of leakage, etc.)�
_.
Tight or Holding Tan (tank must,be pumped at firne of inspection) (locate on site plan).
Depth below grade:
Material of con truuction':
e„
�I concrete metal other(explain):
�m
Dimensions:
apacity: Ilicprna
. ..... _
Desigin 'lc ,
-gaiaorbs per day
154w-d ,•iev 72 r 0i0 1ota¢5 ofrdciaM fngp€sczon Fcu Squib&uif'a 'gewa Ds posal System^Page II of$8
,M, Commonwealth of Massachusefts
d� Title
r",'� subsurface sewage Disposal Systern Form ® Not for Voluntary Assessments
"
72 Pheasant Brook Road
rrmiriry`Address
Ouellette
CMner Owner's Ia Wormat _.._ ..,_
required for
ns i A 01845 Cyr°tuber�,
rq�ir�d��r��� �J �°tlh Andover _
..rn ;e. State ode e of lI Inspection
'u�yl��s�cuy �
D. System Information (cont.)
. Tight or Holding Teak (cont,)
Aiarrn present: 'des [ �
r'n Alarm i�eG': �m rrr�jrr ��mlor: yes
No
"
N
Date f last pLrlrnpin : ate
Comments(condition of alarm -f1 t switches, etc..).
Attach copy of current pumping contract(required'). is copy attached? "des No
1, Distribution Box(if present must be opened) (locate on site plan):
Zero �.� .�
Depth of liquid level aboveoutlet invert m- m� _
��',
Comments (note if box is level and distributiiion to outlets equal, any evidence of solids cairryover, any
I<<� evGdence of leakage into or out f box, etc.):
"b d-box is below grade and is, �1 "� 1 '°. The d-box is in good working condition and shows no
signs of any problems.
r
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Commonwealth of asp chi e
4TRW 5 Offidal Inspection Form
u
Subsurface Sewage Disposal System Form -I Jot for Voluntary Assessments
72 Pheasant Brook Road
0ra rt'V' s ddiress.
Ouellette
Ower Owner's Camas
information rs
required for every North Andover l l Q�� 4October mt Ct
_ .. _ —'' e....
page. r�nny�'��cawn Statec np cr Date wr nM�spa rnnG� ...
Di. System Information (cont.)
10. Primp Chamber(locate can site plan):
PUMPS in working in order: �..... �� E No-
Alarms in working in carder: Yes El No*
U e'„ Comments nt (note ndltl n of pump charnber, dttion�t pumps and appurtenainces, etc.):
m
if pumps r alarms are not in working order, system is a conditional pass.
t't. Sold Absorption System (SAS) (locate on site plan„ excavation not required),
it SAS not located, explain why:
i
previous title v ` 201 .
TN�n SAS� located by bn.nult drawings an pr..�_.
Type:
0 leaching pits number.
E] leaching h rn r number:
leaching galleries number:
leaching trenches number, length: .
leaching, fields number, dimensions',
overflow pool nurn r�
innovativelaiternative system
'yp In rn ,cat technology:
TdIa 5 Offloal Inspeutw Forme Sdamolece S&AA age Mspasal Sys WITI,P-�]3e 13 af 15
mow, Commonwealth of Massachusetts
TRIe 5 Official Inspection Form
1 r us a �1 el � tern Form -Not for Voluntary e ent
� �" F dee errt Iroo e� d
,._ . ® . _ .,... ....._ .,.
Property Addres-s-
uuellette
Owner me
_ --
infor
tion
requ1refor -- _..4 ._.._ i g2
ren�iaored t��eve ny North Andover ll,�u 1�14 tobeln a
page, cityrrow n state Zip Code eats of Imps urn
D. ystem Information (corit.)
11' ull Absorption System (SAS)(cont.)
I Comments (note condition of ii„ signs of hydraulic failure, level of poinding, damp soil, coniditiio�n of
vegetation, etc,):
° The SAS is in good general condition. This area is covered with well maintaMed green grass.
"I2. Cesspool's (cesspool must be pumped as part of Inspection) (locate on site plan),
Number and configuration
Depth —top of iug61d taxi inlet invert
Depth of solid's layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater ter inflow Yes �, No
Ir traernt; ate condition f rollp a "~n f lhydraulic failure, G I f u rn6 ng, condition f vegetation,
etc.):
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dCommonwealth of Massachusetts
. µSubsurface Sewage Disposal! System Farm Not for Voluntary Assessments
72 Pheasant Brook Road
Property Address
Ouellette
Ow Name
inffori turn's
23
requuured for every North Andover U� �5 October �, �
page. State Zip Code Date of Inspection
System Information (cons.)
1 , Privy (locate on site playa):
T' Materials of constructidni
rlwf �� .... _
Dimensions
nsions
f
Depth f lld
Comments (note ondition of soil, r°gn fit dr uli f llwy , levW of pondin , condition of vegetation,
2;5Ju sry.cdl •rev.7126= 8 P'"r6le 5 O6friiN rnspartion F'a¢rm S ubsmFface sae C lapa ac vnpGWr1 P090 15�nf'18
Commonwealth
TRW 5 ci I m For
�a
�,4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
72 Pheasant Brook Road
Pry ert Addues
elle �"
a. ��
Owner ..._.,.,_...
_ ---... -. -
R�wuner e
an ormatron,is
required for every North Andover !I 01 4 a October ,
page, State Zak Code Pate f Vnsp!!! n
._
D. System
V (cont.)
14. Sketch Of Sewage Disposal System: t
r 'Ode a view f the sewage disposal system, including ties to at Ileast[two permanent reference
landmarks r benchimarks, Locate all wwelRs w ithIin 100,feet. Locate uwhe�e PLiblic water s,upiplly enters
the building, Check one oaf the boxes below:
hand-sketch in the area below l
drawing attached separately
i
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t6kir7 .doc»rov !d26? ,r{ µ11 W Irmo 5 Md I
hsrAfNIMan IF orrrw Sl.absr.rl�aps wrasle Istem,P age 116,0118..,,,,— ....
Commonwealth of Massachusetts
14,
T'ItleOfficial Insped For
Subsurfacew Disposal System Form • Not for Voluntary s meet
72 pheasant Brook loud
Property Address
Ouellette
arre �w _. __ ._m.., .. . _ ......_ _ _._. .........
Owner's Name
kftrrnatiaun is
r u for cy North Andover � . 5October ,
page. d awi �� 0o� Od �r �f Inspection
....._. ..... ......_..._. _
.......
D. System Information (cont.)
151. Site Exam:
Check Slope
,F
Z Surface water
Check cellar
lwallraw w wells
f° +/-
Estimated depth to high ground water: mP..
tit
Pgease indicate ali l methods used to determine the high ground water elevation:
Obtained from system design Iplams on record
If checked, date of design plan review d. 8117/9
bat
E Observed site (abutting proper-ty/observation hole wl itlwim 166 feet of SAS)
Cheicked with local Board of Health-explain:
Permit, pr posed, asduilt and prewri us title v from 2016.
Checked with to aV excavators, installers-(attach documentation)
Accessed !tJ' GS database -explain:
You must describe how you established the high ground wrrater,ele atlom
Basement is 7" below grade with, no sur'ip pump, "The property has,a raised teed system to maintain
ground water separation. (Deep hole test drone 8/17/98 showed ground water at 6°", 6 "" 42 and 36",,
Before filing this Inspection Deport, please see Report Completeness Checklist on next page.
wn*meal -m+a ft t77"z— TRfle 5 6ftAl gr spectbn IF(pP17B:S,.bs'I,,raace Sewage Mspoaal SY W at ftge,17 Or 18
Commonwealths Ins
Title 5 Official Inspection Form
ur
Subsufface Sewage Disposal System Form -INa t for,Voluntary Ass ssm nts
7 Thant rural Road
�.w de. ... ._
Propert , rees
ualltt
Owner warder' kei
informatio n Is
t
required for eve 1 5 October 3l, 0 .
e. i ino rrw .,
� � �J�rttn Andover
rd - ate op ode... IDate of nmpecnnord
E. Report Completeness Checklist
Complete all applicable sections of this form In lmm l e of:
A. inspector lnforrmstlon: Complete all fislds In this section.
B. Certification: &9ned & Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
1, 2, r mpl t d as approprlate
(FaHure Criteria)and 61(Che nlmllst) completed
D. System Information:
for : ight/Ho dining Tan — Pumping contract attached
For 14 Sketch f Sewage Dispos i Systern drawn on pg. 16 or attached
For 15: ICxplsnstion of esfirnated depth to high groundwater included
rfinsp,dw a irxvv MCW2018 110L 5 officVrad ln5peckjon Fu ma , u b:stufaw Sewage Ifiiisinssd uS"oaa n P8148 18 of 18