HomeMy WebLinkAboutPass - Title V Inspection Report - 37 SULLIVAN STREET 12/27/2023 Commonwealth th of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm Not for Voluntary Assess
37 Sullivan Street
Property Address
Alex Ura
Owner Owner's Name
information is North Andover Ma 0184 11/21/2023
req,aairr�c4 for every,
peas, CityfTown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
wary.Please see completeness checklist at the end of the form,
hng out forms t,when
filling out A. Inspector Information
on the computer,
use only the tab Clean Dynan
key to move your Name of inspector IV
cursor-do not Dean Dynan
use the return
key. Company Name
2 Suntaug Street "
Company Address
k d� Ala 01940
City/Town estate _ zip Code
508-726-9935 S112837
Telephone Number License Number
B. Certification
I certify that., I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5
(310 CMR 1 .000); l have personally inspected the sewage disposal system at the property address
listen 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. Passes
2. Conditionally Passes
3. E] (Needs Further Evaluation by the Local Approving Authority
4. E] Fails
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or CEP)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 DER The original form should be sent to the system owner and copies sent to
the buyer„ if applicable, and the approving aiuthority.
Please note. This report only describes conditions at the time of inspection and under the
conditions of use at that time.This Inspection does not address how the system will perform
in the future under the same or different conditions of use.
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Commonwealth ealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
37 Sullivan Street
Property Address
Alex tlra
Owner Owner's Nerrye _. _ ... .�
Infor
required
ie North Andover Ala 01845 11/ 1/20 3
rerct4alr for every �._.._.. � ti.... _..
pagop City/Town State Zip Code Date of inspection
C. Inspection Summary
Inspection Summary. Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
I have not found any information wwhiich indicates that any of the failure criteria described
in 3110 CMIR 15,303 or in 316 CMIR 15.304 exist. Any failure criteria not evaluated are
indlicated below.
Comments:
4 Bedroom septic system in working order
2) 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 Health, will pass,
Check the box for"yes", "no" or"not determined"(Y, N, NIA) 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 exAtration 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 its available.
El Y ] N FI ND (Explain below):
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Commonwealth of Massachusett
Title 5 Officinal Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
k'�
w
.,, 7 Sullivan Street
Alex Ura
OwnWormation is
er
Winer" ee
required for every North_.. ._.. Andover, 1 1w� 11
2023
page,
f � � Skate Zi�O Code ... Cute of Inspection
C. Inspection Summary (cont.)
2) System Conditionally lasses (coat.):
[ Pump Chamber pumpsalarms not operational, System will pass with Board of Health approval if
pumps/alarms are repaired.
E' Observation of sewage backup or break out or high static water level in the distribution box dine
to brokers or obstructed pipes)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
E broken pi�pe(s)are replaced F1 Y El N Fj Hd (Explain below),,
obstruction is removed Y n N E] ND (Explain below):
distribution box is leveled or replaced ] Y 0 N ND (Explain Ibelow):
E] The system required pumping more than 4 times a year due to broken or lobstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
]I broken pipe(s)are replaced Y [ N E3 ND (Explain below).
obstruction is removed ] Y n ND (Explain below):
) Further Evaluation is Required by the Board of Health:
0 Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to,protect public hiealth, safety or the environment.
a.. system will pass unless Board of Health determines in accordance with 310 CMR
16.303(1)(b) that the system is not functioning In a manner which will protect public health,
safety and the environment:
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Commonwealth of M:assachulsetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Sullivan Street
Property Address
Alex Ira
Owner Owners Name
Information Is
required for every North Andover Ma 01845 11/21/2023
page. City/Town -�tate Zip Code Da,te of Inspection
C. Inspection Summary (cont.)
01 Cesspool or privy is within 50 feet of a surface water
Ej Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System,will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system Is functioning In a manner that protects,the public health,
safety andl environment:
[] The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
[I The system has a septic tank and SAS and the SAS is within a :one 1 of a public water
supply,
[I The system has a septic tank and SAS and the SAS is within 50 feet of a private waiter
supply well.
n The system has a septic tank and SAS and the SAS is less than 10,0 feet but 50 feet or
more from a private water supply well**.
Method: used to determine distance:
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 must
be attached to this form.
c. Other*
4) System Fallure Criteria Applicable to All Systems:
You must Indicate"Yes" or"'No"'to each of the following for all Inspections:
Yes No
Backup of sewagie into facility or system component due to overloaded or
Eli 0 clogged SAS or cesspool
Discharge or Poniding of effluent to the surface of the ground or surface waters
El rx-1 due to an overloaded or clogged SAS or cesspool
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Commonwealth of Massachusetts M Title 5 f"°I�icill inspection Farm
Subsurface Sewage Disposal System Form-Not for"Voluntary Assessments
37 Sullivan Street
Property Address
Alex Ura
Owner
Owners IJar^ne
inforrequired
berth Andover lie 01645 11/ 11 g .3
re+quired rrar every
page. cityrrrslwn state Zip code Date of Inspedlon ...m.
C. Inspection Summary (cont.)
4) System Failure criteria Appilicable to All Systems: (coif.)
Yes No
Static liquid level in the distribution box above ouitlet invert due to an overloaded
or clogged SAS or cesspool
EJ Z Liquid depth in cesspool is Ness than 6"bellow invert or available volume is less
than day flow
El N Required pumping moire than 4 times iin the last year NOT due to clogged or
obstructed piipe(s),. Number of times pumped;
0 0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well,
E] 0 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 less than 100 feet but greeter 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 ppi
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this formi.]
E N The system is a cesspool serving a facility with a design flow of 20,00 gpd-
10,000 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 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 C.4.
Yes No
z the system is within 400 feet of a surface drinking water supply
the system is within Zoo feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
El 0 Area—IW"A)or a mapped)Zone 11 of a public water supply well
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Commonwealth of Massachusetts
Title 5 Offlocial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary"Assessments
7 Sullivan Street
marl cwddreSS
Alex lira _ .........
Owner 6,;. e .-Wi' ......
.w......._
ie
information requie North w.... M ...._..,... 0184 11/211202
required for every .,s, ..__..._..
page mm ... state Zip Cade pate of inspection
tom. 1rts ion Summary (cone.)
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 move 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 C.4 shall upgrade the system in accordance with 310 CLAP 115,304. The system owner
should contact the appropriate regional office of the Department,
. You must Indicate "yes" or"no" for each of the following for all inspections:
"des No
Z F1 Pumping information was provided by the owner, occupant, or Board of Health
El EI Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
El 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined? (if they were not
available note as NIA)
0 Ej Was the facility or dwwreiling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Z Were all system components, excluding i the SAS, located on site?
(� Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction"
dimensions, depth of liquid„ depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with
information on the proper rnaintenance of subsurface sewage disposal)systems?'
The size and location of the SoI'l Absorption System (SAS)on the site has
been determined based on:
0 El 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 unacceptable) [ 10 CMR 15.302(5)]
o2(b)]
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Commonwealth of Massachusetts
T ftle 5 Offidal Inspection Form
t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Sullivan Street
i5-r-opertyAddreSS-'-----
Alex Ura
Owner Owner's Name ........
information is
required for every North Andover Ma 01845 11/2112023
page. crt rain State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
4
Number of bedrooms (design): 4 Number of bedrooms(actual):
DESIGN flow based on 310 CIVIR 15.203 (for example: 110 gpd x#of bedrooms): 6601
Description:
4 bedroom 1500 gallon tank pipe in stone trenches
Number of current residents: 2
Does residence have a garbage glirinder? Fnj Yes
Does residence have a water treatment unit? F Yes Ej No
If yes, discharges to:
Is laundry on a separate sewage system? (include laundry system inspection El Yes 0 No
information in, this report.)
Laundry system inspected? Yes, n No
Seasonal use? E) Yes 9 No
Water meter readings, if available (last 2 years usage (gpid)): N!/A
Detail:
Well water well setback 100'+
............
Sump pump? Yes F1 No
Last date of occupancy: current
Date
t5tnsp doc A rev,706=1 8 Trfle 5 Offical inspection Form;Subsurface Sewage msposal system-Page 7 of is
Commonwealth of Massachusetts
1p Title Official Inspec i rForm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Psi' T Sullivan Street
Property Address
Alex Ura
Owner Owner's Name
rrtatif r i equi for
every North AndoverMa 01545 1112112023
p +Ciwy�P"r"c �r�_.n..._.......
D. System Information (cont.) _
ate alp c� Cyate rr�Inspckuan
2. Commercial/Industrial Flow Conditions:
Type of Establishment; _.. .._.. _ __ . .....
Design flow(based on 3 10 CMH 15.203); afG pe-d-yt pdi_W
Basis of design flow(seats/persons�sgft, etc.):
Grease trap present" Yes No
'water treatment unit present" El "yes No
Ifyes, discharges to: _.......w ___._. w__......._.___.__ww_ _.......... _..___.......______..__ _...__...._
Industrial waste holding tank present's El Yes El No
Non-sanitary waste discharged to the Title 5 system? 0 Yes El No
Water meter readings, if available:
Last date of occupancy/use,
other(describe below):
Pumping records:
Source of infformation. Homeowner/Board of Health
pumped 1 month ago as per homeowner
Was system pumped as part of the inspection's El "yes 0 No
if yes, volume puimped: sallords.a-.
How was quantity pumped determined"?
Reason for pumipin
g5irn PADC ray,712fit2018 Tula 5 Official Inspedion For .SubuAaMcu Sew agO r8tsgaMa SysteM P890 8 Of'18
Commonwealth of Massachusetts
T Title 5 Official Inspection Form
;. t Subsurface Sewage Disposal System Form -blot for Voluntary Assessments
87 Sullivan Street
Property address ._
Alex Ura
Owner
owners NerveInfor ..
required tion
is
North Andover Ma 1845 11/21/202
r�:qu#red for every
page. Cityfrowwn state Zip Code gate of Inspection
D. System Information (coat.)
4. Type ofSystem:
Septic gunk, distribution box, sail absorption system
Single cesspool
El Overflow cesspool
0 Privy
El Shared system(yes or no) (if yes, attach previous inspection records, if any)
El Innovat ve/Aternative 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 l/A system by system operator under contract
El Tight tank.Attach a copy of the DEP approval.
( Other(describe):
Approximate age of all components, date installed (if known) and source of information:
18g4 aster info on file/2017 C box 12020 1800 Tank/see file
Were sewage odors detected when arriving at the site" El Yes MI No
b. Building Sewer(locate on site plan):
14""
Depth below grade: -
feet
Material of construction:
®cast iron Z 40 PVC El other(explain):Distance from from private water supply well or suction line: -----
filet
Comments(on condition of joints, venting„ evidence of leakage, etc.):
sewer pipe in good condition/ no evidence of leakage
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Commonwealth of M�assachusefts
. ...........
Title 5 Official Inspection rm
t Subsurface Sewage Disposal System Form Not fo,r Voluntary Assessments
37 Sullivan Street
P-r6iwiiy-4aif�wisi.----—-------------- —- ---- --------
Alex Ura
Owner er's Name .......
information�!s
requiredforevery North Andover Ma 01845 11/21/2023
page. State Zip Code Date of hspection
D. System Informit-ion ion-t.)
6 Septic Tank(locate on site plan).
9
Depth below grade., „
feet
Material of construction,
0 concrete El metal 0 fiberglass, polyethylene other(e,xplain)
15010 gallon septic tank
If tank is metal, list age.
Years
Is age confirmed by a Certificate of Compliance? (attach,a copy of certificate) El Yes No,
0'X FX 5'18"
Dimensions: 1
Sludge depth,
29
Distance from top of sludge to bottom of outlet tee or baffle " —------
0-2
Scum thickness 1'
6"
Distance from top of scum to top of outlet tee or baffle
14"
Distance from bottom of scum to bottom of outlet tee or baffle
in field with measure stick
How,were dimensions determined?
and tie
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural iintegrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500 gallon concrete septic tank with PVC inlet and outlet T I Tank in working order with separation
from inlet to outlet / no evidence of leakeage
cast iron covers to grade
recommend pumping every two to three years depending on usage and number of occupants
6pnsp,doc rev 7r2WO1 8 TAW 5 MoW kispecimn Foram Substaface Sawage Disposal System-Page 10 of 18
Commonwealth of Massachusefts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
j" 37 Sullivan Street
Property Address
Alex Ura
Owner
information iis
requked for every North Andover Mal, 01845 11121i12023
d -—- -------------------
page. Ityrrown State Zip Code Date of Inspection
D. System fn—formiii—oin—(cont )
7, Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
concrete ❑ metal n fiberglass E] 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, ........................
ate
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) (Iocate on site plan):
Depth below grade'.
Material of construction',
0 concrete FI metal El fiberglass El polyethylene other(explain),.
Dimensions: -----------
Capacity' go I.on.s ...... ...... .........
Diesigin Flow: gallons per-day
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SZ,\. Commonwealth of Massachusefts
Title 5 Official Inspection Form
Subsurface Se,wage Disposal System Form _ loot for Voluntary Assessments
k qnv 37 Sullivan Street
-——-------------------------------- -
Alex Ura
Owner ........... ---—
information is
required for every North Andover Ma 01845 11121/2023
page. State Zip Code Date of Inspection
D. System Information (cont)
8 Tight or Holding Tank (cont,)
Alarm present. Yes No
Alarm, level: Alarm in working order: 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? F1 Yes El No
9, Distribution Box (if present must be opened) (locate on site plan):
yq�uq.at 0" above invert
Deptlh of fiquid level', above outlet invert . ..... ...........
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc,):
6 Outlet concrete D box level with 3 outlet pipes /little evidence of solids carryover I no evidence of
leakage into or out of box/d box in good conditoin
D box in working order
D Box is 10" below grade
1%nsp,doc-iny,712W.,D 18 Tifle 5 offidal ki"r%cm rorro, &ibsurlsw Sowage Disposal SysWm•Paige 12 of 18
Commonwealth of Massachusetts
Titile 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3�7 Sullivan Street
Address
Alex Ulra
Owner Owne r's-K,a m,e
inf(grnation is
required for every North Andover Ma 01845 11/21/2023
........—-------
page. ti State bp Code Date of Inspection
D. System Information ( ant.)
10, Pump Chamber(locate on site plan),-
Pumps in working order: Ell Yes E] No*
Alarms in working order: El Yes, E] 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 plain, excavation not required):
If SAS not located, explain why;
Type:
El leaching pits number"
1:1 leaching chambers number:
El leaching galleries number,
leaching trenches number, length: .3
leaching fields number, dimensions:
El overflow cesspool number:
El innovativelatternative system
Type/name of technology,
Mnsp.doc w ray.7126120 W TdW 5 Officiali InspectWn Form Subsuface Sewage Disposal SysIm-P090 13 of iS
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments,
37 Sullivan Street
Property Address
Alex Ura
Owner Owner's Name
informsfion is
required for every North Andover ....... ma 01845 11/21/2023
page. 6�/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(count.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc,):
Trenches found in lawn area/ soils in good condition / no signs of hydraulic failure/ no ponding/ no
damp soil/
trenches are co�nstucted of pvc pipe in stone in working order see plan on file
12. Cesspools (cesspool) must be pumped as part of inspection) (locate on site plan).
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes El No
Comments(note condition of soil, signs of hydraulic failure, level of Iponding, condition of vegetation,
etc.),
t5hsp doc rw,7MOIS Me S Offidal hapodion Form:Subsufface Sewage Mvosal System-Pop 14 of 18
.......... ............................
Commonwealth of Massachusetts
Title ,5 Official Inspection Form
Subsurface Se wage Disposal System Form Not for Voluntary Assessments
37 Sullivan Street
Property Address
Alex U:ra
Owner Owner's Name
Informatilon,Is
required for every North Andover Ma 01845 11121/2023
page, Cityrrown State Zip Code bate of linspecUon,
D. System Information (cont.)
13. Privy (locate on site plan):
Miaterials of construction:
Dimensions
Depth, of solids
Comments (note condition of soil, signs of hydraulic failure, level of pondinig, condition of vegetation,
etc.)-
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Commonwealth of Massachusetts
Title 5 Official Inspection Forml
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
37 Suillivan Street
Property Address
Alex U'ra
Owner Ownees Name
information is
required for every North Andover Ma 01�845 11121/2023,
page, alty/rown state Zip code Date of Inspection
D. System Information (cont.)
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:
hand-Sketch in the area below
drawing attached separately
+
3
-3),3
3
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Commonwealth of Massachusetts
Title, 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
37 Sullivan Street
Property Address
Alex Ura
Owner Owner's Name
Information is
required for every North Andover Ma 01845 11 t2l/2023
page,. City Town State Zip Code, Date of inspection
D. System Information (cont.)
15. Site Exam:
0 Check Slope
91 Surface waiter
Z Check cellar
Z Shallow wells
Estimated depth to high ground water: 48"+
feet
Please indicate all methiods used to determine the high ground water elevation:
z Obtained from system design plans:on record
If checked, date of design plan reviewed: 4-12-90
Date
Observed site(abuttiing property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
plans,on file
Checked with local excavators, installers- (attach documentation)
0 Accessed US database-explain.
You muist describe how you established the high ground water elevation:
System Plans on file at BOH!
Previous Titile Five inspections 2017/2020
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Wmp,doc-rev,71260018 Tdia 5 officiali Inspedron Form Sub&Oaca Sewage Disposal Syslem-Page 17 of 18
Commonwealth nw ealth of Maaaachusatta
: . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Sullivan Street
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O wru r _.. -._w_... ..__. __ _.... _..__. _a....._._ ...._ _......
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required for
Nourthma Andover n 0184 11J� 1i/20
required�rrr r�r�r ..�.. _ _....A. ......._ ...,._a,ta Cry.....__ � ..— � _.._..
page. C,jt /`rown p ogre, D"ar of Irl ' rilrl
E. Report Completeness, Check6st
Cl u°nptete all applicablesections of this form inclusive f.
A, Inspector information: Complete all fields in this section,
B, Certification: Signed! & Dated and 1, 2, 3, or 4 checked
C. Inspection a rnm r :
1„ 2, „ our 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
D. System Information:
For& TighttHolding Tank—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
t&nsp,d W rev,712&2018 tole 5 Offiefal Inspecion Frami suburface Sewage Disposal symem.Page to of 1a
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Town of North Andover, MA
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Title 5 Official Irisl ection Form Submittal #76490
December 26, 202
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