HomeMy WebLinkAboutFail - Title V Inspection Report - 911 JOHNSON STREET 3/15/2024 Commonwealth of Massachusetts
2 - Tide 5 Official Inspection Fora
Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
Y 911 JOHNSON STREET
4
Property Address
ELAINE KIRBY
Owner Crwner"S Name
information is NORTH ANDOVER MA 01845 March 14, 2024
required for every ___._._._.._ _._.. ...._..._ .. .,._._._w ....________ _._ __... .. .. _.__ ._ _..-..-..
page. dkyiTl D State Zip Code Date of Inspection
Inspection results must be submitted on this farm. Inspection farms may not be altered in any
way. Please see completeness checklist at the end of the farm.
r
Important.When filling out forms A. Inspector Information
.w_
on the computer,
use only he tab Todd James Bateson
key to move your Name of Inspector
cursor-do not Bateson Enter rises inc °
use the return __ .._.._._._____ �._______... ._..._..____
key. Company Name
111 Argilla Road
ra Company Address
Andover _ ..__.... .. . _....-__ _ 0110
Clty/Tovon State Zip Code
78-47 -4758 Sl 16
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system Inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000) 1 have personally 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. [] Passes
. R Conditionally Passes
3. [ Needs Further Evaluation by the Local Approving Authority
4. { Fails
MARCH 14, 2024
___._ .._.._. _._ ___._ ___._.....__ _.__. . ._...__..._ __. _-.__.. ..._ . ._...... _ __......___ ....._._..._.._.__�_.. .._....... .... .._._.-_-
ins tors Signal Coate
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 DER 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,
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r .
Commonwealth of Massachusetts
T"'le 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
tF,, 911 JOHNSON STREET
Property Address
ELAINE KIRBY
Owner Owner's Name
information is required for every NORTH ANDOVER MA_.-_-_ 01845 March 14, 2024
_- ... ..._
page. City/Fawn State Zip Cade Date of Inspection
__....._._,.._..,__..............._....._.__. ._....._ ..____...._._..___.._ _..,._.m.._...,..,._. ..... _______.__� ...
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 which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 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 bass" 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, NCB) 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.
El Y ❑ N ❑ ND (Explain below):
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w m Commonwealth of Massachusetts
Title 5 0"Micial Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
11 JOHNSON STREET
Property Address
ELAINE KIRBY
Owner owner's Name
infarmatlan is NORTH ANIJ 7VER MA 01845 Larch 14, 024
required for every _
page C wty.. .(Town State Zip Cade Date of Nnspe0on
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C. Inspection Summary (cant.)
2) System Conditionally Passes (cant,).
El 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 [I "Y 7 N El NUJ (Explain below):
obstruction is removed E] Y ❑ N 0 ND (Explain below);.
[] distribution box is leveled or replaced Ej Y [I N El NNE (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):
E] broken pipe(s) are replaced El Y R N 0 ND (Explain below):
obstruction is removed El Y F-1 N El ND (Explain below):
---------- _ .............
3) Further Evaluation is Required by the Board of Health:
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
1 .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 Massachuset
" Tilde 5 fWici l Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
911 JOHNSON STREET
Pr'o eriy Address
ELAINE KIRBY
Owner Owner's Nertne
arrtc Uire t cn is
required for every NORTH ANDOVER MA 01845 March 14, 2024
..
page. CftyfTown State Lip Code Date of Inspection
_.. .. __.w,.... _ ......__. _..._.. .......... _..w. _..... _._.__...n._._.a_.,__..,..
C. Inspection Summary (cant.)
[I 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
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 and environment.
R The system has a septic tank and sail absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
[W The system has a septic tank and SAS and the SAS is within a lone 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 well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis„ performed at a DFP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or Iess 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 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
z Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
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Commonwealth of Massachusetts
w � Title 5 official Inspection Form
.ry ,r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
911 JOHNSON STREET
Property Address
ELAINE l I'RBY
Owner 6wner`s Name
information is NORTH ANDOVER, MA 01845 March 14, 2024
required for every _
page. Cltyrrown Stag Lop Code Date of Inspection
_.,_...._._. _... ..... _ .....__ _. .. _.... _. _.,.,._....._...._._..w._-_
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cant.)
Yes No
Z El Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
N than "/2 day flow
Ej z Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped. ,_, _ .
El z Any portion of the SAS, cesspool or privy is below high ground water elevation.
1:1 z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
1:1 z Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
El z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El 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 waster analysis, performed at a IMP 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.]
E-1 z The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
Z El 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 CA
Yes No
El 1:1 the system is within 400 feet of a surface drinking water supply
El El the system is within 200 feet of a tributary to a surface drinking water supply
D El 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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. 911 JOHNSON STREET„ .
Property Address
EL.AINE KIRBY
Owner bww Name
inforanuataon is NORTH ANDC VER MA 01345 March 14, 2024
required for every
page City/Town state Zip Code fate of Inspection
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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 "ayes" to any question in Section C.4 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
[ Q bumping information was provided by the owner, occupant, or Board of Health
* z 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?
Have large volumes of water been introduced to the system recently or as part of
this inspection?
[I z Were as built plans of the system obtained and examined? (If they were not
available note as NIA)
z 0 Was the facility or dwelling inspected for signs of sewage back up?
0 Was the site inspected for signs of break out?
z ❑ Were all system components, excluding the SAS, located on site?
1:1 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 scum?
z El 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:
0 z 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) [310 CMR 15.302(5)]
a5msp.doc-rev 7J2&20I S Idle 5 Officaii Irnsapaaer6cm Form Subsurrl ace Sewne N,;K n i SW^maern•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
911 JO NSON STREET
Property Address
ELAINE KIREY
Owner owner's Nance
information required for every NORTH ANDOVER _ MA 01845 larch 14, 2024
_
page. City/Town State Zip Cade Date of Inspection
_._,._..m....,_,_,,._ _....._.... ._......_ _.,_....
D. System Information
1, Residential Flaw Conditions:
Number of bedrooms (design): NA Number of bedrooms (actual);
DESIGN flow based on 310 CIVIR 15.203 (for example: 110 gpd x#of bedrooms): NA
Description:
---
Number of current residents: 4
Does residence have a garbage grinder? Z Yes ❑ No
Does residence have a water treatment unit? El Yes Z No
If yes, discharges to: -
Is laundry on a separate sewage system? (Include laundry system inspection Z Yes [] No
information in this report.)
Laundry system inspected? ❑ Yes Z No
Seasonaluse? ® Yes Z No
Water meter readings, if avai➢able last 2 ears usage SEE ATTACKED
g ( y g (gl�))�
Detail:
LAUNDRY ON SEPARATE DRYWELL. NEEDS TIED INTO NEW SYSTEM
Sump purnp? E' Yes E] No
Last date of occupancy: CURRENT..
Date
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Commonwealth of Massachusetts
Iy T"Ll 0"ffi ial Ins ecti n Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
911 JOHNSON STREET
Property Address
EL.AINE IIRBY
Owner Owner's t arne
requir dfo NORTH ANDOVER MA 01845 March 14, 2024
required for every .. .. _.
page CityfTown state Zip Code Coate of Inspection
D. System Information (cant.)
. Commercial/industrial Flaw Conditions:
Type of Establishment.
Design flow (based can 310 CMR 15.203): gallons per day( pd)
Basis of design flaw(seats/persons/sq.ft.„ etc.):
Grease trap present? ❑ Yes No
Water treatment unit present? D Yes L-] No
If yes, discharges to:
Industrial waste holding tank present? [l Yes E ] No
Non-sanitary waste discharged to the Title 5 system? n Yes F] No
Water i-neter readings, if available:
Last date of occupancy/use: Coate
Other(describe below):
......_...... _ ..
3. Pumping Records:
Source of information: OWNER
Was system pumped as part of the inspection? Fj Yes Ej No
If yes, volume pumped: gaIlons _
How was quantity pumped determined?
Reason for pumping:
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Commonwealth of Massachusetts
.. Title 5 Official In p+d'on Form
J, Subsurface Sewage Disposal System Form Not for Voluntary Assessments
911 JOHNSON STREET
Property,address
ELAINE KIPBY
Owner owner's Name
required
is
NORTH ANDOVEI MA 01845 March 14, 2024
rleao�red Tsar every ... _.. .. _ ... _
Cltyfrown State up Code rate of Inspection
page. .. _._.._. ....___ _ _..__._...._..__...._. ... ......... .. ......._.__ _..___..-...___w..,_.. _..._..._u._ ..-_,__w..._.e... _ _...._. . __..
D. System Information (cant.)
4. Type of System:
z Septic tank„ distribution box, soil absorption system
( Single cesspool
[ Overflow cesspool
El Privy
F� Shared system (yes or no) (if yes, attach previous inspection records, if any)
D 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
Tight tank. Attach a copy of the DEP approval.
�] Other(describe):
Approximate age of all components, date installed (if known) and source of information:
NO INFORMATION AVAILABLE
Were sewage odors detected when arriving at the site? Ej Yes Z No
5. Building Sewer(locate on site plan):
Depth below grade: 1
81,
feet
Material of construction:
Z cast iron F-1 40 PVC F! other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting„ evidence of leakage„ etc.):
JOINTS AND VENTING GOOD
NO EVIDENCE OF LEAKAGE
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3dE
Commonwealth of Massachusetts
l Title 5 Official Inspection For
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
11 JOHNSON STREET
Property Address
ELAINE KIRBY
Owner Owner's Name
information is NORTH ANDOVER MA 01845 March 14, 2024
required for every
page ftyrrown State Zip Code gate of Inspection
D. System Information (coat.)
Septic"Tank (locate on site plan):
Depth below grade: 5„„
feet
Material of construction
Z concrete El metal El fiberglass F-1 polyethylene El other (explain)
If tank is metal, lint age:
yea rs
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes No
Dimensions: 1 w 5 4"
5„,
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle NO BAFFLE OR TEE
Scum thicknessNA
1"
Distance from top of scum to top of outlet tee or baffle
NA
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? SLUDGE JUDGE AND TAPE
MEASURE
Comments (on pumping recommendations„ inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
RECOMMEND PUMPING OLDER SYSTEMS YEARLY
CONCRETE INLET BAFFLE OK
OUTLET BAFFLE ROTTED OFF
TANK GOOD CONDITION
NO EVIDENCE OF LEAKAGE
GOOD LIQUID LEVELS
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Commonwealth of Massachusetts
r I4� Me 5 Official Inspection tion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
911 JtJI-MR6SC?N STREET
Property Address
ELAINE KIRBY
Owner owner's Name
information is NORTH ANDk VER MA 01845 March 14, 2024
required for every _ _ ._ _
page cityf own State :�tp ode Gate of Inspection
m.... .. ....m......... _ ........_....... _ _..... _ ............ .........__. ......... _....._ ...__ .__w,__... _,,...,... .._.._._..
D. System Information (cone.)
7. Grease Trap (locate on site plan):
Depth below grade. feet _
Material of construction::
0 concrete El metal El fiberglass F-1 polyethylene El 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: Gate
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
-- .
5. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
[l concrete El metal El fiberglass [Q polyethylene Ej other(explain):
Dimensions:
Capacity:
gallons
Design Flog: I_
gallons per day
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w Commonwealth of Massachusetts
=: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
911 JOHNSON STREET
Oropehy,Address
ELAINE KIRBY
Owner Owner's I4ame
informregWr dfo i NORTH ANDOVER 1'•/IA 01545 March 14, 2024
rer�ulred for every ..
page. Cc /Town State ,Zip Code Cate of Inspection
D. System Information (cant,)
5. Tight or Holding Tank (cant.)
Alarm present: ❑ Yes El No
Alarm level: _ . Alarm in working order: 0 Yes E No
Date of last pumping: bate
Comments (condition of alarm and float switches„ etc.):
Attach copy of current pumping contract(required). Is copy attached? El Yes E] No
9, Distribution Box(if present must be opened) (locate on site plan):
1 "
Depth of liquid 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.):
D-BOX IS FULL OF SLUDGE
D-BOX LEVEL IS ABOVE NORMAL
DISTRIBUTION IS NOT EQUAL
HEAVY EVIDENCE OF SOLIDS CARRYOVER
EVIDENCE OF LEAKAGE
D-BOX IS ROTTED
LEACH LINES FULL OF SLUDGE
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w 4 Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
911 JCHNSON STREET
Property Address
ELAINE KIRBY
Owner Owner's Name
information NORTH AN OVER MA 01€34� March 14, 2024
required taar every ...
page. Cttyrrown Mate Gip Cove Crate of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order. Yes [ No*
Alarms in working order: El 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:
leaching pits number:
(l leaching chambers number:
El leaching galleries number:
El leaching trenches number, length;
leaching fields number„ dimensions; 1; LENGTH
UNKNOWN
[ overflow cesspool number:
El innovative/alternative system
Type/name of technology: _.
t5insp,tim•my 7126J2018 Tulle 5 Official Inspection Font7 SUblSurfaacu Sewage Disposal System-Page 13 of 16
Commonwealth of Massachusetts
Tile 5 OTTI i Il Ire. pe is n c�rrrr
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r /Kd
911 JOHNSON STREET
Property A6dress
ELAINE KIRBY
Owner Owner's Name
illforlliataolr is NORTH ANDOVER MA 01845 March 14„ 2024
required for every
page. City/Town State Zip Cade Date of Inspection
..._........... _....._...w......................_.. _......_............__._._...,._._............_.._.._....._..,_...... ..,........._......_ __.. .._...........__ ...,...........
__ _.w._........w...... _ _m._..w...._....__.._ _.__..
D. System Information (cant.)
11. Soil Absorption System (SAS) (cant.)
Comments (note condition of soil„ signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
TRIED TO PUSH CAMERA DOWN LINES TO MEASURE SYSTEM
LINES FULL OF SLUDGE
SOIL AND VEGETATION GOOD
NO SIGN OF HYDRAULIC FAILURE OR P NDING
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 [l Yes 0 No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
1.
Subsurface Sewage Disposal System Form - Not for VoWntary Assessments
11 Jt HNSON STREET
Property Address
ELAINE KIRBY
Owner Owner's Name _
information is NORTH ANDOVER MA 01845 March 14, 2024
regwred for every
page. City/Town Mate Zip Cade Crate of Inspection
_........ _.....,_.. ...., ____......, __ _..._.. _,.....,_.._.. __.,.. a... _,_,....., .,...,._...._ _..._.._.._.._LL __ .._. .,.._.
D. System Information (cons.)
1 . 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.),,
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Commonwealth of Massachusetts
I Title 5 Official Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�1
911 JOHNSON STREET
Property address
ELAINE KIRSY
Owner owner's Name
informrequired
is
NORTH ANDOVER MA 01845 Parch 14, 20214-1
required for every
page. Cfty(Town State Zip Code Gate of pnspectror1
D. System Information (coat.)
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
C} drawing attached separately
15insp doc•rov."PJ',�& 2018 1 Me 5 O ffcbal Inspection&cAm Subsuffaanva Sewage MspasW$yw.rem-Page'B6 of 16
Commonwealth of Massachusetts
�9Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
7'ro 911 JOHNSON STREET
P'rc�perty Address
ELAINE KIRBY
Owner
information is
required for every ANDOVER MA 01810 March 14, 2024
__t page. 'S a-t—e— 'Z5pCo"de "Date o,f"-I'n's-p"e-"c-tio—n
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:
Z hand-sketch in the area below
drawing attached separately
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t5Xnap.doc-rev 7/26/2018 Intle 5 Official inspection Form,Subsurface Sewage Deposal Systepi-Pago,16 of 18
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Commonwealth of Massachusetts
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Subsurface Sewage disposal System Form -Not for Voluntary Assessments
�ry
11 JC7Ht SON STREET
Property Address
ELAINE KIRBY
Owner Owner's Name
inforrnatict,is NORTH ANDOVER MA 01845 March 14, 2024
requked for every _
page. City/Town State Zip ode Date of inspection
..._.._. ............__ _._ ........... .. _ ............_.___..... ........ ._ ,.. _....... _...... ._ ... .. . _... _... ,_.._.......,wMw.n . _w ._ ____..
D. System Information (cant,)
15. Site Exam:
E Check Slope
El Surface water
El Check cellar
Fj 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: NOT AVAILABLE
mate
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
NO PLANS ON FILE
❑ Checked with local excavators, installers - (attach documentation)
Accessed IJSOS database-explain:
ESSEX COUNTY SOIL MAP
You must describe how you established the high ground water elevation:
CANTON FINE SANDY LOAM
DEPTH TO WATER TABLE >80"
SYSTEM ABOVE WATER TABLE
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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Commonwealth of Massachusetts
i x Tide 5 Official Inspection Farm
i
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
911 JOHNSON STREET
Property Address
EN_AINE KIRBY
Owner
C7wner's Name
-
information is NORTH ANDOVER MA 01845 March 14„ 2024
required for every
page. City/Town State Zip Code gate of Inspection
__....-_..._______._..__.....-..._..__......__._...........
__.._._--.
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2„ 8, or 4 checked
0 C. Inspection Summary:
1, 2, 8, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® 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
t sinsp.cbuc•rev 7Al6/2018 Title 5 Official inspection Form Subsurface Sewage Disposal S'ystern.Page 18 of 16
Sunnevy Rowd Cwd genwaled w 3 120024 11 23,05 AM by Karen HaWon Page I
Town of North Andover
Tax Map # 210-107.A-0093-0000.0
Parcel Id 17918
911 JOHNSON STREET
KIRBY, WALTER
911 JOHNSON STREET
N. ANDOVER, MA
01845
...........
Class 101 Single Family Property Type I Residential
Size Total 1.66 Acres
FY 2024
UB Mailing Index
Narne/Address, Type Loan Number Activelinact. Fronn Until
K RBY,WALTER Payor AcA iv,
9,11 JOHNSON STREET
N.ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 14295.0-911 JOHNSON STREET Last Billing Date 3/7/2024
2100290 02 Cycle 02 Active
UB Services Maint.
Account No 2100290
Service Code Rate Charge Multiplier/Users
MISCFEE ADMiN FEE 0.63 518 7,82 1/
WTR WATER 01 ALL METER SIZE 57.00 11
UB Meter Maintenance
Account No.2100290
Serial No Status Location Brand Type Size YTD Cons
13242,127 a Active ERT HH METE METE w Water 0.625 0.625 194
Date Reading Code Consumption Posted Date Variance
21212024 2071 a Actuat 15 3/1412024
11/2/2023 2056 a Actual 13 12/13/2023
81212023 2043 a Actual 13 911812023 7%
5/312023 2030 a Actual 12 6/14/2023 3%
212/2023 2018 a Actual 12 3/14/2023 -32%
111112022 2006 a Actual 17 12/19/2022 9%
8/3/2022 1989 a Actual 16 9/20/2022 -32%
5/3/2022 1973 a Actual 23 6/21/2022 -10%
2/2/2022 1950 a Actual 26 3/15/2022 21%
11/212021 1924 a Actual 21 12/7/2021 63%
814/2021 1903 a Actual 13 9/21/2021 43%
5/5/2021 1890 a Actual 9 6/15/2021 133%
2(412021 1881 a Actual 4 3/16/2021 -2 9/4
1113,/2020 1877 a Actual 4 12M6/2020 304%
814/2020 1873 a Actual 1 9/9/2020 -91%
51412020 1872 a Actual 11 6/10/2020 41%
2/4/2020 1861 a Actual 8 3/1612020 63%
11/4/2019 1863 a Actual 5 12/2312019 -51%
8/2/2019 1848 a Actual 10 9/2612019 35%
5/212019 1838 a Actual 7 6/13/2019 -16%
2/4/2019 1831 a Actual 9 3/19/2019 76%
11/2/2018 1822 a Actual 5 121l2/2018 -18%
812/2018 1817 a Actual 6 9/20/2018 -1%
51312018 1811 a Actual 6 6120/2018 -53%
202018 1805 a Actual 13 3f2812018 86%
1112/2017 1792 a Actual 7 12/29/2017 -13%
8/2/2017 1785 a Actual 8 9J20/2017 -3%
5/2/2017 1777 a Actual 8 612612017 -66%
2/2/2017 1769 a Actual 24 3/1412017 58%
11/212016 1745 a Actual 15 12/19/2016 -320/6