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HomeMy WebLinkAboutconditional pass - Title V Inspection Report - 14 CRICKET LANE 4/30/2024 Cornmonweatth of Massachusetts fl '"C°*1 Itle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments dr Praaerry Aitdrtss O rer inftmn aWn usrequired ky. every —Ave page. r;rtyfD`own sGnto Zip Code Dato of Inspedion Inspection results must be submitted on this firm. Inspection forms may,not be,#iced in any way. Please see completeness checklist at the end of the form. _._w _. ......._._.. .:, _....,_ ._.._.... Important Whe A. Inispector Information filling out forn-m on the armputer, b f key to move caner -- y rr��trecr c qr use t11 return cursor-do /4. ..." C key, Uarn Narn ,.w..- c Wires - y Star Zip Code Telephone Number License V i mber B. Certification !certify that: l am a DEP approved system inspector in full compliance with Section 15.340 of Title ( 10 C MR 1 . ); l have personally inspected the sewage disposal system at the property address listed above"the information reported below is true, accurate and cornpkAe as of the time of my inspection„ and the inspection was performed based on my training and experience in the proper function and maintenance ofon-site sewage di-sposal systems.After conducting this inspection I have determined that the systemr 1. El Lasses 2. Conditionally Passes . 0 Needs Further Evaluation by the Local Approving Authority 4, Ej Faits n Date The system inspector shall Yl(rit a copy of this inspection report to the Approving Authority(Board of Health or DErP)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 he 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. tUaraspAm-rev.'T; S i:"haPe 'T40 5 Offidal Insrfc-hasna ROWTV, . .aav,SMMOP fXf4XA9A SyStO n.Page'r aid 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r'rrrrerty rr Owner Owner's Narrnrl information d CdtytT state Zip Cr�de ate of tr1, tarn ..­_.__1_­­,._.. _.. _....... ............ ,._ _....._..._,__ _ ...__,.. _.._.._... .w._..,_.., C. Inspection Summary lnspecflokk Summary- Complete 1,2, 3, or 5 and all of 4 and fa. 1) System Pass E' I have not found an it (armatjon which indicates that any of the failure criteria described in 310 CMR 15.303 or i&,34 0 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: One or e system components,as described.in the" iticanal lass"" section,n to be epl or repaired.The system, Capon completion of the replacement or repair, as approved by the Sward of Health„will pass, Checkthe box for"yes", "no"or"neat determined"(Y, N, ND)for the following statements. If"riot determined„"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or neat)is structurally unsound, exhibits substantial infiltration or exfiltratiran 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 Heahfi. *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 E] N ❑ ND(Explain below): L:"B¢rzarw.zd(x my T'26 2111e Tdo 5'a1M8:auaa0&ro n 8"vornr Fakaka&AkaLe Sem4p G:1Gs4xnW S),.aaem^Page 2 of 18 ° Ceawmmonweakh of Massachusefts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments !M } a, Propefly Address Owner Owner' dame information is required for every ............. page. Cityffown State Zip Code rate of Ins .lion C. Inspection Summary (cons.) 2) System Conditionally Passes (cone.): El pump Chamber pumps/alarms not operational.System will pass with Board of Wealth approval if pumps/alarms are repaired. El Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken, settled or uneven distribution trey. System will pass inspection if(with approval of Board of Wealth): broken pipe(s)are replaced El Y El N F1 ND (Explain below): ( obstruction is removed E] Y ❑ N El ND (Explain below):. distribution box is leveled or replaced Y, [1 N El 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 Wealth): trrokr n pipe(s)are replaced [ Y N [ ND(Explain below): obs ion is removed Y N ND (Explains below): 3) further evaluation is Required by the Board of ll'eralth: Conditions exist which require further evaluation b the Board ealth in order to determine if the system is failing to protect public health, safdty or the eftvironm t. a. System will pass sunless Board of Health determines Ira accorda with 310 CMR 1 .3tt3(1 (b)that the system is not functioning in a manner which will rotes t public health, safety and the environment: M'wrrWrA.'&W'.rmrm.P'2612515 I do 5 d"ffla S k'Rsr*K.'bChY11 Nyaaar Sambas+ure«aul S"vvage rNgmW w,ro „Mm.Page 3 M 18 Gornmonwrrealltti of Massachusetts Title 5 Official Inspection Form Not fo Form r Voluntary Assessments Subsurface Sewage Disposal System Propedy Address Owner �r"�Na yF � roctirrraartrl of �y r _ µ ''q 0 i( 7 r. re�q�aw!re�rk fcar every �� .. page. Cityrrown State zip Caere rate of Ins ...*n C. Inspection Summary (cont.) Cesspool or privy is within 50 feet of a surface water E ""C sspool or privy is within bQ feet of a bordering vegetated wettand or a salt marsh b. System wih, ll unless the Board of Health(anal Public Water Supplier, if any) determines that t ,system is functioning in a manner that protects the public health, safety and environnria t: The system has a Sept` nk and snit absorption system (SAS)and the SAS is within 100 feet of a surface grater sup or tributary to a surface water supply. [l The system has a septic;tank a SAS and the SAS is within a Zone 1 of a public water supply. ] The system has a.septic tank and SA d the SAS is within S feet.of a private water supply went. (mm] The system has a septic tank and SAS and tlt S is less than 1ftC►fact but tt feet or, more froma private water supply weft". Method used to determine distance; **This system passes if the ll water analysis, performed at a tip certi' taboratory, for fecal cotrtomn bacteria indicates absent and the preser of AS, nitrogen a id nitrate nitrogen is equal to or tens than b ppm, provided that no other filaare criteria are triggered.A copy of the analysis must be attached to this farm. c. tither: A) System Failure Criteria Applicable to All Systems: You maust indicate"Yes" or"No'"to each of the following for all inspections; Yes No E Backup of sewage into facility or system component due to overloaded or LK slogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool f5insp-d ac ra w.7 26,201 rde 5 C ffidA!Ina;PofaaarAuon Foffm SLft"arfacp SewW,N a sW System>Page 4 of 18 Commonwealth of Massachusetts " T itfle 5 Officalal Inspection Form Subsurface age Disposal System Form -Not for Voluntary Assessments Property/+(chess Owner Ow rss NameN Grrfirifom ratcoort i% ��,p � , q rr 4 teas rr rry " ! r . �. page. City/Town ;state* zip Coder Date of errs tion m_. .w._.____. _......._._.,.,_._ ...,.,._..__ _, . _..,_.ry..w.w ._w_......, _ ...,..-..-___ w.__._. .._,.,_... .,. ._._._... _,..,..,._.__._.._........ G. Inspection Summary (carat.) 4) System failure Criteria Applicable to All Systems: (cant.) "Yes NO 0 Static liquid level in the distribution boar 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 than 1/2 clear flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El Any portion of the SAS, cesspool,or privy is below high ground water elevation. E Any portion of cessped or privy is within 100 feet of a surface water supply or tributary to a surface water supply. E] Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. D Any portion of a cesspool or privy is within 50 feet of a private:water supply well. El 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 conform 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 harm.] The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd, E) 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 1 O,000 gpd to 15,000 gp . For large system ,.y au must indicate either"yes"or"no"to each of the following, in addition to the questions in Section Yes No 0 El the system is within feet of a surface drinking water supply El 1:1 the system is within 200 feet of. 'butary to a surface drinking water supply the system is located in a nitrogen ns " e area (interim Wellhead Protection El EDArea�-IWPA)or a map 'gone II of a pu .t water supply well t5insp.doc^rev '1/26120 d5 Tree 5 Offi dM hwW.Am;m Piet&"uff!'ace&wVo Dispvs,al Sysi in Page 6 of IS .„ Comm onwea th of Massachusetts Title 5 Official Inspection Form .s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w, pp u✓ Property Faa d raa �. d< Owner Owner's Name �� d r _ rase a for every / a � � � "�. page. t rtyBT State Zip Code Date of Inspecton C. InspecUon Summary (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 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 most indicate"yes"or"no"for each of the following for all inspections: Yes No X0 Bumping information was provided by the owner, occupant„ or Board of Health El K Were any of the system components pumped out in the previous two weeks? EE] Has the system received normal flows in the sous two week period? E Have large volumes of water been introduced to the system recently or as part of this inspection? E] Were as built plans:of the system obtained and examined?(if they were not available note as N/A El Was the facility or dwelling inspected for signs of sewage back up? n Was the site inspected for signs of break out? El Were all system components,excluding the SAS, located on site? El 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 it different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Sail Absorption System(SAS)on the site has been determined based on. tT �4.. El `• d Existing information. For example,a plan at the and of Health. Ei ;K,� Determined in the field(if any of the failure criteria related to D'art C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] P5dnap.doc-r6v,/M:,"0'I8' Tile 5".l z ial Ikpv"pectan Form%A)surfzu*Sewwje Mf4xnai Sysimn-Page 6 of 18 Commonwealth lth of Massachusetts mm � Title Offle ial Inspection n Farm Subsurface Sewage Disposal System Form-Not for`voluntary Assessments r� Property Address -7 n _.. Owner -- - _.... _. o+�w r"s eta or evefy ra oreoAredfn�e / y/x 1. S R,� ' t� 2... page. City/Town State Zip Code Date of Inspection ..._._..__.,_.__.._..._._ ...w.___..._.._...._._ ...........__.ry., D. System Information 1. Residential Flow Conditions: L Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15,203(for example- 110 gpd x#of bedrooms): � Description: Number of current residents: . Does residence have a garbage grinder? El 'Yes No Does residence have a water treatment unit? El Yes No If yes„discharges to: - Is laundry on a separate sewage system?(Include laundry system inspection Yes No information in this report.) Laundry system inspected' Yes No Seasonal use? ¢ Yes No Water meter readings„ it available(last 2 years usage(gpd)): CDetail- _..__.... _...,._._ .w.._...-------- _..__._._...._._ ..-_ . _._.. ------- Sump pump? ® Yes)41 No Fast date of occupancy: mate kairarxp.darc t rev.7,262p'N 8 Me 5 Oft dal Inspecton C omr 5takaauxka„'asa Sew aga IDaapanal Splern.Page 7 of 18 Commonwealth of Massachusetts Title 5 0"bl"Tic alai Inspection Form .Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address b � fawner Ow Nana information is required for every ., W page. Cmtyf"rown State Zip Code Date of Inspection D. stem Information (cunt.) 2. Co mercialfindustrial Flaw Conditions: Type of stablishment: --.._ _ ...._... ---- Design ow( sed on 3l O CMR 15.203): Gallons per day(glni) Basis of design ft seats/persons/sq.ft., etc.): . Grease trap present? [l Yes [1 No Water treatment unit present? ❑ Yes No If yes, discharges to: ------ _ - . 11 Industrial waste holding tank present? El Yes ® No ton-sandary waste discharged to the Title 5 sy to ? © Yes ® No Water meter readings,if available: Last date of occupancy/use: D Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? [ Yes No If yes, volume primped: _ „ ......._ _ . --._-._ gallons How was quantity pumped determined? Reason for pumping: t 5irsp.alac•rev,77261;21d Tde 5 Ct dal Inspecton Foit :Subsurl'rare Sewage DispmM System-page 8 or 18 Commonwealth of Massachusetts, ' Subsurface Sewage Disposal System farm-Not for Voluntary Assessments iC Owner matiS.7n i Owner's a9 "" Jam... "� mquirwiforevefy page„ CAyrTc'dwn state Sip Code Date of Insp r-ton D. System Information (cont.) . Type of System: 0( Septic tank,distribution boar,soil absorption system El Single cesspool El Overflow cesspool El Privy Shared system (yes no� it yes„ attach previous inspection records„ if any!) El Innovative/Alternative techndogy.Attach a copy of the current operation and maintenance contract(to be obtained from systemowner);and a copy of latest inspection of the ldA 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 informafion: �.' A t � Were sewage odors detected when arriving at the site? El Yes r_1 No 5. Building Sewer(locate on site plan): n„M ark Depth below grade: feet Material of construction: cast iron 40 PVC other(explain): Dista nce Ice from private water supply watt or suction line: feet- Comments(on condition of joints„ venting„ evidence of leakage„ etc.); t5k%ssp dor•.rev,726/20 M '4e,5 Offidal Nirtsper�+rtk&w Fonyc Subs urtace Sewage Nsfxmi System-Page 9 cA 18 Commonwealth of Massachusefts Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments cV,�"T­ Prorwrty AMress r1fruer (7+nsrro, ` herrura _ C7oaa c�nl�aa�Otan isIr ed for every P ode Moe ei kspecwlon D. System Information (cone.) fa. Septic Tank(locate on site plan); Depth below grade- _feet . .. Material ofconstruction'. concrete rl metal []fiberglass polyethylene other(explain) If tank is metal„ list age; ye ars Is age confirmed by a Certificate of Compliance?(attach a copy,of certificate) (l Yes [:1 No Dimensions: �f aw Sludge depth. � Cl Distance from top of sludge to bottom of outlet tee or baffle �_._ ... .. .... Scum thickness T Distance from top of scum to tope of outlet tee or baffle Distance from bottom of scuds to bottom of outlet tee or baffle -----. Howw were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 154nsp.doc-rev.v T2"a�G"016 Me 5 4'ffi6rl hspecton Fe rnr Subsurface%nu Ve,Uisrx A Systte rn•NVe 10 of IS Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f`zt Prcgxoty AddressC J. - � .. _ ..... Owner irequ foreve _ ..u � information is . ._ 4 Apt- page. crtyffown State Zip Code Date of Inspecton D. System Information (cont.) 7. �se Trap(locate can site plan): Depot kl' rade; " Material of construe concrete metal fiberglass polyethylene [l other(explain): Dimensions: _ Scum thickness Distance from top of scum to toga of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle _ Date of last pumping: Date Comments(on pumping recommendations, inlet and outkwt tee or baffle condition, s ctural integrity„ liquid levels as related to outlet invert,evidence of leakage„etc.): 8. "Ti .car Holding Tank(tank must he pumped at time of inspection)(locate on site plan). Dep law grade: Material of coast n: concrete El metal El fiberglass polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: tt it n t a6mgre.doo.rww 7,262018 'q glk 5 Offi°ear Wuapmfi n Fwury"SaGRnw dw*Sawage Dispos A,:rya:9wm-Page 1 M1 of 18 Commonwealth ealthr of Massachusetts d Title 5 O'k1ficial Inspection Form Subsurface Sewage Disposal System Form_Not for Voluntary Assessments PI(4x-dy Address Owner pnformati��arp as tJwnrar" t z, required'f � � .. " a ." wt}ffowee . State Zip Gods Date of tnspec on _... _..........__ ,...__.___--,_--_ 1. System Information (cant.) . Tight or Holding Tank (cont.) C A�6�present* El Yes No Alarm levee � Alarm in working warder: El Yes [:1 No Date of tact pumping: Cf�atn Comments(condition of alarm and itches„ etc.): "Attach copy of current pumping contract(required),. is cony attached? El Yes No g. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert _ ---------- Comments(note if box is level and distribution to outlets is equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): . 'P. ....... ....___ ....... ------------ w t5in spy c rop,,*tev S'26 Mb I'ille 5 06dal hsp *n Form,",5aada^saaa%ice&wW Cksposal,Sysla T^Page 12 of IS Commonwealth ealth of Massachusefts Title 5 Officloal Inspection Form " Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pro rr rty Akkkess Owner k%1'�ormaff`lK.rt is required for every C it o�rn state i�G� �rrr rime pare. �'y f� of Insper.�raora D. System Information) (cont.) 10. Pump taer(locate on site plan)- Pumps in working 0 El 'Yes [l Flo" !)alarms in working order., �, � ® Yes Noy Comments(note condition of purnp clwaaambe , ridition of pumps and appurtenances, etc.):. If pumps or alarms are not in working order„ system is a conditional pass. 11. Soil Absorption System (SAS)(locale on site,plan, excavation not required); It SAS not located, explain why- _ Type: 0 leaching pits number: El leaching chambers number. 0 leaching galleries number E, leaching trenches number, lengths: leaching fields number, d imensions: [ ove cessl I number: _ EJ innovative/alternative system Typeiname of technology. ti.l in sp.da;oc-rev,7126,20 a TIO 5 d:,XfiBw'wdpai&km4M%brM rmw&Ab,.aarGw*Sewage, x A tim}pntem w Pape 13 of 10 " Commonwealth of Massachusetts i' 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Fong-Not for Voluntary Assessments f roW' ty eras Owner _ . ���� TT�rrS . r�l for eery � d grow peg p of l ped= D. System Information (coat.) 11. Soil Absorption System(SAS)(coat.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil„condition of vegOation, etc.)- 1 ------------- __ W, 12. C is (cesspool must be pumped as part of ins ion)(locate on site plan): Number and configuration l�pth.--top of liquid to inlet invert _ Depth of solids layer Depth of c rn layer _ Dimensions of ces` of Materials of construction Indication of groundwater inflow El "des j- No Comments(note condition of soil„ signs of hydrauti, re, level of ponding, condition of vegetation, etc.): -------._ . f5iiv�Acxn«rani 7,26 2nIA TAW 5(;'ffid.4luuarspmwlan kxrr Subswfah*Sawage UlWxud System^Page 14 of 48 P� `5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System germ-blot for Voluntary Assessments Property Address �N Owner Owner's Nanre .._ information is e required for every C t page. 6typ"fown Mate Zip Cade Date of Inspection __....._._._.....__..__..............,v.._.,_._..._..__..._ D. System Information (cunt.) 13. Privy to on site plan): Materials of�struction: ... ....... .........._. Dimension ._ --___. .. ..... .... ............ Depth of solids _.. ....�._.... _.._ _. Comments(note condition of sot, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): C5insp-doc W rev,712G/018 Tide 5 C,'fidaal Inspertoar FormSudaaaurface Sewage DigxaW Sywtw"•r*aage 15 of 18 h, Commonwealth of Massachusetts TRW 5 Officalal Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T4.. W, .,.f Property Address 7 � �-, , Owner _. _ erg raa�t wnform dfo is ,�+ r ., J requuez9 for every _. ...._...... _._. _^ _ _-----_ page Cdy/Tovwn Mete Zip Code Date of wnspec^tton D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at bast 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, E] hand-sketch in the area below [ drawing attached separately t5tnapAoc.rev.'71"2612018 I'le 5 Cl ad Inspedon Form:Subsurface Sewage t>-nowt System*Waage 16 of't8 °° Common ea fth► of Massachusetts Title 5 Official c r s ion Form ( Subsurface Sewage Disposal System Form Not for Voluntary Assessments PrrmtoertAWress Owner information is requirmi for every ctty�9 own page. tatc; tiff C",. ie fete of irasrr~tirrn SystemD. Informations (cone.) 15. Site Exam- Check Slope 0 Surface water ( Check cellar . r [J_ Shallow wells Estimated depth to high ground water.- feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record If checked„ date of design plan reviewed: D 11 te- El Observed site(abutting prcpertylebservation hale within 150 feet of SAS) Checked with local Berard of Health- expl [l Checked with local excavators, installers _(attach documentation) Accessed USGS database_explain: --- r es. tared water elev feat ettr rraNutdescribe�� to established the highground g .. .... Z.r .. _.. _. . G lf;..�k"1'A_A...` ...�'C..k....... �4. G' d ", .... B,efore filing this.Inspection Report,pee see Report Completeness Checklist on next page. t"%dw%%d oc•rew.72162018 '1 5 Oftal 1 na M.I*n Form u,b.%u&ACe,';"Wa,ma UPpmA Sptlam-Page IT of'4 8 % Commonwealth of Massachusetts Title 5 Official Inspection Form y Subsurface a Disposal System Form-Not for Voluntary Assessments ., Property Address Owner nor"s N_a m,e, ..� information isrequired for emy page. Cityffown Stater, . Zip Codex Date of tra aet'titnn.. - .._. _... ____ ................ _ _ ._...� ........ _.. _ .. ..., _...,_.._. _ ............... E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: El A. Inspector Information- Complete all fields in this section. B. Certification- Signed& Crated and. 1, 2, 3„ or 4 checked El C.Inspection Su rrmary- 1, 2„ 3, or 5 completed as appropriate 4 (Failure Criteria)and.6(Checklist)completed ] D. System Information; For ; Tight/Holding Tank- Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 15 or attached For 15. Explanation of estimated depth to high groundwater included f5h ap,doc::.'rm.7 26,261 8 'Me 5 eJrM6rW Gurapokl aati Form,rSubaLdfa "' WAP,ENSP wd SYUOVI^Page 18 of 18 a BOW9D OF HE IILTH u AS-BUILT SEPTIC SYSTEM LOCATED IN NORTH ANDOVER ,MA. SCALE: 1"=40' DATE:4113196 Scott L. Giles R.P.L.S. 50 Deer Meadow Rood CRICKET LANE North Andover, Mass. 29 .19' 3_ 44 OT 3A = o ' e 43,846 S.F. .= e. za L=38.8 ' ULI EXIST. FOUND. TABLE OF ELEVATIONS }--- INV. OUT HSE. =107. 4 i- co IN TANK =107,06 43: _ OUT TANK=106.69 � �i IN D. BOX =10648 " OUT D. BOX=106.32 (5 WIPES) END PIPE 1=106.04 2=106.03 3=106,03 4g f 4=106.02 5-106.01 IV- 1 CERTIFY I HAT 1}� TIME OFFSETS OFFSETS SHOWN ARE FOR THE USE � SHOWN COMPLY OF THE BUILDING INSPECTOR ONLY .1�372 „o WITH THE ZONING AND SUCH USE IS FOR THE �� BY LAWS OF DETERMINATION OF ZONING ` ' NORTH ANDOVER ,MA. CONFORMITY OR NON-CONFORMITY � WHEN BUILT WHEN CONSTRUCTED. 4 t 13 l 96 i