HomeMy WebLinkAboutPass - Title V Inspection Report - 54 CEDAR LANE 5/28/2024 Commonwealth of �
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Title Official Inspection Forms WM i�
f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 Cedar Lane t '
Property Address d
d,
Santos, David ti
Owner, Owner's Name
information is red for every No. Andover MA 01845 04/30/2024
page,
ge _ _ M _
City Town State Zip Code Gate of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When _...........__...... ......._...__. . . _.
filling out forms A. Inspector Information
an the computer,
use onVy the tab John L. DiVincenzo _
key to move your Name of inspector
cursor_do not J & S Develop me nt/Stewa rt's Septic Service
use the return key, Company Name _
.-- . 58 So. Kimball St.
Company Address
Bradford MA 01835
City/Town State Zip Code
978-372-7471 S113385
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 MOM); 1 have personally inspected thie 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 systerns. After conducting this inspection I have determined
that the system:
1 Passes
2. Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
4, El Falls
_ Y /IY
Ins rynA 1. Date
T e system inspector s 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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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
54 Cedar Lane
Property Address
Santos, David
Owner Owner's Name
information is required for every No Andover MA 01845 04/30/2024
page. 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 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:
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, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y El N Ej ND (Explain below):
t5inap cioc-rev 7a2612018 'Title 5 Offioal lntrpaercimn Form Subsurface Sewage DisposW System.Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
d_
rid Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
" 54 Cedar Lane
Property Address
Santos, David
Owner Omer"s Name
mfofrequired f n Is No. Andover MA 01845 04130/2024
required for every
pule Crtyf'own State _ Zip Code mate of Inspection
_._... .„ ................. . ........_... .._.._ _ _.... .
C. Inspection Summary (cunt.) _ _ ...._..... ..__ ..._._.._._.._......._ .....
2) System Conditionally Passes (cant.):
El Pump Chamber pumps/alarms not operational. System will pass with Sward of Health approval if
purnps/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 pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
broken pipe(s) are replaced Y r-1 N [] NIA (Explain below):
El obstruction is removed (� Y [ ] N ND (Explain below):
El distribution box is leveled or replaced El Y 0 N ❑ ND (Explain below):
[ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
[ broken pipe(s) are replaced [ Y 0 N El ND (Explain below):
El obstruction is removed 0 Y ❑ N NCI (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 CHAR
15.303(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 Massachusetts
,W Title 5 Official Inspection Form
°ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54 Cedar Lane
Property Address
Santos, David
Owner owner's Name
information i e No Andover MA 01845 04/30/2024
required for every _ __ _ _
page. Cotyffown state Zip Code Date of Inspection
.._..._...r.........e.._.._...._,_._...__......._............
_____.._.,_._..... _._..e.__�_. _........._.......m.__..._,__......._......_.......___._
C. Inspection Summary (cant.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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:
❑ 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.
R The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
0 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: 86'
*" 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 Failure Criteria Applicable to All Systems:
You must 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
clogged 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
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Commonwealth of Massachusetts
a
Titl t f nci l Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54 Cedar Lane
Property Address
Santos, David
Owner Owners Name
requiredfo is No. Andover MA 01845 04/30/2024
required for every
pages City/Town State Zip Crime Date of Inspection
C. Inspection Summary (coat.)
4) System Failure Criteria Applicable to All Systems: (coat.)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El Z Liquid depth in cesspool is less than 6"' below invert or available volume is less
than 112,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. ___ _.
L1 z Any portion of the SAS, cesspool or privy is below high ground water elevation.
E] z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supplyEl z .
Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
1] 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 water analysis, performed at a CEP 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 forma
L1 z The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000,gpd.
F1 z The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CIF 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
J El the system is within 400 feet of a surface drinking water supply
F1 Ej the system is within 200 feet of a tributary to a surface drinking water supply
11 El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area I\PWPA)or a mapped Zone iI of a public water supply well
e45i Kre doa;-rev "MM2018 TMe 5(M W&uosywammo n Form Subsurface Stwage Meposapl ryste rn w n as 5&'18
Commonwealth of Massachusetts
iµr Title 5Official Inspection Form
��f/
„ Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
54 Cedar Lane
Property Address
Santos, Gravid
Owner, Owners Name
information is
regUired for every No. Andover MA 01845 04/ 0/2024
page ity/Town State Zip Code Date of Inspection
C. Inspection Summary ....
_.__... _ .. ....._ ...
p oily` (cant.)
If you have answered"yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA alcove 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 CIWIR 15.304. The system owner
should contact the appropriate regional office of the Department.
5. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
H 1:1 Pumping Information was provided by the owner, occupant, or Board of Health
0 Z Were any of the system components pumped out in the previous two weeks?
Z 0 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?
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Z El Was the site inspected for signs of break out?
0 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?
E-1 Was the facility owner(and occupants if different from owner) provided with
Information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on.
Z ❑ Existing information. For example, a plan at the Board of Health.
Z E-1 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)1
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Commonwealth of Massachusetts
=1, Title a Official Inspection Form
Ir' Subsurface Sewage Disposal System Form Not for Voluntary Assessments
tiyr'"
54 Cedar Lane
Property address
Santos, David
Owner Owner's Nanne
information is
required for every No. Andover MA 01845 04/30/2024
page G tyr1 own_ State Zip code Date of Inspection
_.,_.._......�. ..... ...__,_..._... _....._.._..... ........ _,._........_... .__...__ ... . ..................,
D. System Information
1. Residential Flow Conditions:
Number cat bedrooms(design); Number Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example 110 gpd x#t of bedrooms): _
Description:
Number of current residents:
Goes residence have a garbage grinder? Yes No
Does residence have a water treatment unit? ❑ Yes Z No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection 0 Yes Z No
information in this report.)
Laundry system inspected? [l Yes 0 No
Seasonal use? [l Yes Z No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
urnp pump? F-1 Yes Z No
Last date of occupancy: Occupied
Date
t5innp doc^resw.'F92�612018 Tf to 5 'ft*hsp ection F"nam asrh Surfmaa:s sawa2ier MSPOSW System Page 7 of 18
Commonwealth of Massachusetts
Title 5 Offidal Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
rya w
54 Cedar Lane
Property Address
Santos, David
Owner Owners Narne
ir"nfonnation is
required for every No. Andover MA _ 1845 _ 04/30/2024
page City/Town State Zip code' Date of Inspection
._ . ............__.... _.._,__....._..._._.. .....
D. System Information (cont.)
2. Commerciallindustrial Flow Conditions;
Type of Establishment:
Design flow(based on 310 CMIR 15.203): Gallons per day
Basis of design flow (seats/persons/sq.ft., etc,):
Grease trap present? El Yes Ej No
Water treatment unit present" EJ Yes [] No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes E] No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes E] No
Water,meter readings„ if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Last pul 03/24/2023
Was system pumped as part of the inspection's [ Yes No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Sight gauge on truck
Inspect tank
Reason for pumping:
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Commonwealth of Massachusetts
„ 1 Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
54 Cedar Lane
Property Address
Santos, David
Owner Owner's Nanne
information is
required for every No. Andover- MA 01845 04/30/2024
page City/Town State Zip Cade Gate of inspection
_.. -------
,.......
.__...... . _..............
D. System Information (cant.)
4. Type of System,
z Septic tank, distribution box, sail absorption system
E] Single cesspool
EI Overflow cesspool
11 Privy
Q M] Shared system (yes or no) (if yes, attach previous inspection records, if any)
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
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:
:>28
Were sewage odors detected when arriving at the site" [,..I Yes Z No
5. Building Seaver(locate on site plan):
Depth below grade: 20
feet
Material of construction:
Z cast iron F_] 40 PVC El other(explain):
Distance from private water supply well or suction line; 86' (see attached water test)
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
N&nsp aiac•s av '7F26r2018 TO*5 Olfcfal hispirr,4ion F'orrc swbsurtace sewage ni;rposs[System^Page 9 cf 18
Commonwealth of Massachusetts
w0, Title 5 Official Inspection Form
wFNlrzH """i
°<< Subsurface Sewage Disposal System Form - Not for"voluntary Assessments
F , 54 Cedar Lane
e7 5
Property Address
Santos, David
Owner Owners Name
information is
required for every No. Andover MA 01845 04/30/2024
pare. Crfylt own State Zip Cade rate of Inspection
_ . ........ ............ ......... _._.._ ......_ ......
D. System Information (cent,)
8. Septic"rank (locate on site plan)
Depth below grade: 12
feet .
Material of construction:
concrete (w ] metal [". fiberglass [l polyethylene ❑ other(explain)
If tank is metal, lust age: years
Is age confirmed by a Certificate of Compliance"? (attach a copy of certificate) El Yes ❑ No
Dimensions. >X 8 X 4
Sludge depth: 4 u_
Distance from top of sludge to bottom of outlet tee or baffle _
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 8'
Distance from bottom of scum to bottom of outlet tee or baffle 14
How were dimensions determined"? Tape measure/sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both baffles are in good shape. No leakage, liquid,level is good.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
�C Subsurface Sewage Disposal System Form Not for Voluntary Assessments
al 54 Cedar Lane
Property Address
Santos, David
Dater Owners Narne
informationdfr every is
regrequiredrequiredfo No, Andover CIA 01845 04/30/2024
_
page Citylfown ante: Zip Code Date of Inspection
_.----__._.._.._ _..,._ ..._......... ........... ..... _..,.. _......
D. System Information (coat.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
E I concrete E.] metal El fiberglass Fj polyethylene (� other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scrim to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc,):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
0 concrete [ metal fiberglass polyethylene [ other(explain):
Dimensions:
Capacity: gallon
Design Flow:
gallons per clay
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......_......._...-----------------
-._. ...... -..... ........
m Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Cedar Lane
Property Address
Santos, David
Owner Owners Name
anfrWred on for every is
required ta No. Andover MA 01845 04/ 0/2024
_
page, crty[Town State Zip Cade Date a i Inspection
w.w.. ._,... _,.. . ....... _ _ ..,... ._ .... ......... ._.._.w __ _...........
D. System Information (cant.)
. Tight or Holding Tank (cant.)
Alarm present: 0 Yes F-1 No
Alamo level: Alarm in working order Yes ( No
Date of last pumping: sate
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached' El Yes 0 No
. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Cornments (note if box is level and distribution to outlets equaV, any evidence of solids carryover, any
evidence of leakage into or out of box, etc,):
No solids carryover, no leakage Equal distribution.
thins%p doc roa.712612018 T¢%5 Offi,r+a'al hspedirm Form Subsulace°:a wWM Disposal System-Pazaya 12 of IS
Commonwealth of Massachusetts
� I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 Cedar Lane
Property Address
Santos, David
Owner Owner's Narne
information is No Andover MA 01545 04/30/ 024
required fair every
page, City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
10, Pump Chamber(locate on site elan):
Pumps in working carder: El Yes 0 Now
Alarms in working order F Yes [ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order„ system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan„ excavation not required):
If SAS not located, explain why:
Type:
z leaching pits number:
2
E] leaching chambers nurnber:
11 leaching galleries number: _
11 leaching trenches number, iength:
leaching fields number, dimensions:
overflow cesspool number:
Cm� innovative/alternative system
Type/name of technology:
Hasp doc rev 7r M2.018 T[Ue 5 Offlaal h9rection Foon Saabs uul'R4e'Sewag e DisPsnowil SyWern�Page 13 of 18
a.• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for"Voluntary Assessments
.� 54 Cedar Lane
Property Address
Santos, David
Owner Owners Narrae
information for
o. over
r every is
requiredired Sca N And MA 01845 04/ t /2024
_ _ _
page City/Tow,n State Zip Code Crate of Inspection
......._.. . _ ........, _....... _.... _.. ._._.... _._. ....
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.):
No hydraulic failure„ no pondin , no darmp soils. Both pits are dry.
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 0 No
Comments (note condition of sail„ signs of hydraulic failure„ level of ponding„ condition of vegetation„
etc.):
tl,"nsp cdoc rev '7Q@"rf2018 TPOe 5 OftirciW InsIrrection torn Subsuffacp eNaagea Disposa),Syswn.Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not far Voluntary Assessment
I� y Y
�.,.. .. 54 Cedar Lane
Property Address
Santos, David
Owner Owner's Name _
e rngGrired az d for
e
r every o,°
le N AndoverMA 01845 04/30/2024
_
page CityfTowvn State .asp Code Date of inspection
.............. _, ___.. ......._ . _...__..._ .._.__.._...... .. . .... - __
D. System Information (cant.)
13, Privy (locate on site plan):
Mate6als of construction:
Dirnensions
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 Massachuseft
r „ "Title 5 Official Inspection Form
s6 Subsurface Sewage Disposal System Farm • Not for Voluntary Assessments
!11�
- ^.. ..°r / 54 Cedar Lane
Santos„ David
Owner Owner's game
rezrriredit�r is ............ ___,____._.__. _.
required for every p�t� Arwtct�ver . m.... .. ...m . .,. ........ 1ViA 01�345 t�4-.;3(� 04 ....._... . . ........_ .. .
page, i*[Town State I 6oa-e rate of Inspection
SystemD. Information (cant.)
14, Sketch Of Sewage Disposal :system;
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below;
"hand-sketch in the area below
drawing attached separately
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Commonwealth of Massachusetts
Title 5 Offodal Inspec "on Farm
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
54 Cedar Lane
Property Address
Santos, David
Owner Owner's Narne
forn7ation is
required for every No. Andover _ MA 01345 04/3012024
page City[Town State Zip Core rate of Inspection
D. System Information (cant)
15. Site Exam:
Check Slope
�] Surface water
Check cellar
El 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: DIate _
[� Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health _explain:
Title V and pumping records on file
.mm] Checked with local excavators, installers -(attach documentation)
l Accessed USr,3S database - explain:
You must describe how you established the high ground water elevation:
No sump pump in the basement. Bottom of pits are approximately 2'_above the basement floor
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
54 Cedar Lane
Property Address
Santos, David
Owner owners Narn _
reqon is
uired far every No Andover MA 01645 04/30/2024
raired _
page. City/Town State Zip Code Date of Inspection
..__......... ..... .._..__,._... _ _.,,,,._............_ _... _._ _. _....,...,w....._.__...........
.... ._.__..._...__.m.ti__._.........
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
Z A. Inspector lnformation� Complete all fields In this section.
Z S. Certification: Signed & Dated and 1, 2, 3, or checked
Z C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
Z D, System Information:
For& 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
tl.w'Sasp.0or^rev '7a 2612018 TC flea 5 off`iefa(rrvs(,7era2ion Form Suf asiurf'a ay Sewage r mposu.J System Page 18 of 18
41 Dayton Sl r(,O
Danveis, M!A 01923-t015
M 71 7 4 442
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MADEP# M MM23
WRONMENIAL LABORATORY,INC.
David Santos 05/07/24
511 Ccdao ➢.ane Report# 64783
North Andover, MA 0 18415-3202
NFI.P A7(084� Kkfio)s nk at 54 Cedar Lane North Andovercollecled 05/01/24 at 12:30 by DS and recelve.d at NH.05/01/24 M 1100 by
SA
paramcter Result MA DEP StwOard D L, ['Qk Anaiyzerl Method p-ab Ccl t,
Fcxal ColiforM,Co9[lcrt-18,P/A ND /100ml absent n/a 1 05/01/24 13:18 9223B MA123 -
Arnrnonia as N 0.03 rT)g/l,, - OM 0.02 05/03/24 15:53 350.1 c F008 N
Nitrate(as N) ND mg/l., 10 mmct, 0,04 0.1 013/02/24 10:18 300.0 MA123 P, N
'Anaiyses umducted 41 accotda,n'c'-e—w,Vth-M---A--"[)EP 6Crtr-flcatkm standards tear pota I b I I e-I w I a I I t I er I(P)-I og n-on--po t a-b 8e 11 w I a 11 ter(N)un8d1ss rioted,oih'erw I isa 1 2.
Nor Detected (ND)�ndicates thm 1 the analyte Rs presoit,the ccrncentratkon is below the dmecUon limit, Detection Jfn�t(DQ➢stlhe mohod
detection Y00t,adjus(ed foe dilluUcns. Reported cancen(ral ions that faH betweer r rhe DL and Practical QuantfficaUorr I VrrrK(PQL)are esonlared,
MMCL-MassmNAOts Mammum Contamnant Levef
SMCL:mUS FPA Serondwy Maxmnum Camwninaght Levd
P,IRDL- Maw[rnum Res0u,0 DKpnfcrtafV LevO
ORSGvOffict�of Resvmch and 9andards Gwdellme
Andrew I T t ou pis
Laboratory Drector
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41 DAYION STREET
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Microbac Laboratories, Inc, - Dayville
CERTIFICATE OF ANALYSIS
NE0346
Northeast Environmental Lab Project Name:64783
Andrew Troupis Project/PO Number 64783COC1
41 Dayton ST Received; 05/02/2024
Danvers, MA01923 Reported 05/06/2024
Analytical Testing Parameters
Client Sample ID:
Sample Matrix: Collected By:
Lab Sample ID:
Collection Date:
Inorganics Total Result Limits? RL Units Note Prepared Analyzed Analyst
................
Method:Wet-Distillation-DWIEPA 350.1,Rv.2(1993)
Arnmonia as N 0.0288 0.0200 rng/L yl 05/03/24 1553 CL.W
Results in bold have exceeded a limit defined for this project. Limits are provided for reference but as regulatory limits change frequently,
Mirrobac Laboratories, Inc advises the recipient of this report to confirm such limits and urrits of concentration with the appropriate
Federal, state or local authonfies Woes acting on the data,
........ . ...... ....... ........ .......... .........................
Definitions
MCL: US EPA MaXiMUm Contaminant Level
mg/L: Milligrams per Liter
RL: Reporting Limit
YI: Accreditation is not offered by the accrediting body for this arialyte.
Project Requested Certification(s)
Microbac Laboratories,Inc,-Dayville
M-CT008 Massachusetts Department of Environmental Protection
Report Comments Reviewed and Approved By:
Samples were received in proper condition and the reported results conform to
applicable accreditation standard unless otherwise noted, J
The data and information on tins,and other accompanying documents, rplirpsents only the
sample(s,tanalyzed, This report is incomplete unless all pages mrldcated in the footnote are Melisa 1. Montgomery
prcrsent and an authon7ed signature is inclooed, The services were provided under and Quality Assurance Officer
subject to Microbac's standard tears and conditions which can be located and Rep)orted: 05/0612024 17 17
reviewed at���tf AtL
L D iyv,dHE
61 Louisa Viens Drive I Dayville, CT 062411860.774.6814 p I www.microbac.com Pa 1 o=
41 Daytem Street
11k Danvers,MA 01923.WIS ill till 11111 978'777.4442
D 4 E 0 4 6 contact@ nort heasdab,corn
NVIRONMENTAL LAB( Northeast Environmental Lab \JEL Report 64783COC1
Date Time #of
NEL ID Sample 'rype Collected Collected Preservation Bottles Analyses Requested
A76984 drinking water 511124 12:30 pHe>Hn04,4(, 1x250rnL Ammonia as N
PRESERVATIVE
VERIFIED
Initiais--1
Project contains potable water samples, Notify NEL, Inc. immediately upon analysis of all samples that exceed
any EPA or MassDEP established maximum contaminant level,
RelinClUlshed Received By
Date &Time:
Relinquished By: Received By:
.............
Date & Time:
Page" of 2'
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