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HomeMy WebLinkAboutFail - Title V Inspection Report - 21 EVERGREEN DRIVE 6/4/2024 c Commonwealth of Massachusetts 91 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Ever Teen Drive _ Property Address Paul Davis Owner Owner's Name information is required for every North Andover Ma 01845 4-29-2024 ---- - -- page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered-ip any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, use only the tab F. Paul Cardone key to move your Name of Inspector cursor-do not use the return use Compliance,Inc. - key. Company Name e 37 1/2_Baremeadow Street rati Company Address Methuen Ma 01844 City/Town State Zip Code retrm 978-815-3115 or 978-681-0726 #3294 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 propeq,add fess listed above; the information reported below is true, accurate and complete as of the,tirn�p`E t iy, inspection; and the inspection was performed based on my training and exper 'ln`1`the proper function and maintenance of on-site sewage disposal systems. After conductin pl�p�ttion I have determined that the system: ' 160, 1. ❑ Passes ,der 2. ❑ Conditionally Passes 'Oe?`d 3. ❑ Needs Further Evaluation by the Local Approving Authority \-\(;`� 4. ® Fails Inspector's Signature Date 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 DEP. 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t� 21 Evergreen Drive Property Address Paul Davis Owner ---- - __ ----- ----- Owner's Name information is North Andover Ma 01845 4-29-2024 required for every --- _--_- _ __-- --_ -- _ --- _-- 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: ❑ 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 ❑ N ❑ ND (Explain below): t5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Evergreen Drive Property Address Paul Davis Owner Owner's Name information is North Andover Ma 01845 4-29-2024 required for every — page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ 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 ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ 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 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �h I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Evergreen Drive Property Address Paul Davis Owner Owner's Name information is North Andover Ma 01845 4-29-2024 required for every - - ----.--- page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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. ❑ The system has a septic tank and SAS and the SAS is within a Zone 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 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 ® ❑ 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 nf Commonwealth of Massachusetts Title 5 Official Inspection Form '= I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Evergreen Drive Property Address Paul Davis Owner Owner's Name information is required for every North Andover Ma 01845 4-29-2024 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 than 'Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑ 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® 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 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 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.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 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 CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts +� p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Evergreen Drive Property Address Paul Davis Owner Owner's Name information is North Andover Ma 01845 4-29-2024 required for every —-- -- page. City/Town State Zip Code Date of Inspection C. Inspection 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 must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? ❑ ® 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? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, 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 maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on-. ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Parcel Id 18343 21 EVERGREEN DRIVE PAUL V. DAVIS TRUST Since Jan 2014 PAUL V. DAVIS, TRUSTEE 21 EVERGREEN DRIVE NORTH ANDOVER MA 01846 Class 101 Single Family Property Type 1 Residential Size Total 1.06 Acres FY 2024 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until DAVIS,PAUL VINCENT Payor Active 21 EVERGREEN DRIVE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Mactive Bldg Id. 13630.0-21 EVERGREEN DRIVE Last Billing Date 2/8/2024 1090307 01 Cycle 01 Active UB Services Maint. Account No. 1090307 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63 5/8 7.82 11 WTR WATER 01 ALL METER SIZE !1 UB Meter Maintenance Account No.1090307 Serial No Status Location Brand Type Size YTD Cons 46115591 a Active 00 ERT HH b Badger w Water 0.625 0.625 64 Date Reading Code Consumption Posted Date Variance 4/17/2024 249 a Actual 0 -100% 1/17/2024 249 aActual 0 2/15/2024 -100% 10/18/2023 249 aActual 9 11/21/2023 3% 7/20/2023 240 a Actual 9 8/14/2023 771% 4/18/2023 231 a Actual 1 5/10/2023 -49% 1/18/2023 230 aActual 2 2/14/2023 -78% 10/18/2022 228 aActual 9 11/9/2022 -13% 7/20/2022 219 a Actual 11 8/16/2022 -100% 4/15/2022 208 a Actual 0 5/12/2022 -100% 1/192022 208 aActual 0 2/16/2022 -100% 10/19/2021 208 aActual 10 11/22/2021 -13% 7/22/2021 198 a Actual 12 8/24/2021 -100% 4/20/2021 186 a Actual 0 5/18/2021 .100% 1/20/2021 186 aActual 1 2/23/2021 -93% 10/16/2020 185 a Actual 13 11/12/2020 -3% 7/15/2020 172 a Actual 12 8/12/2020 -100% 4/23/2020 160 a Actual 0 5/13/2020 -100% 1/16/2020 160 aActual 0 2/10/2020 -100% 10/17/2019 160 a Actual 9 12/18/2019 9% 7/22/2019 151 a Actual 9 8/13/2019 -100% 4/18/2019 142 a Actual 0 5/1512019 -100% 1/16/2019 142 a Actual 1 2/18/2019 .91% 10/17/2018 141 a Actual 11 11/19/2018 37% 7/18/2018 130 a Actual 8 8/15/2018 -100% 4/18/2018 122 a Actual 0 5/17/2018 -100% 1/18/2018 122 aActual 6 2/20/2018 -35% 10/17/2017 116 aActual 9 11/13120W -16% 7/19/2017 107 a Actual 11 8/15/2017 -100% 4/18/2017 96 a Actual 0 5/172017 -100% 1/19/2017 96 aActual 8 2/162017 -30% Summary Record Card generated on 4/26/2024 8,58:13 AM by Jennifer Bracero Page 2 Town of North Andover Tax Map # 210-107.C-0059-0000.0 Parcel Id 18343 21 EVERGREEN DRIVE PAUL V. DAVIS TRUST Since Jan 2014 PAUL V. DAVIS, TRUSTEE 21 EVERGREEN DRIVE NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.06 Acres FY 2024 10/18/2016 88 a Actual 11 11/16/2016 -44% 7/21/2016 77 a Actual 20 8/16/2016 -100% 4/21/2016 57 aActual 0 5/25/2016 -100% 1/21/2016 57 aActual 4 2/19/2016 -72% 10/21/2015 53 aActual 14 11/2012015 29% 7/23/2015 39 a Actual 11 8/14/2015 -100% 4/23/2015 28 a Actual 0 5/19/2015 -100% 1/22/2015 28 aActual 5 2/20/2015 -44% 10/23/2014 23 a Actual 9 11/14/2014 -1% 7/23/2014 14 a Actual 9 8/13/2014 751% 4/23/2014 5 a Actual 1 5/15/2014 -80% 1/27/2014 4 aActual 4 2/14/2014 -82% 11/18/2013 0 n New Meter 0 2/14/2014 -100% 11/18/2013 442 r Replacement 0 2/14/2014 -100% 10/23/2013 442 m Manual estimate 30 11/18/2013 -100% MSG 7/23/2013 412 a Actual 0 8/15/2013 -100% 4/25/2013 412 a Actual 0 5/20/2013 -100% 1/24/2013 412 aActual 6 2/13/2013 -58% 10/23/2012 406 a Actual 14 11/9/2012 73% 7/23/2012 392 a Actual 8 8/14/2012 14% 4/23/2012 384 a Actual 7 5/9/2012 22% 1/23/2012 377 a Actual 6 2/13/2012 -35% 10/20/2011 371 a Actual 9 11/14/2011 24% 7/20/2011 362 a Actual 7 8/15/2011 15% 4/22/2011 355 a Actual 6 5/16/2011 30% 1/24/2011 349 aActual 5 2/11/2011 -60% 10/21/2010 344 aActual 12 11/12/2010 20% Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments <� 21 Evergreen Drive Property Address Paul Davis Owner ----__- ------- Owner's Name information is required for every North Andover Ma 01845 4-29-2024 -- -- - --- ---- -- -- — ---- - ---- ----- page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ 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, if available last 2 ears usage d Enclosed ---- Detail: ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Evergreen Drive Property Address Paul Davis Owner __----------- --- -- Owner's Name information is North Andover Ma 01845 4-29-2024 required for every -- ____ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment.- Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.).- Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: --- — Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): N/A 3. Pumping Records: Source of information: Website Last time pumped was on 7-6-2023 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? -- -------- - -- -- Reason for pumping: No pumping needed at this time t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �M ,p Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �h a 21 Evergreen Drive Property Address Paul Davis Owner Owner's Name information is North Andover required for every ——_-_----___-- -.---_.- _-- _-_— _ -_Ma 01845 4-29-2024 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ 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 ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 40 Years of age...House was built in 1974 has original system Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): 100 Distance from private water supply well or suction line. feet - - - feet Comments (on condition of joints, venting, evidence of leakage, etc.): All in ok condition,no evidence of any leakage t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Evergreen Drive Property Address Paul Davis _ Owner owner's Name information is required for every North Andover Ma 01845 4-29-2024 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: feet — Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: -- - yea rs Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ® Yes ❑ No 8'xSA.5-1000 gallon3 Dimensions: 3" Sludge depth: --- Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle - - -- - - ----- -- How were dimensions determined? Sludge Judge and tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): We recommend tank be pumped on a yearly basis, inlet baffle was on outlet side needs a tee, tank has a hole in it, it was never plugged during construction after installing outlet pipe through the side of the tank which caused insufficient flow to the dbox. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Evergreen Drive Property Address Paul Davis -------------_____ _ __- - -- - --.___...---------- Owner Owner's Name information is North Andover Ma 01845 4-29-2024 required for every _._ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A 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: 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: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: Capacity: — gallons Design Flow: gallons per day t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21Evergreen Drive Property Address Paul Davis _ Owner - ----- -------- ----- - Owner's Name information is North Andover Ma 01845 4-29-2024 required for every ___ ._ _-___- _-_ __ page. City/Town 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.): N/A Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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 equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was not level, had cracks in it, there was 5" of sludge in the box it appeared to me that some point in time the field surcharged and sent sludge back to the box. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts _ ,` Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Evergreen Drive _ Property Address Paul Davis Owner Owner's Name information is North Andover Ma 01845 4-29-2024 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A * 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: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field Approx. 15'x30' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: ---- -- --- t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts A Title 5 Official Inspection Form ±' I; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Evergreen Drive _ Property Address Paul Davis Owner Owner's Name information is required for every North Andover Ma 01845 4-29-2024 _— -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Good Yes None Yes Grassy side yard area. 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 ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments q Y 4 21 Ever reen Drive Property Address Paul Davis Owner Owner's Name information is North Andover Ma 01845 4-29-2024 required for every — — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): N/A t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 21 Evergreen Drive mayA Property Address Paul Davis Owner Owner's Name information is required for every North Andover Ma 01845 4-29-2024 page. City/Town 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 t _ 1.19 A G 2C 1z /40 t5insp.doc•rev.7/26/2018 Tttle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �^ Title 5 Official Inspection Form III f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Evergreen Drive Property Address Paul Davis _ Owner Owner's Name information is North Andover Ma 01845 4-29-2024 required for every _ . _ _ page. City/Town 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments .s 21Evergreen Drive Property Address Paul Davis Owner -- Owner's Name information is North Andover Ma 01845 4-29-2024 required for every -----_ _ -- - -_ -_-- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 34 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: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: A soil evaluation will need to be done to determine GW for the repair, looking on the map and surrouding properties ground water approx, 34 No information is available on this system from the owner and BOH_ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,,. 21 Ever reen Drive _ ___ Property Address Paul Davis Owner Owner's Name information is North Andover Ma 01845 4-29-2024 required for every page. City/Town State Zip Code Date 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, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, 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 t5insp.doc•rev.7/2 612 0 1 8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18