HomeMy WebLinkAboutFail - Title V Inspection Report - 220 FOREST STREET 6/17/2024 011
Commonwealth of Massachusetts
-� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
L � 220 FOREST STREET
Property Address
MEREDITH KALIL
Owner
Cbwnpr's Name ____.
information is NORTH ANDOVER MA 01845 JUNE 4, 2024
requiredfor suety _..w......__ _._____.___._.__....__..____.._.._..w....._.. ..._________.....__. ___..__.__..._.._ _ ._..____._....._.__ ._._.._.... ._.__.__
page. City/Town State Zip Code Date of Inspten __...._
Inspection results must be submitted on this form. inspection forms may not be altered in any
way. Please see completeness checklist at the and of the farm.
Important:When A. Inspector It1for1"11+r,«ltlol"1__.._._..____ ....�.._._.__...._,_._..�.............._...____....___..__�.___._.
filling out forms
on the only
the tab
Todd James Bateso
use only the tab .�.._.____._._._.._..,....w..._ ..�. ._._.__. ...._......
key to move your blame of Inspector
cursor-do not Bateson Enterprises Inc.
use the return .,.___.. .
key. Company Name
111 ATt a Road
Company Address
Andover MA 01810
Cikyftown Mate Zip Coale
978-475-4786 SI-1.6
"telephone Number License Number
B. Cfr'rtl'I'ICatlOn
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.000); 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 inspections I have determined
that the system:
1. D basses
2. E] Conditionally Passes
. ® Needs Further Evaluation by the Local Approving Authority
4. Fails
JUNE 6, 2024
Cnspe rs 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 flaw 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.doe-rev 7/26t2018 Ti fe 5 O f dw Inspection Foam:Subs".eface Sewage Disposal System Page 1 of 18
Commonwealth of Massachusetts
=� Title 5 Official Inspection Form
IIII Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
` 220 FOREST STREET
MEREDITH KALII_
Owner _._..___ __.._ ___._._._ _. ... ..
Owner's dame
Information is required for every NORTH ANDOVER MA 01845 JUNE 4, 2024
.__.... ...._... __
page. CIty/Town State Zip Code Crate of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2„ 3, or 5 and all of 4 and 6.
1) System Passes:
El 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 0 N El ND (Explain below):
t5xnsp,doc-rev '7/2612018 1 We 5 official InspaatVon Form Subsurface Sewage Disposal Systorn.Page 2 of 18
P
Commonwealth of Massachusetts
TUE jLle 5 C f° I is l I n p i ►rr 1=+ rrr
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
220 FOREST STREET
Or€opefty Address
MEREDITH KALIF
Owner fOwn&s Name
information is NCORTH AND(OVER MA 01845 JUNE 4, 2024
reyafired for every
page. Cftyr own State Zip Code Date of Inspection
_._m. __..,..,..._ ...,.., _...e._....__ . ........_.......___u,.. ___._ _._.. ._ ... w_........,_,....
C. Inspection Summary (cant)
2) System. Conditionally Passes (cant.):
_ Pump Chamber pumps/alarms not operational. Systern will pass with Hoard 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 Hoard of Health):
broken pipe(s) are replaced [ Y ❑ N 0 ND (Explain below):
obstruction is removed El Y [I N El ND (Explain below):
distribution box is leveled or replaced 0 Y 7 N El ND (Explain below):
The system required purnping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection it(with approval of the Hoard of Health):
broken pipe(s) are replaced D Y El N ND (Explain below):
El obstruction is removed Y 0 N Fj ND (Explain below):
) Further Evaluation is Required by the Board of Health:
( . Conditions exist which require further evaluation by the Hoard 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:
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w
Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
W,;'51 220 FOREST STREET
F'rcaperty Address .
MEREDITH KALIL
Owner Owner's Nameinfor
required
is NORTH ANDtOVER MA 01 45 JUKE 4 2024
required for every _ _.... . ._._ ___. .. ._....
page, Otty Icawn Mate Zip Code gate of Inspection
_. ..... ....__.___ _._.._._,. _ .......... ... .....___..w. __..,..m _ .,....._ _..........M,_.. . ........._........_._.....,_ _.....,_. ...__._.._.
C. Inspection Summary (cant.)
Ej Cesspool or privy is within 50 feet of a surface water
0 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 arty)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
F] 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.
El 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.
L] 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 DEE 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 farm.
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
El ,.,p wage
qg p,, f into facility or system component due to overloaded or
� r cesspool
ckidr e�-� z a� _� 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
u Title 5 Official Inspection Form
J� Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
220 FOREST STREET
Property Address
MEREDITH KALIL
Owner Owner's Narne
information is
required for every NCRTHANDOVER MA 01345 JU, NE4_,_2024__....
da c e, Cttyd rown _ State .. . Gip Code Clete of Irrspedo,n
...._._ __..,..___.._... ..... ... ..... ...ww,m,.. ...___-_..... — _ .. . _.._.....,...
C. Inspection Summary (cant.)
4) System Failure Criteria Applicable to all Systems: (cant.)
Yes No
z 1:1 State liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
D z Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 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.
El z 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.
11 z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Fj 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 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 forma
U z The system is a cesspool serving a facility with a design flow of 2000 gpd_
10,000 gpd.
z 1:1 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 w0l be
necessary to correct the failure.
) 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 fallowing„ in addition to the
questions in Section CA.
Yes No
El D the system is within 400 feet of a surface drinking water supply
(-] El the systern is within 200 feet of a tributary to a surface drinking water supply
D D 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
t Title 5 Official Inspection Farm
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
220 FOREST STREET
Property Address
MEREDITH KALIL
Owner bwrier"s Name
required
is NORTH ANDOVER MA 01345 JUhJE 4, 2CI24
reryured far every
page. City/"town State Zip Cade Crate of Inspection
C. Inspection Summary (cont.) __..w._._..____...
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.
. You must indicate "yes" or"no" for each of the following for all inspections:
Yes No
E 0 Pumping information was provided by the owner, occupant" or Board of Health
ED E Were any of the system components pumped out in the previous two weeks?
Z El 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?
0 Ell Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
Z El Was the facility or dwelling inspected for signs of sewage back up?
Z D 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?
E 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:
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)1
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s w Commonwealth of Massachusetts
I Title 5 Offidal Inapect'on Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
220 FOREST STREET
l5roperty Address
MEREDITH KALIL
Owner Owner"s Name
inforrro-ation is NORTH ANDOVER MA 01845 JUNE 4, 2024
rewired for every
parge. Cdtyf ro-wn state Zip Code Date of Inspection
_.......wm....__ .._, ....._..._..�.............,..... _. _. ._.w.....e__.. .................. _..._,_.._. __..... _._.... .. .._ _mw__ ......., _.,
Dw System Information
1. Residential Flow Conditions:
Number of bedrooms (design): A Number of bedrooms (actual): _.
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x##of bedrooms): NA
Description:
Number of current residents:
Does residence have a garbage grinder? El Yes E 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
Seasonaluse? Yes No
Water meter readings, if available (last 2 year's (gp ))`ears usage d WELL
..
Detail:
LAUNDRY HAS LEACH TRENCH INTO YARD. NEEDS TO BE CONNECTED INTO NEW SEPTIC
TANK.
Sump pump? Yes Fj No
Last date of occupancy: CURRENT
.............
Date
P5Fnnµ.0oc-ratv-"7126F20'18 "rMe;a G„Sffria•W kispaaaaturn Form Saura4wface Sewage 8:1 posaa6 SnyWem-Page 7 of 18
°- Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
220 FOREST STREET
Property Address
MEREDITH KALIL
Owner Owner's Name _ _ .. ........
requir dfo is NORTH ANDOVER MA 01845 N11 4, 2024
required tr�r every .. _ _
page. ciyfown State Zip Cade Sate of inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Gaiions per day(9 11 Pd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? El 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? 0 Yes E] No
Water meter readings, if available:
Last date of occupancy/k,ise:
Cake
Other(describe below):
3. Pumping Records:
Source of information: UNKNOWN
Was system pumped as part of the inspection? El Yes E No
If yes, volume pumped: galloras _... .. ..........
How was quantity pumped determined?
Reason for pumping
t5insp,doc w nay.D2612018 'f itlur 5(foci al Inspection Form Subsurface Sewage Disposal Sy„torn-page 8 of'18
Commonwealth of Massachusetts
. I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Vo9untary Assessments
220 FOREST STREET
iDroperty Address _
MEREDITH KALIL
Owner Gwoner"s C rrre
information s NORTH ANDOVER MA 01845 JUNE 4, 2024
required far every _.
page. cityffoww7 State Zip code Gate of Inspection
D. System Information (cent.)
4. Type of System:
z Septic tank, distribution box„ sail 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:
57 YEARS OLD, ORIGINAL SYSTEM, INSTALLED 1967, OWNER
Were sewage odors detected when arriving at the site? El Yes Z No
5. Building Sewer(locate on site plan):
Depth bellow grade: 28
feet
Material of construction:
cast iron E 40 PVC [ other (explain): _- _--
Distance from private water supply well or suction line: 2
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
JOINTS UNDER FLOOR. NOT VISIBLE
VENTING OK- NO ODORS DETECTED
NO EVIDENCE OF LEAKAGE
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form w Not for Voluntary Assessments
,we✓ 220 FOREST STREET
Property Address _
MEREDITH KALIL
Caner Owner Namealf _
required
ds NORTH ANDOVER MIA 01845 JUNE 4, 2024
�eired for every .,.... _ _ _
page. Cityffown State Zip Code Clete of Inspection
J. System Information (cant.)
5, Septic Tank (locate on site plan):
Depth below grade: 15"feet
Material of construction:
concrete [ metal 0 fiberglass El polyethylene other(explain)
_ .----.. ....... .......
If tank is metal, list age: _ _......._
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes E] No
Dimensions: 50" DIAMETER X 5` ROUND
Sludge depth: 0
_..
Distance from top of sludge to bottom of outlet tee or baffle NA BAFFLE ROTTED OFF
5rd
Scum thickness _...._.-
Distance from top of scorn to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle A
Hoer 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.):
SYSTEM FAILED
CONCRETE INLET BAFFLE OK
CONCRETE OUTLET BAFFLE ROTTED OFF
TANK NEEDS REPLACED
LIQUID LEVELS O
NO EVIDENCE OF LEAKAGE
t$f'ap wOcc-rev 7tM2018 ntd e 5 Ofroaau Inspection ection Form Subsurface.Sawaage rfdtap.ir„osal Syskem•Page'10 0 'V S
Commonwealth of Massachusetts
rr, Title 5 Official Inspection Farm
�., 1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
220 FOREST STREET
Property Address
MEREDITH KALIL
Owner _ _
Owner's Name
4„ 2024
p�g informat NORTH ANDon is
requiredOVER MA 01845 JUNE for every _ .. __..., ..
City/Town State Zip Code Crete of Inspection
D. System Information (cant.)
r. Crease Trap (locate on site plan).
Depth below grade:
feet
Material of construction:
�J concrete metal R fiberglass F-1 polyethylene other(explain):
Dimensions:
Scum thickness _
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottorn 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 �.m_] metal [ fiberglass polyethylene ] other(explain):
Dimensions: _
Capacity:
gallons
Design Flow:
gallons per day
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w Commonwealth of Massachusetts
Title 5 Cuff"Icial Inspection ction For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
220 FOREST STREET
Property Address
MERECDITH KALIL
Owner __._____
CDwraer`s Pwfarr�ae
required for is NORTH ANDOVER MA 01845 JUNE 4, 2024
pagentietn uul�rr tar every ._ .. .__,__.._ ... .... .. .. _..
Cptya"1"awn _ State Zip Cade__ t7ete at Inspect8an
D. System Information (cant.)
8. Tight or Holding Tank (cant.)
Alarm present: `des No
Alarm level: __ ..,.. .... Alarm In working order. [I Yes ED No
Date of last pumping: (Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract (required). Is copy attached? 0 Yes ( No
9. Distribution Box (if present must be opened) (locate on site plan).
Depth of liquid level above outlet invert FLOODED
_.
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-SOX. IS FULL OF ROOTS
DISTRIBUTION IS NOT EQUAL
HEAVY EVIDENCE OF SOLIDS CARRYOVER
EVIDENCE OF LEAKAGE
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° Commonwealth of Massachusetts
Title 5 Official Inspection Form
! Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
220 FOREST STREET
Property Address
MEREDITH KALIL
Owner Owner's NameI
information is NORTH ANDOVER MA 81845 JUNE 4, 2024
required for every
page State Zip Cade Date of Inspection
D. System Information (cant.)
10. Pump Chamber(locate can site plan):.
Frumps in working carder: Yes No*
Alarms in working order: D Yes o*
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.
I"I Snail Absorption Systern (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type
El leaching pits number:
El leaching chambers number:
El leaching galleries number: _._..._
z leaching trenches number„ length; UNKNOWN
leaching fields number, dimensions:
[ overfiow cesspool number:
. ] innovative/alternative system
Type/narne of technology: _
t Etna p doc vmw 12 k 2018 Tutte 5 Offico€Irnsawcsa;tlon Fopm;Subsurface Gewage DsP osM System-Page 13 0 16
Commonwealth of Massachusetts
1 T� Tit . 5► fifii+ i l Inspection Form
µ
Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments
W„ 220 FOREST STREET
Property(Address
MEREDITH KALIL
ame
orrw is
c NORTH ANDOVER MA 01845 JUNE 4, 2024
� airedr�for every _. ........ .....
page ityfT"own State Zap Code mate of Inspection
D. System Information (cent.)
11. Soil Absorption System (SAS) (coat.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation,. etc.):
SOIL AND VEGETATION OK
EVIDENCE OF HYDRAULIC FAILURE
NO EVIDENCE OF PONDING
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 0 Yes [1 No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation„
etc.):
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V✓ b
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
220 FOREST STREET
Property Address
MEREDITH KALIL
owner
Owner's Name
required
Is NORTH AND10VER MA 01845 DUNE 4, 2024.
ref�ukred for every
page, CityFTcawn _ State Zip Code hate of tnspec4ion
D. System Information) (coat.)
11 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
220 FOREST STREET
Property Address
MEREDITH KALIL
Owner Owner's Name
information Is
required for every, NORTHANDOVER MA 01845 JUNE�,2q24
pale ityfrown 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
>100
-4A
A T41)
A box -70' di'dinefow
5 q
Vox 7-1 , It
t5inapft.-rev.712612010 Title 5offidW Iropec6onForm Sub swfaw8w"eD%posa1$y&t*m-Pap 10oflB
..........
Commonwealth of Massachusetts
AWE Title 5 official Inspection Form
�x
�is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
jw
220 FOREST STREET
Property Address
MEREDITH KALIL
Owner .. .
C7wner°s Name ........
information is NORTH ANDOVER MA 01845 JUNE 4, 2024
required for every . _..._. _,... ..... _ . ___. _ . ...
page, City/Town State Zip Code Date of Inspection
D. System Information (cant.)
15, Site Exam:
Check. Slope
Surface water
Check cellar
❑ 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: Date ................
[� 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 USGS 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.
t5inspa.rfoc-rev.'7/26/2018, 1ull&5 QfldcBal Inspection Forrrre.Subsurface Sewage DisposaB System-6Iage 17 of 18
Commonwealth of Massachusetts
Title 5 Offocial Inspection Form
N i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/,i
220 FOREST STREET
Property Address
MEREDITH KALIL
Owner .._,
Cy�vner"s GV_arn. .e __._... _.. ,_ ......
information is NORTH A DOVER IAA 01845 JUNE 4„ 2024
required for every _ ... ... .. . . . _ _ ..... _
page City/Town _. State Zip Code gate of inspection
_....__.... .....__.... ..._.__.w _ _..._........__.._., _._.. ....._ _..__...__...._.._ .......... _...
E. Report Completeness Checklist
Complete all applicable sections of this form Inclusive of.
[ A. Inspector information. Complete all fields in this section.
Z E. 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
trunsp afoc rev."P124xE2018 1 aAe 5 Of16cfaV Pnspedoun Form Subsurface Sewage D. spo'sar0 System•Page'68 of'18