HomeMy WebLinkAboutPass - Title V Inspection Report - 7 DUNCAN DRIVE 8/5/2024 Commonwealth of Massachusetts
wip Title 5 Official Inspection For
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7D UNCAN DRIVE
Property Address
VICKIE GALLANT-PACIOS
Owner bwner s Name
information is NORTH ANDOVER MIA 01845 DULY 30, 2024
required for every ..�_...._._.,. , _......_._... _...___..___ _...._._... ...__. _.
page Clty/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be a "'in any
way. Please see completeness checklist at the end of the form. "
Important:when filling out forms A. Inspector Information � a
"
u
on the computer, Todd James Bateson `
useonly the tab _ .............___ _ _ . ____ .._. ...... _.....e___� _._.._. _µ. ... .
key to move your Name of Inspector
cursor-do not Bateson Enter�rlses Inc.
4 �
use the return _..
key. Company(
Name W 4
(� la Road
{ Company Address
- Andover ._. MA 01810
_.... . . _. __ __.,_
CltydTown State Zip Code
578 475-4786 SI-16
Telephone Number License Number
B. Certification
1 certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the; sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection, and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After Conducting this inspection I have determined
that the system:
1. Z Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
_..,, . ._... ._ _ AUGUST 1, 2024
Ins ctor"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.717.6r2016 Title 5 official Inspection Forms Subsurface Sewage Msposal System"Pala i or 18
Commonwealth of Massachusetts
Tide 5 Official Inspection Farm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 DUNCAN DRIVE
Property Address
VICKIE GALLANT-PACIOS
Owner bwne' "s Larne _.
information is required for every NORTH ANDOVER MA 01845 JULY 30, 2024
_ .. _ ...............
page. City/Town State Zip Code Date of Inspect 11 ion
..................._--....................,,._.__......__.... ......_.........._,,.._ _ __..._......__.__... __ .._...._. __._.W..._.__.0..............
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:
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.
�J Y ❑ N ND (Explain below):
-.____.-
tainsp.doc-rev.7/26120 1 8 rMe 5 Offiaiat InspecUon Form,Subsurface Sewage Disposall System•Page 2 of 18
..... __. ... .... --... _.._.. -------_.. .._. ..... ....w_
Commonwealth of Massachusetts
critxxaw
,r Title; 5 official Inspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
!/ 7 DUNCAN DRIVE
Property Address _._ ... _..
VICKIE GALLANT-PACIOS
Owner _
Owner°s Name .......... ._ _...-
information is
required for every NORTH ANDOVER MA 01845 JULY 30, 2024
_ _
page. City/Town state Lip Code date of Inspection
C. Inspection Summary (cant.)
2) System Conditionally Passes (cant.):
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):
El broken pipe(s) are replaced [-1 Y ❑ N [j ND (Explain below):
�] obstruction is removed ❑ Y ❑ N [-1 ND (Explain below):
�] distribution box is leveled or replaced [I 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):
0 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:
t5hsp doc rev.7/2 61201 8 Title 5 Off 6a[lr%pedion Form Subsurface Sewage Msposal System-Papa 3 of'18
r w. Commonwealth of Massachusetts
IE Title 5 Official Inspection Form
44 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 DUNCAN DRIVE
Property Address
VICKIE GALLANT-PACIOS
Owner _. .- _-a _ . ..__._. ....
owner's gme
information Is MA 08.4 JLY 30 22
required for every NORTH ANDOVER 01
8.45 U 04 _
page. cityr-rown State Zip Code Date of Inspection
C. Inspection Summary (cant.)
El Cesspool or privy is within 50 feet of a surface water
El 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.
F] 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 pprn, 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 of
clogged SAS or cesspool
El E Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t rinTsp.doc-rev.7/2612018 '1 iOe 5 Official Irtsperctdorr Form.Subsurface Sewage Disposat System-Page 4 of 18
Commonwealth of Massachusetts
,d Till 5 CJ�fificil Inpc►rarm
m
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
7 DUNCAN DRIVE
Property Address
VICKIE GALLANT-PACItS
Owner OwIner" Neme
information is
required for every NORTH ANDOVER MA 01845 JULY 30, 2024
page. uty/r"own State Zip Code gate of Inspection
_...__....w_ _.. __ww,_ _.._ .._..__.___._ ........ .....___ _ ...._.... ... _ ..... _.,... ,. .
C. Inspection Summary (cant.)
4) System Failure Criteria Applicable to All Systems: (cant.)
Yes No
1 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 '/2 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.
El E 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 coliiform 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 systern is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd,
El 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 falls. 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 C.4,
Yes No
E 1:1 the system is within 400 feet of a surface drinking water supply
R 1:1 the system is within 200 feet of a tributary to a surface drinking water supply
0 0 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
¢rm,rmsp 4}m^owv 7f2612016 rfw 5 Ofliciaal V mpemcwrt r'rrm Su bs,uatinsu.k Sewage MsposaaV System-Page 5 0 18
Commonwealth of Massachusetts
w I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 DUNCAN DRIVE
Property Address
VICKIE GALLANT-PACIOS
Omer Ovvner s Name
information is
required for every NORTH ANDOVER ... MA 41845 JULY 30, 2€�24
page cityfrown :Mate dip Code Cate of anspecflon _.
._. ...._
C. Inspection Summary (cant.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "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 CNIR 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 fallowing for a//inspections:
Yes No
i El Pumping information was provided by the owner, occupant, or Board of Health
E] Z Were any of the systern components pumped out in the previous two weeps?
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?
❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z 0 Was the facility or dwelling inspected for signs of sewage back up?
0 Was the site inspected for signs of break out?
❑ Were all system components, excluding the SAS, located on site?
Z 0 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 frorn 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 1:1 Existing information. For example, a plan at the Board of Health.
Z El 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)]
d'krHq dac•rev.7f26/2 110 I it le 5 f,;'DtlYra,fal oai Form Sa.ibsuifaac a Sewage Drsposau SYrm em-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
" . 7 DUNCAN DRIVE
r
Property Address
VICKIE GALLANT-PACIaS
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 JULY 30, 2024
page, City/Town State Zip Code Date of Inspection
_..._._. ........ _ _........_...._.__........_............._.__.._..._..___.... _ �__.._..._._ _._____._.._.___ ....._....____
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): -- Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x#of bedrooms): 440-GPD_..
Description:
......
Number of current residents: 4
Does residence have a garbage grinder? Lq Yes [_] No
Does residence have a water treatment unit? Yes (-1 No
If yes, discharges to; SEPTIC TANK
Is laundry on a separate sewage system? (Include laundry system inspection D Yes M No
information in this report.)
Laundry system inspected? M Yes ❑ No
Seasonaluse? ❑ Yes N No
Water meter readings, if available (last 2 years usage (gpd)): .._._....._............
_._____.._.._.
Detail:
WELL
. . ..
Sump pump? Yes ® No
Last date of occupancy: CURRENT
bate'
t5lnsp,doc.rev.7t2&2018 'Title 5 Offlciewl Inspection Form,Subsurface Sewage Disposal Sys tern•Page 7 of'18
Commonwealth of Massachusetts
µ "f tl ► fig al In pecUon Form
� r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r »'° ? CDUNCAN DRIVE
Properly Address
VIC IE GALLANT-PACIO S
Owner _
Owner's Nar'w~Me
r ff required
ws NORTH ANCDt�VER MA 01845 DULY 30„ 2024
rectuired for every ................... _ . ..
page Cutyffowrr State Zip Code Date of Inspection
_..... _...w.__._._ _....._.. .._ . .. _.......... . __..._ __....... _.... _....... ._._ ... _. „......._ .._........_
D. System Information (cont.)
2. Commercial/Industrial Flaw Conditions:
Type of Establishment: _
Design flow (based on 310 CMR 15.203).
aekons per clay fpdD
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? El Yes [ No
Water treatment unit present? D Yes E] No
If yes,, discharges to; _
Industrial waste holding tank present? El Yes 0 No
Non-sanitary waste discharged to the Title 5 systern? ❑ Yes El No
Water rneter readings, if available:
Last date of occupancy/'use: bate _..
Other(describe below):
3, Pumping Records:
Source of information: BATESQN ENTERPRISES INC OCTOBER 2023
Was system pumped as part of the inspection? El Yes Z No
if yes, volume pumped:
eDadlons
How was quantity purnped determined?
Reason for pumping:
rEipvroaupa rim•rev 742&2018 7 ite 5 Offirc;wI feostsecwn Forroa ,Sutsurtrace spew aje G7u,u wsa i sys6em•page o of 9s
° Commonwealth of Massachusetts
r � I Tip CJa�►fi I I Insp►ec ar ►rm
} Subsurface Sewage Disposal System Farm _ Not for Voluntary Assessments
r;
Ma 7 DUNCAN DRIVE
Property Address
VICKIE GALLANT-PACItOS
CJwner
Owner "s Narne ........ _..... .. ..... _
requi
red
reyazired for every 30, 2024 NORTH ANDCOVER MA 01545 JULY _.
page City/Town state Zip Cade Date of inspection
_......._..,. __..w _ ..... _._..__e. _ w......... �........ .......m._..
D. System Information (cant.)
4. Type of System:
E Septic tank„ distribution box, sail absorption system
Single cesspool
�] Overflow cesspool
E-1 Privy
[i Shared system (yes or no) (if yes, attach previous inspection records, if any)
w.. Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained frorn system owner) and a copy of latest
inspection of the I/A system by sy tern operator under contract
Tight tank. Attach a copy of the DEP approval.
gyml Other(describe):
Approximate age of all components„ date installed (if known) and source of information:
24 YEARS, INSTALLED MAY 25, 2000, AS BUILT
Were sewage odors detected when arriving at the site? Yes No
5. Building Sewer(locate on site plan),-
Depth below grade: 1. '
feet
Material of construction:
ED cast iron H 40 PVC other(explain):
Distance from private water supply well or suction line: 30
feet
Comments (on condition of joints, venting, evidence of leakage, etc.)
JOINTS AND VENTING OK
NO EVIDENCE OF LEAKING
r5w,spr danc-rev 712612018 Nie 5 om area NnromrJn F orvr Subsurface%^"duW age py s posa Sy+EaRem•Page 9 0 18
Commonwealth of Massachusetts
W Title 5 Official Inspection Farm
Vi'� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`f. 7 DUNCAN DRIVE
Property Address
VICKIE GALLANT-PACIOS
Owner _
Owner's Name
information is required for everya NORTH ANDOVER MA 01845 JULY 30, 2024
_
page CltyCfown State Zip Code Date of Inspection
D. System Information (cant.)
6. Septic Tank (locate on site plan):
Depth below grade
0.3'
feet
Material of construction:.
Z concrete 0 metal fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: X 5"X 4'
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
34"
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
13"
How were dimensions determined? SLUDGE JUDGE AND TAPE
MEASURE
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage„ etc.):
RECOMMEND PUMPING OLDER SYSTEMS YEARLY
PLASTIC INLET AND OUTLET TEES OK
LIQUID LEVELS GOOD
TANK OK
NO EVIDENCE OF LEAKAGE
tbmspy.doc•rev.'1)2612018 Title 5 Official Inspertion Form Subsurfaw Sewage Disposal Syslern-Page'10 of'18
Commonwealth of Massachusetts
Ti'le 5 Off d l In ►p► cfic n Form
µ A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 DUNCAN DRIVE
property Address _
VICKIE GALLANT-PACIOS
Owner Owner's Name
requir�edfo is NGRTH ANDOVER MA 01345 JBULY 30, 2024 required far every .. .. _ .... . .
page. City/Town State Zip Code Fete of Inspection
D. ... Sty.....__....._ ..__....__ _.._... ......v.u.__..._. .... . _.__.w....w_._._._._._...._._.. ..._._A.._m......___-.__-.--___. _......,. . ...._..._...
m Information (cant.)
7. grease Trap (locate on site plan):
Depth below grade:
Material of construction:
concrete 0 metal F] fiberglass C] polyethylene El other(explain):
Dimensions;
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottorn 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.):
....___
3. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
concrete w metal fiberglass polyethylene other (explain):
Dimensions: ..._
Capacity:
yahons
Design Flow:
galions per day
r wwusp dor•tnw.712EW2018 I sde 5 Offiom uinsfsrma.ddern Form Subsurface Sewage V':YmpcmW System•Page 11 of 18
V11 ° Commonwealth of Massachusetts
Tide 5 Offidal Inspection Form
it
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�w
7 DUNCAN DRIVE
Pro'perty Address
VICIIE GALLANT-PACKS
Owner 6,uOier`s Name _
reCjWxu dfo is NORTH ANDOVER MIA 011845 JULY, 8f�, 2(�24
rer;�snred fear every ... . _
gage. Cityrfo"W"n State Zip Cede Clete of Inspection
D. System Information (cant.)
8, Tight or Holding Tank (cant.)
Alarm present Yes No
Alarrn level; _ Alarm in working order: F-1 Yes D No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached" E] Yes D 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 equal, any evidence of solids carryover, any
evidence of leakage into ar out of box, etc.):
D-BOX IS LEVEL AND HAS FLOW EQUALIZERS
DISTRIBUTION IS EQUAL
LIGHT EVIDENCE OF SOLIDS CARRYOVER
NO EVIDENCE OF LEAKAGE
SLIGHT CORROSION IN D-BOX
Q,cor spi,kn^rov.'XRM„018 I a e 5 ofrfaal Ulspec orii Foi''¢tt Subsurface Sewage Drwbgsz,)u'M System*Pa W 12 ry7 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 DUNCAN DRIVE
Property Address
VICKIE GALLANT-PACIOS
Owner
Owner's Name
information Is required for every NORTH ANDOVER MA 01845 JULY 30, 2024
_ ..
page. dityfTown State Zip Cade Efate of Inspection
_..,..._._.,_ _._____._._..._..___ .....w..__.__..__._...__........___..
D. System Information (cant.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes M No*
Alarms in working order-, ❑ Yes M Noy
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. Sail Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
__...._.. . .... ._ .. .... _..._
Type:
❑ leaching pits number:
E] leaching chambers number: _....
❑ leaching galleries number: ---_.-------------------------
® leaching trenches number, length: 2 50' LONG
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
[l innovative/alternative system
Type/name of technology: -
t5insp.doc-rev.'7d"28/20'18 'Tope 5 OfficW Insper„fion Form:Subsurface Sewage Disposal System Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.; 7 DUNCAN DRIVE
Fr'op'erty Addre ' ...
VICKIE GALLANT-PACIOS
Owner Owners Name
mqu4edfo es NORTH ANDOVER MA 01845 wIULY 30, 2CN24
�a� red for every ._, _ _ _ _...
City6Town State Zip Code Cate of In pectIion
SystemD. ion (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,)-
SOIL AND VEGETATION OK
NO EVIDENCE OF HYDRAULIC FAILURE OR PONDING
12. Cesspools (cesspool rnust 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 D Yes F ] No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.).
t5 r•isp doac•rev.7P26/208 "FiVe"'a(Aficwl fnsgaeu^:dion F^`orm Subsurface Sewage 4'°Sos4aosal System•Page 14 aHl 18
w Commonwealth of Massachusetts
tl� Title 5 0"Wi i l Inspection Porn
Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
7 DUNCAN DRIVE
0roperly Address
VICKIE GALLANT-PACIOS
Owner b,wner"s h ame ..-......
requirt required
is NORTH ANDOVER MA 01845 JULY 30, 2024
reet��ired for every _ ,. ... ._
page. City/Town... State Zip Cade gate of inspection
....._..........
_., _.._-..._.___.ew_. _w_......_... ._..n..._..-.______...
D. System Information (cant.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids _ ---___- .... ....
Comments (note condition of sail„ suns of hydraulic failure„ level of ponding, condition of vegetation,
etc.):
C°nsp doc^mv.M6120'18 1 oVe 5 oN1ioat fns pectajn fl-"orrn Su bsu.d ace Sirwage OrrsprosM agrstom•P age 15 cif 18
Commonwealth of Massachusetts
............
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
7 DUNCAN DRIVE
._. Property Address
VICKIE GALLANT-PACICIS
Owner Owner's Name ------...............
information is
required for every NORTH ANDOVER MA 01845 )'U�L.Y30, 2024
page, 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
F-1 drawing attached separately
Vj Q,
C
5 O
cox
J�e4
il)0 "P.)O 50 to
Mnsp.doc-rev.7/2612018 'rills 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
,r Title 5 official Inspection Form
Subsurface sewage Disposal System Form - Not for Voluntary Assessments
7 DUNCAN DRIVE
Property Address
VICKIE GALLANT-PACIOS
Owner _..--_-__.
Owner's Name
Information is required for every NORTH ANDOVER MA 01845 DULY 302 2024
_
page. City/Town State Zip Code Pate of Inspection
.__....____......__......._ .. _..w..._. .........___. ......__.......... ....._..._..._...__,..____..._....._._......__.M.._.._ ._.-_..___.......... _.._.__.._. ....__a,_.____..
D. System Information (cant.)
15. site Exam:
❑ Check Slope
Z Surface water
❑ Check.cellar
F� 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: SEPTEMBER 1998
gate
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
z Checked with local Board of Health - explain:
PLANS ON FILE
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
DESIGN PLAN
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
tSlnsp.doc-rev.712012018 rikBe 5 official Inspection Form Subsurface Sewage Disposal System R Page 17 of 18
Commonwealth of Massachusetts
k %sF"4
h `if, Title Official Inspection ion Form
1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�w
7 DUNCAN DRIVE
Property Address
VICKIE GALLANT-PACIOS
Owner Owner's Name
information is NORTH ANDOVRR MA 01845 JULY 30, 2024
required for every
page. City/Town State Zip Cade Bate of Inspection
.. _ _.._... m.._.... ... ........._ .._.._ .__. ..... _ ..._
E. Report Completeness Checklist
Complete all applicable sections of this farm Inclusive of:
A. Inspector Information. Complete all fiefs in this section.
ry B Certification: Signed & Dated and 1, 2, 3, or 4 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 8: Tight/Holding Tank— Purnping 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
t5pnsp doc.-rev.7JM2018 'T rHe 5 Official hapraa°Wron For Soa@rKbfd'ace Sewage DISP;GSM systwrr-Page is of 18