HomeMy WebLinkAboutPass - Title V Inspection Report - 716 FOREST STREET 8/8/2024 Commonwealth of Massachusetts
iw Tide 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
716 FOREST STREET
Property Address
MARC MIRANDA
Owner Owners Name
I formation is required for every NORTH ANDOVER MA 01845 7/25/24
rage. C ity/Town State _ Zip Code Date of inspection
Inspection results must be submitted on this form. Inspection forms may not red in any
way. Please see completeness checklist at the end of the form.
Important:When A►. Inspector Ir1fC1t"CnatiO�
filling out forms n
Use o iy the tab' JAMES H. CURRIER 11
aa;,f,on0y the tali
key to move your Name of Inspector
cursor-do not J'S SEPTIC & DRAIN
use the return
key. Company Name
.>�.
131 FOREST STREET'
Company Address
MIDDLETON MA 01949
City/Town Statr>. Zip Code
978-774-6685 S1232 7
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 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 bused 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 Ej Conditionally Passes
3. C] Needs Further Evaluation by the Local Approving Authority
4, F' Fails
7/25/24
In 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.
t6rsp7.dac.rev 7P2600 18 I rlin 5 Official Inspection Form Subsurface Se wap 9.7wr%posal sysle m•P''aire 1 of 18
° Commonwealth of Massachusetts
IZ=I I Title 5 Official Inspection Form
yi Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
716 FOREST STREET
Property Address
MARC MIRANDA
Owner Owner's Name
information is NORTH ANDOVER MA 01845 7f25/24
regwrrured for every _ _
page. C1ky[Town state Zip Code Date or 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:.
SYSTEM WORKING PROPERLY
2) System Conditionally Passes:
E] 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 of is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y E] N ❑ ND (Explain below):
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° Commonwealth of Massachusetts
rn�
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
' :...., 716 FOREST STREET
Property Address
MARC MIRANDA
Owner Owner's Name
information is NORTH ANDOVER MA 01845 7/25/24
required far every
page. City/Town State Zip Code Date of Inspection
..._.-_.._......_.. --— ._.......... . .
C. Inspection Summary (coat.)
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):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y n 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:
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F Commonwealth of Massachusetts
i v ,rgr� Title 5 Official Inspection Form
h
.� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`r
716 FOREST STREET
Property Address
MARC MIRANDA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 7/25/24
-
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.
n 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
z 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
o- 'I, Title 5 Official Inspection Form
t= a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.
716 FOREST STREET
Property Address
MARC MIRANDA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 7/25/24
_
page, City/Town State Zip Code Date of Inspection
..........__. ... ._....._ .........
C. Inspection Summary (cant.)
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 '/x 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.
El ❑ 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.
Ito
❑ ❑ 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 forma
❑ The system is a cesspool serving a facility with a design flow of 2000 gpd_
10,000 gpd.
❑ N The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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 C.4.
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
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ommonwwealth of Massachusetts
w� =` Title 5 Official Inspection Form
t
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
, .,,,. 716 FOREST STREET
_.
Property Address
MARC MIRANDA
Owner Owner's Name
unforn at on Is NORTH ANDOVER MA 01845 7/25/24
required for every
purge. Clity/Town State dap Code Date of Inspection
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 C.4 shall upgrade the system in accordance with 310 CMR 15.304. The systern 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
0 0 Pumping information was provided by the owner, occupant,. or Board of Health
El F1 Were any of the system components pumped out in the previous two weeks?
Has the system received norrnal flows in the previous two week period?
El Z 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
avaiiable note as N/A)
Z El Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
N ❑ 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)]
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Commonwealth of Massachusetts
S= ,w Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
716 FOREST STREET
Property Address
MARC MIRANDA
Owner Owner's Narne
required
s NORTH AND OVER, MA 01845 7/25/24
regtaired for every
page. Crty/Town _ State Tip Code Date of Inspection
_._...... _ ..... _._.......__
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedroorns) 600 GPD
Description:
Number of current residents:
Does residence have a garbage grinder? ® Yes E No
Does residence have a water treatment unit? E Yes . No
If yes, discharges to: BACKWASH DOES NOT DISCHARGE TO SEWER
Is laundry on a separate sewage system? (Include laundry system inspection F-] Yes E No
information in this report.)
Laundry system inspected? ❑ Yes E No
Seasonaluse? ❑ Yes E No
Water meter readings, if available last 2 ears usage d WELL
g ( Y g (gp ))
Detail:
Sump pump? ❑ Yes Z No
Last date of occupancy: CURRENT
Date
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"° fiommonwealth of Massachusetts
rw Tide 5 Official Inspection Farm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
716 FOREST STREET
Property Address
MARC MIRANDA
Owner Owner's Name
mforrtrraCion Is
required for,every l 1( R1"E I ANDtJVER _ I iA 01845 7/25/2#
page City dwrl State lap Code Date of Inspection
-- -------
D. System Information (coat.)
2, Commercialflndustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15,203): Gallons per dray igpdi
Bads of design flow (seats/persons/sq,ft., etc.);
Grease trap present? ❑ Yes E] No
Water treatment unit present? ❑ Yes E] No
If yes„ discharges to: _
Industrial waste holding tank present? ❑ Yes [ No
Non-sanitary waste discharged to the Title 5 systern? ❑ Yes ] No
Water meter readings, if available.
Last date of occupancy/use: bate _.
Other(describe below);
3. Pumping Records:
Source of information; l_E'D -�1f17l23 & 7/26J24
Was system pumped as part of the inspection? Z Yes [:1 No
If yes, volume pumped: 1500 GALLONSgallons
How was quantity pumped determined? TRUCES GAUGE
Reason for pumping; MAINTENANCE & INSPECTION
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
ex k
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
716 FOREST STREET
Property Address
MARC MIRANDA
Owner Owner's NIame
information us NORTH ANDOVER MA 61845 7/25/24
required for every _
page City/Town _ "state Zip Cade Date of Inspection
D. System Information (cant.)
4. Type of System:
E Septic tank, distribution box„ soil absorption system
❑ Single cesspool
E] Overflow cesspool
[l 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
El Tight tank. Attach a copy of the [CEP approval.
Other(describe):
Approximate age of all components, date installed ('if known) and source of information:
[DESIGN PLAN - 1989 NEW DBOX-4/23
Were sewage odors detected when arriving at the site? El Yes Z No
5. Building Sewer(locate on site plan):
Depth below grade: 4
feet
Material of construction:
cast iron ❑ 46 PVC ❑ other (explain).-
Distance from private water.supply well or suction line: 0'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
JOINTS LOOK OK, NO EVIDENCE OF LEA94ACCt:I
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° Commonwealth of Massachusetts
Title 5 Official Inspection Form
inl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 p Y Y
u 716 FOREST STREET
W nr"p r
Property Address
MARC MIRANDA
Owner avwner's Name
requiredfo is NORTH AND IVER MA 01845 7/ 5/24
required for every
p<age. City/Town State Zop Cade Date of Inspection
D. System Information (cant.)
6. Septic Tank (locate on site plan):
Depth below grade: 3
feet
Material of construction:
concrete metal fiberglass polyethylene f other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) [l Yes ❑ No
Dimensions:
1500 GALLON
Sludge depth: 6IX
Distance from top of sludge to bottom of outlet tee or baffle 34 d -_
Scum thickness
NA
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? SL LJDCaE ,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.):
TANK WAS PUMPED AS FART OF INSPECTION, LIQUID LEVEL CORRECT, CONCRETE
BAFFLES IN PLACE.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
�l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
716 FOREST STREET
Property Address
MARC MIRANDA
Owner Owner's Name
information is
regUired for every NORTH ANDOVER MA 01845 7/25/24
page. City/Town State Zip Code Date of inspection
D. System Information (cone.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: " ...
El concrete El metal E] fiberglass F-1 polyethylene other (explain):
Dimensions:
Scum thickness
Distance from top of scurri to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: fete
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 F1 metal F-1 fiberglass F-1 polyethylene F, other (explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
i@,iirrvuPr ad :.•raw 712612010 tl ifle"x Officli f kmplvaaa:fon P arrn.Subsurldco Sewage Disposal„,eyswn�Page 11 of 18
' Commonwealth of Massachusetts
Title 5 Official Inspection Farm
4 , j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.- 716 FOREST STREET
property Address
MARC MIRANDA
Owner Owner's Name
information is NOR'rH ANDOVER MA 01845 125/24
graired for every _
page: cityrro' rl state Zip Code Date of Inspection
_..._._._. .... _._ ..-. _........ .... .._ ... __.._-__ - ---..._. . .......
D. System Information (cant.)
83 Tight or Holding Tank (coat.)
Alarm present: M Yes El No
X
Alarm level: Alarrn in working order_: E] Yes No
Date of last purnping: 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
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.):
BOX WAS REPLACED IN 2023, LIQUID LEVEL CORRECT, NO EVIDENCE OF SOLIDS
CARRYOVER, BOX IS 12" BELOW GRADE.
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° Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System form - Not for Voluntary Assessments
716 FOREST STREET
Property Address
MARC.; MIRANDA
Owner Owners Name
� iequi atEon 6s
r€��}xared for every 5 7f 5124
NORTH ANDOVER MA 0184
page C`ityrrwrwn _ State Zip Cade Date tat fnspectmn
_ _. . ....... _ ...... ...... .._ ..... .
D. System Information (cant.)
10, Pump Chamber(locate on site plan):
Pumps in working order: Yes No"
Alarms in working order: El 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:
leaching pits number:
�J leaching chambers number:
[ -1 leaching galleries number:
z leaching trenches number, length:
EJ leaching fields number, dimensions.
overflow cesspool number:
(._w] innovative/alternative system
Type/name of technology:
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Commonwealth of Massachusetts
r� � w Title 5 official Inspection Fora
_ rl` Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
716 FOREST STREET
Property Address
MARC MIRANDA
Owner OW- ner s Name
information &s
required for every NORTH ANDOVER MA 01845 7/2 /2
page, ityff oven State Zip Code Date of Inspection
......... ...
D. System Information (cant,)
11 Soil Absorption System (SAS) (cant.)
Comments (note condition of soul, signs of hydraulic failure, level of pending, darnp sail, condition of
vegetation, etc.):
SOILS DRY, NO SIGNS OF HYDRAULIC FAILURE, VEGETATION NORMAL,
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 No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc,),
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TMe,
commonwealth of Massachusetts
, Title 5 official Inspection Form
n
Subsurface Sewage Disposal System Foam - Not for Voluntary Assessrrtents
" f°A 716 FOREST STREET
Property Address
MARCMIRANDA
Owner Owner's fume
oequir required foron s NORTH ANDOVFR MA 01545 7/ 5/ 4
page
every au
Cityffown 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,):
t,,inSps oC^rev 16 Title S Official hspectcir Form 'Su0surface Sewage DiSPOSW System•Page I 0 78
Commonwealth of Massachusetts
stu ff ,} Title 5 Official Inspection Form
<� Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
715 FOREST STREET
Property Address
MARC MIRANDA
Owner Owners Nance
information is
required
d for every NORTH ANDOVER MA 01845 7/ 5/24
page. City/Town _ State by Cade Crate of Inspection _.
D. System Information (cant.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage dispersal 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 bones below:
E] hand-sketch in the area below
drawing attached separately
i
i
i
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Commonwealth of Massachusetts
1112,� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
716 FOREST STREET
Property Address
MARC; MIRANDA
Owner Owner's Name
inforeWre d"f r'"
g NORTH ANDOVER MA 01845 7/25/24
ever
page y City/"Tawrn State Zip Code Date of Inspection
D. System Informations (cant.)
15. Site Exam:
❑ Check Slope
El Surface water
El Check cellar
El Shallow wells
Estimated depth to high ground water:
feet
Please indicate all methods used to determine the high ground water elevation:
z Obtained from system design plans on record
If checked, date of design plan reviewed: 4/84 & TITLE -V 2023
Date
Observed site (abutting property/observation hole within 156 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:
DESIGN PLAN ON FILE WITH THE BOARD OF IdEAL.TH,
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
I°insp ooc•mare.712raR„,018 V tIe 5 ti,":vftciar Onsq,aaa.hon P=OMI a;;Ubsurfa ce Sewage Ms saf Syrtfvrn•Page 77 of 8
Commonwealth of Massachusetts
Title 5 Official InspecUon Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
5.
t 716 FOREST STREET
Property Address
MARC MIRANDA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 7/25/24
_
page. City/Town State Zip Code Crate of dnspectuon
....__.. ......... _._........_. _ ...... _ ,..,_ ..__.....
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
t5 rsp doc•rev.7126/2018 1itle 5 Officinal lnspectora Form Subsurface Sewage C7dsracsal Systern•Page 18 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Valenta ry Assessments
716 FOREST STREET
Property Address
JUDY ROY
Owner
brformaVom ds
required for every NORTH AID DOVER MA 01845 APRIL 6, 2023
page, State Z1p 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
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TWO 6 offidai 111spftton Farm:Sub�safao*SOW400 MOPOW System•Pogo 16 of 16
Commonwealth of Massachusetts
Z Title 5 official Inspection Form
I"' Subsurface Sewage Disposal System Form Not for Voluntary Assessments
a kM, 716 FOREST STREET
Property Address
JURY ROY
Owner _..__.
MgUtr dfr s NORTH ANDOVER MA 01545 APRIL , 202
required tear awery _ .,.,..._._ ._ .._....... ..
page. CityfTown State Z:p Code Date of Prnspectuori
D. System Information (cant.)
13 Privy (locate on site plan):
Materials of construction:
Dimensions _...... . .._.._.. _ _........_.
Depth of solids .. ..... .....
Comments (note condition of s6 , signs of hydraulic failure, Bevel of ponding, condition of vegetation,
etc.)
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5/2/23,4A5 PM about:blarik
Date Apt 11 18, 2023
Certificate of Compliance #71931
h,s is ari e-perm t,To ksarn mare,scan tNs barawto or visit
COMMONWEALTH OF MASSACHUSETTS
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
[oil
I his or,to certify that 0'ie individual st,ibstArr�ice disposal sy^iteryi received a SAI-ISFAC'IORY IN SPEC I ION:
Repair or replace an existing system component
Replace D-Box and pipe repair
by: 1bdd Batescin, Bateson Enterprises Inc.
At;
716 FOREST STREET
105 D-01 18
the issuarce of this certificate shaH not be c:onstrued as d guarantee that the systern wiIi furictiorl satisfactorily.
/4//4
BRIAN LAGRAS9
NREC TOR,BOARD M: A AL rii
..........
about:b1ank 1/1