HomeMy WebLinkAboutConditional Pass - Title V Inspection Report - 64 SUGARCANE LANE 9/6/2024 w
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
�V
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
- 64 SUGARCANE LANE
Property Address
RACHEL WOOD
Owner Owner°s Name
information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 3 2024
--
page CIty/Town state Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered many
way. Please see completeness checklist at the end of the form.
_....m..._.__.............._.... ............._...........__.._.._.�....__ _........ _._......................_ ....................____--
Important;When ...._._,.
filling aul A. Inspector Information
on the computer.use only the tab Todd James Bateson
key to move your Name of Inspector
cursor-do not Bateson Enterprises Inc.
use the return - -
key. Company Name
111 Argilla Road
taa --
Company-Address—
Andover MA 01810
CltylTown State Zip Code
�r 978 475-4786 SI-16
Telephone Number License Number
_._..._......._.._..___.._..___.__.__ __................. __.._,_......_...........___...._........_....-._. _.w..._.........._________ _.__.......__......................
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 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. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
._
SEPTEMBER 5, 2024
Inspec '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.
151nsp.rloc•rev,U2,.612o18 Title 5 Official Inspection Form Subsurface Sewage Disposal System^Page'I of IS
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
/ 64 SUGARCANE LANE
Property Address
RACHEL WOOD
Owner
Oruner's Name
information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 3, 2024
...... ..._. _
page. City/Town state Zip Code Date of Inspection
.__..............__.._........_.._....._,.._.............._...._........__...__..____..____w..........._..___ _._......__._..._._.,............_...
._......_..
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.
EI Y [-1 N ❑ ND (Explain below):
tt nsp doc•rev 712&2018 TWe 5 OlficiW Inspection Form Subsurface Sewage Disposes system•Page 2 of 18
� Commonwealth of Massachusetts
Title 5 official Inspection Form
"I Subsurface Sewage Dispersal System Form - Not for Voluntary Assessments
-` 64 SUGARCANE LANE _
--------
Property Address
RACHEL WOOD
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 3, 2(124
__.
page. City/Town State Zip Code Date of Inspection
__...__.. __......_..,_._,_....._._._ ___........_.__.. ............ _ ......._._._........_..,_,,,_,,,,a---......_...
.......__.......,...,_._
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):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):.
❑ obstruction is removed ❑ Y El N ❑ ND (Explain below):
71 distribution box is leveled or replaced [ Y ❑ N ❑ ND (Explain below):
D-BOX IS DETERIORATING AND NEEDS REPLACED
�] 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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" Commonwealth of Massachusetts
6 Title 5 !official Inspection Form
�4
Subsurface Sewage Disposal System. Form - Not for Voluntary Assessments
t
64 SUGARCANE LANE
Property Address
RACHEL WOOD
Owner Owner's Name _
information is NORTH ANDOVER MA 01845 SEPTEMBER 3, 2024
required for every
page. GrtyfTown State dap Code mate of Inspection
._..._.__.._..w__ -- _...w...._..__ ... .........a.... .... .._...... _..,., .__... ..... _..,__ _.
C. Inspection Summary (cant.)
❑ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
f The system has a septic tarok and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply,
[_1 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
EJ Z Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm Not for Voluntary Assessments
64 SUGARCANE LANE
Property Address
RACHEL WOOt0
(-caner Owner's Name
information Ie NORTH ANDOVER MA 01845 SEPTE IBER 3„ 2024
required for every __ ..
page City/Cowrn State Zip Code Clete of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cant.)
Yes No
J- Z Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El Z Liquid depth in cesspool is less than 6" below Invert or available volume is less
than "/2 day flow
1-1 z Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
1-1 z 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
Eltributary to a surface water supply.
11 z Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
El Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
11 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 passers 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 pp ,
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.
1-1 The system fails. I have determined that one or more of the above failure
z criteria exist as described in 310 CIR 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) Marge 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 11 of a public water supply well
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Commonwealth of Massachusetts
Title 5 Offidal Inspection ction Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
64 SUGARCANE LANE
Property Address
RACHEL WOOD
Owner Owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 3, 2024
required for every _
page. City/Town State Zip Code Date of Inspection
.. _......... ... __a_.---.-...____. . ...._
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 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 an inspections:
Yes No
Z ❑ lumping information was provided by the owner, occupant„ or Board of Health
0 Z Were any of the system components pumped out in the previous two weeks?
Z 0 Has the system received normal flows in the previous two week period?
1:1 Z Have large volumes of water been introduced to the system recently or as part of
this inspection?
Z ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z E] Was the facility or dwelling inspected for signs of sewage back up?
Z F� Was the site inspected for signs of break out?
Z 11 Were all system components, excluding the SAS, located on site?
Z 1:1 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?
0 7 Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Z ❑ Existing information, For example, a plan at the Board of Health.
Z ❑ Determined in the field (if any of the failure criteria related to Fart C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5))
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Commonwealth of Massachusetts
TO-Lie 5 Officoal Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
64 SUGARCANE LANE
Property Address
RACHEL WOOD
Owner Owner's Name
information as reqtaGred for every NORTH ANDOVER MIA 01845 SEPTEMBER 3, 2024
page. C;,ity[Town Mate Zip Code Date of Inspection
.. ..............._... _. . _. _........ __.,.._. _............ ........... _... _._,.w....
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): 825 GPD
Description,
Number of current residents:
Does residence have a garbage grinder? Yes [:] No
Does residence have a water treatment unit? 0 Yes E No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection 0 Yes No
information in this report.)
Laundry system inspected? Yes No
Seasonal use? 7 Yes Z No
Water meter readings, if available last 2 ears usage d ATTACHED
g (� y g (gp ))� _..
Detail:
Sump pump? El Yes ] No
Last date of occupancy. CURRENT
Bate
t5insp doe-rev 7/26/201 R nue 5 official Inspaerttlan I""onn &IbSUrfsacA� Sewage DsposW f ystem•Page M 18
Commonwealth of Massachusetts
�
Title 5 Official Inspection Form
;N Subsurface Sewage Disposal System Form Not for Voluntary Assessments
64 SUGARCANE LANE
Property Address
RACHEL WOOD
Owner Owner's Nanne
information is NORTH ANDOVER MA 01845 SEPTEMBER 3„ 2024
rea�raXred for every ...
page City/To wn State Zip t:ode fate of Inspection
................_... _.....,..., _ ...... _............... ..... .....,..
D. System Information (coot.)
2. Commerciallindustrial Flow Conditions:
Type of Establishment
Design flaw(based on 310 CMR 15.203) Gallons per day(9pd)
Basis of design flaw(seats/persons/sq.ft., etc.):
Grease trap present? [l Yes ❑ No
Water treatment unit present? El Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? El Yes ❑ No
Nan-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: date
Other(describe below):
3, bumping Records:
Source of information: BATESON ENTERPRISES INC AUGUST 2024
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes„ volume pumped:
ailns _
How was quantity pumped determined?
Reason for pumping:
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Commonwealth of Massachusetts
i ) Title 5 Official Inspection Farm
,;� Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
64 SUGARCANE LANE
Property AdIoress.
RACHEL WOOD
Owner Owner"s Nanwe
information is NORTH ANDOVER MA € 1845 SEPTEMBER 3, 2024
required for every
page City/Town State Zip Code Date of Inspection
_..._._._....__. .__......, ,,,,_._,.. ..... _. __... - ..... _. _._.._....
D. System Information (cost.)
4. Type of System:
E Septic tank„ distribution box, soil absorption system
E] Single cesspool
Overflow cesspool
Privy
El 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
F1 Tight tank. Attach a copy of the DEP approval.
.� Other(describe)
Approximate age of all components„ date installed (if known) and source of information:
SYSTEM 29 YEARS OLD INSTALLED JULY 1995 AS BUILT PLAN
Were sewage odors detected when arriving at the site's F1 Yes E] No
5. Building Sewer(locate on site plan):
4Q"
Depth below grade feet
Material of construction:
El cast iron 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feed
Comments (on condition of joints, venting, evidence of leakage, etc,):
JOINTS AND VENTING OK
NO EVIDENCE OF LEAKAGE
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Commonwealth of Massachusetts
s I Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Farm Not for Voluntary Assessments
64 SUGARCANE LANE
Property Address
RACHEL WOOD
Owner Owner's Game
inforrequired
is NORTH ANDOVER MA 01845 SEPTEMBER 3, 2C124
rer�ured for every
page. 6tyffown State Zip wade Date of Inspection
........ ...........
D. System Information (cant.)
6. Septic"Tank (locate on site plan):
Depth below grade: 28"
feet
Material of construction:
2 concrete ❑ 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: 1 Q 5 X 4
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle A
Scum thickness
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle
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
INLET AND (.CUTLET BAFFLES OK
TANK OK
NO EVIDENCE OF LEAKAGE
LIQUID LEVELS GOOD
CENTER COVER 8" DEEP HAS RISER
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
i., Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
�;� • 64 SUGARCANE LANE
Property Address
RACHEL WOOD
Owner Owner's Narne
nfarmataan us NORTH ANDOVER MA 01845 SEPTEMBER 3, 20 4
required for every
page, City/fawn Mate Zip Code Date of Inspection
D. System Information (coat.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction,
El concrete [ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
..._.........
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 purnping: 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.):
& Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction
El concrete n metal ❑fiberglass polyethylene other (explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
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Commonwealth of Massachusetts
i, TuAle 5 Official In p►ect'on Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 SUGARCANE LANE.
Property Address
RACHEL WOOD
Owner Owner`s Nance
infwrequired
dfo 6s NORTH ANDOVER MIA 01845 SEPTEMBER 3„ 2024
re�pulrert for every _
page Citynlown Stake Zip Code gate of Inspection,
...... ...... _._.._.._........ _......... _ _.. ..............._....._.__...._..._._..._.. _.
D. System Information) (cant)
8. Tight or Holding Tank (cant.)
Alarm present: Yes No
Alarm level: Alarm in working order: [l Yes ❑ No
Date of last pumping: cD to _
Comments (condition of alarm and float switches, etc.):
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.):
DISTRIBUTION IS NOT LEVEL OR EQUAL
D-BOX IS DETERIORATING AND NEEDS REPLACED
HEAVY EVIDENCE OF SOLIDS CARRYOVER
EVIDENCE OF LEAKAGE
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Commonwealth of Massachusetts
Tit 5 Offidal Inspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
. ` 64 SUGARCANE LANE
Property Address
RACHEL WOOD
Owner Owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMSER 3, 2024
fequ°rrc;dfcrrevery
page City/Town Mate Zip Cade Crate of Inspection _ ...
_ ____.___.........—..._, ..................__. __.__w__ ......._______ ...... ____.._....
D. System Information (cant.)
10, Pump Chamber(locate on site plan):
Pumps in working order: El Yes [] No*
Alarms in working order: EJ Yes C] No*
Comments (note condition of pump chambers 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:
z leaching pits number: 3
1 leaching chambers number:
[l leaching galleries number:
❑ leaching trenches number, length: _
❑ leaching fields number„ dimensions:
El overflow cesspool number:
0 innovative/alternative system
Type/name of technology:
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Commonwealth of Massachusetts
Title 5 Official Inspection Farm
1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 SUGARCANE LANE Property Address _.
RACHEL WOOD
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01645 SEPTEMBER 3, 2024
_.
page. Cityltown State Zip Code ...... ................_.....
D. System Information (cont.)
11. Soil Absorption System (SAS) (cant.)
Comments (note condition of sail, signs of hydraulic failure, level of panding, damp sail, condition of
vegetation, etc.):
SOIL AND VEGETATION GOOD
NO SIGN OF HYDRAULIC FAILURE OR PONDING
RAN CAMERA DOWN TO PITS, PITS WORKING PROPERLY.
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 panding, condition of vegetation,
etc.):
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� Commonwealth of Massachusetts
i w Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` 64 SUGARCANE LANE
_ ---...
Property Address
RACHEL WOOD
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 3, 2024
.... _.
page. Cltyitown State ZIp Code Date of Inspection
D. System Information (cant.)
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.):
*insp.doc•rev.712612.0'18 1"Me 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection or
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 SUGARCANE LANE _
Pia6Wrty Address
RACHEL WOOD
Owner _. .... .. ........__....._......... ._._._.._ .. _..... . .. ...............,,.
C3wwtter"�hlame ......
requ ro tiondfo is NORTH i ANDOVER MA 01845 SEYPTEMBER 3, 2024
page. frnrev every __...___.._. _...__..___.�............._._._......._
�� � Gi4y"T�wn State ���t bode .., r�ette of lns,pecttctn _ _ _ ..
D. System Information (cant.)
14. Sketch of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the bones below:
hand-sketch in the area below
drawing attached separately
� l
150
se
i
A ox
37',3
F
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Commonwealth of Massachusetts
1�7 Title 5 Official Inspection Form
� �m. FmmW
°I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 SUGARCANE LANE
Property Address
RACHEL WOOD
Owner Owner's Nerve
information i NORTH ANDOVER MA 01845 SEPTEMBER 3, 2024
required for every _ _
page tatty/"town state Zip Code [)ate off inspection
_, __ . ........_...._. _.,.
D. System Information (cent.)
15. site Exam:
Z Check Slope
0 Surface water
Z 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: JUNE 1992
[late
[ ] 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)
Q Accessed USES database _explain:
You mint describe how you established the high ground water elevation:
DESIGN PLAN ON FILE
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
65msp doc•rev 01612018 'N`Me 5 Offirialll It`o�4agd'ra564awty F'onn Subsurface Sewage rlisposa0 System Page 17 of 18
Commonwealth of Massachusetts
18 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 SUGARCANE LANE
Property Address
RACHEL WOOD
Owner Owner"s Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 3, 2024
required for every
page. CltylTown State Zip Code bate 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 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— 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 7/2612 0 1 8 Title 5 Official Inspection Fomi,Subsurface Sewage CDdsposaB System•Page 18 of 18
Sunrinavy Rea ogd Cmd garwated an 811=024 5 3?34 PM by Kmen Hm%on Page t
Town of North Andover
Tax Map # 210-106.A-0238-0000.0
Plarcel Id 17383
64, SUGARCANE LANE
ALLAN & RACHEL WOOD
64 SUGARCANE LANE
NORTH ANDOVER MA 01845
FY 2025
LAB W�iliEqLndex
NarnelAddress Type Loan Numbm� Activennact, Frovn UnM
ALLAN& RACHEL WOOD Owner Aefive
64 SUGARCANE LANE
NORTH ANDOVER MA 01845
SAMARGYA, DEBBIE Previous Usforner Inai:,five 4/15/2005
64 SUGa %R(,,Al%E LANE
P40 ANDOVER,MA
0 845
KEVIN 8 YYl RA KELLY Previous Customer hriactive 7111t2014
64 SUGARCANE LANE
N01:�Tl S A N DOVE R, MA 0 184 5
NICOL[ MARK TINA Previous Customer lrx active 11/7/2016
64 SUGARCANE LANE
NOR rl-I ANDOVER MA 01845
UB Ac,�;otjnt Maint.
Ac7r'Z;Z;4i'iW---- Cy(-,Ie Occupm,A Narne Active/Inactive
Bldg ld 76610.64 SUGARCANE LANE Last BiMng Date 7/15/2024
3170333� 03 Cy(.,le 03 Active
UH Sr�rvices Maint.
Account No 3170333,
Service Codo Rate Charge MuIflpHer/Osors
MISCMADWN FEE 0635/8 T82 I/
WTR VVA IE R, 01 ALL METER S0ZE 102,98 /1
Ul.].', M,l ter Maintenance
Acxoun Nu, 3170333
Serial No Status Location Brand Type, Size Y'TD Cons
4928241,, a Active HH#64 b Badger w Water 06250.625 499
Date Readbiq Cods ConsumptIorr Posted Date Voidance
6/12/2024 1160 a Actual 25 7/22/2024 172%
311 ;24 1135 a Actual 9 4/16/2024 -34%
121'10023 1,126 a Actual 13 1115/2024 -74%
9/1' 2923 1113 a Actual 56 10/1312023 254%
1057 a Actua 1 15 7/14/2023 11 01ya
1042 a Actual 7 4112/2023 -66%
12,,, ,2)22 1035 a Actual 19 1/1612023 -87%
9/1, ;%:22 M16 a Actual 169 '1011812022 663%
6/8 12 847 a Actual 21 7/18/2022 157%
826 a Actual 8 4/1312022 -49*/6
818 a Actuat 16 1/17/2022 -81%
802 a Actuai 83 10/15/2021 217%
719 a Actual 27 712712021 106%
692 a Actual 12 4121/2021 -35%
680 a Actual '19 111312021 -77%
661 a Actual 87 10/14/2020 565%
(3/1" 1 574 a ACtUal '12 7115/2020 -7%
562 a Actual 13 4/812020 •59%
549 a Actual 32 '1/1512020 -.77%
517 a Actual 151 to/1012019 398%
366 a Actual 30 7125/2019 181%