HomeMy WebLinkAboutTitle 5 Inspection Report - 108 Windkist Farm - Title V Inspection Report - 108 WINDKIST FARM ROAD 10/11/2024 Commonwealth of Massachusetts
. ............. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Y
108 Windkist Farm Road
Property Address
Blue Ocean Realty
Owner Owner's Name -------_-___-_----__
information Is
required for every North Andover Ma 01845 10-11-2024
page, City/Town State Zip Code Date of Inspection
-----------------
Inspection results must be submitted on this form. Inspection forms may not be altered In any
way. Please see completeness checklist at the end of the form.
Important:When --------------
filling out forms A. Inspector Information
on the computer,
use only the tab F. Paul Cardone ——- -----
key to move your Name of Inspector
cursor-do not Septic Compliance,Inc.
use the return Company Name ..............
key.
37 1/2 Baremeadow Street
V 01,16 Company Address
Methuen Ma 01844
............. ....... ..............
,a, r ❑❑ City/Town State Zip Code
978-815-3115 or 978-681-0726 #3294
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 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 inspection I have determined
that the system:
1. Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. El Fails
Ins cto r's Signature
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/2W018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
`W Commonwealth of Massachusetts
_= m ►wayTitle 5 Official Inspection
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
108 Windkist Farm Road
Property Address
Blue Ocean Realty
Owner
Owner's Nafne
information is required for every North Andover Ma 01845 10-11 2024
__— _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes;
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
[� Y ❑ N ND (Explain below):
t51nsp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
tie 5 Off"dal Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
x ` 108 Windkist Farm Road
Property Address
Blue Ocean Realty
Owner _ ._ . .. ......._. ...._-____......._.
Owner's Name
information is North Andover Ma 01845 10-11-2024
required for every ---__—, ---------------
page. City/Town State Zip Code bate of Inspection
C. Inspection Summary (coat.)
2) System Conditionally Passes (cost.):
F1 Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N 0 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 0 ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N Q ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/2612618 Title 5 Official inspection Farm:Subsurface Sewage Disposal System•Page 3 of 18
e Commonwealth of Massachusetts
-- --- �q� i l ill Inspection
_ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
:
�r 108 Windkist Farm Road
Property Address _._. ... ----
Blue Ocean Realty
Owner
Owner's Narne
information is North over 01845 10 11 2024
required for every _._-- And— Ma_ ....._.....____...._._._
page. City/Town State Zip Code Date of Inspection
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.
❑ 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.
Q The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria ,Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ N Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7126/2018 Title 5 6flicial Inspection Form:Subsurface Sewage Disposal System,Page 4 of 18
Commonwealth of Massachusetts
it �;�� I Official Inspection
A iin Subsurface Sewage disposal Systern Form -Not for Voluntary Assessments
.� 108 Windkist Farm Road
Property Address
Blue Ocean Realty
Owner _...... _.._..._._.
Owner's Narne
information is North Andover Ma 01845 10-11-2024
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (coat.)
4) System Failure Criteria Applicable to All Systems: (cant.)
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 1/2 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.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
Q The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design-flow of 10,000 gpd to 15000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section GA.
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
❑ N 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
t5insp.doc-rov.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
,w Commonwealth of Massachusetts
I` W 3�q{ 1 tle 5 Official1
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.; 108 Windkist Farm Road
_....... _..... __._ _......_ ........
Property Address
Blue Ocean Realty
Owner owner's Name
information r e North Andover Ma 01845 10-11-2024
required far every _._.__...... __._.._.._
page. City/Town State Zip Code date of Inspection
C. Inspection Summary (cons.)
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 system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
0 ❑ Pumping information was provided by the owner, occupant, or Board of Health
® Were any of the system components pumped out in the previous two weeks?
1 ® Has the system received normal flows in the previous two week period?
❑� Have large volumes of water been introduced to the system recently or as part of
this inspection?
] Were as built plans of the system obtained and examined? (if they were not.
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
l5insp,doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pago 6 of 18
Summary Record Card ganoraled on 1018/2024 1:50:48 PM by Jennifer eracaro Page 1
Town of North Andover
Tax Map # 210-109.0-0056-0000.0
Parcel Id 18873
108 WINDKIST FARM ROAD
ONE HUNDRED BIGHT WINDKIST RD Since Apr 2011
ELOISE Y. JOHNSON, TRUSTEE
108 WINDKIST FARM ROAD
NORTH ANDOVER MA 01846
Class 101 Single Family Property Type 1 Residential
Size Total 1.49Acres
FY 2025
UB Mailing Index
Name/Address Type Loan Number Activellnact. Frorn until
BLUE OCEAN PROPERTY MANAGEMENT Managing Agent Active
15 N BEACON STREET,#1A
ALLSTON MA 02134
YOUNGMAN,ELOISE Previous Customer Inactive 912/2022
108 WINDKIST FARM ROAD
NORTH ANDOVER,MA
01845
WUJI SENG Owner Inactive 9/12/2022
108 WINDKIST FARM ROAD
NORTH ANDOVER MA 01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id.13794.0-108 WINDKIST FARM ROAD Last Billing Date 8/6/2024
1090470 01 Cycle 01 Active
UB Services Maint.
Account No. 1090470
Service Cade Rate Charge Multiplierlusers
MISCFEE ADMIN FEE 1 1 9A 8 1/
WTR WATER 01 ALL METER SIZE 136.67 11
UB Meter Maintenance
Account No. 1090470
Serial No Status Location Brand Type Size YTD Cons
29983130 a Active 00 b Badger w Water 1 1 379
Date Reading Cade Consumption Posted Date Variance
7/19/2024 2809 a Actual 31 8/13/2024 2%
4118/2024 2778 a Actual 30 6/13/2024 -6%
1118/2024 2748 a Actual 32 2115/2024 113%
10/19/2023 2716 aActual 15 11/21/2023 -42%
7/20/2023 2701 a Actual 26 8/14/2023 17%
4119/2023 2675 a Actual 22 6/10/2023 29%
1/1812023 2653 aAcluai 17 2/14/2023 109%
10/19/2022 2636 aActual 5 11/9/2022 -87%
8/2412022 2631 f Final BIII 24 8/24/2022 24%
7/2012022 2607 a Actual 51 8/16/2022 229%
4/19/2022 2556 a Actual 15 5/1212022 3%
1/20/2022 2541 aActual 15 2/16/2022 -41%
10/20/2021 2526 aActual 25 11/22/2021 -31%
7/22/2021 2501 a Actual 37 8/24/2021 113%
4/21/2021 2464 aActual 17 5/18/2021 3%
1/21/2021 2447 a Actual 17 2/23/2021 •64%
10/20/2020 2430 a Actual 49 11/12/2020 3%
7/16/2020 2381 a Actual 41 8/12/2020 185%
4/24/2020 2340 a Actual 17 5/13/2020 21
1/17/2020 2.323 aActual 13 2/10/2020 -69%
10/18/2019 2310 a Actual 41 12/18/2019 29%
7/22/2019 2269 a Actual 14 8/13/2019 108%
Summary Record Cord generated an 101812.024 V50:48 PM by Jon0or 6racero Pogo 2
Town of North Andover
Tax Map # 210-109.0-0066-0000.0
Parcel Id 18873
108 WINDKIST FARM ROAD
ONE HUNDRED EIGHT WINDKIST RD Since Apr 2011
ELOISE Y. JOHNSON, TRUSTEE
108 WINDKIST FARM ROAD
NORTH ANDOVER MA 01846
Class 101 Single Family Property Type 1 Residential
Size Total 1.49 Acres
FY 2025
4/19/2019 2236 aActual 16 5/1512019 0%
1/17/2019 2219 a Actual 15 2/18/2019 -63%
10/23/2018 2204 a Actual 45 11/19/2018 -6%
7/19/2018 2159 a Actual 46 8/15/2018 114%
4/1812018 2113 a Actual 21 5/17/2018 13%
1/18/2018 2092 aActual 19 2/20/2018 -69%
10/18/2017 2073 a Actual 46 11/13/2017 16%
7/19/2017 2027 a Actual 40 8/16/2017 108%
4/19/2017 1987 a Actual 19 5/17/2017 -19%
1/19/2017 1968 aActual 24 2116/2017 -48°fa
10/19/2016 1944 aActual 45 11/16/2016 -18°fa
7/22/2016 1899 a Actual 56 8/16/2016 155%
4/22/2016 1843 a Actual 22 5125/2016 -3%
1/22/2016 1821 aActual 23 2/19/2016 -58°fa
10/2212016 1798 a Actual 53 11/20/2015 18%
712412015 1745 aActual 44 8/14/2016 107%
4/27/2015 1701 a Actual 21 6/19/2016 A%
1/3012015 1680 a Actual 24 2/20/2015 -47%
10/2412014 1656 a Actual 42 11/14/2014 18%
7/26/2014 1614 a Actual 36 8/13/2014 62%
4/24/2014 1578 a Actual 21 6/16/2014 6%
1/27/2014 1557 aActual 22 2/14/2014 -50%
10/2312013 1535 aActual 42 11/18/2013 37%
7123/2013 1493 a Actual 30 8/16/2013 24%
4/24/2013 1463 a Actual 24 6/20/2013 6%
1/25/2013 1439 aActual 24 2/13/2013 -35%
10/23/2012 1415 a Actual 36 11/9/2012 -27%
7/23/2012 1379 a Actual 49 8/14/2012 63%
4/23/2012 1330 a Actual 32 5/9/2012 19%
1/2312M 1298 aActual 27 2/13/2012 -37%
10/24/2011 1271 a Actual 44 11/14/2011 -44%
7/22/2011 1227 a Actual 76 8/15/2011 134°fa
4/22/2011 1151 a Actual 31 5/16/2011 10%
Commonwealth of Massachusetts
alW Title i Inspection
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
z, 108 Windkist Farm Road
,._.J .,. ...... .. .....______-. _-..._..........._.--
Property Address
Blue Ocean Realty
Owner owner's Name
information is North Andover Ma 01845 10-11-2024
required far every _ ._.._.,... ._____... _......_ _ _--
page. Cltyrrown State Zip 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 bedrooms): 440_
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? F1 Yes M 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 Na
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Enclosed
g ( Y g (gp ))� _
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 1 month prior to
inspection
l51nspAoc rov.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Farr
{ ...fir.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
108 Windkist Farm Road
Property Address
Blue Ocean Realty
Owner
Owner's Name
information is North Andover Ma 01845 10-11-2024
required for every _ .. _.....___.._..____..__.,__.._..__._ .._.._ ...r.. � ......_.._.
page, City/Town State Zip Code Date of Inspection
D. System Information (cant.)
2. Commercial/industrial Flow Conditions:
Type of Establishment: ----.._ _......... _ .............-....
_
Design flow(based on 310 CMR 15.203): ____....._..........
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): _--- _
Grease trap present? ❑ Yes E} No
Water treatment unit present? ❑ Yes El Na
If yes, discharges to:
Industrial waste holding tank present? E) Yes n No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes El No
Water meter readings, if available: _.
Last date of occupancy/use:
Date
Other(describe below):
N/A
3. Pumping Records:
Source of information: Pumped 3 years owner and North Andover website
Was system pumped as part of the inspection? ❑ Yes M No
If yes, volume pumped:
gallons
How was quantity pumped determined? —
Reason for pumping:
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurraco Sowago Disposal System•Page 8 of 18
Commonwealth of Massachusetts
c mm,lg Title 5 OfficialInspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t 108 Windkist Farm Road _..._.._...._____ _.
-m_ __...__.. __........ _... ---
Property Address
Blue Ocean Realty _---_
-
Owner
Owner's Nartte
information is North Andover Ma 01845 10711-2024
required for every .. _..___..._ _.�__...._____..__..__ _...--_-.___
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (coat.) _._..
4. Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
[ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
24 years of age —_-_ 3-5-98 Owner and information on file
Were sewage odors detected when arriving at the site? ❑ Yes M No
5. Building Sewer(locate on site plan):
36"
Depth below grade: f e__et___-- _._.._._
Material of construction:
n cast iron ® 40 PVC [I other(explain);
Distance from private water supply well or suction line: - - —-
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
All in good condition No evidence of any leakage
tSinsp.doc-rev.712MO18 Title 5 Official Inspection Farm:Subsurface Sewage,Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 OTTIcIalInspection
{ Subsurface Sewage Dispersal System Form - Not for Voluntary Assessments
f% 108 Windkist Farm Road _
Property Address
Blue Ocean Realty
Owner Ciwner`s Name
information is North Andover Ma 01845 10-11-2024
required for every ....__ _ ..._. . _. _._..__.._ ....._ _ _. .....,....._.._
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
6. Septic Tank (locate on site plan):
Depth below grade: 45" deep with riser to 12"below
,grade
Material of construction:
® concrete D 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: 10 6 x5 6 x5 4
4ei
Sludge depth: _._......._
Distance from top of sludge to bottom of outlet tee or baffle211
--
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 ---- —--
How were dimensions determined? Sludge Judge and Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc,):
We recommend tank pumped on a yearly basis, baffles were on in good condition,structural integrity
appeared to be good, liquid levels were good, no aprent leakage in or out of tank
t5insp.doc-rev.7/26/2018 Title 5 0 ficial Inspection Form:Subsurface Sewage Disposal Systern-Page 10 or 18
<? Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
z �!� 108 Windkist Farm Road
Property Address
Blue Ocean Realty
Owner _ . —.—_ _ _- -------
Owner's Name
information is North Andover Ma 01845 10-11-2024
required far every w—.._..__...._ _— -------...---_..__
page. Cttyfrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: ._. - ------
f 11 eet
Material of construction:
❑ 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 pumping: bate",--.._..._.... ..._.... .__.__.._ _.........._
ate..
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: —__.._. __ ......_..._ .._....
Material of construction:
Q concrete ❑ metal 0 fiberglass ❑ polyethylene El other(explain):
NIA
Dimensions; __..._. _.__--- ___.. _ _._._. -- __— ---
Capacity: _..._....
.gallons
Design Flow: _ _.._r...._.....
gallons per day
t5insp.doc+rev.7Y2&J2018 Title 5 Official inspection Form:Subsurfaco Sewage Disposal System+Page 11 of 18
Commonwealth of Massachusetts
Title i i l Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
108 Windkist Farm Road
Property Address
Blue Ocean Realty __.._...___....._..__
Owner Owners Name
information is required for every North Andover Ma 01845 10-11-2024
�w:.___.._ _
page, CitylTown Staten Zip Code —Date of Inspection
D. System Information (cunt.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: _. _....._ _ ......._.. _........ Alarm in working order: U Yes El No
Date of last pumping: _......
Date
Comments (condition of alarm and float switches, etc.):
N/A
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Good and Even
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 Level,ran a small amount of water through box to check equal distribution it was equal, no
solids carryover, no apparent leakage in or out of box Box is 3'Deep 17"x28"
t5insp.cloc rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sovlage Disposal Systom-Pago 12 of 18
Commonwealth of Massachusetts
Title1 [ Inspection
Subsurface Sewage Disposal ,System Form - Not for Voluntary Assessments
108 Windkist Farm Road
Property Address
Blue Ocean Realty
Owner
Owner's Narne
information is North Andover Ma 01845 10-11 2024
required for every --- — _
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
10. Pump Chamber(locate on site plan):
Pumps in working order: U Yes F1 No*
Alarms in working order: D Yes 0 No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number: -
❑ leaching chambers number:
❑ leaching galleries number: _
(� leaching trenches number, length: 6 Trenches each
37.51
❑ leaching fields number, dimensions:
1-1 overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: _.. . ... _.._._..._ _..._..._.., ._. __.
tSinsp.doc•rev.7f2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
x aiF�� Title 5 OfficialInspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
108 Windkist Farm Road
Property Address
Blue Ocean Realty
Owner _� ....._.
Owner's Name
information is North Andover Ma 01845 10-11-2024
required for every __..._.w..._.___.__
page. CitytTown State Zip Code Date of Inspection
D. System Information (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.):
Good No None No Grassy
back yard area
12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert —_______ _.__
Depth of solids layer _...__........._...._
Depth of scum layer _ ... _.....__. ._. ..._..__.......__._
Dimensions of cesspool -
Materials of construction _ ... ......_......
____—_
Indication of groundwater inflow Yes No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
t5inspAoc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
110 Totle 5 Official
= Subsurface Sewage disposal System Farm - Not for Voluntary Assessments
108 Windkist Farm Road
Proper#y Address
Blue Ocean Realty
Owner Owner's Name
information is North Andover Ma 01845 10-11 2024
required far Query .._.._.__._..._._.._._._..__—_. —_
--- __...._. .,.__..... ._..,..._.._.._ .......______--
page. CityiTown State Zip Code Date of Inspection
- — --------- ----------- - -- ----
D. ysteml 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.):
N/A
t5insp.doc-rev.7128C2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
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AS BUILT PLAN
°. Commonwealth of Massachusetts
l Titlei i
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 108 Windkist Farm Road
Property Address
Blue Ocean Realty_
Owner
Owner's{Name
information is North Andover Ma 01845 10-11-2024
required for every _-...._. _ _ .._...._ .._..__..._.__.._._..._.
page. City/Town State Zip Code Date of Inspection
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 boxes below:
[mm] hand-sketch in the area below
drawing attached separately
i5insp.doc-rov.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
tit Commonwealth of Massachusetts
Title i l Inspection
l'S Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f✓ 108 Windkist Farm Road
Property Address
Blue Ocean Realty_...._.....
Owner _.......___ _.... ........... _
Owner`s Name
information is required for every North Andover Ma 01845 10-11-2024
page, City/Town State Zip Code date of Inspection
D. System Information (cant.)
15. Site Exam:
M Check Slope
® Surface water
Check cellar
Shallow wells
Estimated depth to high ground water: _44"__.._..._.... _ .. __._
feet
Please indicate all methods used to determine the high ground water elevation:
LA Obtained from system design plans on record
If checked, date of design plan reviewed: D.- -
Date
El Observed site (abutting property/observation hole within 150 feet of SAS)
El Checked with local Board of Health -explain:
El Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
All liquid levels are good, basement is dry, no sump pump,dug close to 5' down in the area soil was
Ay.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2Fi/20t8 -Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page'17 of 18
r
Commonwealth of Massachusetts
p, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
108 Windkist Farm Road
Property Address
Blue Ocean Realty
Owner O
wner's Name ------
information
egUiredo is North Andover Ma 01845 10-11-2024
required for every . . _ . ...._ .... __ .__...— _.._. __... _ ........_.... .,......_ ._... _ _._....._._
page. Cityfrown State Zip Code Date of inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
B. Certification: Signed& Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
(51nsp.doc rev,7128/2e18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18