HomeMy WebLinkAboutTitle 5 Inspection Report - 1560 Salem St - Title V Inspection Report - 1560 SALEM STREET 11/7/2024 FILE
TITLE V INSPECTION
Dean G. Lus 1,1 & Sons
28,8 Maple Street
Middleton, MA 01949
978-774-4065
Title, V License # S1848
SUBSURFACE SEWAGE DsSPOSAL SYSTEM INSPECTION FORM
PROPERTY OWN ERS NAM E C(;Lf Jb t)n e-
P t
A ncdcov'e� to M/t
DATE OF INSPECTION c) v e NAME OF INSPECTOR
Gommonwealth
R"N
4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
a. 0,,
fg Salem Street
r '*?tyr Address
arrkll _ ,m
Owner
Owner's
rstrrrrrnatyfor Zip code .v.�rtkr�i r'7 t� 4
ra�raUr�„ for vuwt �� � �i rndno� t' .���� 14� � " _
ue air
page, Cifty/Town ._. .__ .._... _�..�._�. ..__ .. ._ .� .. ..m
Inspection results must be submitted on this form. Inspection forms may In t be altered in any
way. Please see completeness checklist at the end of this form.
kmwa rtant`When A. Inspector
fifing out form
on the computer,
use ontr the tab Dean G. t.0 s omb 111
key to rnove your Name of kn gr air
,U rsrrr-do not Dean . Lu s crab 11 Sots
a,me the returrw
key Company Nam
288 MapleStreet
r i Company Address
0,1 g49
lddletr�ru ....
c tyff own
State Zip Grade
11'1_1__�Izl XU 978-774-4065
tttr epone Nralrrher License Number
B. Certification
II certify that t am a DEP approved system inspector in full rnpiialun e with Section 15,3410 f Title 5
tt CMR 15 000); l have personally inspected the siewage 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 fturncUon
and uttalruteruarn e of on-site sewage disposal systems. After conducting this inspection A have determined
that the system
1. M Passes
Conditionally lasses
. Needs Further I valuafion by the Local Approving Authority.
4. Falls
k9l(
w
w November , 2024
.„, _
firi;spktrrr"s'Signature
��4
"me system,inspector shall submit a copy of thts inspection repart to the Approving Authoirfty (Board
of Health or i )within 30 days of completing this inspection, If time system has a design flow of
10,000 gprf oir greater, the inspector and the system owner shall submit the report to the appr pdate
renal office of the DER The original form should be sent to the system,owner and copiers sera to
the buyer, of applicable, and the appiroving authority,
Please note: This report only describes c nd,t...
tips 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.
TiMO 5 UMM81 111SPO0fi ueo V'""N',arm-qulk'uuurt,aor'x Smyaga Dhtitmµ'osa= SVFF Rvn»FAR1 41 I Of 18
; *w Commoiiwealth of Massachusetts
Title 5 Official w7Y Hw w'M Inspection
H
tSubsurface Sewage Disposal System Fear . Not for Voluntary Assessments
7r. w 1560 SalemStreet ...
Property Address
Carbonell
r ier Owner's Canna
r r rkfn ns
urured A 0184 November r�', f 4
a� for every Norlhm Andover h
; S ad — t rn tion
CtylTo r .e� _. ..._..._
C. M
spection Summary
Inspection urnr°nsry Complete 1, 2, 3, or d and all of 4 and 6,
1) System sets:
I have riot found any information which Mdlc tss that any of the failure criteria described
; in 31015',303 or in 10 CM:R 15,30,4 exist. Any failure crits�ris not evaluated are
indurated below.
J R
Comments:
System Conditionally Passes,
one or more system comp n nts as described in the "Conditional bass" section mead to b
replaced or repaired.. The system, upon complebon of the replacement or repair, as approved Idy
the Board of Health,, illl pass.
Check the box for"yes", "no"'or"not determined" )for the f Ho iinr statements. If"'not
determined," pi se explain.
14, The septic tank is m ull and over 20 year's oW r the septic tank (whether metal or not) is structurally
r unsound, exhibits substantial infiltr Lion or e ,filtr tron or tank failure iis imminent. Systern will pass
" ir1spe bore if the existing tank is replaced with a complying septic tank as approved by the Board of
HeaIthr.
metal septic tank will pass inspection if it its structurally sound, not Leaking arid if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
N ND (Explain below):
'Tlie 5 a'.fiaad h9pec9on r u"°iro subaaE'ace Sa'wwa ge Di srwusai svgtem*Paoe2 18
r,;6rrdsrr,rrW. rev 7P2W211018
;AA'4.,y mots l
t`dl'vW y �
on Form
l Subsurface Sewage 'DisposalSystem Form� �"� for �lmunt VoluntaryAssessments
160 Salem Street
Property ddress
Carbonell
Owner .Owner's Nara
rm4orNrar6 1t4 ibr
eves North n�dnvgr _..
ty/TState....��.. .. ..... ._.pup Code Date
C. .a�.
Inspection
Summary...... .__. (cant"
System, Conditionally passes( ont.)e
PUMP MP Chamber pumps>i lr nrrms not operational, 'system,Will pass with IB,oard of Health approval if
pumps/alarms are repaired.
'G Obsrer° abon of sewage backup or break out or high static water r 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 l al'th)
El broken pipe(s) are replaced [] Y El NND (Explain below)!
)!
rvobstruction is removed L N D(Explain below):
distribution box is leveled or replaced 'y N El ND ( xplam n below):
):
El The system r quired p rnping more than 4 times a year due to broken or obstructed pip (s). The
system,will pass inspection if(with approval of the Board of Health):
broken pipe(s) are replaced N D (Explain balr w)r
F- obstruction is removed Y N El ND(Explain below)�
Further Evalulat,ion is Required by the Board of Health'.
Conditions exist which req&e further evaluation by the Board of Health in order to determine if
the system, is failing to protect public health, safety or the environment,
., System,will pass unless Board of Health determines in In accordance with 3 C '
15.303(1)(b)that the system is not functioning in a manner which will protect pubfic health,
safety and the environment:
"tl"We 5 MOM Ikngpac ion FGMT Substrface SeW890 fyiSMW SWW" page)of 18
Commonwealth f'massaehuseds
TRW 5 Official Inspection Form
�MSuibsurface Sewage Disposal System Farm Not fir Voluntary Assessments
M ^
q"r
F 1660 Salem Street
PropeO;µ"Addiress
Carbonell
ann r boners Nan,)e —
k forrruatlon is rn MA 1 4 November tt24
regWr d for every r�rth Aridawer � _ e. _...
page. City/Town fasf
Zip Codef�uaff V spec' on
tit SUmmary (oot.
El Cesspool or privy is within 50 feet of a surface water
0 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
s System wil,l fall unless the Board of health (aired Public titer Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
d safety and environment:
u, n s�rll absorption system(SAS)and the SAS its within
� " hr��system tins septic tank d y
1 100 feet of a SUr-face wafer supply or tributary to a suirface water supply.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
-rhe system has a septic tank and SAS and the SAS is within 50 feet of a private water,
Supply wail,
0 The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more fr rn a private water supply well".
Method used to determine distance:
�*This system passes if the welt water analysis„ performed at a ti p certified laboratory, for fecal
colitorrn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than d ppm, Provided that no other faHure criteria are tri icdered. A,�nopy of the analysis must
be attached to this,form.
. Other..
System Failure Criteria Applicable to AllSystems:
o I MuAl indicate"Yes"' or"No",to each of the following for all inspections:
Yes No
° Backup of sewage into a illty or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of ttte ground or surface waters
El z due to an overloaded or clogged SAS or cesspool
Tftle 5 offi �i R spro„tom r rho ltm uxfa,,�'Sewage� ���'t,&�
Commonwealth of Massachurseftslei
Tjotle 5 Official Inspection Form
" Subsurface SewageDisposal System Form mm Not for"Voluntary Assessments
t 1 lern Street
�.
Carbonell _.
Owner
Peforr e eNI
are T s Name
u agf-I ti rw is' _ �......_ . ._..�._.. Z p Gode I ^w r n
rq�ufrdfr,rvery Cqu ruodwoer S _ ticary ,..
n
024
C. hspection Siummary (cortt)
System Failure Criteria Applicable to All stenos; (coat.)
`des No
Static liquid ievel in the distribution box above outlet invert due to an overloaded
or clogged 'SAS or cesspool
Liquid depth in cesspool is less than „ below invert or available olu�rrue is less
than %day flow
Required pumping more than 4 times in the last year NOT due to clogged or
- obstructed pilpe(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 suipply.
Any portion of a cesspool or Iprivy is within a Zone 1 of a public water supply
well.
Any portion of a cesspool or privy is within 60 feet of a (private water supply well.
Any portion of a cesspool or privy is iess 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 grater analysis, performed at s ti p certified
laboratory,for fecal coluform 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 fora.]
The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
The system fsdls'. I have determined that one or more of the above failure
criteria exist as described in 10 R 1 5.30 , therefore the systern fails„ The
system owner should contact the board of Health to deterrniEne what will be
necessary to correct the failure.
5 Marge Systems: To considered s Barge system,the system must sere s feoiq,fty,,, � h
design flow of 1 ", 0pd to 15,000 gpd.
s"
For large systems, you indicate either '`,yeas" or"no" to�each of the olt�o�win , in addition to,the
questions in Section CA.
• "des No
M
� D El the system i wuthup- 1d f eet ofl srfpce drirn9ing water,s�uplal�y
E] the� ate r„is within o feet of a tributary t v'� surface drinkingwater suuuppl
theVsystemm is located in a nitrogen sensitive area.(Iruf r ,"u ebead Protection
Area—1 )or a mapped Zone Ill of a public water supply well
"cwYt~,p�s off owl Inspection Foam s,,ibaowrh'a�;reo sewage B)Ispn aG:5ymenl n P�w 5,of 18
C'armsp-d roc^rev.712rII1.0"V 8
,. Commonwealth of Massachusetts
ion
Title 5 Officmal Inspect" Form
:.� Subsurface age Disposal System Form Not for Voluntary ssessrnents
� .wA
1560 Sallem Street
' a"op rty Address
srbnielllCYNiner _ a
Owner's Narne
on
r u i�d N tor
re everyNorthAndover MA 01845 November 7, 2024
Gode Date .f nmw Non
page. Utyffo' uw �w mm . �.._ ....
If you have nswwrered "yes"to any question in Section C.5 the system is considered s 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 sunder Seal n C,5 or failed
Under Section CA s ali upgrade the system in accordance with 310, CMR 15.304, The system owner
shoWd contact the approphate regional office of the Depairtment.
. You must indicate "yes" r"no"for each of the following for an inspections:
"des No
0 0 Pumping information was proMed by the owner, occupant, or Board of Health
e Were rry of the system components pumped out in the previous twoweeks?
E] 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 plains of the systems obtained and examined? (if they were not
awaillable note as NIA),
Was the fa llity or dwelling inspected for signs of sewage back nip"
Was the site inspected for signs of break nut?
Were all system components, earcWding the SAS, located on site'?
Were the septic tank manh ates uncovered, opened, and the interlrir of the tank
inspected for the condition of the baffles or,tees, material of construction,
dimensions, depth of licluld, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
information on the proper malntenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based n:
Existing information For example, a plan at the Board of i~tealith.
Determined fined In the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[ f g GMR f . ( )]
Tfla s Dffur'w NnsperN;iml F fr'.s,llbstgface Sewage Di.,dms,,N SYStmn Page 6 of 18
° Commonwealth ofWassachusetts
�A 1Inspection
._ g
r� Subsurfe Sewagie Disposal System Form lu rut ry Assessment
11 0 Salern Street
Oroperty Address
;one�� _.
_. _
Wormat
� '"
requiredpr rN Andover November 7 W
Owner
on
every North
page
of nm�
for, ..�... .....� .
D. System Information
1. Residential Flow Conditions:
Nurriber of bedroom (design): 4. Number of bedrooms (e tU V):
440
DESIGN flow based on 310 CMR 1 . 0 (for example: 110 gpd x#of bedrooms):
gp
Description:
erfption:
"Town and owner,
2
Number of current re 6dernt :
Does residence have a garbage grinder? E] Yes
No
Does residence have a grater treatment unit? "des No
ff yes, discharges to:
Is laundry on a separate sewage aterr " (MeVuude laundry to Vruaefin "fee No
M rrrnati rn, in this report.)
Laundry system ins ec:ted � e tV
Seasonal use? Yes No
Water rrieter readings, if avaflaWe (last 2 years Usage(gpd)): _�..
h eta V
r
Z Yes, No
SUMP pUrrwp r;Urr'ent
.,,.
Last date of r Uparn : Date
�'¢tN r&M't&i 1aN qx"ram E ct p"orm quvwar€ o t"Su aga Disp osM Sy+stem,.qIw T(9 16
yw ry„ Commonwealth ofMassachusefts,
^rotaSYw q
� mOffic"al Inspection Form
d1 ubstau s Sewage f po t "st r For Not for Voluntary Ass ssrn nts
1560 Salem Street
Property Address
Carbonell ...
iwner Owner's Narne
nfo ion i North nd wrr r f ,, ov rmber , 02
StateCat of Mspecwn
m • City/Town ._.. _... ._ .._ . ..
D. System Information (cone.)
. ComirnierciaVindustrial FlogConditions:
Type of staMslhrm' nt:
sign flew(based on 310 CM R 15 203): auu'ns per,d y
Basis of design flow(seats/persons/sp.,ft., etc.),
Grease trap present" � Yes N
Water treatment Harsh present? "des No
If yes, dis h r i s t ,
l nduastria i waste holding tank present? � Baas F No
ikon-sanitary waste discharged to the Title d system? Yes No
'Water meter readings, ilf available:
Last date of a c a n lus :
Date
Otter(describe bei w )r
3. Pumping Re rd -
Pu ps every year, Last pumped 8/13/24
Source of information:
o
Was s stern pumped s part of the inspection? Yes f
u
If yes, volume pumped: uuon"s
How was quantity purmp di determined?
No need at this tine Stay on scdeduaie ., _.....
_-
Reason for,puarrapirn' :
Tdlo�,�oft nva:l Gngpe4°,Abf ofm „Sub.aurfa�e,eseveage virpoaaN systlavn«F^ati966 of 10
Commonwealth of Massachusefts
Title 5 Official Inspection Form
d '
l Subs,urface SewageDisposal System Form _ Not for Voluntary ry rrn ents,
Pr p rty Address
Carbonell
rnr _ .
r s Nrrn
information is �Irnr"� ndrnw� r 01845 November 7,
2024
p eo °tyr o Code Date t Inspection.M Information ' nit .......
4, Type of System'.
Septic tank, distribution box, Soil absoirption system
uEl Single cesspool
Overflows cesspool
Ivry.
El Shared system (yes or no) Off yes, attach previous Inspection records, of any)
Innovative/Altemative technology. attach a copy of the current operation and
maintenance orntr ct(to be obtained from system owner) and a copy of latest
inspection of the l/A system by system operator wander contract
Tight tank, Attach a copy'of the P appr'ovall.
Other('describe)'
Approx mate age of all compoinents, date installed (If(known)and source of information:
System is from 1969- 55,years,old. _ __ ........
Were sewage odors detected when arriving at thesite?
yes Z No
5. Building Sewer(b ete on site plan):
Depth below grade: teet
Materiel (g construction':
cast,Iron 40 P� El other(explain)-
Distance frown private water supply well or suction dine:
Comments ton condition of joints, venting, evidence of leakage, etc,):
1aln line and joints are in goad condltion„ no signs of any pro learn .
F h
off[�ckW gpee't4'on'� om ,ubf�nnr£ace�S'�:aUUQ L"ri*s�.r�03, �SY�t
TWO °Paj e 9
Colmmonwealth of Massachusefts
Title 5 Official Inspection, Form
4 4Subsurface Sewage 'Disposal!System Form-blot for Voluntary Asses! m nt
1560 Salem Street
n
Property Address
rnlll -
Owner bmer's Nees
ormtouwn taorn l 01 45 November 7, 21024
req inured for every North Andover
_ _
_ �_..... ..�m.
state
up Cade Date of Inspecton
Page. cityrrom
D. System
._.. Information (cone.)
5. Septic Tank(locate on site plan):
Depth below grade:
107
�p Material l of construction:
„ Z concretemetal fiberglass F] polyethylene other(explain)
1000 gallons
It tank`R r e l"� t ,
" � I1�m w e w,
l$- t�tt'ftFr ed ley ert"ifi t of Compliance? (attach copy t certificate) � "� ,,,, ,;�
l lr ern ion ;
Sludge depft
Ora
Distance tror°n trap of sludge,to bottom of outlet tee or da ,
tl''
Scum thickness
601
l i tan e frr,m trip Of scum to top of nutlet tee or baffle
151" w._.... m. ...__
Distairrce tr rn 5 ttorn of scum to bottoirn of outlet tea or baffle
h measurernent _.
How were.dimensions
rran� determined?
orn ment (on piumping r nf.orrnm endatuorm „ inlet and outlet tea or baffle condition, striuctural 'inte irit „
HgOd levels as related to outlet Mv°ert, evidence of leakage, etc.):
The tank and battles are in good general condition. The tank is running at Ws correct working height.
TMea 5 r)fflriw 6nsprmr4.an F¢s n -'n�lobs' rbce SfPNagO D'sPr" yz+NWffl•is +ea'U�V f f ff
Commonwealith of Massachusetts
lTitle 5 OfficialInspectmon Form
w�x r Subsurface Sewage Disposal System Form Not for V6untary Asememt
1560 Salern street
Property Address
Carbonell a, _
r
i is
reu a d for every fl rttn Andover _ _ _ A _ ..0.1845 mbeir .2 7,111, __
City/Town r, 4 a gad r r of Oc� g a
Grease Trap (locate on site pl n)
Depth belowgrade:
'a,tehall of co n trtu tiom
r ra mete [] metal E fiberglass � pollyeth len � other(explain):
F
Dlemslru °. __.._ ..
Scum thickness
Distance from top Of SCUM to tOp of ouutlet tee or b ffle,,..
Distance frorn bottom of scurn tru boti m of outlet tee or baffle
Date of last puirmp'im : Dare
Comments(earn pvrnl6lrn ' recomimendatio rn a inlet and nutlet tee or baffle,condition, structural inte rl4 ,
liquid levels related to olutlet invert, evidence of leakage, etc.):
Fight or Holdliaa Tank (tank Must be pumped at tonne of inspection) (locate on site pWan):
..........
Depth belts"want rude:
Material of constructiom
concrete metal flberl plethlernie other(explain):
Dimensions:
Capacity', gallons
Design l ' P gallons per day
TiMe 5 aff�ciaw Pnapec0.ion Form S'abisu TfIce sewage lui ,'D'rasw aysli 1•F`aai,go I
t5prfsp fps •ruru 712,612.Ul8
ter, Commonwealth
�f! TRW 5 I
' �A4 Subsurface Sewage Disposal System Fora Not for Voluntary Assessments
15 Salem Street Property Address
Carbonell
0n0fon ration is
024
^
required for every North Andover � � November tl �
Page, wtyFrua in ;state Lp Code Date of I ispe Lion
stem Information (cont.)
Tight or Holding Tank(carrot.)
Alarm present: Yes El No
� Ai arm a w l: - �. Alarm in w orkrr 6� ir: r '
Date of�ast ping: t
Comments nts co ndlt rn of alarm and float wit !),/f , et .}:..
Attach copy of'current ptwrrrnparng contract(required). Is copy aftached? Yes No
9 Distribution Box(if pir s nt must be p rn d) (IIocate on site pVa n):
Zero m...._..
Depth of lig�und [ v'el above olutlet invert _
Comments (rncota'�f box is lavall and distribution to OUtIlets equal, any evidence of solids carryover, any
evidence c of leakage into or out of box:, etc.):
The d-boxis 2 " below grade. The d-box is in good working condition and shows no signs of any
prodi'srrros.
ff'irtsq doe rev lMu'�.'41"fi B
"'p ;OrfmW Cr+spaft6on Form sut'surifaco sewage Mbrwr sal SYsferrd'x*Pap 12 sf E8
µp Commonwealth u
fJ
n Subsurface Sewage Disposal System Forma w Not for Voluntary ry Assessments
Mp
156,0 Seierru street __e,A _. .
0 rope r Xddre SS
Carbonell e.._
Owner owner's l4ame
kiformation R
regWred for every North Andover 018,45 November' , 2024
page, State.m. burr Code Date of Vnspectooru...—.....
Informaffon (coat'.)
10, Pump Chamber f lo ete on site plan)
1re Ito*
µq' Pumps Ara rarurag order:Ik b,
yF i 000 Alarms un working carder; El Yes [j *
Comments t (note condition of pump hoer b r- b drtu ru of pumps and appurtenances, etc,):
9f pumps or alarms are not in working order„ system is e conditional pass,
11. Sioll Absorption System (SAS) (locate on Me plan„ excavation, riot r Uired):
If SAS not llocated, explain,why`
The SAS was located by d-box to level area of yard,
r
0
Type:
S. leaching pits
El leaching chambers number:
leaching gaHedes
number:
leaching trenches number, rrgth: _
ieachilrag fields number, dimensions,
� overflow esspoom
number: ._ ... �.,
irn ab e/alternafl e system
Typefraairme of technology:
15h9p doc.rvu T3.lWW18 rifle s�3f3h�Bal nnwµ e(,tbn Fo nw subsafavxi Sewage rdwosw SYSta',-P0,90 13�A 1 a
monwealth of Massachusetts
Tftle 5 Official Inspection Form
'%4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1560 Salem Street
' nty Addrr
G rboneH
Owiner mi ry Narne
ii0orrrnation is
rpqWired for every North Andover
Me. cify?rown State Zip Code Date of�nspecfion
D. System Information (coat)
11, Soil Absorption System (SAS) (cont.)
Comments(note condition of sail, signs of h drsaLilic faH red IleveI of p ndin , damp soil, condition of
vegetatoon, 'tc ):
The SAS Is in goad genera,l condition,
.........
12, Cesspools (c sspl cl rnust be pumped as part of inspection) (locate on site pisrn):
Number and configuration
Depth-W trip of liq uid to,inlet inner m
Depth of solids ir
r
,
Depth of sicum l yeir ...,
Dimensions of cesspool
Materials f construction
Indication of groundwater inflow � "des No
Comments(note condition of scnj, sngns of hydraulic failure„ level of, onoin , c ndiotion of vegetation,
etc.),:
W ftb 9rr � r,r rrA n1C Ti#lie?5 OfncW IWAWi fva FOrcn scckarawmrRace Sewage DV"lposm Sy,rftm^Page 14 of re�
i(,,, InspectionFlorm
s) Subsurface Sewage Ca at System Form _ Not for Vlu nt rw Assessments
1560 Salem Street
Property Address
tr ru �l
O neir Owner's Nees
»int rm afion i ..
r qWr d for vr rm North Andover _ 'love,, r 71,111120.24
� f Code
page, sn d r r wn o ectb n
. . �. ._ t6�wm. —.
D. System Wormation (cont)
13, Privy(locate n site plan):
Materials of construction:Dimensions
_.
w�
.
Depth of solids
Comments (mote condition of soil, signs,of h tlawl failure„ Revel of ponding, condition of vegetation,
etc.):
t5iinspA —rev 712,V2 1 "nuo off w w lvrmTm—n Porm,guh surfwa 5 66 INmPi i 4:SSYS'nGm"page 15 C'r r¢�,
�ommonwealth ofMassachusefts
III %...i ®.
Official�
�I L drw7
h lubsurface Sewage Disposal System, Form Not for Voluntary Assessments
15 0 Salem Street -
Carbonell m�
s twor � �r Arnd r lr �.
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µSys,tem Information (coat.)
14, Sketch Of Sewage Disposall System.
Pr a id sewage disposal system, �ncli dirr ,ties to t Yeast two permanent reference
landmarks or blench marks, Locate YY wells w,ithin 100,feet. Locate wire pubYYc water supply enters.
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the building. Check one of the boxes bellow:
r � hand-sketch in the ra IksBo
drawing t t h d separately
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Commonwealth, of Massachusetts
i t Subsurface Sewage Disposal System Form Not for Voluntary Assessments
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,'-.P111 1560 Salsa Street _.
ramp Addr
Carbonell
Owner
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farared rorr North i �� r
page„ City/Town _ State p Code Date of duirae colon
D,. System.. Information (cont.)
15, Site Exam,
Check Slope
Surface meter AJO ''°;,,, ''.,,
Check cellar � r r; ,r,jr^ mJ c�^` , .
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s" /-
Estimated depth to high groundwater: _. __ a®
Please indleate all methods used to deterinine the high ground water elevatiom
Ell Obtained d from system design plansm record�
It ch k d, date gut'design plan re ie d: Date
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Observed site(abutting property/obseirvation bale within 150 feet of SAS)
Checked with IocaI card of Rea lthe pl:"aim
,i , �b r�L, ,40r+
Checked with local excavator , installers d(attach documentation)
Accessed USGS database-explain:
You gust describe trove you established the high ground rater elevation:
Basement i T below grade with a sump purrup. No grater in the urnp purnp.
Before filing this Inspection Repot, please see Report Completeness Checklist on next page.
f5µm sf ma^aid 'J r ? 1 a TAWoffirlaq Inspedion Fom�rm:Subsurface Sewage t"Yw�spoldacak 5axs�pcm'a�i•IPaga i"7 rA 18
Commonwealthn.
chins
Title 5 Official Inspection
Subsurface Sawage Disposal System For Not for Voluntary sssrrnts
1560 l Street
Ar"ope ty Address
Owner, .._ m. _. ®._ -
Warrn 4ion u
_. _ tat e up Cade Date or a�u p on
r ��unr��tr�n`every
E. Report Com�pleteness Checklist
North And lover _ . MA ti p# November , -
24
page ut ��'�w�srki
'Complete all applicable sections of this form inclusive
. Inspector Ilrnforrrn flo n: Complete aH fields, ui n this section.
RZ B. Certification: &gned & Dated and 1, 2, 3, or 4 checked
C. lrnsp u:ttrnrn summary:
1, 2, 3, or 5 completed as appropriate
(,Failure Criteria) and 6 (Checklist) co,mp� te'ld
D, System information:
For : Tights aldlrn, n Pumping ontr ct tt to 'd
For 1 : Sketch of Sewage Ddspos 1 Systeni drawn on pg. 1 r attached
For t 5: Explanation of estimated depth to high groundwater ater included
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