HomeMy WebLinkAboutTitle 5 Inspection Report - Pass - 124 Stonecleave Road - Title V Inspection Report - 124 STONECLEAVE ROAD 12/5/2024 Dean G. Luscomib 11 & Sons
288 MapleStreet
Middleton,
978-77'4-4065
'Title License # S1848
SUBSURFACE SEWAGE USPOSAL YSTEM INSPECTION FORM
PROPERTY OWNERS NAME
..
PROPERTY ADDRESS EL 1
" a ,
DATE OF INSPECTION
ME OF INSPECTOR
r+A �W4
Commonwealth of Massachusefts;
'Title 5 Official Inspectlion Form
psi Subsurface Sewage Disposal System Form Not for Voluntary Assessments
124 Stoneicleave Road
Orop rty Address
Ppel1
Owner lolrt r' Nameos�9'�rxrr•r"a� �sdf r pt 4 eoe ber ,
r nraa
rer��r� r every Andover
at, ti .,,,.,. Dag of inspectionp a s
Inspection results must be submitted on this form., Inspection forms may not,be altered in any
way please see completeness checklist at the and of the'form.,
�. .. ... � .. �" Information_ ma�..... _..
raa^rp rrrrn:When
rrnnn�q, out torryas
an the computer,
use only H)e rib Dean G. l trscomb 111
array to move your Name of nrwsrre tarr
cursor-dal not Dean G. Lusoolmrb lip & Sons
u%e die return
key. Complany iNf rra'r
_.�. 288 Maple street
_.............. _ ..
.... ..
...
t"or pary Address „_..
Middleton MA dtg- g
rty Darr state Zuga 1 ode
Trateprnone Number License Number
B. Certification
1 certify that: I am,s DEP approved system Inspector in full compliance with Section 16340 of Title 5
1 1 .g ll ; 1 have personally inspected the sewage disposed systems at the property,address
listed above„ the information reported below is true, accurate and complete as of the timne of tray
inspeotlornl and the inspection was performed based on my training and experience in the proper function
and maintenance of onl-site sewage e disposal systems. After conducting this inspection I have determnrned
that the system,
't. 0 Passes
. 0 ConditionaIly masses
Needs Further Evaluation by the Lo-cal Aplprov4ig Authority
IFails,
)I U�ni mp�lor °w� W �mA December2kJ
Irutor' sulrutrurce bit'
'The system imspectolr shall s,ub lit a copy of this inspection report to the Approving Authority(Board
of HeeNth or DEP)within 30 days of completing this inspection. 1f the system has e design flog of
10,000 gpd or greeter, the inspector and the system owner shell subrnit the report to the appropriate
regional office of the DEP. The original form should Ible sent to the system owner and copies,sent to
the buyer, if epplicaWe, and the approving authority.
Please mote:' "his report only describes conditions at the time of inspection and under the
conditions of u,se at that time.This inspection doles not address how the system will perform
in,the future under the same or different conditions of use.
tP,.4isga,.ercm-rnv 7 f26129018 TRW 5 d,`yffidal Ilrwsprad cn Flarm,Suukaswowe Sewage ORsp pain&Yioam�.Page 1'of 18
Commonwealth of Massachusetts
Title
® I Inspecti"on, Form
mi Subsurface e a Disposal System Form Not for Voluntary Assessments
124 Stonecleave Road
rriO'Pe�AdidireS'
fall
Owner Owner's Narne
unfnrm ation m
requ.upired for vv�jy. North Andover 184 December 0
_ _..
page. � '" wu°n pp od rats of pnsp ectibru
Inspection,
inspection "t umrnar r omplete 1, 2, 3, air 5 and all of 4 and 6,
.t) System Passes,
l have not found any information which Indicates that any of the failure criteria described
„„ in 31fl C 15.303 r In 31 CM 15.304 exist. ,any faulure criteria not evaluated are
b indicated d lo,w.
Comments:
System Conditionally Passes:
One or m re system components as described in the°" onditional Pass' section need to be
replaced or repaired, The system, upon cornpletion of the replacement or repair, as approved by
the Board of Health, wwHI pass.
hack the box for"yes", „„no„„ r""nlot determined"'( „ N, )for the following statements. if"not
det rmOed," please explain.
The septic tank,is metal and over 20 years old* r the septic tank (whether metal or not) is structurally
unsound, exhibits substantial mnfiltration or axf'iitrati n or tank tikire is imminent, System lm will pass
inspection if the existing tank is replaced with a cornplying sei 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
t Compliance indlcating that the tank is less than 20 years old is available.
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Commoinwealth chose
Title 5 Off"I'dial Inspection, Form
Subsurface Sowage Disposal System Form, Not for Voluntary Assessments
1 t na laa a Ro' ad
Property Address
papll,,.. _11...
N nerOwner's Narnie
information i
required for every North Andover Decle b r 5, 0
24
page ctty/t n State Zip Code Rafe of Inspection
C. Inspection ( rat.
System Conditionally Passes (cont,):
Puurrwp Chamber'pumps/alarms not oparatinorwal. System wifl pass with Board of Health approval if
prurnpa/alarms are repaired.
�j"" E] Observation fsewage backup or break Dint r high static water(level in the distribution boar du e
i'' to broken or obstructed pipe( or duce to a broken, settled or uneven distribution box, System will
r , ' pass inspection it(with appravall of Board of Health):
E] broken pipe(s) are replaced El Y [:1 N MID (Explain below,):
Ej obstruction is removed E, Y El NJ NJ (Explain below):
distribution box is laureled of, replaced Y N ND(Explain below)
El The system required pumping more than d tirrwaa a year dine to broken or obstructed,pip ( ). The
system will pass inspection if(with approval of the Beard of(Health):
broken pipla( )are replaced El Y N 0 ND (Explain below):
):
obstruction is removed Y El N El Nwll (Explain below):
r; Further Evaluation, is Required by the Board of Health,
El Conditions exist which require fUirther e ai atiurm 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 pave untess Board of Health determines In accordance with 310
f m (l)(h)that the system is not functioning In a manneir which will protect public health,
safety and the environment,
E5insp.doc^^rev 7122601118 T°fle 5 OfhrW hype ion corm,Subsurtaaua lsa wago C]Isgrnvw;'yqsmn—Pavr a 3 of'M
Commonwealth of Massachusefts
k..-.xaTitle 5 Official Inspection Form
4M"
k4 Suibsuirfaice Sewage Disposal i yst rrm Form Not for Voluntary Assessments
1 t o q s � Road
........ .
Property Address
pm ii
_ __.. w . _ _ �,,.. ._.... --,...
Owner
um�`or�muahon os
Owner's Name
re Wred for emT 9 rth Andover �..�,.., _ _v Ml 1 December a 2
024
_ _...... ..... ,. . .. .....,_ .fm�on µ
pie. m�:�m�yva"°ru� 'm.,_.�. __._ ,_ ��� ����s �� ��nmm �t.�..._.W .....
mi
nt
El Cesspool or privy iswithin 50 feet of a surface water
DI Cesspool or privy is within 50 feet of s bordering vegetated wetland or a snit marsh
b. System will fall unless the Board of Health tamed public Water Supplier, if any)
determines,that the system is functioning is,a z s i r that protects the public health,
safety and environment:
El The system has s septic tank and soii absorption system(SAS) and the SAS is within
100 feet of s SUrface grater supply or tributary to s,surface water supply.
[-,I The system has a septic tank and SAS and the SAS is,within a Zone 1 of a public water
supply.
El The system has a septic tank and SAS and the SAS is within feet of a private water
supply / ii.
El The system has a septic tan k rnd SAS and the SAS is Mess than 1010 feet but 50 feet or
r n re from a primate water supplywell".
Method used to determine distance'.
This system 1p sses if the well water analysis, performed at a i` Fp certified laboratory, for fecai
oiif mrrm bacteria indicates absent and the presence of srnimoninas nitrogen and nitrate nitrogen is e u i
to or less than s pprrm„ provided that no ether failure criteria are triggered.. A copy of the analysis must
be attached to this form.
tm, tither:
) Systems Failure Criteria Applicable to All Systems;
You must indicate"Yes" or"No"to each of the following for all, inspections:
"es No
010 Backup of sewage into facility or system component due to overloaded or
° clogged SAS or cesspool
Discharge or p nding of effluent to the surface of the ground or surface waters
dire to an overloaded or clogged SAS or cesspool
T'akW 5(WicW Bnapeod.ort Ccwm Siubsuface'Sowage.DIRN,s"W 5y5t8Mi W r"ap 4 of"d
Coniinrionwealth of Massachusetts
n, Title 5 Official Inspection Form
Subsurface Sewage IDisposai System Form Not for Voluntary Assessments
124 Stonecleave Load
Property Adiiress'
N apell
owu°war O iner's Name
_ ®... ........ . ..... _ . ,.,,,�.., . �. .....____..
uTlf rrw ufron is
required for every North Andover gt 4 December , 4
page. iltyf° owwrl State _ Zip Cade ie of lru p cfion
Inspection
cont.
4 Systern Falluire Criteria Applicable to All Systems- (cont.)
Yes No
11 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
13 H Liquid depth in cesspool is less than '"" below lnverl or available volume is less
than '/2 da,y flow
w equ.uiired pumping More than 4 times in the last year NOT doe to clogged or
11 obstructed pipe(s). Number of tiirnes puurnpe : _.
' [:1 _ Any portion of the SAS„ cesspool or privy is below,high ground water elevation,
El 0 Any portion of cesspool or privy is within 1010,feet of a surface water SUpplly or
tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone t of a public water supply
weli.
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 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 IDEP certified
laboratory,for fecal coliforrn bacteria indicates absent and the presence
of a rnonla nitrogen and nitrate nitrogen is equal to or less,than 5 pipm,
provided that no other failure criteria are triggered, A copy of the analysis
and chain of custody must be attached to this form.]
El 1-1 "'he system is a cesspool serving a facility with a design flowof 2000 gipd-
1 ,00g gpd.
EwerAThe system falls. 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 wull be
necessary to correct the failure.
51) Large Systems. To be considered a large systemthe system must serve a facility with ate,
dlesiign flow of 10,000 gpdl to 15,000 gip
For large systems„ you must indicate either"'yes"or"no"to each of tie foil swing, un addition to the
questions in Section CA.
"yes No
op
El 11 the systern,11 I",W bif ggfeet of a surface drinking water supply
W t system is within gl feet.6f,,a tributary to a surface drinking water supply
the systern is located in, a nitrogen seitl areainteriuw elllhead rotectiion
Area --�l )or a mapped Zone ll of a pu blie aler supply well
*;In sp.doo•rev 7'f2612018 01rekr y 4. w.mk Inppectuerra Form UbburH':uue S ages t3.PuSnl 8yatom 5 04 1 a
Commonwealth u
Title
Subsurface Sawage Disposal System Form Not for Wuntary Assessments
124 Sto�neciea e Road
m.......... .. .. . _ ., ...,.... ® ,...
Property Address
Ia .l.l.,. ,.„� ..,.
=er _ �,. _ .._ . ._. .._ .. _..
� ro�r'� an�t�
roor6
amid r amy „. .... .§__. P
.,,� goon ........_... . st t n ends _ ....nts Mgt mans rtu .. —required North Andover ....._ 01 4 December w � �_
. Inspection Sumimary (count.)
If you have answered "yes", to any question in Section C,5 the system is considered a significant
threat, or answered"yes to any puuesboan in Section CA above the large system has falled. 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.
. ' u must indicate"Yes:"' r"no"for each of the following for all inspections:
Yes No
El Pumping information was proOded by the owner" occupant, ouir IBoard of Health
Were any of the system components pumped out in the previous two weeks`
ZI E-I Has the systernnn received normal f to was in the previous two week period,
Have large volurnes of water been introduced to the system recently or as Ipar"t of
El z this inspection?
Were as built plfans onf the system obtained and examined?(if they were not
available note as N/A)
Was the faciiity or dwelling inspected for signs of sewage back up?
..I Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
AEI Were the septic tank rnanhonlies uunco Bred, opened, and the interior of the tank
inspected for the conditmoun of the bathes or tees, material of construction,
dimensions, depth of Nnpluuid, depth of sludge and depth of scrum?
Was the facility owner(and occupants if d0erent from owner)pro v"iuded with
information on the proper maintenance of subsurface sewage disposal systems?
The sips and location of the Soil Absorption System,(SAS) on the site has
been determined based onlm
Existing infourirrnationn. 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) [ 1 01 R 15.30 ( )]
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rtl moini It
Title 5 Official Inspection Form
Subsurface
Sewage IDisposall System Form Not for Voluntary Assessments
.. 124 Stonecleave Road
PIN
hiformofion is
requked for every North ndo r d11 December ..., 0 ., _.
_ ......... ® .®,_.. _ _
paige, State Zip Code iDate of Inspection
SystemD. IInformation
1, Residential Flow nditN n :
Number of bedrooms (d N n)n Number of bedrooms (actual): m... __
440
d
� DESIGN flow based on 310 GMR 15.203 (fair example, 110 gpd x#of bedrooms):
pd
Description:
Town and owner.
3
Numbeir of cuirrent residents: ...........
Does residence have garbage irind r Yes No,
Does residence have water treatment unit? No
If yes,, discharges t ; ®, _ _ _ _ ---
Is laundry on a separate sewage system (Include laundry system Inspection Ej Yes 2 No
information Nn this,report.)
Laundry system inspected? Yes [] No
Seasonaluse? E] Yes 0 N
Water meter readings, if available(last 2 years usage
Detail:
u
Sump pump?
Yes No
current
t date of occupancy: t '
C�iinmp dewc rey 712,612018 Tft 6 Offx iW inspection Foffn. UV)$u�jW,.,e W@ge D Mi p�mo� 5y+ma n,, r"ajo 7 of'W
� Comimonwealth
Title 51 OfficialI Form
4 Subsurface e Diisposal Systems, Form ® Not for Voluntary Assessments
Prope Addr as
NpNN
Owner rear t l
pnfurnl to n na
reqUired for every North Andover 018,451 December y
page, Stare zip le rare of ha action
D. System Information (cont.)
. C rruprrr r l llindu trital Flow Conditions-
Typeof Establishmilent
Diesigna flow (biased on 31 R15.2 ): uuo'ln per d�y,t��l
Basis of design flog( t 1p r ra "spft, etc.):
Grease trap present'? E] Yes [:I N
"water treatment unit present? N
If yes, discharges to:
In u tirii l waste hou ding tarok pr rdf 0 Yes 0 No
Non-sanitary waste di ( at ad t the Msystem? Yes No
water meter re , , It aaNladl
Last date' t'occupancy/use: lbate .. .._
Other(daa rlta to N r):
. Pumping Records:
S r t information: Pumpsy y every Last pumped October 2024
001 Was system purnped as pad'of.the inspection? J Y
r Nt yes,. volume plumped.,d.,
ua�uq�_raa ..
How quantity pumped determined?
as in for p irrwplr�� No in d t this taw t _ n scheduler_ .
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
? w l SubsurfaceSewage Disposal System Form Not for VoWnt ry Assessiments
124 StonecleaveRoad
_ ,,... .... ®_. _ �. ...
Property Address
ppll
a rr'ner Ownees Nerve
information is
requked for every North rth Andover 1 1 _ December 5,112024
page. Gr„ .. . p Date_ ._.....o Inspection...._.
D. System Wormation (cont)
. Type of Sy :
"2 Septic tank, dl thbuuti n box, soil absorption ;system
` N &ngie cesspool
E, Overflow cesspool
Ik
Privy
Shared system (yes or no)(if yes, attach previous inspection records, if any)
Innovative/Aiternafive 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 l/A system by cyst rrr operator render contract
Night tank, Attach a copy of the EP approval.
Other(describe):;
Approximate age of all components, date installed (if known) and source of inf rn°nati m
Leach field is ord final to house, tank and d-box are from 008
Were sewage odors detected when arriving at the site? EI "des Z No,
. Building Sewer(locate on site plan);
OR
Depth bellow grade: m � _
rat
r ,Material of construction:
cast iron 40 PVC ether(explain),
Distance from private water supply well or suction liras;. r��ll� _ _ ,�..
e arnents(on condifion ofjoints, arenitin , evidence of leakage, etc.):
Main line and joints are in good rx)nditunn, no signs of any problems.
fingp. n-Vev 7126J2018 .q ftP 5 DffidW IngrodonForriv Subsurface image fl n-a[SYS-1 T auo q us 16
Commonwealt f Massachuseft
'Title
w Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property trrire&e
P p ll
- _......
� rwsr� �. ,_. .._. , ...
wnee am.e
anon re
required for eve"y No th Andover MA 1 December a 2024
gage. bit r�r State� .....
, Zap ba�...�__�...._ �wtgw'�sgaletww^��v
W�w�......_ .. ...__. m _. Code e� .._.... �....._ ._...._.�
D.
System I (cont.)
nt.
Septic'ran (locate on site plan):
Epp
Depth Ibelow grade; feet--"'
Material of construction"
concrete m t ll fiberglass polyethylene E] other( xpl M
ml,
t 00 gallons
d
_ .o�ro...If tr"r� qs r"� tal, lint�
�� w r t' l rtrflc t ofCompliance? (attach a copy of certificate) �.
_NI
x 1 g" ti t g gallons
imensw rm� : �. m _ �m, _
Sludge depth ...
EI
Distance fr rru top of sliudge to bottom of outlet tee or baffle
T
Scum thickness ..mw. .---Distance from top of scum to top of outiet tee or baffle
I ,
Distance from bottom f scum to bottom of outlet tee or baffle � ®. _em, _ _ .......
lad Te srurernlent
How were dimensions determined?
�
Comments (on pumping, recommendations, iMet and outlet tee or baffle condition, structural integrity,
Iig ld levels as related to outlet invert, evidence of leakage, etc.):
The tank said defiles are in good general condition, The tank is running at it's correct working height.
t5 nGsm'a:doc rRv.7/26/20'W Itle s ojfk;u,w I spectlion raron:Subsurface Sewage C13VOM11 SYBs Wm. P &10 18
1 . f r � '� � �u
Title 5 Official
Suibsurface Sewage Disposal System Form'm Not for-Voluntary Assessments
.; 'P '124 St necliRolad
O`i&l Addfiess
up .11
Owner uwn°u is Nw,ne
Wormation is
required for ev'mery North Andoy,ef, A . 5111111111111111111 1 rnbeir ,
page It d`rown t Zip _
ro
D. i Information (cont)
a Grouse Trap (locate on site plain):
Depth bellow grade: ffeu —.... �...
t irm l of constru tr m
d concrete Elmetal' El fiberglass Po lye ter l m�� other(explain):
_. _.
0
l llrr s'
Scum thickness
Distance fu°om top of scum to top of outlet tee or Oa#6
Distance from bottorn of scum to bottom o &�tl t tee or b _..� .,. � m®.. _. �_ _s.....
,
Date of last pumping.
Comments (on purnping r coup r� rndatlol ns, hl t and outlet tee or baffle condition, structural integrity,
liquid; levels as related to olutlet invert, evidence of leakage, etc.):.
w T'ight or Holding Tank(tank must be pumped at the of inspection) (locate on site plan):
CODepth bellow grade:
Material ccrrstructiom
El concrete El metal [.D,�lb irrgl ss Ej p l ethyl ne a tNuar� plalra):
_..
n
Dimensions:
Capacity: garparns -
Design Flow: ..
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4 Commwwealth ofWassachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal posal System Form Nrat for VoWntary Assessments
124 Stoneicleave Road
...._.... ®.... , ..._
Property Address
Ppii
Owner ow, na r`s Name
i�ur�rrrmmcao�is
required2024
for very North Andover � � � December� m
page, ity to at ip Colde Dare of Inspec:Jtian
D. System Information (cant.)
. Tight or Holding"dank(cont.)
>larrn present: El Yes Nara
Nr � ii. Alarm in r �rriirurd � ,� '" ,.
r
J
Q o
_ _
Date of i st pumping: D
,ate
Comments (condition of alarm and fi m t, mt s, etc,):
e
_.
Attach copy of current pumping contract(required). Is crap} attached? E-3 Yes No
. I i tri tm , if present rout be opened) (locate on site plan):
Depth of liquid level above outlet invert ru
r Comments(note if box is level and distribution to outlets equal, any evidence of sciiids carryover, any
���R 0d n f leakage into r out f etc.):
.):
"O rh -box is '" below grade. The d-box is in good d Larking condition and shows no signs of any
prrabirns,
P 6arrre a dor,°rev-M612018 TWe 5 WOW 1i17SpOCtiOn FO'rr!n''SubsW a'er Sewage D spvW S Yom*paps 12 of 1
Commonwealth of Massachusetts
TRW 5 Offalcmial Inspection Form
Subsurface Sewage Disposal System Fo'rm Not for o'lunt ry Assessments
124 t o 6 mr I la d
Property mdressi —
P p mll
Owner Owner's Name
inforrnation i
required fire eery
r s.,,_. .... cember 51,1,202.4
page.
lT), _ ®. _. _ _.._
State Zip Cade .Date of Inspection
�D. System Information (cont.)
10, pu mip C Ih m be r(locate Omni s ite plan).
Pumps oin working order;
�m Alarms in working order: El Yes
Comments (not condition of pump chamber, tm It Apn of pumps and appurtenances, etc.)':
M w"M
c
u�u m
a�
If pumps or alairms are not in working order, system is a conditional pass.
11. So,il Absorption System, (SAS) (locate on site plan„ excavation not r q�uir d):
If SAS not located, explainwhy:
"The SAS was ioicated by asbuilt drawings and pr v o s title ww from,2007.
...... ® ._
p ru� r Type:
m leaching pits number:
leaching chamb rs, number: .............
El leaching galleries number: _
leaching trenches number, length:
1 - g"
leaching fields numb' r, dirn nsions„ . .m...
overflow n ssp lmol number:
El inrnnv tmv / It rimm tiv system
Type/name of technology:
�&nsp doc; rev d P WUr..e"?,8 "n'"[oa 5 orrmw inspect on ForCTY suwurjace sewa'p C4gs 1 System-Page 13 of IS
Commonwealthi
u but Title 5 Offical Inspection Form
i i i
a.
Subsurface Sewage Disposal System Formw Not to Voluntary Assessments
nts
, 124 Stonelcleavec . _ ..,.. _.... �e.
Property Address
pil
Owner a Owner's Narn
uu�f�urrwl tGaan�" 2024
� ��u d for v a North Andover � � ,
_..
catyrron State dap� od Date of�ns e Sara
to mnformation cr"it.),
1 t. Soil Absorption System(SAS) (cent.)
Comments(note condition of s hl, signs of hydr ulhc failure, ievel of ponding, d rnp scfi„ condition of
q viegetablon, etc.):
"'o The a �s in good general condifion,
12, Cesspools (cesspool must be pumped as part of inspection) (locate on site plan),.
Numb r avid configuration
Depth—top of liquid to inlet invert
Depth of solids Dyer
Depth of scum layer
Dimensions nsions of cesspool
tsrnls act construction
Indication of groundwater intBo'
Comments (note condition of soil, signs of hydraulic failure, hovel ,,ppndin,g, condition of vegetation,
etc.):
pp,, d oc"rev,MM201 8 .V.me 5 Cmcw aI1lS4'pe n`a an Forric°S't,Ibs uOfacd Sewaw Msrmsal S;YY'OM'iPage 14 W"M
Commonwealth
Title 5 Official Inspection Form
..
� - Subsurface Sewage [deposal Systemi Form Not for Voiuntary Assessments
41
� 124 Stonecleave Road
Property Address
1Vl
Owner Owner's I
inforrnafion is
MA
W 01845r
Pa u for v�
Paige. oo _ ate Ipode �e of Inspection
ction
Information (cone.)
1 . Privy(locate on site plea);
Materials of construction: __.e.. _
Depth of lids
Comments (note condition of soH, signs- f dfiulic failure, level of pon un , condition of vegetation,
t&nsp dc&,•rvr 71"—W2018 TiP t 5 OfftoiW li ampGctk tl'= ¢m Sub"face sewage Disi2caw 8 Wam Page 15 of 10
Commonwealth of Massachusetts
Title 5 Official InspecUon Form
k'e
Subsurface Disposal System Form Not for Voluntary ' mrrt
., ,. 124 Stonecleavie .....
Propin y Address
Papefl
Owner i nfrarrna,tion is
Owner's r"rne
required for every North Andover MA 018451,11, De cem'Per, ®..
page. City/Town Stag
' "'Information (coat.)
14, Sketch Of Sewage Disposal System-.
PraMe a view of the sewage d#osai systern, including ties to at least two permanent ref rence
a landmarks� r benchmarks, Locate al l wells thim�m�1 0,t t. Locate where water supply esm�r�mer�s d-W hand-sketch in the area below
drawing attached separately
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t5ins 5.i�,"Nc.^rev.7➢26121rs'W8 T*5 6 Offif umi[Inspecton FWvr"M SRAb6-Macs:ewe Sew&90 fW69 ~b�1:S Stam
Commoinwealth, of Massachusefts
14
41 Title 5 Official Inspection Form
Subsurface Sewagie Disposal ste Fora Not for Voiuntary Assessments
4y
Property Address
p l l .. ....... ....., .......
-
arnrormabon tis 0t g December 5, g
required for everts Nor Andover �_ � _. . ,
page. 'styiTowin
atz � �n ��� Date�nr nrbs ec�uirnn
r� "
D. System Information (cont.)
15. Site Exami.
Check l p l"I "40./
Surface water
Check cellar r,uo » !a
Shallow wells t O (1-
5. " - m.
stiirrnst d depth to high ground water: ,nee
Please indicate all methods used to determine the high,ground water elevation:
btaunad from system design plans one record
If checked, data f design plan reviewed.
�..11/1
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked^moth focal Board o,f Health -explain:
's�rot,,_pr� ps���",a ��nit and pr �n ��title from 20017. _...
El Checked with local excavators, installers m(attach documentation)
El Accessed USES database-explain:
You must describe hoer you established the high ground water elevation:
Deep hole tryst done 1997 showed depth to ground aster at 3", a deep hale test was done in 2007
for the We v and he fund no water at The basement is " below grade with a sump pump, dry
today.
Before fining this inspection Report, please see Report Completeness Checklist on next page.
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Comimonwealth of Massachusefts
Title 51 Offalculal Inspection Form
ga ySubsurface Sewage Disposal System Forth Not for Voluntary Assessments
14 Storms Road
Property address
Papell
Owner n r"s Name
ra°�tbri is
2024
required for every North ,doer �1 December r ,
page. Uy/Town State Zip Code Date of Inspection
., Report CompletenessChecklist.
Complete ail applicable sections of this form, inclusive of:
I A, Inspector,Infdrm tiom Complete all fields in this section.
. rtil`i floe: Signed & Dated and 1, 2, 3, or 4 checked
C. kispection urnm r°y:
1„ 2, 3, or d completed as appropriate
(Failure Criteria)ancl 6(Checklist) completed
D. Systern Inform tiom
For T ght Holding Tank .Pumping contract attached
For 1 : Sketch of Sewage Disposal System drawn oin pig. 16 or attached
oir 1 : Expianafion of estimated depth to high grOUndwater included
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