HomeMy WebLinkAboutPass - Title V Inspection Report - 24 CROSSBOW LANE 8/25/2025 Commonwealth of M,ass,ach�usetts
ici,a ion
P Id T"tle 5 Off" I Inspect' Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments,
OA
...............
ri
Property Address
Owner
Owner'5 Name
information is ft 1 91 A I a In A r%A I—
require for very
Norin Andover Ma U 10/40
d e
page. CityFl own State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not blo altered in any
way. Please see completeness checklist at the end of the form. Town of Nod,Andover
Important:When A., Inspector Information
filling out forms
on the computer,
I Ion Anki+kn+-4% F. Paul Cardone U G 2T Z025
kv^y to move your Name of Inspector
cursor-do not Septic Compliance,Inc.
use the return a
1�^qr Company Name
1XVY,00, 37 1/2 Bare meadow St reet He im, Liepd,t,1 ixo
1Afit Companv Address
11 11'4 VW
Methuen Ma 01 84A
City/Town State Zip Code
"M
978-815-3115. or a`78-6.181-0726 #3294
T011r
Tplpnhnnp Mimhpr I irp.nqp Niimhpr
u, u0nification
I certify that: I am a DE,P approv tem inspector in,full compliance with Section 16.340 of Title 5
(310 CMIR 15.000)- 1 have rsonally inspected the sewage disposal system at the property address
0
listed above; the information reported below is true, accurate and complete as of the time of my
i,nspaction; and thes inspection was ►peerformed based on my training and experience in the proper functi()n
-Y Ll I I I k %�, V ja I%A$1%.OLI
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined,
that the system:
1. Passes
F fonditionallyPasse
3. El Nee.,ds Furtheor Evaluation by the Local Approving Authority
4. Fai'l.
as"
Inspector's Sign re 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
101000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DER The original form should,be sent to the system owner and copies sent tn.
the buyer, if applicable, and the approving authority.
Please note: is 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 systern will perform
a
in the future under the same or different conditions of use.
t5insp.doc-rev.712&2018 Tifte 5 Official Ire specOon Form Subsufface Sewage Disposal System-Page I of 18
("omirnonlan
V WCOMI i MassachuscOts
g F^rm T'ur' la Inaner4k..,
I 81111%p 110%RN4.40 111I.... %.13t%n a %ap a a w w
(4
------------- Sewage D 0 INJ TO V y Assessments
ubsury'ace S Disposai 'ysiem Form - Noi F r 'oluniar
24 Crossbow Lane
Property Address
Nell G Manning
Owner Owner's Name
infnrmnfinn i-z
North Andover Ma 01845 8-25-25
required for every
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.
UIY,7tc-M VPCX00U10
ax in n ot ft_*.i.u n d a ny i nform at lio n%ivh i ch i n d i cate s th at a ny of the fa,fl u re cri te ri a de s cri bed
I hLA V%-.1 1 VA I VY I I%.? 5 %.%.e V 1. CA LAI I %_Ie 1 %..0 1 1 U %-f%;, I
in 41 n r,RA P 1 r-,qn,4 nr in q 1 n ('_NAP 11; end av i izf A n%i fain i ra rrif aria nr-sf onwp I i icif n ri n ra
indicated holoW.
d be
Comments:
2) System Conditionally Passes:
F1 One or more, system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, unon com■ pletion of the replacement or repair, as approved by
the Board of�ealth. will pass.
Check Check the box for"yes", "n6; or"not determined"' (Y, NR -N--U')for the following statements. it"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):
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposa I System-Page 2 of 18
M W%q AF1%nw
%.OV Ith of IWICA
Tifla R InarN n
� _ �
aefirm Fe%rm
a a W
% ubsu ' ce*5 ria Sewage Disposal %'11'3`ysiem lForm ii,'42ot TO r'Voiuniary Assessments
\71
24 Grossbow Lane
Property Address
Nell 0 Manning
Owner Owner's Name
infnrmnfirin i4z
North Andover
required for every Ma 01845 8-25-25
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
with Board of Health approval, if
L.0 W1 LAI U I I
F not operational. Qystem will pas.
Pump Cl-lar"ber pumps/alarmL
imnQ/n1nrmQ ranpironrl
F1 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):
\,\-) are Elbroken pipon I... replaced Y N l',,41 D (E.\x,p lain 10%e.I o w 1:
%.7 - removed ❑ Y ❑ N ;plain 1
El obstruction is ND (Explain below)-
kof I luti *4 bjelow):
El distribution box is or replaced El Y 11 F=\"0 ND I
F-1 r,rA ..1x rr.I I JV OYOLUI I I I Vk4UI1 C;U VUI I Ifill IV I I JUI U U 101 1-t L11i.I IVO 0 yVC11 UUAZ; LU Q1 VMV1 I UI UkJOLI W.AUU FjIpUko). I I IV
System will pass) inspection if(with a-Pprove-41 0f the Board of HeathHeath1).
r] broken pipe(s)are replaced F] Y F1 N R ND (Explain below):
❑ obstruction is removed El Y El N F1 ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
_JL I-
LA-
_j kjul IU I uu[lb t�Alz>t WI I It.;1 I I t-,'.iU'1 t:-' 1 U1"It:[ t::Vt3l UOLIU1 I L)y LI IC UUdI U U1 [AVdi LI I II I U1 UVJ LU UVM:1 I I III m: II
the system is failingto protect public health,h, 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
C 0 M Ir n 0%n lei VeCa"Ithl (Yel
.......... Tml@ Ifin A ("I I I 1()n PnrM
ONE 1W V40%W%4 R I a VAWV 0
ubsurface SE iewage Disposai System Form N"ot for'Voluniary Assessi-nenis
J4
A oft
24 Crossbow Lane
Property Address
Nell G Manning
Owner Owner's Name
infnrm!P inn is
0...-A...——,- North Andover Ma 01845 8-25-25
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
B
F] CpSSpool or
I privy iS within 1450 feet of a Surface.water
❑ cesspool or
privy is ,V#,Vit,h,;,n 530.fiele_,t.of En. bordgE)ring Vege1.t1a,.,ted wetland or marsh
VVfC4L ;f
%V%011111 unlesS-.,.,_,s the BOCAlrdwl I VulrAl L I (l QA1 1%A a LA Mor %Wl %JUfJtJll No I E411y1
A a+eh rmi n gaa f h ri++h o *,%ta+o r" is fa v n e+i e%n i n ro ire !n m n n n a r h ct+n rt%+ch#-+a a n e i I it- h o vi I f h
0 45 boo I"%' �.v a-.- 00 N'.. 6"o mile GZ2 4%1, %,,%, a a m-oko I'm*%P* %,a 4 0 a%.,v 46 1%.0"0 V.1 9
and enxiirr%nment:%,-L 1qr 1.1 v4A 4 0%,1 %0 V a m W.a 0 a 2 9%,or
H 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 I of a public water
supply.
n The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
L] 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:
Thict c%mfsam nncczav- if tha%A/all xqnfar nnnlxmic narfr-irmarl at !:i nPP rsnrtifionrl h:ihnrafnrx/ fnr for-ni
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:
K
Yes i n
El M Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5!nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
41k, to%AF%00&%tft%6ft A M 0%4ft 111% r%f V Ma SS CA ko I tts-
"1 0
C11 5 Tif a A K'A ff"I e'I n I I n a natw&
17 fi 0 K M*AR ro%P%0 a%W 1%0
I a%, %P %7 %Will 11 M%RU%A11 nn 1 2 NOW
Pnrm
" i
left 10-W ON., 0 System
V Assessments
bubsurface Sewage Disposall System Form - i ot for Roluntary
k% '4 'rossbow Lane
Property Address
Neil G Manni_ng
Owner Owner's Name
Information ation is North Andover Ma 01845 8-25-25
reaLlired for every
page. City/Town State Zip Code Date of Inspection
C. Inspection u (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
es X/ � N�
o I
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El M 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
I-- V;P
obstructed pipe(s). Number of times pumped:
❑ Any portion of the 'E6')AS, cesspool or privy is below high ground water ele_.%V1,,LnAtion.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
El M Any portion of a cesspool or privy is within 50 feet of a private water OQ I supply W 11.
Any
❑
A - -f
Any porltion of a cesspool or-privy is 'less than 100 feet but greateir th an Z.)E70 feet
t:it
ir r Wo%ll WA, I ";r, rr 9.
from a privatG►w-c"iAteir s"PFIY %z,-11 1th no a%cceptcelbl9e►wCalter quC@1lityc;U1cA1Y010. L11114-2
.-.%S.-ft 4—&-w% 0.f t t%OL I A A.0%11 21 A V 4W&4 ffl%�"analysis,
4-A I S AV AM:Aft w%o%I mo%fru ap2pm%Aw&A at ift DEP cem-tinfic-d
;0 Y QP LU I I I passes I I I W VV V I I VV C1 U;1 0 11 ca I Y ZF I Z.10) VVI I U I I I IVU L C1 1UI U I IV
11M III ft&%c.0%r4 .%" -^n^^
%..MMbr, 1J%;t%rL1Uo11U 1111MM-C4L U D4%__P 44 1 IL ULN I L jil %,Iw OU14"I UL i yj for fecall col, d"he w%v^r
0%,V*%,W-L,%&.0%A-.Lft*0 4ft Lft;J. e s s 4-h a n 55 1�V%&,%ft
%J1 CU1111111%J11101 111Lrogeri, ainidd nitrCaltE;* Inieltif-OU—CeIn h0ft ecmuCall to ol 1 0 L Q iJ PpIllp
AAA l6dk# *Z011UP
#;Anrl 4, --% o other fl-3.1flume criteift mv^ A ^o %9
p%r0%V1%A%r." LIN"Ut n %03 1 1L r PY of t"Am
and chain of custody must be attached to this form.1
❑ The system is a cesspool serving a facility with a design flow of 2000 gpd-
101 000 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 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.
Y e S- No
❑ egg within fen' of a surface drinking supply
system 1L IL 0 %a CA %.0 Q❑
-yL the Loy Q N, 1%2 inking water c
the%.-p system -within 000 feet of a tributary to a surface drinking he is 1 14- NJ \..* CA Q r.A %A[, king 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
t151nsp.doc-rev.7/2612018 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page's of 18
r,
4N, tommom -Ap%k%J VV CAI LI I %JI RVICA;�%-30k#1 I US TIES;
orlim A C)ffiPini Inanar n
%F a R 1%FN%0%G tin
T I*10V Fnrm
0 19%0%0 1 %0%M0 8,%w 0 1 1%011 own
S
00% &- P
Z ubsurface
i Sewage Disposai *System Form -Not for Voluntary Assessments
2- Crossbow Lane
4
Property Address
Nell G Manning
Owner Owner's Name
information is
North Andover Ma 01845 8-25-25
reauired for every
page. City/Town State Zip Code Date of Inspection
C. Inspection u (cont.)
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 C.4 above the large system has failed. The
at
or or opel-aLor of
any lairg"e.. sy.1--itt-74m considered a significant'threat undt-Vir SectiOn VC.5 U-1-failed
lUndeQee%Cov-% n.A -ill i ipgrade ;kr% ^%re%teM ':)10 0 K A 0 1 r,.'.-)0 A, The eY^4,^r" oweNcr
ir Q tatl I I %..*1-t Shall U I cauu ki IV 0yo in 'Exc-cve-kirdainice-,VRV,;ItLh %..� \-d0I%fIIX %J%j "T a %:�o 0tvill It I
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
%I?_
U TS No
❑ Pumping informm ation wac:,- provided I ilde-fd by the owner, occupant, or Board of Health
❑ two"Afnn
\.-I WI I M. system components r%l emped out in the previous vveeks?
Wern any of tl,%es %-f Ful I I \,, L 0 L
,nc- f system received normal flows, in the previous two week period?M El Has the-, E-2 y 7 L received\-.0 W1 " \,1 %-1- 2 %-If
F1 M 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 asN/A)
❑ Was the facility or dwelling inspected for Signe.of Sewage back up?
❑� MC-4c-+in
V V 0 the Site inspected for Signs of break out?
M ❑ Were ail system component., excluding the SAS,
located on site?
M El `v1v1er0 th%^::; e3eptic tG,1nl`-\- manholes uncovered, opened, cal Id the inteirioir of the tank
in-s!pear,ted for the 0r 1 1"%+i nI o tIh n k a ff 1 e S o.r teed M ntn Ir i",ll
of construlction,
depth of liquid, depth of sludge and depth of scum?
dimensions, %-4 r L %.I- �1.1" I depth 5 sludge and 6 %-F
N El Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ Existing information. For example, a plan at the. Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage[Disposal System-Page 6 of 18
Summary Record Card generated on 8/21/2026 9:56:24 AM by Tara Hurley Page 1
Town of North Andover
Tax Map # 210-106.B-0196-0000,0
Parcel Id 17591
24 CROSSBOW LANE
MANNING, NEIL C. Since Jan 2088
MANNING, JAN ET MARI E
24 CROSSBOW LANE
NORTH ANDOVER MA 01845
Class 101 Single Family �ropetty Type 1 Residential
Size Total 1.001 Acres
FY 2026
UB Mailin Index
Name/Address 'ape Loan Number Activellnact. From Until
JANET&NEIL MANNING Owner Active
24 CROSSBOW LANE
NORTH ANDOVER,MA 01845
FRIDLAND,ANATOLY Previous Customer Inactive 4127/2007
35 WINCHESTER STREET
BROOKLINE,MA
02446
UB Account Faint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 17566.0-24 CROSSBOW LANE Last Billing Date 7/2/2025
3170236 03 Cycle 03 Active
UB Services Main .
Account No.3170236
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.63 518 7.82 11
WTR WATER 01 ALL METER SIZE 49.40 11
UB Meter Maintenance
Account No.3170236
Serial No Status Location Brand Type Size YTD Cons
33563410 a Active ERT RT h Badger w Water 0.625 0,625 500
Date Reading Code Consumption Posted Date Variance
6/1012025 2598 a Actual 13 7/9/2025 1%
3/11/2025 2585 a Actual 13 4/16/2025 -21%
121912024 2572 a Actual 16 1/14/2026 -G7%
9/10/2024 2556 a Actual 49 10/812024 122%
6/11/2024 2507 a Actual 23 7/22/2024 69%
3/612024 2484 a Actual 13 4/1612024 -7%
12/812023 2471 a Actual 13 1115/2024 -38%
9/1412023 2458 a Actual 24 10/13/2023 34%
618i2023 2434 a Actual 17 7/14/2023 3%
3i712023 2417 a Actual 16 4/12/2023 -12%
12/7/2022 2401 a Actual 18 1/1612023 -79%
9/9/2022 2383 a Actual 89 10/18/2022 218%
618/2022 2294 a Actual 28 7/18/2022 28%
31712022 2266 a Actual 21 4/13/2022 -2%
12/812021 2245 a Actual 22 1/1712022 -48%
91812021 2223 a Actual 43 10/15/2021 55%
6/7/2021 2180 a Actual 28 7/27/2021 30%
31512021 2152 a Actual 20 4/21/2021 -38%
121812420 2132 a Actual 34 1/13/2021 -65%
9f8/2020 2098 a Actual 100 10/14/2020 182%
6/5/2020 1998 a Actual 34 7/15/2020 101%
3/612020 1964 a Actual 16 4/8/2020 -17%
12111/2019 1948 a Actual 20 1115/2020 -57%
9/13/2019 1928 a Actual 50 10/10/2019 160%
6/1012019 1878 a Actual 19 7/25/2019 5%
3/8/2019 1859 a Actual 17 4116/2019 13%
Summary Record Card generated on 8121/2025 9:56:24 AM by Tara Hurley Page 2
Town of North Andover
Tax Map # 210-106-B-0196-0000,0
Parcel Id 17691
24 CROSSBOW LANE
FANNING, NEIL C. Since Jan 2848
MANNING, JANET MARIE
24 CROSSBOW LANE
NORTH ANDOVER IAA 01 845
Class 101 Single Family Property Type 1 Residential
Size Total 1.001 Acres
FY 2026
12/10/2018 1842 a Actual 15 1/22/2019 -48%
9/1312018 1827 a Actual 32 10/15/2018 33%
6/8/2018 1795 a Actual 23 7/23/2018 39%
31712018 1772 a Actual 16 4/23/2018 -3%
121712017 1756 a Actual 16 1125/2018 -62%
9/1112017 1740 a Actual 46 10/18/2017 162%
61812017 1694 a Actual 17 7/25/2017 3%
3/8/2017 1677 a Actual 16 4112/2017 -32%
121912016 1661 a Actual 24 1123/2017 -77%
9/9/2016 1637 a Actual 109 10124/2016 188%
618/2016 1528 a Actual 37 812i2016 118%
3/912016 1491 a Actual 17 4/2212016 -30%
12/9/2015 1474 a Actual 24 1/20/2016 .48%
9110/2015 1450 a Actual 48 10/16/2015 158%
619/2015 1402 a Actual 18 7/24/2015 20%
3/11/2015 1384 a Actual 15 4/28/2015 -28%
12/11/2014 1369 a Actual 21 1/16/2015 -32%
9/11/2014 1348 a Actual 31 10/15/2014 -12%
6/11/2014 1317 a Actual 35 7/16/2014 97%
3112/2014 1282 a Actual 18 4/11/2014 -7%
12/10/2013 1264 a Actual 19 1/17/2014 -53%
9/11/2013 1245 a Actual 41 10/15/2013 46%
6/12/2013 1204 a Actual 28 7/24/2013 35%
3/1312013 1176 a Actual 21 4/22/2013 -8%
12/11/2012 1155 a Actual 22 1/912013 -55%
9/13/2012 1133 a Actual 52 10/16/2012 1 fl1%
6/11/2012 1081 a Actual 25 7/16/2012 44%
3/12/2012 1056 a Actual 17 4/14/2012 -24%
12/1412011 1039 a Actual 23 1/17/2012 -66%
%.AV1IIIIIVI1WVW01th 0%IF M Cal%a-,.I to, it%I ou,1 Is-ve 4E 4E S,
ziubsurface .ems 'Disposai System Form Nlot for'Voluntary Assessment,, � s
z i�c 24 Crossbow Lane
Property Address
Nell C; Manning
Owner Owner's Name
regUirnformation it.,-
ed for every North Andover Ma 01845 8-25-25
page. City/Town State Zip Code Date of Inspection
D, System Information
1. Residential Flow Conditions:
,,-%W.of 11-1-0 (design): 4 4
Numbe, 1 bear Numtjer of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 for example: 110 gpd x.#of bedrooms)- 600
[1),e-0,cri pti o n:
!umber of current residents.: 2
^nO r eap
, ...idence have a gat bagE.) gr;nder? ❑ Yes No
Does residence have W afn r tr%e Fe.AL mant uni#O ❑ Ye c Klo
f yX..0n
I Q) "I
o el;o -nrgnc- to t,h
Is laundry on a separate sewage system?(include laundry system inspection ❑ Yleas I'm K10
information in this report.)
laundry L- s-ystern inspected? ❑ Yes No
no es
seasonal used El Y IN No
Enclosed
,water mc-Atcenr re—ca-idiii-igs, if available k/flast*2 years usagefk�pd)):
Detail:
,,�Ump Fnump? ElVas M No
%-;
La-st date of occupaancy: Currently
Occupied
t5insp,doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
I Y. `dam V W e s `•v.+K • V`la. ■ w.■ r w• s`a•+� •` �•w
_Q%iatam Peomnin" Ree-nrd
m
Fora
DIP has provided this farm for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or u;!per approving authority within A days from the pumping datg%,:�l it!
accordance with 310 Cal R 15.351.
A. Facility Information
Impo,r4kant:When
filling Out forms I. System Location:
on the computer,
use only the tab 4 Crossbow Lane
key to move your Address
cursor M do not North Andover MA o1845-3036
usethe return .._..._..�-...I—"' ". .. __.--�_. .._�_.... ___.._.._. _... ___..� _. - _ .. - �.
►1'T'n::►r, eta#� ?in r..nrip
key. - .i-
2. System Owner:
Neil banning
A�ir�r���!if�iff�r�nt frr�m Ir���t:nnl
City wn State Zip Cade
617-872-2471
Telephone Number
B. Pumping
3/13/2024 1500
1. Date of Pumping 6�t ---.-________._ _____._w w 2. Quantity Pumped:, Gallons-__.___.___.
3. Type of system: El Cesspool(s) E Septic Tank Ej Tight Tank Ej Grease Trap
Ej Other(describe):
4. Efidluent T ee Fii ter present? %Yes No if yes,was it cleaned? Yes No
5. Condition of System:
Good, system operating properly
Q. Systei Purrped 0y:
Jason Elliott _87 1 437 or V85257
Name Vehicle License NumberW�.�
lvester and Elliott Services L.L.C-DBA Jason
Elliott Pumping
7. Loo.nbon where contents wero disposed:
GLSD
3113/2024
eSiZu*re of Hauler Date
S;gnature of l t 9 f acilIty D0-to
t5form4.docs 03106 System Pumping Record•Page I of 4
AM
I I IV I I VVWCA ILI I I W I la-S SO CA C I I U S E;E US
'Itla A nIffle'l&1al InSparflon PnrM
I W%0 %F NkWINIVA00 G BIG %1W*d0%;M son %08
bubsurface Sewage Disposal System Form - Not for Voluntary assessments
4 Crossbow Lane
Property Address
Nell G Manning
Owner Owner's Name
requiredf;?is
�or every North Andover Ma 01845 8-25-25
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
I ype of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
of designfl OW(seats/personstscift, et .):
Basle T V %W
Trap present? ❑ Yes ❑ No
V'J,,-14 t e r IL r e a t m e-t Ing t u ni tIL p r e S en n t? ❑ Yes N
N/A
If yes, distc gar go-S to.,
KI o
Indi iotrial waste holding tanl/ present? Yes ❑ I V
%A%3 1 ► V L I lix present'?
Non-Q"e-iniary waste discha rge.d, to hn T1 i5 Qy stem? Q ❑ N%j
ear
Wa+,..-., meter readings,I A 11 if r-4V
L....L date of occupancy/use:
Date
Other(describe below):
N/A
3. Pumping Records:
vwnei
Source of information:
Was system pumped as part of the inspection? ❑ Yes I No
If yes, volume humped: gallons
HOW iqnq rp lantity pumperl determined?TV ►wv
time umped 3-�3� 4
Reason for pumping: Last
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
common iwat IRA C--Ab e'.3-0 0a,-C C 1*U%'Jp LLO
R nffiriza 1nanartir%n Po%rM
%&W T aft In AVWV leor W
V
AM.
b ubsurface Sewage D m 1N /-Disposal System Formal for ^\ssessments
le
'4 Crossbow 'Lane
-j-e' 2
Property Address
Nell G Manning
Owner Owner's Name
i,nfnrMntio n iS
W4 %A I a I North Andover Ma 01845 8-25-25
required for every
page. City/Town State Zip Code Date of Inspection
M System Information (cont.)
4. Tyrner o.f.
Q c-tr soil aboorplion 0%l0tnm
erptic di. I ibution 1'."loxr, Qu %I I 1,11W 7yQ
El Single cesspool
El Overflow ce-.sspoo!
PrivyI V
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
El Innovu-,tive/A 11 IL lernaaltive technology. Attach a copy of the current operCaltion and
maintenance contract Ito be obtained fro; sys aM n%VVinnr1 and a copy of hated
inspection of the I/A System by system operator under contract
'T system 01 L%..r %+106
Attach a copy of the DEP apnrr%V--,3j.
El Tight tank. Attach V-A Y
❑
Other Westcribe):
age of all components, date installer' (if lenown\ and source of information:
ApproXim.at,.n.) age %J %a %.-1 1 Its,
Tank 1986.....D-Box replaced 2008
-nrr;ving at the, site? ❑ k10
Wereo. se..wagt(�.!odors.de,.te.\cted when .-, I I I I CA %-f Qt. 1 4
,5, Qm1rJj.qg Snvnitw ljorqfn an site plan\:
1611
LaUpth below gnade: feet
Material.of construction:
F-VI V\jcast iron ® d!l 1P\/r.
- F] other(explain):
Distance from private water supply well or suction line:
feet
,Mf C.
evidence of leakage,
C',,omme.,nts (o n condition of Joints, vnntingl, f.
All in good condition....no evidence of any leakage.....
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
W IUCIlLh
c,,� T-Iflin%8® -5 nff o irt won npe%14 *av wwaa ..... ..,n
10 Subsurf�ace Sewage 'Disposai System Florm - Niotfor"voluntary 'Assessments
G\S
24Crossbow Lane
Property Address
Nell G Manning
Owner Owner's Name
informatieNn is
rI�t 9 F 4"k k.F1 a
e I quired for every North Andover Ma 01845 8-25-25
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
511
Dept h below grade:
feet
Material of construction:
concrete mptni
El fiberg11K:.3,Q.s polyethylene ,other texplain)
If tank is metal, list age:
Veal
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) N Yes Ej No
c
Dimensions- 1 U XID XA+
AI!
Sludge depth:
4
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 211
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? Tape and Dip-Stick
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 be pumped on a yearly basis..Structural integrity appeared to be good..All liquid
levels.were.good..No evidence of any leakage.
t5insp.doc-rev.7/26/2018 Title 5 Offic ia I inspection Form:Subsurface S eveage Disposal System-Page 10 of 18
<X .owl I I vwmal 11th Of ",
LO
rIffeei=1 inaneetio Pormm
� �,�`� 10 Subsurt"ace S"xewage 'Disposall yst em Form Not fOr%Voluniary Assessment's
24urossbow Lane
Property Address
Neil C Manning
Owner Owner's Name .
hnformation is North Andover Ma 01845 8-25-25
reauired for every
page. City/Town State Zip Code Date of Inspection
D, System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction-
[I concrente El metal El fiberglass r-1 polyethylene ❑ other(explain,:
j %
N/A
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: 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.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
0 concrete Q metal ❑fiberglass Polyethylene, ❑ other(explain):
N/A
Dimensions:
capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
04: I%fi^^ t% 11r,^44A,
S'C I I U-2 V L
%.0%JmmonVVK;CX1L11 I 1V1Q%11XzDCA
R n ff Ago
I a I AMIN 1 411 11 Inanaetion P^rM
T"thm
11 0 0%MV W vow ago %00
.0% 8 A-ft
ziul3surtace bewage Uls N posal System Form Noi nor VO luntary 'Assessments
A
24urossbow Lane
Property Address
Neil G Manning
Owner Owner's Name
requirediom is for every North Andover Ma 01845 8-25-25
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
B. Tloht n-.r 1.40olldinn Tnntf (cont.)
Alarm present: ❑ Yes No
Alarm rm in wor r:level: Alaking order:f-1 1 V-4 %.1 0 Yes-, No
Date of last pumping.
Date
7 1 1 11.1 EA I CA I LAI 1 VA Q I j e
C'Pornments [Condition of nlnrM
and float sw;tches,
N/A
Attach copy of current pumping contract (required). Is copy attached? D Yes F] No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert C)u u d a n d rE-V-tz,1-1
t.,,omments (note IT DOX 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 the box distribution was equal,all for lines had
speed levelers, no apparent leakage in or out of the box, box is 2' deep.
t5insp.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
to",P%a.W%*90%0%&%,%Aso%-%14-6 0% M-%st, M^
I11I1IUIIVVWCAILII V f I ICA
-----------------------
Tifla -ft I'liffirini lr%anerfinn F:nrm
Mor %0
io Subsurface Sewage Disposai System [Form Not for'Voluntary Assessments
ti
24 Crossbow Lane
Property Address
Neil G Manning
Owner Owner's Name
iffifformation i.e. North Andover Ma 01845 8-25-25
reauired for every
page. City/Town State Zip Code Date of Inspection
D, System Information (cont.)
10. Pul.m,,,n Cha M,,h,.er(locate. on site plan):
Pumps in Working order: Yes No*
W1 %.10
Alarms in Workinf",order: El Yes El rxln*
corer Hants note condition of pump cha mba r,
condition of pumps and appurtenances,
etr%.):
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:
F1 leachina pits number:
11 leaching chambers number-
0 leaching galleries number-
1:1 leaching trenches number, length;
ns 2x45
z Ieaching fields. numbi!ar, rftnncio I %A I I W -a. 1 field- 0'
rVnrfl1oTA cesspool number:
tnrnaf ivn n loll a t i v e/a[l
Type./n.a.me-. of technology:
U.-Rinsn-rinn-rev.7/2R/2018 Title 5 Official!nsnprfion Form:Subsurface Sewage nisno-zal system•PartA of 18
-----------------
"41 1 1>
STAP& RtaIA % nffielml
Inanaefie%n aP orBmul
ubsurface sewage Disposal System
Form lNot for Voluntary Assessments
24 crossbow Lane
Property Address
Nell C Manning
Owner Owner's Name
informati.nn is North Andover Ma 01845 8-25-25
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Good No None No Grassy
front and 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 gro,indwater inflow Yes No
as �� v � W V q %.1 %.,- 9
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc,):
N/A
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Town ofNorthAndover > >
>w.tc. ... ... .M..._.. .G... .-.. ...i.. �'"rr' ..,.".+?� ..�' .. .•-.^.:rain
�w
.>' .. s ._."^..... ..x-n..........;..-....� ........,�<...-.. .w.a. a... .... .... e:o-'T:'r.�. .M :-:a✓'?:•.:✓..
_. .... .... ._ .,...o-*rbv.. .�.�,.._^ .:.. �'+:� s..• r.•-.,.,v�^ :, .,fir
.. ..... rn^u�.. .... ......i- .� ,i.. e...... 5 .. -,. >> .�. _. .✓^� rx..,.... --. Via, w`W�•. ..'�„l',:�.".�>:'r:w^:,^ -^":��
-
r,
t dth
PART C
SYSTEM INFORMATION
srK:;
rProperty Add 24 Crossbow Lane� +_
North Andover
-;3 ' F�d�A�d
4"F Oter: ..
Date of Inspection.'I I26l2 i
SKETCH OF SEWAGE DISPOSAL SYSTEM
yy X
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
i.3
benchmarks,Locate all wells within 100 feet.Locate vallere public'water supply enters the building F a
)4 3
H
A'
.House F,
kl Driveway
rY c`A
is
f A
uT Water
:s A to 1 3414"
Meter 3 3
A to 2=36
-: A tv 3 3813"
Ir 5 r 1
`Z
A to D-Box=55,8" r:
S"s4 B to 1=19"r f
Septic B to 2 2214"
2 B to 3 25'4" 3_s
Tank B to D-Box=46'
-a
�3
i-
{ids
D-Box
is
r'J ?.
r.a
z EA
r„
i
i�
s Sz
7 �A�
r•:r.�
is
El.
j
�r5
F.-:-
feltt PF,I/record nort1)candovcsI'ma.qovly'h,'�1)Uiik/Dor_Vie w.a 9 px?i d=.240S)8&db� jd.=08s•-e o Tow WU0orthA n dove 912-11215 '11: 5 AM
lagw I ofl
C91LI1 V3 MCA%-51;DC4V#11U0 LUa
----------
T"t1a R nffirumJ21 1napecv4.,1e0,.n I
I I %W %W nor a %0 1 GO&8 R R 1A%kov
10 Subsurface Sewage Disposai Z`iystem Form - Not for Voluntary Assessments
4 -0 24 Crossbow Lane
Property Address
Nell G Manning
Owner Owner's Name
i4n4forma"trion iv required for every North Andover Ma 845 8-25-25
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construCtiu-11:
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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
L&WIlryl(onwealth of fWassactiusettj
it;"IN tS
anaCt.ion Porm
oil
J-0 Subsurface Sewage Disposai System Form Not for Voluniary Assessments
ti
24 Crossbow Lane
Property Address
Neil G Manning
Owner Owner's Name
information is North Andover Ma 01845 8-25-25
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet, Locate where public water supply enters
the building. Check one of the boxes below:
h annd=sketch in the area below
drawing attached separately
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
M I i I V mtrjeCalt-h 0-A Massac"use"s
T rim t 1 a (I
ffiel%ini 1nanC%Cfie%n F:Orrr
141W Is 0 N%#, a%0a 8 0 M a%W9 *kop 16 11%Mir a a IN
1>
ubsu f ce sal 151ystem Form Not T"Or Voluntary
b rr Sewage a Disposal Assessments
4 Crossbow Lane
Property Address
Nell 0 Manning
Owner Owner's Name
hnformation is- North Andover Ma 01845
required for every 8-25-25
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site EFE Vvv I aq r P.:
rNIM
0 check Slo...,
Surface.water
('Oil-tieclK.cellar
Shallow wells
4+Feet
L-OLimated d e P-th to high groul-ld wcatel-: feet
Please indicate all methods uS,,!-Nd to determine the high w ground ater
A I elevation:
- on record
design system
des plans Q
obtained from
If c1 V-ckV^d, dcate of dt-;sigl-*,l plic-11-1 revilzewce;d: 5-31-1983
Date
F
within 150 feet of SAS}
Observed site (abutting property/observation hole
❑ Checked with local r.loard of Heafflk, =explain:
❑ C installens. (attach documentation}
Checked ked with local excavators,o r s,
❑
Accessed USES database-explain-
You mlst describe you established then high ground Vater elevation.
. i , V fl\
Design Plan-All liquid levels were good..No Sump Pump..Basement Dry-Dug around leaching area
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
6'r
CornrylonweAth of massactiusetts
T"f e I C 41B d insnactir%n Form
>
F Subsurface Sewage Disposai System Form W Not for Voluntary Assessments
24 Crossbow Lane
Property Address
Neil G Manning
Owner Owner's Name
information is required for every North Andover Ma 01845 8-25-25
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inchusive of:
A. Inspector Information: Complete all fields in this section.
B. Certification: Signed& Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
11 23 $, or 5completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketr-,,h of Sewage Disposal System drawn on pg. 1 C- or attarc hed
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc,-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18