HomeMy WebLinkAboutConditional Pass - Title V Inspection Report - 120 GRAY STREET 9/23/2025 uommonwealth of Massachusetts
Town of'
FloI Andover
T"tle 5 Offi"ciai' 'inspection Form
Nodh
Subsurface Sewage Disposal System Form Not for voluntary Assessments
aW . 120 GRAY STREET SEP 9 2o25
Property Address,
MONICA DEMERS
owner Owner's Name Lj partm,11t
information is NORTH F �F"I� AN Co1,lE I MA1 4
required for every SE TEMBER 19, 202
page. City/Town State Zip Code Date of Inspection
Inspection results must he submitted can this form. Inspection forms may not he altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. In r" Information
filling out forms
on the computer, Todd games Bateson
use only the tad __
Ivey to move your Name of Inspector
cursor-do not Bateson Enterprises Inc.
use the return -�- - _. . __.�. �._. �.. .
key. Company Name
1111 Argilla Road
tab
Company Address
Andover IAA 018110
CityfTown State Zip Code
Telephone Number License Number
13, Certification
I certify that, I am a DEP approved system inspector ins full compliance with Section 1 . of Title
(310 CMR 15. ; I 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. El Lasses
2. E Conditionally Fusses
3. E] Needs Further Evaluation by the Local Approving Authority
4. El Fails
SEPTEM ER 23, 2025
In ctor's Signatup� Cate
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or E within 30 days of completing this inspection. If the system has a design flow of
I 01000 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 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.
t in p.dee.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 1 of 18
Commonwealth of Massachusetts
T"tie 5 Officioal Inspection For
Subsurface Sewage Disposal System Form .. Not for Voluntary Assessments
M1
9 Y
120 GRAY STREET
Property Address
MONICA DEMERS
Owner Owner's Name
information is NORTH ANDOVER MA 01 845 SEPTEMBER 19 2025
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.
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);
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form;Subsurface Sewage❑isposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 O Form
P.
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
q �r
120 GRAY STREET
Property Address
MONICA DEMERS
Owner owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 19, 2025
required for every
page City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑� 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):
E:1 broken pipe(s) are replaced ❑ Y [:1 N ❑ ND (Explain below):
El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced E Y [] N ❑ ND (Explain below):
D-BOX IS ROTTED, NEEDS REPLACED
3
❑ The system required pumping more than 4 times a year due to broken or obstructed pipes), The
system will pass inspection if(with approval of the Board of Health):
brokenpipe(s) are replaced
❑] Y ❑ N 0 ND (Explain below):
El P
❑ obstruction is removed ❑ Y ❑ N El 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
1 a.3o3(l)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc►rev.71261 0 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System►Page 3 of 18
Commonwealth of Massachusetts
Y rrTitle 5 Official Forrr�
' Subsurface Sewage Disposal System Form Not for Voluntary Assessments
w
,- 120 GRAY STREET
Property Address
MONICA DEM ERS
Owner owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 19, 2025
required for every
page, City/Town State Zip Code Date of inspection
C. Inspection Summary (cont.)
❑ 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 anv)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
El 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.
El The system has a septic tank and SAS and the SAS is within a,done 1 of a public water
supply.
F� 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:
F Yes No
Backup of sewage into facility or system component due to overloaded or
El ® clogged SAS or cesspool
gg p
Discharge or ponding of effluent to the surface of the ground or surface waters
El E due to an overloaded or clogged SAS or cesspool
gg p
t5insp.doc•rev.712E12018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
i
Commonwealth of Massachusetts
Title 5 Official Forrr�
r
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M1
120 GRAY STREET
Property Address
MONICA DEMERS
Owner Owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 19, 2025
required for every
page. City/Town State Zip Code Date of inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems; (cont.)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded
El ® or clogged SAS or cesspool
gq P
Liquid depth in cesspool is less than 0" below invert or available volume is less
El N than '/2Y
da flow
Required pumping more than 4 times in the last year NOT due to clogged or
® obstructed i e s . Number of times pumped:
ed:
pp � � p p
❑ 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
❑ tributaryto a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public water supply
El ® well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El N 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 ppnn,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000 gpd
3 101000 gpd.
The system fails. I have determined that one or more of the above failure
❑ ® described in 310 CM R 15.303 therefore the s
criteria exist as d stem fails. The y
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 C.4.
Yes No
El El the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
El ❑
Area— IWPA) or a mapped Zone 11 of a public water supply well
S
t5insp.doc-rev.7/26/2018 Title 5 official inspection Form.Subsurface Sewage Disposal System-Page 5 of 18
„,
V. Commonwealth of Massachusetts
x eOffic�aI Inspection Forrn
Subsurface Sewage disposal System Form .. Not for Voluntary Assessments
120 GRAY STREET
Property Address
MONICA DEMERS
Owner owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 19, 2025
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cant.)
If you have answered "yes” to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section C.4 above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
0. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ 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?
® ❑ 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?
E ❑ 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?
E ❑ 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) 31 0 CMR 1 5.30 5
lap p � � � )]
t5insp.doc•rev.7/26/2018 Title 5 Official inspection Farm:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
�YTitle 5 Off For�'"�1
i> Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
z
°q 120 GRAY STREET
Property Address
MONICA DEMERS
Owner owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 19, 2025
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
� }
DESIGN flow based on 310 CMR 15.203 ( p for example: 110 op x#of bedrooms):: 550 OPD
Description:
Number of current residents:
0
Does residence have a garbage grinder? ❑ Yes Z No
Does residence have a water treatment unit? El Yes Z No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes Z No
information in this report.)
Laundry system inspected? Z Yes ❑ No
Seasonal use? El Yes Z No
Water meter readings, if available last 2 ears usage d : SEE ATTACHED
g � Y g �gp }�
Detail:
Sump pump? EJ Yes Z No
Last date of occupancy: SEPTMEBER1212025
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
E
f
Commonwealth of Massachusetts
uTitle 5 Official Forrr�
Subsurface Sewage Disposal System Form ,. Not for Voluntary Assessments
� 120 GRAY STREET
Property Address
MONICA DEMERS
Owner Owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 19, 2025
required for every
page. City/Town State Zip code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seatslpersonslsq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? El Yes [_1 No
If yes, discharges to:
Industrial waste holding tank present? El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: BATESON ENTERPRISES INC MARCH 2O24
Was system pumped as part of the inspection? El Yes E No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
r .
Commonwealth of Massachusetts
uTitle 5 Off Form
w
15 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 f �� 120 GRAY STREET
Property Address
MONICA DEMERS
Owner Owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 19, 2025
required for eery
page. City/Town State dip Cade Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
1:1 Single cesspool
1:1 Overflow cesspool
El 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 ilA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
El Other(describe):
Approximate age of all components, date installed (if known) and source of information:
30 YEARS, DESIGN PLAN 1995
Were sewage odors detected when arriving at the site? El Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 4'feet
Material of construction:
❑ cast iron N 40 PVC El other(explain):
Distance from private water supply well or suction line: feet
Comments lion condition of joints, venting, evidence of leakage, etc.):
JOINTS ARE NOT VISIBLE, IN WALL
VENTING OK- NO ODORS DETECTED
NO EVIDENCE OF LEAKAGE
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
rw
FA =rTitle Form
Its
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 {
Ik,
� : yb 120 GRAY STREET
Property Address
MONICA DEMERS
Owner owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 19, 2025
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
5. Septic Tank(locate on site plan):
Depth below grade: 3'feet
Material of construction:
concrete El metal El fiberglass E:1 polyethylene E:1 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'X 5' X 4'
rr
Sludge depth: 0
Distance from top of sludge to bottom of outlet tee or baffle
2811
Scum thickness 0
Distance from top scum of to to of outlet tee or baffle NA
P
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? SLUDGE JUDGE AND TAPE
MEASURE
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
RECOMMEND PUMPING OLDER SYSTEMS YEARLY
PLASTIC INLET AND OUTLET TEES OK
TANK IS OK
LIQUID LEVELS ARE GOOD
NO EVIDENCE OF LEAKAGE
t5insp.doc-rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
i.
�uTitle 5 Official Fors
Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments
t �
9 �
120 GRAY STREET
Property Address
MONICA DEMERS
Owner owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 19 2025
required for every f
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:
El concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or bade
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:
El concrete El metal El fiberglass El polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Officoial ForP.
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
120 GRAY STREET
Property Address
MONICA DEMERS
Owner Owner's Name
information is NORTH ANDOVER MA 01 845 SEPTEMBER 19 2025
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(coat.)
Alarm present: El Yes ❑ No
Alarm level: Alarm in working order: El Yes [I No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? D Yes El No
9. Distribution Box (if present must be opened) (locate on site plan):
q
Depth of liquid level above outlet invert 0
p
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.):
D-BOX IS NOT LEVEL
DISTRIBUTION IS NOT EQUAL
D-BOX IS ROTTED AND NEEDS REPLACED
LIGHT EVIDENCE OF SOLIDS CARRYOVER
EVIDENCE OF LEAKAGE
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
' 5 OffiCIa I Inspection r1r1
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
9
120 GRAY STREET
Property Address
MONICA DEMERS
Owner Owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 19 2025
required for every
page, CitylTawn State Zip Code Date of Inspection
D. System Information (cont.)
10. bump Chamber(locate on site plan):
Pumps in working order: ❑ Yes El No*
Alarms in working order: ❑ Yes El No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc,):
* 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:
El leaching galleries number:
® leaching trenches number, length:
2; 55' LONG
El leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
#5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
r Commonwealth of Massachusetts
luTitle 5 Off For
�M1
' Subsurface Sewage Disposal System Form Not for Voluntary Assessments
f L 120 GRAY STREET
Property Address
MONICA DEMERS
Owner owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 19 2025
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SOIL AND VEGETATION OK
NO EVIDENCE OF HYDRAULIC FAILURE OR PONDING
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.):
t5insp.doc-rev.7/26/2016 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of [Massachusetts
.
xTitle r
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
g p Y rY
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Y.
7 �
120 GRAY STREET
Property Address
MONICA DEMERS
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 19, 2025
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
ici"al Inspecti"on For
T"Itle 5 Off"
Q Subsurface Sewage Disposal System Form Not for Voluntary Assessments
120 GRAY STREET
Property Address
MONICA DEMERS
Owner owner's Name
information is NORTH ANDOVER MA
required for every 01845 SEPTEMBER 19, 2025
page, City/Town State Zip Code Date of inspection
D. Systems Information (coat.)
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:
hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc rev,7126/2018 Title 5 Official Inspection Form:Subsurface Sewage disposal System•Page 16 of 18
Commonwealth of Massachusetts
�xTitle 5 Off Form
Subsurface Sewage Disposal System Form - Not for Voluntary} � y Assessments
120 GRAY STREET
Property Address
MONICA DEMERS
Owner owner's Name
information is required for every NORTH ANDOVER MA 01845 SEPTEMBER 1 9, 2925
page, City/Town State Zip Code Date of inspection
D. System Information (cant.)
15. Site Exam:
Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked date of design plan reviewed: MAY 1995
g p Date
❑ Observed site (abutting property/observation hole within 159 feet of SAS)
Checked with local Board of Health -explain:
DESIGN PLAN ON FILE
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
DESIGN PLAN
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
1-IN
s `T Commonwealth of Massachusetts
i
.� I cIInspecti"onFor�Y1
f Subsurface Sewage Disposal System Form Not for Voluntary Assessments
K
g p Y y
120 GRAY STREET
Property Address
MONICA DEMERS
Owner Owner's Name
information is NORTH ANDOVER MA 01845 SEPTEMBER 19 2025
required for every
page. City/Town 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:
11 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 1 5: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/28/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Summary Record Card generated on 9/16/2025 4:28:44 PM by Nancy viens Page 1
Town of North Andover
Tax Map # 210-407D,-0120-0000oO
Parcel Id 18557
120 GRAY STREET
MONICA DEMERS
120 GRAY STREET
NORTH ANDOVER MA 01845
Class 101 Single Family Property Type 1 Residential
Size Tota 1 1.06 Acres
FY 2026
a
U_B_. Mailing-Index
Name/Address Type Loan Number Activellnact, From Until
MONICA DEMERS Owner Active
120 GRAY STREET
NORTH ANDOVER MA 01846
CARROLL,JOHN C. Previous Customer Inactive 2/28/2005
120 GRAY STREET
NORTH ANDOVER,MA
01845
UB Account Maint,
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 13716.0-120 GRAY STREET Last Billing date 8/6/2025
1090394 01 Cycle 01 Active
UB Services Maim.
Account No. 1090394
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0,63 518 7.82 11
WTR WATER 01 ALL METER SIZE 164.42 11
UB Meter Maintenance
Account No. 1090394
Serial No Status Location Brand Type Size YTD Cons
29956866 a Active 00 b Badger w Water 0.626 0.625 4.91
Date Reading Code Consumption Posted Date Variance
7/17/2025 2701 a Actual 36 8/13/2025 291%
4116/2025 2665 a Actual 9 5/20/2025 -16°/0
1/16/2025 2656 a Actual 11 211212025 _71
10/16/2024 2646 a Actual 37 11/812024 101°ro
7/19/2024 2608 a Actual 19 811312024 109°/0
4/18/2024 2589 a Actual 9 5/13/2024 -25%
1/18/2024 2580 a Actual 12 2/15/2024 9°/v
10/19/2023 2568 a Actual 11 11/21/2023 _44%
7/20/2023 2557 a Actual 20 8/14/2023 10%
4/19/2023 2537 a Actual 18 5/10/2023 -25%
1/18/2023 2519 a Actual 24 2114/2023 '
-69%
10/19/2022 2496 a Actual 78 1119/2022 29°/°
7120f2022 2417 a Actual 61 8/16/2022 293°/°
4/19/2022 2356 a Actual 15 5/12/2022 -9%
1/20/2022 2341 a Actual 17 2/16/2022 -28°/°
10/20/2021 2324 a Actual 23 11/22/2021 _60%
7/22/2021 2301 a Actual 59 8/24/2021 265%
4/21/2021 2242 a Actual 16 5/18/2021 1%
1/20/2021 2226 a Actual
16 2/23/2021 -66°IQ
10/20/2020 2210 a Actual 49 11/12/2020 -46%
7/16/2020 2161 a Actual
78 811212020 385%
412412020 2083 a Actual 19 6/13/2020 -16%
1/17/2020 2064 a Actual 21 2/10/2020 -63°Io
10/18/2019 2043 a Actual 55 12/18/2019 68%
7/22/2019 1988 a Actual 35 8/13/2019 1144/0
4/19/2019 1953 a Actual 16 5/15/2019 .5%
1/17/2019 1937 a Actual 16 2/18/2019 -50%
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