HomeMy WebLinkAboutConditional Pass - Title V Inspection Report - 378 SALEM STREET 11/29/2025 Commonwealth of Massachusetts,
»_ AV ANN R
ecto Form
�vp le 5 Otticiai i�nsp i�on
mm ' Subsurface Sewage Di ..
�pv���l System �►rrn Not for voluntary Assessment
Property Address
vA NA BLASCZAK
Owner Owner's Name
information is NORTH AN. VE l 'A 01845
required for every _ _ . NCyIIVII� � �, ��
page. C ity/"rown ,State Zip Code Date of Inspection
Inspection results must he submitted on this form. Inspection n forms may not be altered in any
way. Please see completeness checklist,at the rend of the form.
Important:WhenA. uover-
filling out term
InspectorInformation .
on the computer, Todd James
use only the tab � teCn
key to move your Name of Inspector
cursor do not Bateson Enterprises Inc. D E C
e the return _W. �......_ �__ �__ _ ---
key. Company Name
111.
Mlle Roadni rtment—.
Company Address
Andover ILIA 01810
City/Town State Zip Code
97 -4 5-47 6 SI-16
Telephone Number 'License Number
B. Certification
I certify that: l am a CEP" approved system inspector In full compillance with Section 15.340 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 Can-site sewage disposal systems. After conducting this inspection I have determined
that the system
1. Passe
2, Conditionally Passes
3.. El Needs Further Evaluation by the Local Approving Authority
4. El Fails
December 2, 2025
Inspe or's Sinatur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or EPA)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 to
the buyer, if applicable, and the approving authority.
Please note; This report only describes conditions at the time of inspection and under the
. that time. Thi
conditions of use at s inspection does not address how the system will perform
in the future under the same or different conditions of use.
t lr sp.dec rep. 12 J2o1 Title 5 Official inspection Form,Subsurface Sewage Disposal System,Page 1 of 1
Commonwealth of Massachusetts
I T
i
Officia
Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�6~ V 378 SALEM STREET
Property Address
VAN NA B LASCZAK
Owner owner's Name
information is required for every NORTH ANDOVER MA 01845 NOVEMBER 29, 2025
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary. Complete 1, 21 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.
El Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
a
Title 5 Ol Inspection Forr�
�10 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,JV 378 SALEM STREET
Property Address
VANNA BLASCZAK
Owner Owner's Name
information is NORTH AN DOVE R MA
required for every D 845 NOVEMBER 29, �D25
page. City/Town State Zip code Date of Inspection
C. Inspection Summary (cant.)
2) System Conditionally Passes (cunt.):
El 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):
El broken pipe(s) are replaced ❑ Y Ej N ❑ ND (Explain below):
❑ obstruction is removed El Y ❑ N ❑ ND (Explain below):
distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
D-BOX ROTTED, NEEDS REPLACED
El The system required pumping more than 4 times a year due to broken or obstructed . The
system
will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced El Y El N Ej ND :below
(Explain )
❑ obstruction is removed El Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
Ej conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment,
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(l)(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
Commonwealth of Massachusetts
luTitleIIIInspection or rY1
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
378 SALEM STREET
Property Address
VAN NA BLASCZAK
Owner Owner's Name
information is NORTH ANDOVER MA O'1845 NOVEMBER 29 2025
required for every z
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cant.)
[� Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
[:1 The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well,
[:1 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:
TIE IN WASHING MACHINE TO MAIN DRAIN
INSTALL INLET TEE IN TANK
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"Noy'to each of the following for all inspections:
Yes No
0 z Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
1:1 z Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/2512018 Title 5 official Inspection Farm:Subsurface Sewage Disposal System-Page 4 of 18
r Commonwealth of Massachusetts
4Title 5 Official Forr�
�} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
378 SALEM STREET
Property Address
VAN NA BLASCZAK
Owner Owner's Name
information is NORTH ANDOVER MA 01845 NOVEMBER 29 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: (cunt.)
Yes No
0
® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
1:1 ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipes). Number of times pumped:
El E 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 supply.
El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well,
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this forma
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
1 0,000 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 C.4,
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area —IWPA) or a mapped Zone 11 of a public water supply well
t5insp,doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
p T'Itle IC1al Inspection Folip >
r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 1;
378 SALEM STREET
Property Address
VAN NA B LASC,ZAK
Owner Owner's Name
information is NORTH ANDOVER
required for every MA 01 845 NOVEMBER 29, 2025
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
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 C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no" for each of the following for all inspections:
Yes No
® ❑ 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 IA
® ❑ Was the facility or dwelling inspected for signs of sewage back u ?
g P
® EJ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes un
covered,ncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based an:
® ❑ 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
Commonwealth of Massachusetts
Title 5 OffcInspection or1as
Subsurface Sewage Disposal
g p al System Form Not for Voluntary Assessments
378 SALEM STREET
Property Address
VAN NA BLASCZAK
Owner owner's Name
information is NORTH AN DOVE R
required for every MA 01845 NOVEMBER 20, 0�5
page. City/Town State Zip code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): NA Number - 2
e of bedrooms factual}.
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes E No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) E Yes ❑ No
Laundry system inspected? El Yes F1 No
Seasonal use? El Yes E No
Water meter readings, if available (last 2 years usage (gpd)}: ATTACHED
Detail:
Sump pump? E Yes Ej No
Last date of occupancy: FE B R UARY
2025
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
x wTitle 5 Official Forn�
Q Subsurface Sewage Disposal System Form Not for Voluntary Assessments
f� rY
378 SALEM STREET
Property Address
VAN NA BLASCZAK
Owner Owner's Name
information is NORTH ANDOVER MA 01845 NGVE
required for every MBER�9, 05
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 d
p Y�9p 3
Basis of design flow(seatslpersons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? El Yes ❑ 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: TOWN RECORDS J U LY 35 2023
Was system pumped as part of the inspection? ❑ Yes Z No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/2 612 0 1 8 Title 5 official Inspection Form;Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
4 Ti e icIaInspectionForl�''1
ru
17 Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments
ti
t
� , 4V 378 SALEM STREET
Property Address
VAN NA BLASCZAK
Owner owner's Name
information is NORTH AN DOVE R
required for every MA 01845 NOVEMBER 29, 2025
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
El overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any
)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract into be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
53 YEARS, ORIGINAL TO HOUSE, TOWN RECORDS
Were sewage odors detected when arriving at the site? El Yes E No
5. Building Sewer(locate on site plan):
Depth below grade:
30"
feet
Material of construction:
E cast iron El 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
JOINTS AND VENTING OK
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
ci'al Inspection For
,t,p Title 5 Offi
Subsurface Sewage Disposal System Form Not for Voluntary° Y Assessments
378 SALEM STREET
Property Address
VAN NA BLASCZAK
Owner Owner's Name
information is NORTH AN DOVE R
required for every MA D $45 NOVEM BER �9, 2025
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Septic Tank(locate on site plan):
4
Depth below grade: 1811
feet
Material of construction:
® concrete El metal El fiberglass El polyethylene other(explain)n)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes El No
Dimensions: 5' ROUND 850 GALLONS
Sludge depth:
3"
Distance from top of sludge to bottom of outlet tee or baffle
35"
Scum thickness ill
Distance from top of scum to top of outlet tee or baffle 611
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? SLUDGE JUDGE
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. : g y'
RECOMMEND PUMPING OLDER SYSTEMS YEARLY
NO INLET TEE
OUTLET TEE CLAY PIPE
TANK OK
LIQUID LEVELS GOOD
NO EVIDENCE OF LEAKAGE
t5insp.doc•rev.7/26/2018 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
(.P Title 5 Offi
ci"al Inspecti"on Form
'T is Subsurface Sewage Disposal System Form �. Not for Voluntary Assessments
a � v
378 SALEM STREET
Property Address
VAN NA B LASCZAK
Owner owner's Name
information is
required for every NORTH ANDCVER MA D $45 NOVEMBER 29, 2025
page. CitylTown State Zip Code Date of Inspection
D. System Information (cunt.)
7. Grease Trap (locate on site plan);
Depth below grade: feet
Material of construction:
El concrete El metal El fiberglass El polyethylene El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: 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 E:1 fiberglass ❑ polyethylene
El other explain):
Dimensions:
Capacity. gallons
Design Flow; gallons per da
q p y
t5insp,doc•rev.7/2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
�-p Title 5 Officia
I Inspection For
1!� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
f`1
378 SALEM STREET T
Property Address
VAN NA BLASCZAK
Owner Owner's Name
information is NORTH AN DOVE R MA
required for every 91 845 NOVEMBER 29, 2025
page. City/Town State Zip Code Date of inspection
D. System nforlmation (cont.)
8. Tight or bolding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: El Yes El No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? El Yes [:1 No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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 LEAKING IN GROUND
D-BOX IS NOT LEVEL, DISTRIBUTION NOT EQUAL
HEAVY EVIDENCE OF SOLIDS
EVIDENCE OF LEAKAGE
D--BOX IS ROTTED AND NEEDS REPLACED
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
,�,,A Title 5 Official Form
to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
fJ �w4`bV 378 SALEM STREET
Property Address
VAN NA SLASCZAK
Owner Owner's Name
information is NORTH ANDOVER MA 01845 NOVE
required for every MBER9, �OZ5
page. City/Town State Zip Code Date of inspection
D. System Information (coat.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes D No*
Alarms in working order: [I Yes D 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:
El leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length;
2; 50' LONG
El leaching fields number, dimensions:
El overflow cesspool number:
El innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Forr�
�ti a
b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
378 SALEM STREET
Property Address
VAN NA BLASCZAK
Owner Owner's Name
information is NORTH AN DOVE R MA D 1 45
required for every 8 NOVEMBER 29, 24�5
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.):
SOIL AND VEGETATION OK
NO SIGNS OF HYDRAULIC FAILURE OR PONDING
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —fop of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes El No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Farm;Subsurface Sewage Disposal System-Page 14 of 18
�., Commonwealth of Massachusetts
Title 5 Offic'ial Foriu s
' 4 Subsurface Sewage Disposal System Form _ Not for Voluntary p y y Assessments
„ 4,tl�`b. 378 SALEM STREET
Property Address
VANNA BLASCZAK
Owner owner's Name
information is NORTH ANDOVER
required for every MA 01848 NOVEMBER 29, 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
-' Title 5 Official I Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
n
f.� hyy1 378 SALEM STREET
Property Address
VANNA BLASCZAK
Owner owner's Name
information is NORTH AN DOVE R
required for every MA 01 845 NOVEMBER 29, 2025
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.-
hand-sketch in the area below
❑ drawing attached separately
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t5insp.doo rev,7126/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System►Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Form
�~ a
' Subsurface Sewage Disposal System Form - Not for Voluntary
� ry Assessments
{: Y`V 378 SALEM STREET
Property Address
VANNA BLASCZAK
Owner owner's Name
information is NORTH ANDOVER MA 01845 NOVEMBER 29 2025
required for every ,
page. City/Town State Zip Code Date of inspection
D. System Information (cunt.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
Ej 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: Date
[] observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
PREVIOUS TITLE 5 ON FILE
El Checked with local excavators, installers - (attach documentation)
® Accessed USOS database-explain:
ESS EX COUNTY SOIL MAP
You must describe how you established the high ground water elevation:
CANTON LOAM
DEPTH TO WATER TABLE >80"
SYSTEM ABOVE WATER TABLE
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/28/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
n �pTitlecIInspectionFor- T
1�1
' � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a rY
t. k
378 SALEM STREET
Property Address
VAN NA BLASCZAK
Owner owner's Name
information is NORTH AN DOVE R MA required for every 01845 NOVEMBER 29, 2025
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
Z A. Inspector Information: Complete all fields in this section.
Z B. Certification: Signed & Dated and 1, 21 3, or 4 checked
Z C. Inspection Summary:
11 21 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
Z D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Summary Regard card'generated on I I h 9/2025 9:00:41 AM by Nancy Viers Page 1
TNorthown of , Andover
Tax Map # 210-037,B-0038-0000,0
Parcel ld 12874
378 SALEM STREET
US BANK TRUST NATIONAL N.
NEW RESIDENTTTIAL MORTGAGE
LOAN TRUST 2020-NPL2
1661 WORTHINGTON ROAD, SUITE, 100
WEST PALM BEACH FL 33409
Class, 101 Single,Family Property Type 1 Residential
Size Total 0.226 Acres
Fy 2026
UB Mq1,ljnq Ind ex
N�ame/'Ad'dress, 'Type Loan Num�ber Activellinact. From Until
US BAND TRUST NATIONALASSN. caner A c t i
NEW RESIDENTTTIAL MORTGAGE
LOAN TRUST 2020-NPI-2
1661 WORTHINGTON ROAD,,SUITE 100
WEST PALM BEACH FL 33409
KAHN,JULES Previous Customer 4/1/2024
COGBURN,JEAN MARIE
378 SALEM ST
NORTH,ANDOVER,MA
01845
UB Account Maint.
Accotint No Cycle Occupant Name, Active/Inactive
Bldg Id. 16058.0-378 SALEM STREET Last Billing Date 1012/2025
3160113 03 Cycle 03 Active
UB Services Maint.
Account No.31'I
60113
Service,Code at Charige Multiplier/Users
MISCFEEADM�IN FEE 0.635/8 7.,82 I/
WTR WATER 01 ALL METER SIZE /1
U'B MAter Maintenance,
Account No.3160113
Serial No status, Location Brand Type Size YTI)Cons
163,36765 a Active 00 METE,METE w Water 0.6250.625 261
to Reading Code Consumption Posted Date Varlance
9/4/2025 1839 a Actual 0 10/10/2026 -100%
6/4/2025 1839 a Actual 0 7/9/2025 -100%
3/5/2025 1839 a Actual 4 4/16/2025, -73%
12/4/2024 1835 a Actual 15 1/14/2025 6/
9/4/2024 1820 a Actual 14 10/812024 -10%
6/6/2024 1806 a Actual 16 7/22/2024 -2%
3/5/2,024 1790 a Actual 16 4/16/2024 13%
12/5/2023 1774 a Actual 14 1/15/2024 -17%
9/6/2023 1760 a Actual 18 10/13/2023 8%
6/2/2023 1742 a Actual 16 7/14/2023 -5%
3/2/2023 1726 a Actual 16 4/1,2/2023 -3%
12/5/20,22 1710 a Actual 17 1/16/2023 13%
9/6/2022 16913 a Actual 16 10/18/2022 10%
6/2/2022 1677 a Actual 14 7/18/2022 -7%
3/2/2022 1663 a Actual 14 4/13/2022 3%
1216/2021 1649 a Actual 15 1/17/2022 21%
9/2/2021 1634 a Actual 12 10/15/2021 -25%
n
6121202ot 1 1622 a Actual 16 7/2,7/2021 11%
3/2/2021 1606 a Actual 14 4/21/202,1 3%
12/3/2020 1592 a Actual 14 1/13/2021 18%
9/2/2020 1578 a Actual 12 10/14/2020, 28,3%
6/1/2020 1588 a Actual 3 7/15/2020 .75%