HomeMy WebLinkAboutTitle V Inspection Report - 44 CARLTON LANE 6/17/2011 I
1
Commonwealth of Massachusetts "
w Title 5 Official Inapectilon F6 m
Subsurface Sewage Disposal System Form-Not fort/ N ntary sses ehts
,.•' 44 Carlton Lane ftlA f 8plt f181
Waft
Property Address
Mike Ebert _...
I
Owner Owner's Name
information is
required for North Andover MA 01845 6/17/2011
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Neil James Bateson
cursor-dp not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
VQ 111 Argilla Road
Company Address
Andover MA 01810
n City/Town State Zip Code
978-475-4786 S115
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs/Further Evaluation by the Local Approving Authority
6/17/201
Insp c rs Signature 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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector*and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""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.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
1
Commonwealth of Massachusetts 1
W Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments
44 Carlton Lane 1
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/17/2011
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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:
After permit from B.O.H., replace collapsed pipe& new outlet tee in septic tank, inspection from
B.O.H., septic system now passes Title 5 Inspection.
B) 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):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
t �
Commonwealth of Mmssachusetts �
=
Title ffi i I Inspection F 9
ry
Subsurface Sewage Disposal System Form e Not for Voluntary ssessments t
o
VIUN
44 Carlton Lane
yV Property Address ICI ANDOVER
I
Mike Ebert
Owner North Andover MA 01845 _ 6/8/201
information is
required for 1
every page. City/Town State Zip Code Date of Inspect
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form. �✓
—
Important: A. General Information
When filling out f
forms on the
computer,use 1. Inspector:
only the tab key
to move your Neil J. Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover Ma 01810
City/Town State Zip Code
978-4754786 S115
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system;
❑ Passes ® Conditionally Passes ='' ❑ Fails
,f
❑ Need Further Evaluation by the Local Approving Authority
6/8/2011
Inspector's Signatu 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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority,
****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.
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
i
Commonwealth of Massachusetts
Official Title 5 i
i
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) 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:
B) 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):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts�..
..
u Title 5 Official Ind et'on Form
Subsurface Sewage Disposal g p 1 System Form Not for Voluntary Assessments
r 44 Carlton Lane
Property Address r
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 0184 6/8/2011
every page. City/Town State Zip 96de Date of Inspection
B. Certifi tion (cont.)
B) Sys em Conditionally Passes (cont.):
❑ Ob ervation of sewage backup or break out o igh static water level in the distribution box due
to roken or obstructed pipe(s)or due to a b ken, settled or uneven distribution box. System will
pa s inspection if(with approval of Board Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is levele or replaced El E] N El ND (Explain below):
❑ The system requi pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass i s ection if(with approval of the Board of Health):
❑ broken ipe(s) re replaced ❑ Y ® N ❑ ND (Explain below):
❑ obs ction is remo d ❑ Y ® N ❑ ND (Explain below):
C) urther Evaluation is Required by the Board of Hea
Conditions exist which require further evaluation by the Boar of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303 1 stem is not functioning( )(b)that the system g in a manner which will protect public health,
safety and the environment:
❑ 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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
ii
Commonwealth of Massachusetts
i
Title Official
Subsurface Sewage Disposal System Form-Not"for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. Cityffown State Zip Code Date of Inspection
B. Certification (coot.)
B) System Conditionally Passes (cont.):
❑ 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):
❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y 2 N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
C) 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.
1. 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 mariner which will protect public health,
safety and the environment:
❑ 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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17.
Commonwealth of Massachuseft
Title i i Inspection
Subsurface Sewage Disposal System Forme Not for Voluntary Assessments
44 Carlton Lane 1
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
2. 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.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ 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 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.
3. Other:
Outlet pipe out of septic tank crushed, needs to be replaced.
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® 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
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title i i Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Z 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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a 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 form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® 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.
E) 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 D.
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
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title i i 1
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner
Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. Citylrown state Zip Code Date of Inspection
C. Che list
Ch ck if the following have been done. You must ndicate"yes"or"no"as to each of the following:
Yes No
® ® Pumping inf/syst provided by the owner, occupant, or Board of Health
❑ ® Were any of components pumped out in the previous two weeks?
® ❑ Has the syst normal flows in the previous finro week period?
Have large vater been introduced to the system recently or as part of
this inspectio Were as bui e system obtained and examined? (If they were not
available to as N/A)
❑ Was th acility or dwelling inspected for signs of sewage back up?
® ❑ Was a site inspected for signs of break out?
® re all system components, excluding the SAS, located on site?
® ❑ 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,
imensions, depth of liquid, depth of sludge and depth of scum?
® W the facility owner(and occupants if different from owner) provided with
infor tion on the proper maintenance of subsurface sewage disposal systems?
The size nd location of the Soil Absorption System(SAS)on the site has
been deter 'ned based on:
® Existing inform . n. For example, a plan at the Board of Health.
❑ Determined in the fi 4 (if any of the failure criteria related to Part C is at issue
approximation of distan'be is unacceptable) [310 CMR 15.302(5)]
. System Information
Residential Flow Conditions:
Number of bedrooms(design): N/A Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title =nts
Subsurface Sewage Disposal System Form-Not for Voluntary Assessm 44 Carlton Lane VaR
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
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?
• ❑ 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?
® ❑ 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): N/A Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert .,..µ . . ... . .. .." "
Owner Owner's Name
information is North Andover MA 01845 6/8/2011
required for
every page. City/Town State Zip Code to of Inspection
D. System InformatI1 1
Description: 7
Number of cur ent residents: ��� 2
Does residenc have a garbage grinder? ❑ Yes ® No
Is laundry on a eparate sewage system? [if yes separate/pectfion required] ❑ Yes ❑ No
Laundry system i spected? ❑ ❑ Yes ❑ No
Seasonaluse? ❑ ❑ Yes ® No
Water meter readings, if available(last 2 years°usage(gpd)): Yes
Detail:
Sump pump? ® Yes ❑ No
Last date of occupancy;
Current
Date
Commerci /lndustrial Flow Conditions:
Type"establishment:
,,-b sign flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 1 Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
F
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): Yes
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: pumped 2006, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank, baffle&tee
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ 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(to 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):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title i i Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cant.)
Approximate age of all components, date installed (if known)and source of information:
Original to house, owner
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
4"Cast iron thru wall, 3" PVC in house, no leaks visible
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ 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'
Sludge depth:
6"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 1 1 Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (coot.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
23"
411
Scum thickness
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
19"
Now were dimensions determined? 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.):
Pumped septic tank. Inlet.tee ok. Outlet tee ok.Outlet pipe to d-box#1 crushed. Needs to
be repaired. Depth of liquid at outlet invert. No evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ 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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
H Title 5 Official Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachuseft
Title Official tl
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner Owners Name
information is
required for North Andover MA 01845 6/8/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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# 1 ok. D-box cover broken, replaced it. D-Box#2 level &distribution equal. Evidence of
carryover. No evidence of leakage;
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cost.)
Type:
❑ leaching pits number:.
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 4 trenches 50'
long
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forme Not for Voluntary Assessments
M s•' 44 Carlton Lane
J
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cant.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title fi i Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
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
l V v-
D--
AL'�-t-i i C�
-�vc A)
t5ins 09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title i i Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Carlton Lane
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >4
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:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Essex County Soil Map.
You must describe how you established the high ground water elevation:
Essex County Soil Map, Sheet#36 , Canton Soil, Water>6'deep
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Forme Not for Voluntary Assessments !
44 Carlton Lane "r
Property Address
Mike Ebert
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2011
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
l
I
Commonwealth of Massachusetts
µ
City/Town of
System Pumping ec r
Form 4
DEP has provided this form 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 other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of house, left side of house, right side of housLe
rear ofEio right rear of house, left side of building, right rear of building, under deck. W
L"i t AZ1,\ UPI Ae / 6 cx---�� ":u-Q-r-
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State N Sip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D y 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) k eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: '
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where content's were disposed:
G.L.S.D� 4owell Waste Water
Signatu H u er U Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Summary Record Card generated on 6/3120112:03:51 PM by Karen Hanlon Page
Town of North Andover 1
Tax Map # 210-106.0-0092-0000.0
Parcel Id 17728
44 CARLTON LANE f
EBERT, MICHAEL
44 CARLTON LANE
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 1 Acres
FY 2011
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
EBERT, MICHAEL Payor
44 CARLTON LANE
NORTH ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id.7613.,0-44 CARLTON LANE Last Billing Date 3/2/2011
2100195 02 Cycle 02 Active
UB Services Maint.
Account No.2100195
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 76.00 /1
UB Meter Maintenance
Account No.2100195
Serial No Status Location Brand Type Size YTD Cons
13242307 a Active ERT HH METE METE w Water 0.63 0,63 311
Date Reading Code Consumption Posted Date Variance
5/2/2011 787 a Actual 15 -180/(
2/4/2011 772 a Actual 20 3/15/2011 5%
11/1/2010 752 a Actual 18 12/13/2010 -55°k
8/3/2010 734 a Actual 41 9/13/2010 76%
5/3/2010 693 a Actual 23 6/9/2010 0°/r
2/1/2010 670 a Actual 23 3/11/2010 -12%
11/2/2009 647 a Actual 26 12/11/2009 14%
8/3/2009 621 a Actual 22 9/11/2009 45%
5/7/2009 599 a Actual 16 6/16/2009 -12%
2/3/2009 583 a Actual 18 3/16/2009 -58%
11/3/2008 565 a Actual 44 12/10/2008 -28%
8/1/2008 521 a Actual 60 9/12/2008 1920/(
5/1/2008 461 a Actual 19 6/18/2008 8%
2/6/2008 442 a Actual 20 3/14/2008 -510/(
11/1/2007 422 aActual 38 1/15/2008 -11°/C
8/3/2007 384 a Actual 43 9114/2007 1270/c
5/4/2007 341 a Actual 15 6/22/2007 -140/(
2/21/2007 326 a Actual 27 3/23/2007 -31 0/c
11/1/2006 299 aActual 32 12/22/2006 -310/(
8/1/2006 267 a Actual 45 9/13/2006 1450/(
5/4/2006 222 a Actual 19 6/20/2006 -240/c
2/1/2006 203 a Actual 25 3/13/2006 100/(
11/1/2005 178 a Actual 22 12/14/2005 -470/c
8/4/2005 156 a Actual 44 9/12/2005 131 0/c
5/2/2005 112 ,a Actual 18 6/8/2005 4°/r
2/2/2005 94 a Actual 18 3/15/2005 7°/r
I