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Home My WebLink AboutTitle V Inspection Report - 1459 TURNPIKE STREET 10/17/2012 �v� �� (��30N00��nV�ealth of Massachusetts 131 Fonwil Stmo ~�"=�� d��|°��=�� °�� N�� A�B�LETO�]��Q1 � W�� y� � ��0 �mm��mm Form (��8>774'�G8�� ~~ Subsurface Sewage Disposal System Forrn -Not for Voluntary Assessf-rients 1459 TURNPIKE s-r., NO. ANDOVER, MA 01845 Property Address Owner Owner's Name information is NO ANDOVER MA 01845 10/17/12 required for � �x��— Z�c de Date of|nspechun every page. CU�rmwn ~ Inspection results must be submitted on this fnnn. Inspection forms may not he altered inany way, Please see completeness checklist at the end of the form. RECEIVED Important: A. General Information � VVhnnUNnQmd ^ ' -- - — forms on the cornputer,use nn �hp �� Inspector: � � mmoveyour JAMES M CURRIER — ��-�mm use the return Inspector key. J'S SEPTIC & DRAIN Company Name 131 F[}RESTST Company Address MIDDLETON MA 01949 lephone Number License Number B. Certification | certify that | have 9onsuDaUy inspected the sewage diapume| 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 aysJema. | am m DEP approved system inspector pursuant tu Section 15.340 of Title 5 (310 GKAR15.D0V). The systexl: K0 Passes El Conditionally Passes E Fails [l Needs Further Evaluation by the Local Approving Authority 1D/17/12 1�el Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board ofHaakh urDEP) within 30 days ofcompleting this inspection. if the system is a shared wystmnn or has a design flow of 10,000 gpd or greater, the inspector and the systern owner shall submit the report tothe appropriate regional office of the DEP. The original should be sent to the systern owner and copies sent tothe buyor, if applicable, and the approving authority. ""This repoft only describes conditions at the time of inspection avid under the conditions of use at that time. 'rhis inspection does riot address how the systern will perform iin the future under the same or different conditions of use. t5ins 11110 Title noowm Inspection Form:o"bsoifa"°Sewage Disposal nysmrn'Page 1"/z Commonwealth of Massachusetts 131 Forest Street MIDDLETON, NIA 01949 Title 5 Official Inspection Form (978)774-66£35 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 01345 _--- Property Address KEVIN DUBE Owner Owner's Name information is NO ANDOVER MA 01345 10/17/12 required for State Zip Cade Date of Inspection every page. City/Town B. Certification (cont.) 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: SYSTEM WORKING PROPERLY. B) System Conditionally Passes: ❑ One or mo system components as described in the "Condition ass"section need to be replaced or r aired. The system, upon completi/Nfor cement or repair, as approved by the Board of H Ith,will pass. Check the box for"yes , "no"or"not determined" (Y, following statements. If"not determined,"please expl The septic tank is metal and ver 20 years old* or t° e septic tank(whether metal or not) is structurally unsound, exhibits s stantial infiltr on or extiltration or tank failure is imminent. System ' will pass inspection if the existin ank is rep ced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspe o if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the to is les than 20 years old is available. ❑ Y ❑ N ND (Explain b ow): Title 5 officiai inspection Form.Subsurface Sewage Disposal System•Page 2 of 2 t5ins 1'U1D �c�rnr>ilonureaith of Massachusetts 1,11 l=atest Street Official M1001 -TON, MA 01949 Title 5 ( 18) 774-6685 ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1458 TURNPIKE ST., NO. ANDOVER, MA 01845 — Property Address KEVIN DUBE Owner Owner's Name information is NO. ANDOVER MA 01545 10117/12 required for state Zip Code Date of Inspection every page. Cityrrown B. Certification (coat.) B) System Conditionally Passes (cunt.): ❑ Observation of sewage backup or break out or high static water level in the di 'bution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distrib on box. System will pass inspection if(with approval of Board of Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ (Explain below): ❑ obstruction is removed ❑ Y ❑ N ND (Explain below): ❑ istribution box is leveled or replaced ❑ Y ❑ ❑ ND (Explain below): ❑ The system required pump.ng more than 4 Imes a year due to broken or obstructed pipe(s). The system will pass inspection i (with appro I of the Board of Health): ❑ broken pipe(s) are rep) d ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) F/athe ivatio is Required by the Board of Health: ❑ Cexist hich require further evaluation by the Board o Health in order to determine if this f iling to protect public health, safety or the environ ent. 1ill pass unless Board of health determines in accor ce with 310 CMR 1that the system is not functioning in a manner which wi rotect public health, sthe environment: sspool or privy is within 50 feet of a su rface water sspool or privy is within 50 feet of a bordering vegetated wetland or a salt ma Title 5 Official Inspecion Form:Subsurface Sewage oiaposal System•Rage 3 of 3 t5ins•11110 -PTOC � VNrsEaUi,', 131 Forest street MIDDLETON, MA 01949 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form a Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 — --- Property Address KEVIN DUBE Owner Owner's Name information is NO. ANDOVER MA 01845 10/17/12 required for state Zip code Date of Inspection every page. City/Town B. Certification (cunt.) 2. System 111 fail unless the Board of Health (and Public Water Supplier, if any) determines at the system is functioning in a manner that protects the public health, safety and en\ea ent: ❑ The ss a septic tank and soil absorption syste /ewatersupply. ) and the SAS is within 100 feurface water supply or tributary to a suit ❑ The ss a septic tank and SAS and the SA s within a Zone 1 of a public water suppl ❑ The sas septic tank and SAS and t SAS is within 50 feet of a private water supplThe system htic to and SAS and the S is less than 100 feet but 50 feet or more from a pater su ly well**Method used ine disc ce: — **This system passes if the well water lysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent an a resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that o othe ailure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 El ❑ , than "/z day flow t5ins 11/10 Title 5 official Inspection Form'Subsurface Sewage Disposal System•Page 4 of 4 j UcN3 l=etl�f�'t� gib fSJU dtl Commonwealth of Massachusetts 131 Forest Street Title a MIDDIrTON, MA 0114"- {978)774-6685 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1459 TURNPIKE ST., NO.ANDOVER, MA 01345 Property Address KEVIN DUBE Owner Owner's Name information is NO required for ANDOVER MA 01345 10117/12 every page. city[rown 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: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ (l� Any portion of cesspool or privy is within 100 feet of a surface water supply or i$ 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. ❑ ❑ A t� 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 conform 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 c nsidered a large system the syZofthe erve a facility with a design flow of 10,000 gp 15,000 gpd. For large systems, you must indi to either"yes"or"no"to lowing, in ad dition to the questions in Section D. Yes No ❑ ❑ the system is within 4 f t of a surface drinking water supply ❑ ❑ the system is within 0 fee f a tributary to a surface drinking water supply ❑ ❑ the system is to ed in a nitrog sensitive area (Interim Wellhead Protection Area— IWPA r a mapped Zone f a public water supply well If you have answered "yes"to y question in Section E the stem is considered a significant threat, or answered"yes" in Section above the large system has fail . The owner or operator of any large system considered a signi ' nt threat under Section E or failed un r Section D shall upgrade the system in accordance w' 310 CMR 15.304. The system owner shoul ntact the appropriate regional office of the apartment. t5ins•11110 'ritfe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts 1-41 Forest Street Title 5 Official Inspection Form MIDDLE�"ON, MA 01949' (978)774-6685 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments hL 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 Property Address KEVIN DUBE Owner Owner's Name information is required for NO. ANDOVER MA 01845 10/17/12 every page. Cityfrown 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts 1�� t�T�rl, Street �nit��t_ nnA 01949 Title 5 Off"Icial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 _ Property Address KEVIN DUBE Owner Owner's Name information is required for NO.ANDOVER MA 01845 10/17/12 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 110 GPD X 3 BEDROOMS Number of current residents: 4 Does residence have a garbage qrinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® Na Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gP d))� 105.25 GPD Detail: Sump pump? ® Yes ❑ No Last date of occupancy: CURRENT Date Commercial/industrial Flo Conditions: Type of Establishment: Design flow(based on 310 CMR .203): Gallons per day(gpd) Basis of design flow (seats/persons/s ft., et . Grease trap present? ❑ Yes ❑ No Industrial waste holding tank prese ❑ Yes ❑ No Non-sanitary waste discharged the Title 5 Sys 7 ❑ Yes ❑ No Water meter readings, if a ilable: t5ins.11110 Me 5 Official Inspoofion Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Jill SEPTOC W;�fu% 131 Forest Street Title 6 Official Inspection Form® MI€DLETON, MA 0194', (978)774-60135 Subsurface Sewage Disposal System Form m Not for Voluntary Assessments ,A 1459 TURNPIKE ST., NO. ANDOVER, MA 01 845 Property Address KEVIN DUBE Owner Owner's Name information is required for NO. ANDOVER MA 01 845 10117/12 every page. city[rown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date - -- Other(describe below): General Information Pumping Records: Source of information: LPD 619/11 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons -- How was quantity pumped determined? — Reason for pumping: --- — — 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-11110 Tdle 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 ,hr OsEpytc ii�J�e;sJl ! 131 Forest Street MIDDLETON, MA 019*1 Commonwealth of Massachusetts (978)7711-6685 Title r LL } - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 01545 Property Address KEVIN DUBE Owner Owner's(dame infonnation is NO. ANDOVER MA 01545 10/17/12 required for every page. Gityrrown State Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components, date installed (if known) and source of information: REPAIR DONE IN 1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 6" Depth below grade: feet Material of construction- 2 cast iron ❑ 40 PVC ❑ other(explain): 22' FROM PUBLIC WATER Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): PLUMBING LOOKS GOOD, NO EVIDENCE OF LEAKAGE Septic Tank (locate on site plan): 6" Depth below grade: 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 1000 GAL. a 6' DIAMETER Dimensions: V, Sludqe depth: t5ins•11110 Tdie 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 9 of 9 rr t s' a �.,., ukt\Sdy lk, .� _. �'c".if�i11�� Commonwealth of Massachusetts 131 sorest Street MIDDLF-TON, MA 01949 T"Itle 5 Official Inspection Form 774-5585 t Subsurface Sewage Disposal System Form ®Not for Voluntary Assessments tiN 1459 TURNPIKE ST., NO.ANDOVER, MA 01545 Property Address KEVIN DUEE Owner Owner's Name information is NO.ANDOVER MA 01 845 10/17112 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (coat.) 24"Distance from top of sludge to bottom of outlet tee or baffle 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 5"-6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? SLUDGE JUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): LIQUID LEVEL CORRECT, INLET AND OUTLET RAFFLES IN PLACE AND IN GOOD CONDITION PVC. TANK DOES NOT NEED PUMPING AT THIS TIME. Grease Trap (locate on site plan): Depth below gra feet Material of construct n: ❑ concrete ❑ etal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to to of outlet tee r baffle Distance from bottom of um to bottom of outlet to r baffle Date of last pumpin : Date t5ins•11!10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 L Commonwealth of Massachusetts i-,At rbresit Street V:rON,MA 0194, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 1459 TURNPIKE ST., NO.ANDOVER, BRA 01845 Property Address KEVIN DUBE Owner Owner's Blame infornnation is NO.ANDOVER IAA 01845 10/17/12 required for State Zi Code Date of Inspection every page. City/fown p D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evil nee of leakage, etc.}: Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth bet�w grade: Material of co struction: ❑ concrete ❑ metal ❑ fiberglass ❑ poly ylene ❑ other(explain): Dimensions: -- Capacity: Ions Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: to Comments (condition of afar and float switches, etc.): *Aft h copy of current pumping contract(required). Is copy attached? ❑ ❑ No i5ins•11110 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts 1131 Forest Street Title Mll-)I�r,cTON,MA 01049 (0978)774-6685' 970)774-66€5 Subsurface Sewage Disposal system Form®Not for Voluntary Assessments 1459 TURNPIKE ST., NO.ANDOVER, MA 01845 Property Address KEVIN DUBE Owner Owner's Name information is NO.ANDOVER MA 01845 10/17/12 required for 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.): BOX IS LEVEL AND WORKING PROPERLY, LIQUID LEVEL CORRECT, NO EVIDENCE OF CARRYOVER, BOX 24" BELOW GRADE. _ Pump Cham r(locate on site plan): Pumps in working rder: ❑ Yes ❑ No Alarms in working ord ❑ Yes ❑ No Comments (note condition f pump amber, condition of pumps and appurtenances, etc.): i I Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11110 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 94 � & ifk 'j Commonwealth of Massachusetts 131 Forest Street MIDDLE170N, MA 01949; -�—ffi Title 5 Official Inspection Form (978)774-6689 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1459 TURNPIKE ST., NO.ANDOVER, MA 01845 Property Address KEVIN DUBE Owner Owner's Name information is required for NO. ANDOVER MA 01845 10/17/12 every page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: - ® leaching fields number, dimensions: ONE- 15'X60' ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOILS DRY, NO SIGNS OF HYDRAULIC FAILURE, VEGETATION NORMAL. Cesspools (cesspool must e pumped as part of inspection (locate on site plan): Number and configuration Depth—top of liquid to inlet inve Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundw er inflow ❑ Yes ❑ No Bins-11110 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal system,Page 13 of 13 '., Commonwealth of Massachusetts J"qt �IEPTU & f�G3��li Title 31 Ft7P5i SYP @t Y 'NIIDDLETO 1, MA 01949 Subsurface Sewage Disposal System Form o Not for Voluntary Assessments M78)774°6685 1459 TURNPIKE ST., NO.ANDOVER, MA 01 845 Property Address KEVIN DUSE _ Owner Owner's Name information is NO. ANDOVER MA 01845 10/17/12 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (coat. 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 o soil, signs of hydra lic failure, level of ponding, condition of vegetation, etc.): t5ins•11!10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 J's SEPTIC & DRAIN Commonwealth ssa use 131 Forest street M11MLEMN, AAA 01949 Title 6 Official Mspection Form (978)774-6685 Subsurface Sewage Disposal System Forme m Not for Voluntary Assessments 1459 TURNPIKE ST., NO.ANDOVER, MA 01845 Property Address KEVIN DUBE Owner owners Nam information is NO.ANDOVER MA 01845 10117/12 required far every page. Cify/1 own State Zip Cede Date of inspection D. System Information ton (coat.) 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 .0 0, i • B t5ins•11110 Titles 5 official Inspection Form:Subsurface Sewage Disposal Sy%Wm Page 15 of 15 J's SEPTUC �f� 1z Commonwealth of Massachusetts 131 Forest streot MIDDLETON, MA 019?;,g Title 6 Official Inspection Form (978)774-GSaE, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1459 TURNPIKE ST., NO.ANDOVER, MA 01545 Property Address KEVIN DUBE Owner Owner's Name information is NO. ANDOVER MA 01845 10/17/12 required for — every page. City/Town 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: eat FROM SELL 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: PREVIOUS TITLE V 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: You must describe how you established the high ground water elevation: DATA FROM PREVIOUS TITLE V SHOWS JOHN SOUCY ESTABLISHED GROUND WATER ELEVATION BY AUGERING HOLES. TITLE V DATED 5/1712001. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins 11110 Title 5 Official Inspection Forms subsurface Sewage Disposal Systerlt•Page 16 of 16 Commonwealth of Massachusetts T's SEPTOC & op( i--�'I'b" 131 Forest Street - Official lVil[IDLEIUN, MA 01949 (978) 774-6655 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, IAA 01645 Property Addre,5s KEVIN DUBE Owner Owner's Name infonnation is NO.ANDOVER MA 01845 1011711 _ required for every page. cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, S, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17