HomeMy WebLinkAboutTitle V Inspection Report - 230 GRANVILLE LANE 4/18/2017 /iii ...
f �
/i// FILE# K D P`7
TITLE V INSPECTION
Dean G. Luscomb U &. Sons 00, r
P.O. Boy 135
Middleton, MA 01949
978-774-4465
Licensed Plumber # 20285
SUBSACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNERS NAME .1 ,
_ C _ . ._. -)
PROPERTY ADDRESS 3( C. .. ._ y C
r 1
DATE OF INSPECTXON "�ALU C� C 1 7
:NAME OF INSPECTORL t.L. 0 t
QUALITY IS NUMBER ONE TO US
i
i
Commonwealth of Massachusetts
Title Official Inspection
_ w
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.. 230 Granville Lane
Property Address
Donna Clements--
Owner _..__.._. __,._._......_ _
Owner's Name
information is North Andover MA 01845 A rll 10, 2017
required for N
_ _--.. . �__.__.. t
every page. City/Town State Zip Code Date of Inspection
i
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,
Im p octant:
When filling out A. General Inforrlration "ro
forms on the
computer,use k.
Inspector:
1. Ins
only the tab key p
to move your Dean G. Luscomb 11 °W
cursor-do not _ __ __.._.__._._._.._
use the return Name of Inspector
key. Dean G. Luscomb II & Sans
- Company Name
r� 288 Maple Street
Company Address _._..
Middleton MA 01949
City/Town State Zip Code
978-774-4065 S1848
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 DPP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
i
Passes ❑ Conditionally Passes ❑ Fails
Vtor's
urther Evaluation by the Local Approving Authority
c April 10, 2017
Iature 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.
i
****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
I the same or different conditions of use.
t5ins 3113 "title 6 Oficial Inspection Form:Subsurface Sewage Disposal System•page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
230 Granville Lane --
Property Address
Donna Clements
Owner Owners!Name
information is North Andover MA 01845 April 10, 2017
required for
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Chec0p,
C,D or E 1 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
g the Board of Health, will pass,
1
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
i
1 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.
[I Y F1 N ❑ ND (Explain below):
15ins•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 230 Granville Lane
Property Address
Donna Clements
Owner Owner's tdarne
Information is North Andover MA 01845 April 10, 2017 '
required for
every page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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 ❑ 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 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
t51ns•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17
I
3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments
M r 230 Granville Lane
Property Address
Donna Clements
Owner Owner's Name
information is
required for North Andover _MA 01845 April 10, 2017
— -
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 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.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
u
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
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
i:. t5ins•3113 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 4 of 17
I'.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments
230 Granville Lane
Property Address
Donna Clements
Owner Owner's Name
information is
required for North Andover MA 01845 April 10, 2017
every page. Cityfrown 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.
❑ ® 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 forma
❑ ® 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
desi flow of 10,000 gpd to 15,000 gpd.
For large system , u must indicate either"yes"or"no"to each of the owing, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within et of a surface drinking water supply
❑ ❑ the syste ' w"�it�h in 200 feet o tributary to a surface drinking water supply
systems located in a nitrogen se ve area (Interim Wellhead Protection
El ❑ Area—IWPA)ora mapped Zone li of a pu water supply well
If you hay answered "yes" to any question in Section E the system is c idered a significant threat,
or aq vs i6red "yes" in Section D above the large system has failed. The owne r operator of any large
sy9#em considered a significant threat under Section E or failed under Section D I1 upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the a n hate
regional office of the Department.
S
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 17
I.
i
Commonwealth of Massachusetts
v Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 230 Granville lane
Property Address
Donna Clements
Owner Owner's Name
information is North Andover MA 01$45 Aril 10, 2017
required for — p
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?
❑ 0 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 NIA)
® ❑ 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)j
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms(actual): 4 -
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). 440 qpd _
3 l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
P'
i
3.
Commonwealth of Massachusetts
Title 5 official Inspection Form
}
4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
230 Granville Lane
Property Address
Donna Clements
Owner Owner's Name
information is
required for North Andover MA 01845 Apr ril 10, 2017
--
every page. Citylrown State Zip Code Date of Inspection
i
D. System Information
Description:
owner and town
Number of current residents: 2
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): G./h --
Detail:
Cp
Sump pump? ❑ Yes ® No
current _
Last date of occupancy: pate
fommerciallindustrial Flow Conditions:
Type of Establi nt:
Design flow(based on 310 C 5.203): �'~�- —
Gallons per day jgp*--__
Basis of design flow (seats/persons/sq.ft., et --
Grease trap present? ❑ Yes ❑ No
Industrial waste holding to 1 went? ElYes ❑ No
Non-sanitary-w a discharged to the Title 5 system? Yes ❑ No
Water meter readings, if available:
t5ins•$113 Title 5 Official Inspection Form:Sut>surtace Sewage DIsposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
230 Granville Lane _
Property Address
Donna Clements _
Owner Owner's Name
information is
required for North Andover MA 01845 April 10, 2017
----.
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
La of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Last pumped approx 2 months a o.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: ,Zero
gallons
How was quantity pumped determined? — --
Reason forum in No need at this time �._.
p p 9�
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 DFP approval.
❑ Other(describe):
u
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposaf System-Page 8 of 17
t
i
1
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
230 Granville Lane
Property Address
Donna Clements
Owner Owner's Name
information is
required for North Andover MA 01845 April 10, 2017
-
every(sage. City/Town State Zip Code Date of Inspection
D. System Information (cont:)
Approximate age of all components, date installed (if known) and source of information:
System is from 2014 _
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"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.):
Main line and joints are in good condition.
Septic Tank(locate on site plan): ) j
J Depth below grade:
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
Precast rectangular concrete- 1000 gallons
If tank is mel'a'r`tislac}e _ �_ years m
Is a e I Icate of Compliance? (attach a copy of certificate) a No
Dimensions: 4'deep x 6'wide x 8' long - 1000 ga
1"
Sludge depth:
t5ins•3113 We 5 Official Inspection Form Subsurface Sewage disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Sunsurface Sewage Disposal System Form Not for Voluntary Assessments
230 Granville Lane.
Property Address
Donna Clements _--
Owner Owner's Name
information is
required forNorth Andover MA 01845 April 10, 2017
---------. -----
every page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 28 --
1"
Scum thickness -� -_
GFI
Distance from top of scum to top of outlet tee or baffle v
Distance from bottom of scum to bottom of outlet tee or baffle 15" --
How were dimensions determined? by measurements_
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic tank and baffle are in very good shape. The solids are light and do not require pumping at this
time. The liquid is running at it's correct working heigth. _— T
Grease Trap (locate on site plan):
Dep elow grade: feet--
Material of co traction:
❑ concrete metal ❑ fiberglass ❑ poly ethylenother{explain}:
Dimensions: �.
.•ham.
Scum thickness �` ---
Distance from top of scum-to-top of outlet tee or baffle
>Date
from b 'm of scum to bottom of outlet tee or baffle - -
t��
st pumping: Date ,_.__ ----
t5ms•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disppsal System•Page 10 of 17
is
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
230 Granville Lane
Property Address
Donna Clements —.---
Owner Owner's Name
information is North Andover MA 01845 Aril 10, 2017
required for
every page. City/Town State Zip Code [date of Inspection
D. System Information (cont.)
Cnjs (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels a ated to outlet invert, evidence of leakage, etc.):
Ti ht or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth b w grade:
�1 Material of con uction:
V ❑ concrete metal El fiberglass ❑ polyethylene other(explain):
Dimensions: --
Capacity: gano
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Ala in working order: ❑ Yes ❑ No
u
Date of last pumping: Date -----
u
i
'l Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes No
i
!' t5ins-3/13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 11 of 17
u
is
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
230 Granville Lane _
Property Address
Donna Clements _ W
Owner Owner's Name
information is
required for North Andover MA 01845 April 10, 2017
-.--.
every page. CitylTown State Zip Code Date of inspection
D. System Information (cont)
Distribution Box(if present must be opened) (locate on site plan):
f Depth of liquid level above outlet invert Zero
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.):
The d-box is 16"x 16" and is 4' below grade. The d-box is in very good shape.
mp Chamber(locate on site plan):
V rumps in wo ' order:
El Yes ❑ No*
V Alarms in working order: ❑ Yes® No*
Comments(note condition of pump cha r, condition of pu d appurtenances, etc.):
i
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
/ SAS was located by asbuilt drawings. _ W�
15m•3113 Title 5 Official Inspection Form:Subsurface Sewage disposal System•Page 12 of V
I.
t
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°w 230 Granville Lane
Property Address �� �� -----------.
Donna Clements -- — —
Owner Owner's Name
information is North Andover MA 01845 Aril 10, 2017
required for � � _ p —_-------._..__,_
every page. CityfTown State Zp Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number: -- -- ------
J� ❑ leaching chambers number: -
❑ leaching galleries number: -------
(( ❑ leaching trenches number, length: --
® leaching fields number, dimensions: 1 - 10' x80` --
❑ 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.):
The SAS is in good condition. There are no signs of ponding or breakout.
0
0
esspools (cesspool must be pumped as part of inspection) (locate on site plan):
d
°
Number a onfiguration
Il
V yF
g Depth-top of liquid to ' It invert -
p
Depth of solids layer ,
Depth of scum layer —
Dimensions of cesspool ---
�r
Materials of construptio>1
N. M1
Indication, groundwater inflow ❑ Yes ❑ No
t5ins•3173 Tit#e 5 Oficial inspection Form:Subsurface Sewage Disposal Syste •Page 13 of 17
I'
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
230 Granville Lane _
Property Address
Donna Clements
Owner Owner's Name
information is
required for North Andover MA 01845 April 10, 2017
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
—1C76mr-nentsw,(note condition of soil, signs of hydraulic failure, level of ponding, conditetation,
etc.):
Pr locate on site plan):
Materials of con tion.-
Dimensions
ion:Dimensions ---
Depth of solids
Comments (note condition of soil, signs of hydra ure, level of ponding, condition of vegetation,
etc,):
t5ins•3713 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System f=orm -Not for Voluntary Assessments
230 Granville Lane
Property Address -
Donna Clements
Owner Owner's Name
information is North Andover MA 01845 April 10, 2017
required for _ �. p
every page. City/Town 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
A h,TT
70
,)730 Ci �c
&AC ti. 14,j W,0W i
C-
Irl [kW
Wil____
q�
�10�
Rot
'
15#ns-3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal Syslem-Page 15 of 17
Commonwealth of Massachusetts
u Title 5 official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
230 Granville Lane
Property Address
Donna Clements----
Owner
lements _-_Owner Owner's Name
information is North Andover MA 01845 R rll 10, 2017
required for �?
every page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope G rcl�c
®
Surface water /U()/V-
® Check cellar Ply Q A
® Shallow wells /uem,,
Estimated depth to high ground water: 5.166' -----
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: 5/23/01
Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Permit, proposed, asbuilt and previous title v from 12/17/03 on file.
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Test hole# 1 showed ESHWT at 62". Test hole#2 showed ESHWT at 72". By B. Dufresne
Merrimack Eng. Services 5/23/01.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins•3713 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
230 Granville lane
Property Address
Donna Clements
Owner Owner's Name
information is North Andover MA 41845 April 10, 2017
required for
every page. Citylrown state Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, 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
9
9
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Nsposal System•Page 17 of 17
a
9
4
P