HomeMy WebLinkAboutTitle V Inspection Report - 202 FOSTER STREET 6/10/2014 Commonwealth of Massachusetts
- -_ W� Title 5 Official I r
> Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w
Foster Street
Property Address
Katherine M. Cain
Owner Owner's Name
information is NoAndover Ma. 01$45 6-10-14
required for 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.When A
filling out forms ►. General Information
on the computer,
use only the tab 1. Inspector: �i°;�
key to move your '
cursor-do nottfL� tk C i�ld n I k d lsif�t @ i
TCIF. Paul CardaneAll
use the return
�ii -I t tT
Name of Inspector " "�
key. � m �m
Septic Compliance, Inc.
Company Name
447 Boston Street
– __ _ _.. _._.....
Company Address ,
Baan To sfleld Ma. 01983
City/Town State Zip Code
978-8'15-3115 or 978-881-0726 3294
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 DI=P approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further luation by the 1,o. I Approving Authority
Ipec is 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
--****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 3113 1"itle 5 official inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
r Commonwealth of Massachusetts
Title 5 Official Inspection F `
S,�bsu `ace Sewage Disposal System Form - Not for Voluntary Assessments
�,� � g p y
f
202 Foster Street ._.
Property Address
Katherine M. Cain
Owner Owner's Name
information is Ma. 01845 6-10-14
required for every No. Andover
page, City/Town State Zip Code Bate 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:When A. General Information "`
filling out forms RECEIVED
on the computer,
use only the tab 1 _.. .
oF Paul Cardone do not your
curs01
Y YJUN 16
USe the return
kckey. Se Name of Inspector p t;"'WN O VN(N� t l�U��@�DOVII R
r
Septic oMpance, Inc. 1Jll „t omU q r4 DL f
__.
r., CompanyName
447 Boston Street
Company Address
erwR Topsfield Ma. 01983
City/Town State Zip Code
978-815-3115 or 978-681-0726 3294
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:
i
[� passes Conditionally Passes ❑ Fails
❑ Needs Further Eval by t cal Approving Authority
4 s tor's 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.
tins 311:3 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
f Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 f=oster Street
Property Address
Katherine M. Cain
Owner Owner's Name
information is Ma. 01845 6-10-14
required for every No. Andover
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,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:
y
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):
60s•3113 TiVe 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
202 Foster Street
Property Address
Katherine M. Cain
Owner Owner's Name
lifo oration is N_Q Andover Ma. 01$45 6-10-14
required fot evefy
page. Cityffown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cant.):
❑ 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):
D-Box is beginning to deteriorate and is in need of re Ip acement
❑ 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):
E] broken pipe(s) are replaced E] Y ❑ N E] ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
i
........ ........_ _..
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
35.303(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
!! Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
t5ins•3113
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
4
202 Foster Street
Property Address
Katherine M. Cain
Owner Owner's Name
information is Ma. 01845 6-10-14
required for every No. Andover
page. CftylTown 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
I 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:
r
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® 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
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
Page 4 0€17
;Sir_ 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Foster Street _
- Property Address
Katherine M. Cain
Owner Owner's Name _.
information is No Andover Ma. 01845 6-10-14
required for every _... • ...�
page. CttylTown 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.
El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
9
❑ ® 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.]
El ® The system is a cesspool serving a facility with a design flow of 2000gpd-
i
10,000gpd.
El ® 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•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of W
Commonwealth of Massachusetts �
Title 5 Official
Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
` 2U2Foster_Street
Property Address
Katherine M`_Cain
Owner's Name
i^m`ma«o« |» No. Ma.�� O1845 8'10-14
page.^*n«�m« w'e«»'v Cuy�owo --�������------------����----- l�eo^�- opsoe-�� Date ufInspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
E El Pumping information was provided bythe owner, occupant, orBoard ofHealth
El E Were any ofthe system components pumped out inthe previous two weeks?
E El Has the system received normal flows inthe previous two week period?
��
[�
Have large volumes ofvvatarbeen introduced tothe system recently orompa�of
�� �� this inspection?
Were as built plans of the system obtained and examined? (if they were not
[� Fl
�� ��
available note aoNA\)
E El Was the facility urdwelling inspected for signs ofsewage back up?
Was the site inspected for signs ufbreak out?
Were all system components, excluding the SAS, located nnsite?
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 ofliquid, depth nfsludge and depth ofscum?
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 ofthe Soil Absorption System (SAS) onthe site has
been determined based on:
Z El Existing information. For example, aplan at the Board ufHealth.
Determined inthe field (if any ofthe failure criteria related toPart Ciasdissue
[�
[�
�� ��
approximation nfdistance iaunacceptable) [310CMR 15.3U2(5)]
D. System Information
Residential Flow Conditions:
44
Number ofbedrooms (denkgn): Number ofbedrooms (acbun|). -----�����—'
OOO
DE8|GNf|ovvbased nn31D (�N1R15,2O3 (horexmmp|�� 11Ogpdx#�fbedronma\� ��----------
Commonwealth of Massachusetts
m�A
11F,41e 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
._.P..e
202 Foster Street
Property Address
Katherine M. Cain
Owner Owner's Name
information is No Andover Ma. 01845 6-10-14
required for every -- --- �.
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
2
Number of current residents:
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)): ---
Detail:
I
i
i
Sump pump? ❑ Yes ® No
Occupied
Last date of occupancy: Date"
Commercialllndustrial Flow Conditions:
NIA
Type of Establishmenti
flow
Design based on 310 CMR 15.203
9 ( talions per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): --..
Grease trap present? El Yes ® No .
Industrial waste holding tank present? ❑ Yes ® No
Nan-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available:
t5ins•W13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°p 202 Foster Street
Property Address
Katherine M. Cain
Owner Owner's Name
information is Ma. 01845 5-10-14
required for every No. Andover
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: Owner and records on file
Was system pumped as part of the inspection? ® Yes El No
1000
If yes, volume pumped:
_... W.
gallons -...
' How was quantity pumped determined? P !n�Truck a uge
Routine and toproperly check interior of the tank.
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)
ElInnovative/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 IIA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 8 of 17
r Commonwealth of Massachusetts
F Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
_ 202 Foster Street
Property Address
Katherine M. Cain
Owner's Name
r�Eo,wnauon is
equired for every No. Andover Ma. 01845 6-10-14
Page. CltylTown State Zip Code Date of Inspection
D. System Information (cant.)
Approximate age of all components, date installed (if known) and source of information:
20 years of age
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 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.):
All appeared to be goad.
Septic Tank (locate on site plan):
811
Depth below grade: feet —_._-._......_......
I
I 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 El No
I Dimensions: 5'deep 6'_wide 8'long
3"
I
Sludge depth: __..._.... ._._ _
i.
Title 5 Official Inspect€on Form:Subsurface Sewage Dksposal System•Page 9 of 17
„. Commonwealth of Massachusetts
i 5 officiaTit
l Inspection Form
--`1 i' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
"Y 202 Foster Street
Property Address
Katherine M. Cain
Owner Owner's Name
information is No Andover Ma. 01845 6-10-14
required for every — -...... _...
page. Cltylrown 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 -
2”
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 -- .. _
Tape and dip-stick
How were dimensions determined? ----
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
i
We recommend tank be pumped on a yearly basis,outlet baffle on.inlet pipe needs to be moved away
from outlet baffle, squid level was evidence of leaks e.
I _..... good,no evid �... �...... _.. ... -�
u
u
Grease Trap (locate on site plan):
NIA
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•2113 Title 5 Official Inspection Eorrrr Subsurface Sewage Disposal System-Page 10 of 17
ij\\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
202 Foster Street
Property Address
Katherine M. Cain
Owner Owner's Name
information is
required for every No. Andover Ma. 01845 6-10-14
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
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: N/A
Material of construction:
❑ concrete El metal ❑ fiberglass El polyethylene El other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: El Yes El No
Alarm level: Alarm in working order: El 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? El Yes ❑ No
15ins•3113 Title 5 Official inspection Form,subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official
Inspection Norm
Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments
2O2Foster Street
Property Address �
�
Katherine M. Cain
- �
uw^e, Owner's Name
i«fc'ma««»is N And Ma. 01845 6'10'14
mnv/,eum,a"�� ~� ~` _-----_ ______
page. City/-Town State Zip Code Date uxInspection
D. System U0Ufor00at^o0U (cont.)
Distribution Box (if present must beopened) (locate onsite p|an):
Good level
Depth of liquid level above outlet invert -------�����--------������----------�����—
Comments (note ifbox |olevel and distribution hnoutlets equal, any evidence ofsolids carryover, any
evidence ofleakage into orout ofbox, ebz.):
Box was level,ran some water through box distribution was equal,nonarryover.box is in need of
seriesrei�Iacement due to deterioration and needs a of risers to bring, up to within 8^ below_qrade.
'--
Pump Chamber(locate onsite plan):
Pumps |nworking order: �l Yea El No*
Alarms inworking order: F1 Yes E] No*
Comments (note condition cfpump chamber, condition ofpumps and appurtenances, eto.)�
_NAA
° |fpumps ovalarms are not inworking order, system ivaconditional pass.
Soil Absorption System (SAS) (locate on site p|en, excavation not required):
If SAS not located, explain why:
C om -ionwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
202 Foster Street
_ —......� _ ...... .....
Property Address
Katherine M. Cain
Owner Owner's Name
information is Ma. 01845 6-10-1.4
required for everyo_Andover
page. City/Town State Zip Code Cate of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length: - -
1 field 21'wide
® leaching fields number, dimensions: 45' Ion
❑ overflow cesspool number:
❑ innovative/alternative system
i
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
good none none no grassy
back yard area -
i
i
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NIA
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•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'q 202 Foster Street
Property Address
Katherine M. Cain
Owner Owner's Name
information is No Andover Ma. 01845 6-10-14
required for eery —_.:.._.._... ___....- ----..,..,.. ..._ __.....,.. �.
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)-,
Privy (locate on site plan):
Materials of construction: NIA
Dimensions
Depth of solids ___...
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Usposal System•Page 14 0 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
202 Foster Street
Property Address
Katherine M. Cain
Owner Owner's Name
information is
req tairedfor every No. Andover Ma, 01845 6-10-14
-.. ----- ------ --
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
.J,
GH
lack '
Ab = L�
74
G i
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 17
Cotnnnonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form - Not for Voluntary Assessments
a, 202 Foster Street
Property Address
Katherine M. Cain
Owner Owner's Name
information is NoAndover Ma. 01845 6-10-14
required for every .
page.
W._... ---....._.
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: $' Soil Logs- Perc Rate 4minlinch
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 propertylobservation 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:
All liquid levels were gond No Sump Pump Basement was dry „Soil Logs
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5in5•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of W
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
202 Foster Street
Property Address
Katherine M. Cain
Owner Owner's Name
information is
required for every No. Andover Ma. 01845 6-10-14
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p2ge. City[Town State Zip Code Date of Inspection
E. Report Completeness Checklist
M 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
15ins-3113 Title 5 Official trispection Form:Subsurface Sewage Disposal System-Page 17 of 17