HomeMy WebLinkAboutTitle V Inspection Report - 350 BERRY STREET 8/21/2017 RECEIVED
Commonwealth of Massachusetts
Title 5 Official Inspection Form Tow"OFNWHANDOVIM
IjEALM
0 Subsurface Sewage Disposal System Form Not for Voluntary Assessments DEPARNEW
350 Berry Street
Property Address
Scott Wright
Owner Owners Name
information is North Andover MA 01845 8-11-2017
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. General Information
filling out forms
on the computer,
use only the tab 1 Inspector:
key to move your
cursor-do not Neil James Bateson
use the return ----------
Name of Inspector
key. Bateson Enterprises Inc.
4L CompanyName
111 Argilla Road
Company Address
rshm Andover MA 01810
City/Town State Zip Code
978-475-4786 SI-15
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:
0 Passes El Conditionally Passes El Falls
E] Needs Further Evaluation by the Local Approving Authority
1'7 tA8-11-2017
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 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 DER 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.doc-rev.6116 Titfe 5 Official 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
Y
350 Berry Street
Property Address
Scott Wright
Owner Owner's Name
information is
required for every North Andover MA 01845 8-11-2417
page. CitylTown State Zip Code tate of inspection
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:
After permit from B.O.H., install new outlet tee in septic tank,new riser over inlet cover on septic tank,
new outlet pipe to d-box& new d-box with risers, 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•!'age 2 of 17
Commonwealth of Massachusetts
C[tyfrown of .
System Pumping.Record
Form 4
DEP has provided this forrri 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
focal 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. Facloty. information
'f. System Locatian:�Righ# tont eaf Piou , Left 1 Right rear of house, Leff I right side of house, Left/
Right side of building, Left 1 Right cont of building, Left/Right rear of building, Under deck
- Address � �.�.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Citylrovsrn _ Stats .� _ Zip Code ,
Telephone Number � K
1
.B, Pumping Record
1, Date of Pumping date 2. Quantity Pumped. Gallons N
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present's ❑ Yes If yes,was It cleaned? ❑ Yes ❑ No
5. Condition of System•
6 System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
.
Bateson E nteTrises Inc
Company
7. Locatio where contents-were disposed:
GL S: Lowell Waste Water
"o
SignAije I HbU14 mate
I
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