HomeMy WebLinkAboutTitle V Inspection Report - 95 CAMPBELL ROAD 9/11/2017 r
Coimmonweblth of Massachusetts
_ Title 5 official Inspection Form
VM
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Campbell Road
i
Property Address
Michael Rice
'
Owner Owner's Name
Information is North Andover Ma 01845 7-26-17
required for every
page, Cify/Town State zip Cade Date of Inspection
on this form. Inspection forms may not be altered in an
� Inspection results-must be submitted p Y Y
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 John DiVincenzo
use the return Name of Inspector
key. J Ad S Development Corp/Stewarts Septic Service �
rs6 Company Name
58 South Kimball St
Company Address
Bradford _ MA 01835
City/Town State Zip Code
978-372-7471 s113386
Telephone Number License Number
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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
El Need Further valuation by the Local Approving Authority
----------
In sp ors Signature Dake
Th 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 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.
tSins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
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Cornmonwebtth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
am
95
Campbell Road
P
Property Address
P Y
Michael Rice
Owner Owner's Name
information is North Andover Ma 01845 7-26-17
required for every
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.
Col?lments:
The distribution box was replaced
i.
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):
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t5lns.doc•rev.`6116 Title 6 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
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