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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Sherwood Drive
North Andover, MA 01845
Owner George E. Canellakis
information is g
required for 4/26/2011
every page. 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?
N ❑ 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?
p� ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Do ❑ 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.
❑ D� 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): f— Number of bedrooms(actual): -- --
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): =44`10
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