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OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 59 Rocky Brook Road_
_North Andover—
Owner: Powell_
Date of Inspection:_9/27/2003_
FLOW CONDITIONS
RESIDENTIAL
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):_660_
Number of current residents:_4
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no):_No_
Laundry system inspected(yes or no):
Seasonal use:i(yes or no):—No_
Water meter readings: Yes_
Sump pumps(yes or no):_No
Last date of occupancy:_Current_
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COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gnd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:—Pumped this year,owner_
Was system pumped as part of the inspection(yes or no):_No_
If yes,volume pumped:Jgallons--How was quantity pumped determined?
Reason for pumping:_
TYPE OF SYSTEM
_X 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)
_Tight tank _Attach a copy of the DEP approval
Other(describe):_
Approximate age of all components,date installed(if known)and source of information:_9 years old,11/30/1994,
As built plan_
Were sewage odors detected when arriving at the site(yes or no):_No
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