HomeMy WebLinkAboutTitle V Inspection Report - 537 BOXFORD STREET 6/7/2018 Commonwealth of Massachusetts
r_ Title 5 Official Inspection Form
� Subsurface Sewage disposal System Form - Not for Voluntary Assessments
537 Boxford Rd
Property Address
10
Jim Baptiste
ists
Owner Owner's Name""
information is North Andover MA 01845 5-2-2018 j
required far every
page. CltylTown 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
filling out forms General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not John DlVincenzo
use the return Name of Inspector
key.
J and S Development Corp/Stewarts Septic
r Company Name
58 South Kimball ST
Company Address
BradfordMA 01835
City/Town, State Zip Code
978-372-7471 s113386
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:
❑ Passes Z Conditionally Passes ❑ Fails
❑ e F her v lua 'on by the Local Approving Authority
5-2-2018
-- -----.....-----_----
Inspector'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 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 l
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
i
t5ins.doc•rev.6116 Title 5 Official Inspection d=orm:Subsurface Sewage Disposal System•Page 1 of 17
r Commonwealth of Massachusetts
Title 5 Official Inspection For
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
n
t
537 Boxford Rd
Property Address
Jim Baptiste
Owner Owner's Name
information is City/Town
5 5-2-2018
required far every .. _. MA 0_ ...— State Zi C - _., .,..__ ....
North
page Cit n p ode Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E I 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:
13) 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 F] N ❑ ND (Explain below):
I
i
15tns.cloc•rev.6116 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
i
Commonwealth of Massachusetts
❑.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
537 Boxford Rd
Property Address
Jim Baptiste
Owner owner's Name
information is North Andover MA _ 01845 5-2-201$
required for every _.._. _....,, --
page. City/Town 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 (cont.):
❑ 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):
Box needs re Facing , leaking around outlet inverts
❑ 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):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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
15.303(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
15ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
|
|
�
d�- Commonwealth of Massachusetts
��"��0�� �� �=����°�����0 N���������*��~���� ����0°�8M�
Title �� ��o� � ������� Inspection N-��mm� �
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
537 �oxfondRd
Property Address
Jim Bap U ha
Owner Owner's Name
information is
required for every
North Andover MA 01845 5-2-2018
------ ---- ---�--
page. state Zip Code Date ovInspection
B. Certification (cont.)
2. System will fail unless the Board of Health (smd Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
F-1 The system has a septic tank and soil absorption system (SAS) and the SAS iawithin
1OOfeet ofasurface water supply ortributary toasurface water supply.
n The system has a septic tank and SAS and the SAS is within a Zone 1 of public water
supply.
n The system has oseptic tank and SAS and the SAS iswithin 5Ofeet Vfa private water
supply well.
Fl
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 w*||°°
Method used hodetermine distance:
** This system passes ifthe well water analysis, performed at a DEP certified |abona\ory, 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. Aoopy of the analysis must
be attached tothis form.
3. Other:
O} System Failure Criteria Applicable boAll Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yea No
�� �8 Baokupofsewage into facility orsystem component due hocmadoadedor
�� �� clogged SAS orcesspool
�� �� Discharge orponding of e� surface waters
�� �� due toonoverloaded orclogged SAS or cesspool
�
� �� 8taUcliquid level inthe distribuUonbox above oudetinve�due tVanoverloaded
�� �� or clogged GAS or cesspool
Fl �� Liquid depth in cesspool is less than U'' below inve�oravailable volume is |000
�� �� than 1/2 day flow
mms oo"'rev,ans Title oOfficial Inspection Form:Subsurface Sewage Disposal System`Page"u1r
a Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
537 Boxford Rd
Property Address
Jim Baptiste
Owner Owner's Name
information is 01
Andover MA 45 -2-2018
required for every North Aw.........._ - ..,.....-_._ _..._ _ ..8..._..., 5
_ _ ... . .....___ l
page. City/Town State Zip Code Date of inspection —
B. Certification (cont.)
Yes No
❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ E 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.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® 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.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ❑ 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-doe-rev.6/16 1itle 5 Official inspection corm:Subsurface Sewage Disposal System•Page 5 of 17
�
�
�* Commonwealth of Massachusetts
Title 5 Official
Inspection Form
Subsurface Sewage Disposal SystamnFqrnn -No(fnrVo|umtaryAeaeaaments �
587Boxford Rd
Property Address
Jim Baptiste
Owner Owner's Name
infomnminnim
North MA 01845 5-2-2018
required for - - ---- '---��--
oG1a� �i��o�� ooVemmepo�mo
o kyrrmwo
page. ~ --� ^ �
C. Checklist
Check ifthe following have been done. You must indicate^vea or"no" estoeach Vfthe following:
Yea No
0 El Pumping information was provided by the owner, occupant, orBoard of Health
El 0 Were any ofthe system components pumped out inthe previous two weeks?
Z El Has the system received normal flows inthe previous two week period?
Fl ��
Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were aobuilt plans ofthe system obtained and examined? (If they were not
available note aeN/A)
E El Was the facility urdwelling inspected for signs ofsewage back up?
N R Was the site inspected for signs ofbreak out?
• E] Were all system components, excluding the SAS, located on site?
• FJ 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 ofsludge and depth ofscum?
�� VVgethe facility ovvner(and occupants ifdifferent hnmowner) provided vvith
�� �� information on the proper maintenance of subsurface sewage disposal systems?
The size and location mfthe Soil Absorption System (SAS) nnthe site has
been determined based on:
• El Existing information, For example, a plan at the Board of Health.
�� Fl `
Uebarminedinthe�ald /ifenyofthe failure criteria related toPed(� ieetissue
�� �� approximation ofdistance isunacceptable) [31OCMR 15.3O2(5)]
D. System Information
Residential Flow Conditions:
|
44
/
Number of bedrooms (design): -------- Number nfbedrooms (actual): ------����
440
OES|(�NUowbased on31OCK8R15203 (for example: 11Ogpdx#ofbedroomo): -��=-==�---
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
537 Boxford Rd
Property Address
Jim Bap
-- Baptiste
Owner Owner's Name
information is MA 01845 5-2-2018
required for every North Andover . ......-
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 F1 Yes E No
information in this report.)
Laundry system inspected? El Yes E] No
Seasonaluse? El Yes F] No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
recommend removal of qar_bage disposal
Sump pump? El Yes E No
Occup
Last date of occupancy: Date led
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): .............
Grease trap present? El Yes Ej No
Industrial waste holding tank present? El Yes F] No
Non-sanitary waste discharged to the Title 5 system? F1 Yes El No
Water meter readings, if available:
15insAoc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys(ern-Page 7 of 17
Commonwealth of Massachusetts
(-!P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
537 Boxford Rd
Property Address _.
Jim Baptiste
- _ _. _ ___ _ _._....
Owner Owner's Dame
information is North Andover MA 01845 5-2-2018
required for every _. ._. ........._. _ ....._ .. _ ..__.. ... ._..
page. Cityl..Town. State Zip Code Date of In
D. System Information (cont.)
Last date of occupancy/use: Date ........
Other(describe below):
General Information
Pumping Records:
Source of information: Andover septic
Was system pumped as part of the inspection? Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? site uage on truck
Reason forpumping: ins ect tank
_... _. . ........_
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
El 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) and a copy of latest
inspection of the I/A system by system operator under contract
i
® Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
15ins.doc•rev.6116 Title 5 Official Mspeciion Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
537 Boxford Rd ..... .
Property Address
Jim Baptiste
Owner Owner's Name
information is North Andover MA 01845 5-2-2018
required for every ---------
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? F-1 Yes M No
Building Sewer(locate on site plan):
24"
Depth below grade: feet - -----------
Material of construction:
0 cast iron [140 PVC El other(explain):
Distance from private water supply well or suction line: ----------
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
B.T.G
Depth below grade: feet
Material of construction:
E concrete F-1 metal El fiberglass El polyethylene R other(explain)
5-5 x5-5 x10-6"
.............. ..... ------------........... ......... ..............
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) R Yes El No
Dimensions: ------- --------- ............
Sludge depth:
l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage disposal System Form - Not for Voluntary Assessments
537 Boxford Rd _.._
Property Address
Jim Ba Iste._u......
Owner
Owner's Name
information is North Andover MA 01$45 5-2-201$
required for every _.._ _. ---.._._. _.
page, CltylTown 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
0
Scum thickness _ __-
6"
Distance from top of scum to top of outlet tee or baffle —_
14"
Distance from bottom of scum to bottom of outlet tee or baffle _
How were dimensions determined? tape measure , sluge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both baffles good , no leakage ,liquid level good
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete Q 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 doe•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
== Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/n
r.;� ❑ 537 Boxford Rd
Property Address
Jim Baptiste
Owner Owner's Name
information Is North Andover MA 01845 5-2-2018
required for every - .. .. .—�_ _- _ ....
page. City/Town 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:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity.
gallons
n
Desi Flow:
Design gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: _ _ Alarm in working order: ❑ 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? ❑ Yes ❑ No
t5ins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
«�~ Commonwealth of Massachusetts
Title=�"°��0�� �� �=����°�*=��0 0���������m��~���� ����U����
�� �°�� � ������� �mm���������N��mm Form �
Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments �
�
537Boxford Rd �
Property Address �
JimBo dhe
Owner Owner's Name
information is
required for every North Andover MA 01845 5-2-2018
page. City/Town State Zip Code DammInspection �
D. System Information (cont.)
Distribution Box (if present must beopened) (locate onsite p|an):
Depth ofliquid level above outlet inve -
�
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence ofleakage into orout ofbox, ebz):
No solidsr leakage around outlet in,vlertls
Pump Chamber(locate onsite p|an):
Pumps inworking order: Fl yes F] No*
Alarms inworking order: Fl Yes Fl No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not |ooated, explain why:
15io~uoe'rev,611m Title aOfficial Inspection porm�nub"m"ceSewage Disposal System'Page Qmv
Commonwealth of Massachusetts
ix rtTitle 5 Official Inspection Farm
=.. T Subsurface Sewage Disposal System Form Not for Voluntary Assessments
537 Boxford Rd _
Property Address
Jim Baptiste
Owner Owner's Name -
information is North Andover MA 01845 5-2-2018
required for every ._.._.._. ..__- - . ......... _.. — ......... _ . _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: ....
❑ leaching chambers number: -- _
❑ leaching galleries number: -
❑ leaching trenches number, length:
1-20x30
® leaching fields number, dimensions: -
❑ overflow cesspool number: —........_...
❑ innovative/alternative system
Type/name of technology: _..............
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No hydraulic failure , nooonnding , no dam soils
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 13 of 17
Commonwealth of Massachusetts
a� Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
537 Boxford Rd
Property Address _
Jim Baptiste
Owner Owner's Name
information is North Andover MA 01845 5-2-2018
required for every _._ -__......_ _ _. _..
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: __ . _
Dimensions --
Depth of solids — . . .......
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6116 Title,5 Official Inspection form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
wn Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
537 Boxford Rd
Property Address
Jim Baptiste
Owner Owner's Name
information is North Andover MA 01845 5-2-2018
required for every ........ _ _.
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
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
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
'.~ Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
537 Boxford Rd
Property Address
Jim Baptiste
Owner Owner's Name
information is North Andover MA 01845 5-2-2018
required for every _.._.rt _ _._ .......__.. — _.. _ ....,._ _.._
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Site Exam:
® Check Slope
❑ Surface water
Z Check cellar
❑ Shallow wells
6'+
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
n Ian reviewed: 11-5-07 TV 4-22-13 TV
If checked, date of design p Date
Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
,Lulled.files
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
Taken from_previous title 5
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6116 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 16 of 17
A ,k Commonwealth of Massachusetts
go Title 5 official Inspection Form
_w 7 Subsurface Sewage Disposal System Forma Not for Voluntary Assessments
' 537 Boxford Rd
Property Address
Jim Baptiste
Owner Owner's Name
information is North Andover MA 01845 5-2-201$
required far every --_ _,_.....__.. ._.__... _ - ..........._.
page, CityfTown State Zip Code Date of Inspection
E. Report Completeness Checklist
E 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
I
15ins.doe-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17
ry
Town of North Andover
HEALTH DEPARTMENT
CHECK#: DATE:
LOCATION:
H/O NAME:
CONTRACTOR NAMEV,:
jy2�g of Permit 9E.LicensD(Check box)
• Animal
• Body Art Establishment
• Body Art Practitioner $
0 Dumpster
0 Food Service-
0 Funeral Directors
• Massage Establishment $
• Massage Practice
• Offal(Septic)Hauler
• Recreational Camp
• Sun tanning
• Swimming Pool,
• Tobacco
• Trash/Solid Waste Hauler $
0 Well Construction
SEPTIC_5�stem�.-
0 Septic-Soil Testing
0 Septic-Design Approval
0 Septic Disposal Works construction(DW0 $
D Septic Disposal Works Installers(DWI) $_
0 Title 5 Inspector $
Title 5 Report $
0 Other:(Indicate)----- $
00,01",
Heaft/tAgent Initials
White-Applicant Yellow.-Health Pink--'Treasurer
...............