HomeMy WebLinkAboutTitle V Inspection Report - 93 ROCKY BROOK ROAD 6/11/2018 j
Commonwealth of Massachusetts
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Title 5 Official Inspection Farm fr
Subsurface Sewage Disposal System Farm Not for Voluntary Assessments93 ,
ky Property ARocky d Brook Road
Matthew Drury
Ownerowner's Name
information is Niorth Andover MA 01845 5-29-20118
required for every
page. City/Town State Zip Code Date of Inspection
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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 --._. ___.----....------- _. _.__n____--------------
key. Name of Inspector
Bateson Enterprises Inc.
WAQ Company Name
111 Argilla Road
Company Address
. _An_d_over 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 inspect on
was performed based on my training and experience in the proper function and maintenance of on'sit
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
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❑ Needs Further Evaluation by the Local Approving Authority
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.5-29-20,18
Insp ct s 'gnatur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Boa d
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 un er t
the same or different conditions of use.
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 c f 17
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' - - __ _ _ Official Inspection
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
93 Rocky Brook Road
Property Address
Owner Owner's Name
information is
required for every '~'"'"' "''°,,^r
----
page. ~r'~~^ State Zip
Code Date of InspectionB. Cortificaffion (cont.)
Inspection Summary: Check A,B,C,D or E always complete all of Section D
A) System Passes:
1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.3G4,exist. Any failure criteria not evaluated are
indicated below.
After permit from B.O.H., install new inlet tee, inlet cover&d-box, septic system now passes Title 5
13) System Conditionally Passes:
F1 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 )y
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 structu-ally
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 o
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate o
Compliance indicating that the tank is less than 20 years old is available.
El Y nN n ND (Explain below):
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t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2?o I f 17
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