HomeMy WebLinkAboutTitle V Inspection Report - 25 HOLLOW TREE LANE 8/15/2018 Commonwealth of Massachusetts
REVED
Title 5 Official Inspection Form CEI
Subsurface Sewage Disposal System Form Not for Voluntary Assessments A[K' 1 ,5
25 Hollow Tree Lane MWNOF,N044H ANPOV�":,�
Property" - - -Address - HEALTH I)EPARTMEN'r
Larry Fixier
OwnerOwnersVa
information is
required for every North Andover -------- MA 01845 8-6-2018
page. City/Town 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 A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Neil J. Bateson
use the return Name of Inspector
key. Bateson Enterprises Inc.
VQ Company Name
111 Argilla Road
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Company Address
Andover MA 01810
City/Town State Zip Code
978-475-4786 SI-15
........................ ................
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 16.000).The system:
Z Passes El Conditionally Passes F-1 Fails
❑ Nee s Further Evaluation by the Local Approving Authority
8-672-018-i
p ------
-.-
In ecto Signa 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 DER 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.
t5ins,doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
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uwner Owners Name
information is
required for every North Andover N18 page. � O1845 O-8-2O18
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Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A.B.C.0 or E/always complete all ofSection O
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:
After permit from R.(}.H., replace outlet pipe kzd-box, new outlet tee . newd-box & risers on d-box,
inspection from B.<].H., septic system now passes Title 5 Inspection.
E8> System Conditionally Passes:
�l
One ormore system components asdescribed inthe "Conditional Pass" section need to be
replaced or repaired. The aygtgm, upon completion of the replacement orrepair, 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
dmtermined." 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 ifthe 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 ioless than 2Oyears old inavailable.
El Y E] N Fl ND (Explain below):
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