HomeMy WebLinkAbout- - 265 HAY MEADOW ROAD 8/23/2018 1�, Commonwealth of Massachusetts
x Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for VoluntaryAssessmentsc wltt'
iNO �
265 Haymeadow Rd
ii j'k
Property Address
Serrano Renee
ner
Ow
ner's Name
Information is
required for every _. _.No. Andover
MA _ 01645 07-18-2018__._�_ _._—'
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
filling out forms . General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not JohnDlVincenzo
use the return
key. Name of inspector
J and S Development/Stewarts Stic Service _
rib Company Name
58 South Kimball St
Company Address
n Bradford
_ __. .._..._... _._...._._�..... MA._..__...___.__.___....._ 01835
State Zip Code
978-372-7471 S113386
TelephoneNumbar
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
❑ Conditionally Passes E3 Fails
❑ Needs Further Evaluation by the Local Approving Authority
Ins 's Signature — -- —
Date
The/system inspector s a submit a copy of this inspection report to the Approving Authority(Board
ofh or DEP)within 30 days of completing this inspection. If the system has a design flow of
10gpd 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 under
the same or different conditions of use.
Wns.doc•rev.6/16
"title 6 Official Inspedon Form:Subsurface Sewage Disposal Sysiem-page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
. ..... Subsurface Sewage Disposal System Form Not for Voluntary Assessments
265 HpyTeadqw Rd
Properly Address
Serrano, Renee
Owner Owner's Name
information Is
required for every No. Andover MA 01845 07-18-2018
page. Cityfrown State Zip Code DateofInspection
B. Certification (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 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Distribution box wasrelaced__
B) 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,
R Y F1 N n ND(Explain below):
t5ins.doe•rev,6116 Title 5 official Inspection Form*Subsurface Sewage Disposal System-Page 2 of 17