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Home My WebLink About- Title V Inspection Report - 59 WILLOW RIDGE ROAD 10/24/2018 Commonwealth of Massachusetts RECEIVED Title 5 Off idal Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Gf 2 4 Z 0 18 59 Wlllow Rid TOWN OF NORTH ANDOVER — Ridge Rd AfTMENT—_ Property Address Ll Robinson Owner Owner's Name information is required for every No. Andover MA 01845 10-09-2018 ...................... ......... 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 filling out forms A. Inspector Information on the computer, use only the tab John DiVincenzo .......... key to move your Name of Inspector cursor-do not use the return J & S DevelopMent/Stewart's Septic..Service key. Company Name 58 So, Kimball St. ............ rab Company Address Bradford MA 01835 City/Town State Zip Code 978-372-7471 S113386 Telephone Number License Number .............. B. Cerfification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CIVIR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the systern: 1. M' Passes 2. El Conditionally Passes 3. E] Needs Further Evaluation by the Local Approving Authority 4, El F Spector Sign turb ...... Date The system inspector s"ll suh, 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority, .......... Please note: 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. t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 59 WIllow Ridge Rd ............. Property Address Robinson Owner Owner's Name information is required for every "No. Andover MA 01-845 10-09-2018 page. ityrrown State Zip Code Date of Inspection C. In.,spection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: ...........11................... ..................... 2) System Conditionally Passes: El 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. F1 Y n N F1 ND (Explain below): --------------------------- ---------- .................................. -------- ------------------ t5insp.doe-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commormealth of Massachusetts Title 5 Off IcIal Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 59 Willow Rid ge.-R.,d- Property Address Robim cn ............................ Owner Owner's Name information is required for every No. Andover MA 01845 10-09-2018 page. City/Town State Zip Code Date of Inspection C. lns�pledon Summary (cont.) 2) Systarn Conditionally Passes (cont.): F-I Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. FI 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): 0 broken pipe(s) are replaced 0 Y 0 N F-I ND (Explain below): El obstruction is removed ❑ Y F-I N n ND (Explain below): distribution box is leveled or replaced F-I Y El N ❑ ND (Explain below): . .............. ............................ E 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): El broken pipe(s) are replaced R Y F-I N FIND (Explain below): ❑ obstruction is removed 0 Y F-1 N F-1 ND (Explain below): ................ .............. 3) Further Evaluation is Required by the Board of Health: El 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System-Page 3 of 18 e�� x�oy��]nV�ea�h of Massachusetts ��0 �� `��° o H � ��° �� 8 �� 0��H�� N�� W�0�� @ �� /Q � � � �� m �� n��m�� mm �� m��mm ��wmmm Subsurface Sewage Disposal System Form NotforVo|untmryAs��aam�nte 5gVV|Uow Rid Rd Property Robinson Owner Owner's Name information is required for every No. Andover MA 01845 1009 page. City[Tmwn State Zip Code Date ufInspection C. Inspe-,c-t^on Summary (cont.) [] Cesspool or privy ia within 5O feet ofe Surface water � [] Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ! L System will fail unless the Board of Health (and Public Water Supplier, if any) � determines that the system is functioning in m manner that protects the public health, � a�fetyand environment: | Fl The (SAS) and � �� ` � 10O feet cJa surface water supply or tributary toa surface water supply. � �] The system has a septic tank and SAS and the SAS is within o Zone 1 of public water | uupp/y. � [] The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. [] The myetann has a septic tank and SAS and the SAS is less than 1OO feet but 5O feet or more from a private water supply we|l* Method used tndetermine distance: 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. Acopy of the analysis must be attached to this form. c. Other: / i � 4) System Failure Criteria Applicable to All Systems: � You must indicate "Yes" or"No" bm each mfthe following for all inspections: � Yes No [�Fl Backup of sewage into haoi|Uyorsyahsnn component due toovedmadedVr �� ~ clogged SAS orcesspool �l �� Discharge ocpondingof effluent to the ou� � wat ers �� due toan overloaded or clogged SAS orcesspool mms^.d^"'rev.nm6/2010 Title o Official inspection Form:Subsurface Sewage Disposal System'Page 4",m Commonwealth of Massachusetts mTitle subsurface Sewage Disposal System Form Not for Voluntary Assessments 59 Willow Ridge Rd______ Property Address Robin ron Owner Owner's Name _.—__..__._._.�__......_ .......... __.,,. information is No Andover MA 01845 10-09-2018 required for every _,_.. . m...._........_.._.w ...._ ..m__.____. ..._m....... . ..._..__.._ _._ page, City/Town State Zip Cade Date of Inspection_ C. Inspection Summary (coat.) 4) Systein Failure Criteria Applicable to All Systems: (cant.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: 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 water supply I _9 well. r".wl FX1 Any portion of a cesspool or privy is within 50 feet of a private water supply well El Z 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 forma The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. El ® 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. 5) 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 CA. 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 El El the system is located in a nitrogen sensitive area (interim Wellhead Protection Area— IWPA) or a mapped Zone 11 of a public water supply well t5insp.doe•rev.7/26/201 B Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Off"Icial Inspection Form Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 59 Willow-Ridge Rd Property Address Robinson .......... Owner Owner's Dame information is No Andover MA 8 10-09-2018 required for every 01 _..._._ .,,,...._, . .___45_._......� ..__..__._ page. CItylTown State Zip Code Date of Inspection C. I speo-° i Summary (cunt.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed undrsr "action CA sh211 upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the department. 6. You niust indicate "yes" or"no" .for each of the following for all inspections: `(es No Cy F-1 Pumping information was provided by the owner, occupant, or Board of Health 13 r7l Were any of the system components pumped out in the previous two weeks? C ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as NIA) ED ❑ Was the facility or dwelling inspected for signs of sewage back up? 1. 1 El W�--,s the site inspected for signs of break out? l ) ❑ Were all system components, excluding the SAS, located on site? A U 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 of liquid, depth of sludge and depth of scum? Z El Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. LRl ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev,7126/2,018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts T atie 5 Offmcoal Inspect'on Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments fw -519--Wl I low_Ridge_Rd Property Address Robin on Owner Owner's Narne information is required for every No, Andover MA 01845 10-09-2018 page. "eky-IT- own- State Zip Code Date of Inspection D. Systern Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 4 DESIGN flow based on 310 CIVIR 15.203 (for example: 110 gpd x#of bedrooms): 600 Description: .............................................................................................................................. ....................... ------ Number of current residents: Does residence have a garbage grinder? Yes El No Does residence have a water treatment unit? 0 Yes F-1 No If yes, discharges to: Is !:,,undry on a separate sewage system? (Include laundry system inspection ❑ Yes 2 No information in this report.) Laundry system inspected? El Yes F-1 No Seasonal use? ❑ Yes M No Water meter readings, it available (last 2 years usage (gpd)): . ......................- Detail: .......... Sump pump? ® Yes El No Occ Last date of occupancy: Date pied -u t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts P We 5 Off Ocnal Inspection Form To 1 0 Subsurface Sewage Disposal System Form Not for Voluntary Assessments i 59WIllow dgeRd R_ - 11.. ............ .......... Property Address Robin,,= Owner Owner's Name information is required for every No. Andover MA 01845 10-09-2018 ............. page. City/Town State Zip Code Date of Inspection D. Systorn Information (cont.) 2. Commorcial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/pe rsons/sq.ft., etc.): .......... ........................................ Grease trap present? El Yes El No Water treatment unit present? Fl Yes R No If yes, discharges to: Industrial waste holding tank present? F] Yes R No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: ..................... Last date of occupancy/use: Date Other (describe below): .......................... .......................... . .....................--_---------__ .................. 3. Pw,rrplrig Records: Sourco, of information: Stewart's Was system pumped as part of the inspection? M Yes F] No If yes, volume pumped: 1000__ ............. gallons Flow was quantity pumped determined? Site gauge on truck ---__----- Reason for pumping: inspect tank t5insp.doc-rev.712812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 4, M1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,;� ;%� 59 Wlllow Ridge Rd Property Address Robinscn Owner Owner's Name _..... .......____._.....___ information is No Andover MA 01845 10-09-2.018 required for every _..._...._......... page. City/Town State Zip Code Date of Inspection D. Systurn Information (cont.) 4. Typ&o1 System: Septic tank, distribution box, soil absorption system I� Single cesspool Overflow cesspool L Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) LEI 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 .J Tight tank. Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: 1976 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. BuHding Sewer (locate on site plan): Depth below grade: 18" _ ... ._._ .......... feet Material of construction: El cast iron [J 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet_.._..._. ------ Comments (on condition of joints, venting, evidence of leakage, etc.): l5insp.doc•rev.7/2612018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 9 of 16 Commonwealth of Massachusetts Title _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Y 59 WIIiow Ridge Rd Property Address Robinson Owner Owner's Name information is No. Andover MA 01845 10-09-2018 required for every Andover--.-,,,,,,,,,,, .. .. _...... ..._..._.. ....,......__ page City/Town State Zip Code Date of Inspection D. Systern Information (cunt.) 6. Sepdc Tank (locate on site plan): Depth below grade: 6" et Material of construction: j concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years ---- - Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5X8x48" Sludge depth: 8" ._._. _...__... _........... _. ....._ Distance from top of sludge to bottom of outlet tee or baffle 22" Scurn thickness 1" Distance from top of scum to top of outlet tee or baffle 5" 18" Distance from bottom of scum to bottom of outlet tee or baffle ........_ .......... How were dimensions determined? tape measure/sludge 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.): 2u(KI baffles are in gocft...._hape.No leakage, laic uid levels are good 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 ,T"� Commonwealth of Massachusetts TWe 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 59 Wlilow_Ridqe Rd -------------......... Property Address Robinson Owner Owner's Name information is required for every No. Andover MA 01845 10-09-2018 .......... ........... - ----.1-1 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: -fe I et Material of construction: concrete r-1 metal ❑ fiberglass ❑ polyethylene F-1 other (explain): Dimensions: --------------------------- Scurn 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 Cornments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ----------- ...... .............. 8, Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: D concrete 0 metal El fiberglass M polyethylene ❑ other(explain): Dimensions: Capacity- -g.a 11 o n s ------------ Design Flow: I-g-allons per day t5insp.doc rev.7/2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title A I.Y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Willow Rid e Rd Y Property Address Robinson Owner Owner's flame information is No. Andover NIA 01845 10-09-2018 required for every ............_ ..._. — page. city/-rown State Zip Code Date of Inspection D. E,'jysteni Information (cunt.) 8. Tight or Holding Tank (cant.) Alarm present: ❑ Yes ❑ No Alarm level: _..__._.__..... Alarm in working order: ❑ Yes ❑ No Dale of last pumping: -... _..__.__ Date Comments (condition of alarm and float switches, etc.): h Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Cc rni-nants (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): ECIua1 distribution, no leakage or solids carryover t5insp.doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts ---- ----- ----- Title 5 Off Icial Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 59 Willow Ridge Rd ............. ........... ............... Property Address Robinson Owner Owner's Name information is required for every No. Andover MA---------- 01845 -1 0-09720 18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No* Alarms in working order: E-1 Yes E-1 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. 11 Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ...................... ........... Type: El leaching pits number: El leaching chambers number: ....... U leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: 20 X 45 ❑ overflow cesspool number: El innovative/alternative system Type/name of technology: t5insodoc-rev.7/2612018 'title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 13 of 16 Commonwealth of Massachusetts irkMile 5 Official Inspection Form 4. Subsurface Sewage Disposal System Form Not for Voluntary Assessments 59 Willow Ridge Rd Property Address Robinson Owner Owner's Name information is required for every No. Andover -MA 01845 page. btyiT-o w n........ State Zip Code Date of Inspection .......... D. Systum Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure, no ponding, no damp soils ........ ------------- - -1-1-11-- ---------------- .......... --------------------------- —--------- 12. Ces-spools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration ---------------1.1-1-11--- --- 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 n Yes F-1 No Corj�j..rj(�JrJLS I (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, ............. ............. --- -------- ................ ---- —---------------- ........ ----------- t5insodoc rev,7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 c Commonwealth of Massachusetts — n Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 59 Willow Ridge-Rd ....._. Property Address Robin,>on Owner — Owner's Name information is No Andover MA 01845 10-09-2018 required for every _..._ .........._..__. _�_____w_ page, City/Town State Zip Code Date of Inspection D. Systern Information (cont.) 13. PHvy (locate on site plan): Materials of construction: Dimensions _..._ Depth of solids ........ _. Cori m0aeats (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, t5insp.cloc-rev.712612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Tffle 5 Official Inspection Form �4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 69 Willow Ridge Rd -Property Address Robinson OwnerOwner's Name information is required for every No. Andover MA 01845 10-09-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14, 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: ER/hand-sketch in the area below F] drawing attached separately '7v yrl ec,e4 33, 6 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 Commonwealth of Massachusetts LL .--W i Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �? 'l 59 Willow Ridge Rd Property Address Robinson Owner owner's Name information is No Andover MA 01845 10-09 2018 required for every _....._ _,,,_..... ..._... _ page, Cityrrown State Zip Code Date of Inspection D. Systern Information (cons.) 15, Site L:xam: Check Slope EI .surface water ZJ Chick cellar [_j Shallow wells Estimated depth to high ground water: 6 feet Please indicate all methods used to determine the high ground water elevation: GXi Obtained from system design plans on record If checked, date of design plan reviewed: 1976 Date Observed site (abutting property/observation hole within 150 feet of SAS) ! 'J Checked with local Board of Health -explain: Fulled file LJ Checked with local excavators, installers - (attach documentation) (� Accessed USCS database-explain: You rnust describe how you established the high ground water elevation: Ar(r a of leachfield raised above origina} ground M-:f'ore fiiing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doe-rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts TWe 5 Offico"al Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 59,WIHOW Ridge Rd Property Address Robiri�cn Owner Own,er's Nam.e ........ information is required for every No. Andover MA 01845 10-09-2018 page. City/Town State Zip Code, Date of Inspection E Repci Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked LXJ C. inspection Summary: '1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed R1 D. System information: For 8: Tight/Flolding 'rank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doo-rev.7/2612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 oq Town of North Andover HEALTH DEPARTMENT CHS, CHECK #: /J/�� , LL) DATE: (9 LOCATIONo H/O NAME: CONTRACTOR NAT\4E 0 A0 Type of Permit or License: (Check box) 0 Animal 0 Body Art Establishment 0 Body Art Practitioner 0 Dumpster 0 Food Service- 0 Funeral Directors 0 Massage Establishment 0 Massage Practice 11 Offal(Septic)Hauler 0 Recreational Camp 0 Sun tanning 0 Swimming Pool 0 Tobacco 0 Trash/Solid Waste Hauler 0 Well Construction SEPTIC Systems: 0 Septic-Soil Testing $ rl Septic-Design Approval 0 Septic Disposal Works Construction(DWQ EJ Septic Disposal Works Installers{DWI) 0 Title 5 Inspector , Title 5 Report f-11 0," $5,0 ........ 0 Other. (Indicate).-___ f Health Agent Initials Whites Applicant Yellow-Health Pink Treasurer