The URL can be used to link to this page

Home My WebLink About- Title V Inspection Report - 43 OXBOW CIRCLE 10/31/2018 Commonwealth of Massachusetts Title i I I Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 43 Oxbow Circle Property Address _.._-. Robinson Owner .__.... _ .. ........ Owner's Name information is No. Andover MA 01845 10-02-18 requited for every _._ ....._..__..._ ___....... 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 J & S Development/Stewart s Septic Service use the return -- key. Company Name 58 So. Kimball St, rsh Company Address Bradford MA 01835 CIty/Town State Zip Code 978-372 7471 S113386 Telephone Number License Number ----------- . Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 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 system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Need Further Evaluation y the Local Approving Authority 4, F is 'g I Mature - � '' Date e system inspector shall submit a copy of this inspection report to the Approving Authority (Board o 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 1 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.doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts ��Q �� Official Q Inspection �� Title 0��U�� Q�� @ �� /O � �� @ �� m�� w �� m u�� ° x��ox Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Oxbow Circle Property Address Robinson Vwner Owner's Name information is required for every N �A O��5 1 page. City[Tpwn State Zip Code Date ufInspection C. Inspection Summary Inspection Summary: Complete 1, 2. 3. or 5 and all of and 8. 1) System Passes: I have not found any information which indicates that any of the failure criteria described in31OCK8R15.8O3orin310CKUR15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The distribution box �a re 2\ System Conditionally Passes: Ej one or more system components as described in the "Conditional Pass" section need to be nep|euad o,repaired. The ayatom, upon completion of the replacement or napair, as approved by the Board of Health, will pass. Check the box for"yeo". "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 ifthe existing tank is replaced with a complying septic tank as approved by the Board of Health. ^ A metal septic tank will pass inspection ifit is structurally sound, not leaking and ifa Certificate of Compliance indicating that the tank ie less than 2O years old ioavailable. Fl Y N ND (Explain be|nxx : Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ( 43.,.,Oxbow Circle __.._. .._...___-_ ........ ....... ...._.._....._............. — 'C � t EV—I .. Property Address Robinson _..__. . ....._._.— _.............. _..... Owner _ ..._...._ .___., Owner's Name information is No Andover MA 01845 10-02 18 required for every _....:_ _......_.— _.._.......... 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. Inspector Information filling out forms on the computer, use only the tab John DiVincenzo key to move your Name of Inspector cursor-do not J & S Devel /Stewart Septic Service use the return _.._ opment s _._. 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. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 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 system: 1. © Passes 2. ® Conditionally Passes 3. © Needs Further Evaluation by the Local Approving Authority 4. Fa' i i In ors Si atu �- ° ' Date t TtSe system inspector shal ubmit a opy of this inspection report to the Approving Authority (Board of Health or DEP) within 0 days,-o completing this inspection. If the system has a design flow of 10,000 gpd or greater, the in 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.7/2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ' Title 5 Official Inspection F orm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Oxbow Circle Property Address Robinson Owner Owner's Name information is required for every No. Andover MA 01845 1 1O page. Qkm'm*n �� Zip oa0eof|napemion C. Inspection Summary Inspection Summary: Complete 1. 2. 3, ur5 and all of4 and O. 1) System Passes: [] | have not found any information which indicates that any of the failure criteria described in 310 CK4R 15.303 or in 310 CK8R 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: -------------- 2) 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, am 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 Certificate of Compliance indicating that the tank is less than 20 years old is available. �I y [l N F-1 ND (Explain ba|ow): mmsp.uoc'rev.ruam10 Title o Official Inspection Form:Subsurface Sewage Disposal System'Page emm Commonwealth of Massachusetts lye TitleIInspection - I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Oxbow Circle Property Address Robinson Owner Owner's Name t information is No Andover MA 01845 10-02-18 required far every � .....,_ _.._....,_.. ....__..__..___ page, City/Town State Zip Code Date of Inspection C. Inspection Summary (cons.) 2) System Conditionally Passes (cant.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): Distribution box needs replacing and there is leakage around the 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): ..... ...... ......... i 3) Further Evaluation is Required by the Board of Health: 1 ❑ 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 Commonwealth of Massachusetts ~�~"�� Official � Inspection �� Title B�pU�� 0°0�� N �U�� &�� m�� m� �mm�� ' w m �� u��nm ��mmm � Subsurface SoxxageDispoea| SVatemmFmrmn - NutforVo|umtaryAsoeoamenta 43 Oxbow Circle Property Address Robinson Owner Owner's Name information is mquimdfurove� N A �A�__� O1845 1OO� 1 page. Cd �n State Zip Code Date ofInspection C. Inspection Summary (cont.) [] Cesspool or privy ie within 50 feet ofo surface water Fl Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fall unless the Board mf Health (and Public Water Supplier, \f any) determines that the system is functioning in u manner that protects the public health, safety and environment: El The system has a septic tank and soil absorption system (SAS) and the SAS is within 1OU feet ufo surface water supply or tributary toa surface water supply. n The system has a septic tank and SAS and the SAS is within m Zone 1 of public water supply. [l The system has a septic tank and SAS and the SAS is within 50 feet nfa private water supply well. F] The system has a septic tank and SAS and the SAS is less than 1OO feet but 5U feet or more from a private water supply vve||°° � Method used to determine distance: � This system passes ifthe well water analysis, performed sdaDEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or|aoe than 5 ppm, provided that no other failure criteria are triggered. Anopy of the analysis must be attached to this form. o. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No F| �� Backup of sewage into facility or system component due to overloaded or clogged SAS orcesspool [l �� Discharge orpondingof effluent to the surface of the ground or surface vvahara �� due homn overloaded or clogged SAS orcesspool mmon.doo'rev./uo/2o10 Title o Official Inspection Form:Subsurface Sewage Disposal System'Page 4w10 Commonwealth of Massachusetts w _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Oxbow Circle Property Address Robinson Owner Owner's Name information is No Andover MA 01845 10-02 18 required for every ...�._..__._..._._._.......__ .._... _...._. .___....__... ....... I page. City/Town State Zip Code Date of Inspection C. Inspection Summery (cant.) 4) System Failure Criteria Applicable to All Systems: (cant.) Yes No El ® 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 'Y2 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 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 2000 gpd- EJ 10,000 gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 ® 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 t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts =0�=��0 �� Official Q Inspection �� Title ��U�� N�� W°�� N �� /� @ � @ � �- o �� w��v�� m w�� m��m m Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Oxbow Circle Property Address Robinson Owner Owner's Name information is No Andover MAO1O�5 1U-O2-18 required � ___- ______ page. City/Town Otum Zip Code Date ufInspection C. Inspection Summary (cont.) 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 under Section C.4 shall upgrade the system in accordance with 310 CK8R 16,304, The system owner should contact the appropriate regional office of the Department. O. You must indicate"yes" or"no"for each of the following for all inspections: Yee No Pumping information was provided by the owner, occupant, or Board of Health Were any uf the system components pumped out |n the previous two weeks? 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 port of this inspection? �� VVereae built plans of the system obtained and examined? (If they were not �� available note aeN/4) Z 1:1 Was the facility or dwelling inspected for signs of sewage back up? R Was the site inspected for signs of break out? [l Were all system components, excluding the SAS' located on site? �� [l 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 uf liquid, depth ofsludge and depth ofscum? Was the facility owner(and occupants ifdifferent from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location m7the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, o plan at the Board of Health. �� l Determined in the field (if any of the failure criteria related toPa�� inatissue �� `^ approximation uf distance iaunaonaptob|e) [31UCK8R15M2(5)] Commonwealth of Massachusetts ----------- Thle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Oxbow Circle Property Address Robinson .........------------------------------------------------------------- Owner Owner's Name information is required for every No. Andover MA 01845 10-02-18 ............... ------- page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4-- Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440gpd Description: ----------------- Number of current residents: 4 Does residence have a garbage grinder? Yes ❑ No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes E No information in this report.) Laundry system inspected? El Yes E] No Seasonal use? El Yes Z No Water meter readings, if available (last 2 years usage (gpd)): Detail: ........... Sump pump? ❑ Yes No Last date of occupancy: Occupied Date t5insp.cloc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form tiro Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Oxbow Circle Property Address Robinson Owner Owner's Name information is No. Andover MA 01845 10-02-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2, 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 El No Water treatment unit present? El Yes FI No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes E] No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): ........................ 3. Pumping Records: Source of information: Was system pumped as part of the inspection? El Yes 0 No If yes, volume pumped: ......................... gallons How was quantity pumped determined? Reason for pumping: ------- t5insp.doc•rev.712612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts ~�="��M �� Official M Inspection �� Title Q��U�� R�� &~0�� 0 �8 �� w�8M �� Nun�� ' � �� m m �� n��um Form Subsurface Sewage Disposal System Form - Not for Voluntary Asoemmmant$ 43 (]xhovv Cin:|w Property Address Robinson Owner Owner's Name information is required for every No. Andover MA 01845 10-02-18 page. Q��o°n Smva Zip Code Date nfInspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system Single cesspool �l Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) E] Innovative/Alternative technology. Attach m copy mfthe current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the |/A system by system operator under contract [l Tight tank. Attach G copy ofthe DEPGppnJva|. E-1 Other(describe): Approximate age of all oonoponente, date installed (if known) and source of information: -Built im 1897 er as-built VVave sewage odors detected when arriving at the site? Fl Yea E No 5. Building Sewer(locate on site plan): Depth below grade: 16" feet N1ebario| of construction: R cast iron 40 PVC R other(exp|ain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence ofleakage, etc.): _ ;�, Commonwealth of Massachusetts X wTitle Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 43 Oxbow Circle _.... Property Address_..._.._...... __ Robinson Owner — --.. Owners Name information is required for every No Andover MA 01845 10-02 18 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) 6. Septic Tank (locate on site plan): Depth below grade: 12° feet Material of construction: ® concrete ❑ metal El 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: 13" 5'5" x 10' X 49" Sludge depth: 22" Distance from top of sludge to bottom of outlet tee or baffle __-- Scum thickness 0 611 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" 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.): Both tees are in good shape, no leakage and liquid levels are good. 1 t5insp.doc•rev.7/2612018 Title 5 official hspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts T ft i i'le 5 Offcial Inspecton Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Oxbow Circle Property Address Robinson Owner Owner's Name information is requi. J for every No. Andover MA 01845 10-02-18 red ..........I.-_' ... I——... ___ _ I page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: F-1 concrete ❑ metal El fiberglass El polyethylene El 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 Comments (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: EJ concrete El metal F] fiberglass F-1 polyethylene F-1 other(explain): Dimensions: -------------- Capacity: gallons Design Flow: gallons per day t5insp.doe-rev-7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c; Commonwealth of Massachusetts (fTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Oxbow Circle Property Address Robinson Owner Owner's Name __.___. _._._....__ .....__._ .._.__.__. .........__ information is No Andover NIA required for every 01845 10-02-18_.._. .__._..__ _......_............... page. Cltyrrown State Zip Code Date of Inspection D. System Information (cant.) 8. Tight or Holding Tank (cant.) 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 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of ieakage into or out of box, etc.): Box needs replacing. There's leakage round the outlet inverts. I i 1 i t5insp.doo-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Z' Commonwealth of Massachusetts it 5 Official Inspectiti on Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments tyr 43 Oxbow Circle Property Address Robinson Owner Owner's Name information is required for every No. Andover MA 01845 10-02-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: 0 Yes F-1 No* Alarms in working order: F] Yes M 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: D leaching pits number: F1 leaching chambers number: ............................—-------- E] leaching galleries number: leaching trenches number, length: 2 - 52' El leaching fields number, dimensions: E-1 overflow cesspool number: 0 innovative/alternative system Type/name of technology: t5insp.doo-rev.712612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c Commonwealth of Massachusetts 27 Title 5 Official - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Oxbow Circle Property Address Robinson Owner Owner's Name information is No Andover MA 01845 10-02-18 required for every page. City/Town State Zip Code Date of Inspection I D. System Information (cons.) t 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 leakage around the outlet inverts 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Oxbow Circle —_ ......... .... Property Address Robinson Owner Owner's Name information is No Andover MA 01845 10-02 1$..... required for every No. Andover ._..._....._ _-- _w _ page. City/Town State Zip Code Date of Inspection D. System Information (coat.) i 13. 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.): i 1 t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts . ......... Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments K,0 43 Oxbow Circle ................ ............ ......... Property Address Robinson Owner Owner's Name information is No. Andover MA 01845 10-02-18 required for every 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: ❑ hand-sketch in the area below drawing attached separately ...................... 16insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 Commonwealth of Massachusetts Titlef l Kin Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Oxbow Circle _. .. Property Address Robinson Owner Owner's Name information is No. Andover MA 01845 10-02-18 required for every page. City/Town State Zip Code Date of Inspection —-.......------------- ---.... D. System Information (cant.) 15. Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 6" - - feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1997 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: pulled files ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: System built 4' above ground water. There is no sump pump in basement Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.712612618 title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 16 Commonwealth of Massachusetts -- ----------- �4 ::.-_ p Its 5 Off I al Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Oxbow Circle Property Address Robinson Owner Owner's Name information is required for every No. Andover MA 01845 10-02-18 page. Cityfrown State Zip Code Date of Inspection E. Report 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 Z C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed D. System Information: For 8: Tight/Holding Tank— 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.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 1i 14), Of i z13 ILL 51, O 9 9 f f HdRTH 1 3 ( # A p i Town of North Andover HEALTH (DEPARTMENT pS$AGHU5t1 CHECK DATE; � LOCATION; H/O NAME: CONTRACTOR NAME ' , .,; Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $� ❑ food Service-Type.----- $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC S stems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ Title 5 Inspector $_ 0 Title 5 Reports � � $ ❑ Other:(Indicate) C. Head li Agent Initials; White-Applicant Yellow-Health Pink-Treasurer f