HomeMy WebLinkAbout- Title V Inspection Report - 265 HAY MEADOW ROAD 11/13/2018 commonwealth of Massachusetts RECEIVED
Title 5 Official Inspection Form IN V (,) �1 R
NOR-fli
Subsurface Sewage Disposal System Form Not for Voluntary Assessments DE.To
8EAI,.TH " MANDOVEAMENT
265 Haymeadow Rd
Property Address
Serrano, Renee
Owner 6'w n—e rs—N a'm-e
information Is
required for every No, Andover MA 01845 10-01-2018
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. General Information
on the computer,
use only the tab
key to move your 1 Inspector:
cursor-do not
John DlVincenzo
use the return
key. Name of Inspector
J and S Development Stewarts
Septic Service
raa Company Name
58 South Kimball St
ny Address
- ,;—6-0Pa —----------
Bradford MA 01835
CitylTow State Zip Code
978-372-7471Telephone S113386
Nlu—m-ber 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 16.340 of
Title 5(310 CMR 16.000). The system:
Passes El Conditionally Passes Fails
Ne d
s u er va atio 4�y the Local Approving Authority
-i—gnature'-
c r Date
is
he system inspectors ubmit 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 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.
15!ns,doc•rev.6116
Title 5 Official Inspection Form:Subsurface Sewage Disposal system-page 1 of 17
Commonwealth of Massachusetts
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Subsurface Sewage Disposal System Form ~Not for Voluntary Assessments
265
Property Address Owner Owner'sSerran Renee
m -----------------
innn�Non)o�
required for every No. Andover MA 01846 10-01-2018
page, u/qv/vwn State Zip Code Date ofInspection
B. Certification (cont.)
Inspection Summary: Check A.B.C.DorE/always complete all uf Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
|n31OCyNR15.3D3or|n31DCK0R15.3O4 exist. Any failure criteria not evaluated are
indicated below,
Comments:
Distribution
B) 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 |fthe existing tank im replaced with a complying septic tank ae approved bythe 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 im less than 2O years old isavailable.
El y El N [l ND(Explain be|nw):
em,^oc'rev,6/1a Title 6 Officral Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17