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Home My WebLink About- Title V Inspection Report - 350 SHARPNERS POND ROAD 12/17/2018 Commonwealth of Massachusetts Title fi i l Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessmer� 350 Shar ner's Pond Rd tli f Property Address ;7� �tN f Marley, Robert 0 s °u...¢ r Owner Owne Name information is No. Andover MA 01845 11-06-18 _ requiredfor every ._...__._._. . .. .. .......... _. ._..............w . ._..._._.._ ._........_.� _.._.._._..__ j page. City/Town State Zip Code Date of Inspection I 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 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. Company Address Bradford MA 01835 City/Town State Zip Code a�n 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); I 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. M Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fail Insp is Sig tu4d Date T4 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 j 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 � dN Commonwealth of Massachusetts ��=��0�� `��"��"��0 ��~�� M�� Q ��D �� Official� Inspection 0—��ounm / �� m �� Subsurface Sewage Disposal SymtemnFmrmn -NotforVo|untmryAnsenementa 3508har ' Pond Rd PmpertjAddnens Robert Owner Owner's Name information is MA O184� 11 �quinadfor eve� '` -------- -06-18 page, City/Town State Zip Code Date ofInspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3. or 5 and all of and 8. 1) System Passes: 1 have not found any information which indicates that any of the failure criteria described in310CKAR15.3O3nrin31OCN1R15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Distribution box was replaced 2) System Conditionally Passes: El One ormore system components as described in the "Conditional pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, ae approved bv the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not detanmiOed'" 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. . Fl y El N F-1 NO (Explain below): Commonwealth of Massachusetts ��=��Q �� Official D Inspection Form � Title U��U�� H�8�� /� Q �� mQ �* w�� mw �-�� mm m m m �� u Subsurface Sewage Disposa| SyatemnFornm - NotforVo|untaryAssassmenhs 35�OShar r' Pond Rd PmpertyAddnmam PWor|� Robert Owner Owner's Name information is required for every No. Andover MA 01845 11-05-18 page. CVynown @tova Zip Code Date ofInspection Inspection results must be submitted on this form. Inspection forms may ered in any way. Please see completeness checklist at the end of the form. Important:When A UU��U�4�o�� UK8��00��'KD8� O||ingou�fonno ^~~ Inspector~ Information ~~ un the computer, uaoonly the tab uu/x/ u/vn/ue/uu key m move your Name mInspector cursor -go not J & S D | t/S ' Septic Seryi.ce use the return Company Name key. 58 So. Kimball [t. Comp�yAddeo `---� Bradford MA 01835 City/Town State Zip Code A78-372-�471 O113386 ------- Telephone Number License Number B. Certification | certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CKUFk15.¢00): | 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 | have determined that the system: 1. F Passes 2. Z Conditionally Passes 3. F"� Needs Further Evaluation by the Local Approving Authority 4. Fail insp tor ignature Date system inspector shall submit o copy of this inspection report tothe Approving Authority (Board o Health or DEP) within 30 days of completing this inspection. If the system has a designfNwof 18.O0Ogpdor 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 app|ivab|e, 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 ordifferent conditions o7use. � Commonwealth of Massachusetts ~�~°�� .J��"��~��D N�� N'��H Title �� '� � ��w�� Inspection Form Subsurface Sewage Disposal SystemForm - NotforVo|untary Assessments 350 Sharpner's Pond Rd Property Address Marley, Robert_ Owner Owner's Name information is mqui��rnve� N MA 01845 11-05-18 page. QtyfTown State Zip Code Date nfInspection C. Inspection Summary Inspection Summary: Complete 1, 2. 3. or5 and all nf4 and 0. 1) System Passes: F-1 | have not found any information which indicates that any of the failure criteria described in 310 CyWR 15.303 or in 310 CKAR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Posses: Z one or more system components madescribed in the "Conditional Pass" section need to be replaced or repaired. The eystem, upon completion of the replacement or napair, 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. Theea[diobankiameta| endovar2Dyuonao|d° orMheoepUchonk(mhathermeba| ornot) ieebu:tunm||y unsound, exhibits substantial infiltration orexfi|tnation or tank failure in 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 ia less than 2O years old ieavailable. ' Fl y F-1 N F-1 NO (Explain below): Commonwealth of Massachusetts Title 5 OfficialInspection Form m Subsurface sewage Disposal System Form - Not for Voluntary Assessments hn 350 Sharpner's Pond Rd Property Address Marley, Robert Owner Owner's[Jame information is No. Andover MA 01845 11-05 18 required for every .....__ .. _... ._.._.. -- ........_..— ........ _..-_� ......._._ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ 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 because of 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): 3) Further Evaluation is Required by the Board of Health: ❑ 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 (�j' CKnmmoNV�ealthof Massachusetts � =�=°��U�� =�J��=��Q 0��"�� N�R�� ------------ Title �� Official 0 Inspection��wu 0—��m . mm �� * mm �,�� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350Ghar *r'a Pond Rd Property Address Marley, � be� Owner Owner's Name information is N" Andover MA 01845 10 �quinad�revery ��---- -------- page. oi��own State Zip Code Date nfInspection C. Inspection Summary (cont.) R Cesspool or privy ia within 50 feet ufa surface water F� Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh h. 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, safety and environment: [l The system has a septic tank and soil absorption system (SAS) and the SAS is within 18O feet ofa surface water supply mrtributary to a surface water supply. [l The system has a septic tank and 8/\8 and the SAG is within e Zone 1 of public water supply. R The system has septic tank and SAS and the SAS is within 50 feet of private water supply well. F� The system has a septic tank and SAS and the SAS is less than 100 feet but5O feet or more from a private water supply vve||^^ Method used to determine distance: This system passes if the well water analysis, performed ate OEP certified |aboratory, for fecal oo|iform 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 ofthe analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable tmAll Systems: | You must indicate "Yes" mr''No" to each mf the following for all inspections: | . Yes No | Backup ofsewage into facility orsystem component due to overloaded or [� [� �� ~ clogged SAS orcesspool [� �8 Discharge orpondinguf effluent to the eu�aceof the ground orsu�aoawaters �� due toon overloaded or clogged SAS nrcesspool Commonwealth of Massachusetts Title i i I Inspection i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 350 Sharpner's Pond Rd.,.. Property Address Marley Robert Owner Owner's Name information is o. Andover MA 01845 11-05-18 required for every N _ ... ............ .__.... __.... _ ___... _.. ..._.. , ._...._. j page City/Town State Zip Code Date of Inspection C. Inspection Summary (cant) 4) System 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 1/2 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 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- 10,000 gpd. ❑ ® The system fails. l 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 ❑ 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 l5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 5 of 16 I I Commonwealth of Massachusetts Title 5 OfficialInspection r W Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4a ` 350 Sharpner's Pond Rd _. Property Address Marley_, Robert j �__..._ ....._..... _ ........... Owner _.............. Owner's Name ' information is required for every No. Andover MA _ 01845 11-05-18 _ page, City/Town State Zip Code Date of Inspection C. Inspection Summary (cons.) 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 C.4 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 CA shall upgrade the system in accordance with 310 CMR 15,304. The system owner should contact the appropriate regional office of the Department, 6. You must indicate "yes" or"no" for each of the following for a!1 inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in 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 part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? ❑ ❑ 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? ® ❑ 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. ® ❑ 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)] I i t5insp.doe-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 18 <Z\ Commonwealth of Massachusetts �� .vµ- l'qTitle 5 Official Inspection orm Subsurface Sewage Disposal System Form Not for Voluntary Assessments t. 350 Sharpner's Pond Rd Property Address Marley, Robert ........... Owner Owner's Name information is No. Andover MA 01845 11-05-18 required for every 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): 440 Description: Number of current residents: Does residence have a garbage grinder? Yes ❑ No Does residence have a water treatment unit? El Yes 2 Na If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection F] Yes 0 No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? El Yes E No �uied ql Last date of occupancy: Date cc t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 350 Sharpner's Pond Rd ........------ Property Address Marley Robert ................ Owner Owner's Name information is No. Andover MA 01845 11-05-18 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): Gal .......... lons per day(gpd) Basis of design flow(seats/persons/sq.ft,, etc.): Grease trap present? El Yes E] No Water treatment unit present? El Yes F-1 No If yes, discharges to: Industrial waste holding tank present? D Yes R 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: Andover Septic Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: 1500gallons ......... q_ on truck How was quantity pumped determined? Site gpq �� Reason for pumping: inspect tank t5insp.doc•rev,7/26/2018 'title 5 official inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 <elCommonwealth of Massachusetts (wTitle 5 Official Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Sharmer's Pond Rd Property Address Marley Robert _.. .......... _. Owner Owner's Name information is No Andover MA 01845 11-05-18 required for every —.._w........_ _._ .._ page. Clty/Town State Zip Code Date of Inspection t D. System Information (cant.) 4. Type of System: ® Septic tank, distribution box, soil absorption system D Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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 ❑ Tight tank. Attach a copy of the DEP approval ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ED Na 5, Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): - >100' Distance from private water supply well or suction line: feet Comments (on condition of joints, venting„ evidence of leakage, etc.): t5insp.doc-rev,7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Tifle 5 'ff Mil Inspection Form 1� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 350 Sharpner's Pond Rd ............. Property Address Marley, Robert ---- --- ...... Owner Owner's Name information is required for every No. Andover MA 01845 11-05-18 .... ....... .......... page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: 0 concrete F-1 metal R fiberglass ❑ polyethylene El other(explain) ........... ........... If tank is metal, list age: years -.-1---- Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No Dimensions: 5'6"X 10" X 48" 610 Sludge depth: -- --- Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness Distance from top of scum to top of outlet tee or baffle 511 16" 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.): Both baffles in good shape, !Io leakage and liquid levels are good. ---------- -------------- .......... t5insodoc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts . ... . ............ Titl 'ff icial Inspection Form e 5 u Subsurface Sewage Disposal System Form Not for Voluntary Assessments 350 Sharpner's Pond Rd Property Address Marle obert -- Owner Owner's Name information is No. Andover MA 01845 11-05-18 required for every - ----............. ----.................... -- page. Cityl-rown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feat Material of construction: F-1 concrete ❑ metal El fiberglass F-1 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.): & Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: El concrete F metal F] fiberglass ❑ polyethylene F1 other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.712812018 Title 5 Official Inspection Form:SUbSUrface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 350 Sharpner's Pond Rd Property Address Marley Robert .......... ......... ---------- Owner Owner's Name information is required for every No. Andover MA 01845 11-05-18 page. Cityfro State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: D Yes El No Alarm level: Alarm in working order: 0 Yes E] No ............. Date of last pumping: Date Comments(condition of alarm and float switches, etc.): .......... Attach copy of current pumping contract(required), Is copy attached? F1 Yes F1 No 9. Distribution Box (if present must be opened) (locate on site plan): 0 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 leakage into or out of box, etc.): Box is leaking around the outlet inverts and needs to be replaced t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systern-Page 12 of 18 Commonwealth of Massachusetts it 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 350 Sharpners Pond Rd .............. Property Address Marley, Robert Owner Owner's Name information is required for every No. Andover MA 01845 11-05-18 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 0 No* Alarms in working order: El Yes n 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: ❑ leaching pits number: ❑ leaching chambers number: El leaching galleries number: 3 -45' leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5inspAOG rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts f lip it 5 Official Inspection Form P Subsurface Sewage Disposal System Form Not for Voluntary Assessments ........... v.� 350 Sharpner's Pond Rd Property Address Marley, Robert --------------------- Owner Owner's Name information is required for every No. Andover MA -01�845 11-05-18 ............. page. CityfTown State Zip Code Date of Inspection D. System 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 .......... ............. .......... ........ ........... 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 El Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): .......... .......... t5insp.doc-rev.7126/2018 Title 5 Official lnspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title i i l Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Sharpner's Pond Rd Property Address Marley, Robert Owner Owner's ... ............_ _.... �.ww-__ ....._ .......,._._ � ......__._.. Name information is No Andover MA... 01845 11-05 18 required far every . �._......._ �.... _ _.._ page. Cttyrrown State Zip Code Date of Inspection D. System Information (cant.) 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 I i t5insp.doc•rev.712612018 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 350 Sharpner's Pond Rd ................... Property Address Marley, Robert Owner Owner's Name information is No. Andover MA 01845 11-05-18 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: M hand-sketch in the area below drawing attached separately II t5insp.doc-rev,7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18 Commonwealth of Massachusetts � ,(µA Title 5 OfficialInspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •"'w -W b"4K 350 Sharpner's Pond Rd .... ....._ _.....�_.._ Property Address Marley_,_Robert .......... Owner Owner's Name information is No Andover MA 01845 11-05-18 required for every _.......... __........._......___ _....� — .._........__. page City/Town State Zip Code Date of Inspection D. System Information (cunt.) 15. Site Exam: ® Check Slope ❑ Surface water Z Check cellar ® Shallow wells 6' Estimated depth to high ground water: _...___ 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: 04-07-86 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: Taken from plans on record. No pump in cellar. Bottom of floor is 5' below bottom of system. i ...._ .......... _ ............ _.._._ _........__ _ ........ ......_..... _. .._. Before filing this Inspection Report, please see Report Completeness Checklist on next page. tSinsp.doc•rev.7/26/2018 Title 5 Official Bnspection Form:Subsurface Sewage Disposal System-Pape 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 350 Sharpner's Pond Rd Property Address Marley, Robert� Owner Owner's Name information is required for every No. Andover MA 01845 11-05-18 page. City/Town 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 C. inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed Z 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 ........... ...... R,2411VI Tl(')IVM,,,AN LOCIVED IN I)A GIL ES R. S. LAPV1M-,-A1C'E4? NoRrHANDOWE'H (l,fv 00 A/ Q,1 66 'T-f 7,77F )Wev (TH71F)"' ?'IIllr THE 511-10MIN ARIT THE US/ OA11)WN 9 7 1,45E /S FOR 01"I"ERMICI, 170N 01",210AIING 21" Y L A 1410/ (,"ONFORMITY" OR NON (,"ONI-' TY 1411-11"'Al 7A/0,.' N, ......... ....... ............. ...... f Town f o l-h Andover HEALTH DEPARTMENT , sACNUSES CHECK#: DATE: a .m „ r . LOCATION: v, H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $� ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service- Tt/Pe: ___._ __ $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic a Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ p $ Title 5 Report ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer