HomeMy WebLinkAbout- Title V Inspection Report - 507 SALEM STREET 4/29/2019 Commonwealth of Massachusetts
on
I Inspectim Form
T'tle 5 Off'icia
a'
Su,bsurface Sewage Disposal System FoIrm Not for Voluntary Ass sn nts
. n uisnz, Antonio
mm Property Address
507 Salem St
. ..... .............
Owner n r Owner's Name
information
reqsired f e er __,_.._______....._.m_... , ._..w..rv__._.._ _.w ,, ____...MA 01845 ... __...... 19
_.__..._.__._...._.__._._.._..._ .... _..__..w. __....
City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form,. Inspection forma may not be altered in any
way. Please see completeness checklist at the end of the form.
Iwt art nV When ��1 , % �
illin frrr, A. Inspector no a i r
use onlyt t John,on the computer,
IVin:c
e
.........
key to move yoIur Name of Inspector �
cursor- not �
l rn nit St wart` Septic Service
use the return Company Name
� w
58, So. Kimball ;fit.
r Company Address
Bradford M 835
City/Town Stag _. I odl
3386
_.._._._.__ _..._.......
Telephone Number r License Number
r
B., Cerflification
l certify that: I am a DEP approved system inspector in full compliance with Section 15.340, of Title
3 ; l; have personally inspected the swage disposal system at the property address
listed above; the information reported below is true, accurate and corn ilete as of the time of my
inspection; and the inspection was performed basedn my training and experience in the proper,function
and maintenance of on-site sewage is l ; 1 systems. After conducting this inspection l have determined
that the system:
M Passes f
f
i
2.. El Conditionally Passes
1
3. Needs Further Evaluation by the Local Approving, grit
. ils
I P ' r Biena w �a Dt
The system, inspect s1 al, ubmit a copy Du this inspection report to the Approving Authority (Board
f Health r EP), witIT1610 days of completing this inspection. if the,system has a.design flaw of
101000 gpd or greater, the inspector and the system owner shall submit it the report to the appropriate
regional office the DEPI. The original fora should , sent to the system owner and copies sent t
the buyer, if applicable, �n the rind authority.
Please n This report only describes conditions at the,time f inspection and under the
conditions of use at that time. This inspection does not address how thIe system will perform
in the future under the same or different conditions of use.
15,insp. oc rev.7126,12018Titl Official:Inspection Form"Subsurface Sewage Disposal System-I Page 1 of 18
I
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awCommonwealthas
icia Oi
T'"It'gle 5 Offm I Inspecto Fiorm
Subsurface Sewage
e
f Disposal System dorm Not for Voluntary Assessments
Ruisanchez, Antonio
PropertyAddress
507 Salem Sit
Owner Owners Name
informaflon is
MA 01845
4
19-20 19
required for every No. Andover ..e.... _..._... __..r._... ._..__.._... _ _.... _.._ _._.__. ._.
City/Town State Zip Code Date of Inspection
C,,
In'spectilon Summary
i
Inspection Summary-, Complete 1, 2, 3, or 5 and, all of 4 and
1) stem asses:
I have not founid any information which indicates that any of the failure criteria described
in 310 CMR15.303 or in 31 CIVIR 15,304exist. Any-failure criteria not evaluated are
indicated ' 1w.
Comments.:
, System CondiltionaIly Passes:
one or more system components as described in the "Conditional Passill section need to be
replaced r repaired. The system, upon, completion of the replacement or repair, as, approved b
the Board of Health, will, pass.
Check thie box for s", "n r"riot determined, 1 i , for the following statements. If not
determined," please explain.,
The septic tank is metal and,over,20 yearsold* or the septic teak (whether metal r riot) 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 compil inn septic tank.as approved by the Board of
Health.
,A metal septic tank,will pass 'Inspection if it is stru,clurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y I (Explain below).
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,
_...... _ . __........._.__. a ..
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t5insp.doc reap.7/2612018, Tillie a Official Inspection n Form:Subsurface Sewage Disposal t yster .Bags f 18
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uommonwealth of Massachusetts
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" 5Inspect'imon
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s oral
Subsurface Sewage System FormNot for Voluntary Asses tints
Ruisanichez, Antonio,
s
57Salem St
Owner Owner's Name
information is
MA 01845
9-2019
r ui�red for every Nq.. ___...._ ... __w...__.m „ ... w_.._..__ _.._._ _... _N.
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City/Town State I Code Date of Insplection
page*
C. Inspection Summary (cont.),
System Condifilonally Passes (coat.):
Pump Char her pumps/alarms not operational. System will pass with Board of Health approval if
mps ,l rms are repaired.
El Observation of sewage backup r break out or high static water level in the distribution box due
to broken or obstructed pipe(s) r due to a broken, settled or uneven istri"buti rr box. System will
pass inspection if(with approval of Board of Health):
broken files are replaced [:1 Y _ N (Explain below)-
obstruction is removed E] N (Explain below)-
E]
distribution box is leveled r replaced N (Explain below):
The system required ir+ umpin more than 4 times a year due to broken or obstructed i e s . The
system will pass inspection if(with approval of'the Board of Health):
broke i s are replaced F1 Y El N El ND (Explain below):
obstruction is removed ND (Explain below):
3 Further Evaluation s Requillried by the Board f' eatth:�
El Conditions exist which require further evaluation by the Beard of Health in order to determine if
the system is failing to ,protect public he� lth, safety or the environment.
w
a. stem will ass less Board f Health I determines � cc r � with � CMR
5.3 3 that the systems not functioning in a manner which will protect public health,
safety and the environment:,
t5in p.do-rev.7126/2018 Title 5 Official Inspection Forni,Subsurface Sewage Disposal al System•Page 3 of 18
Commonwealth of Massachusetts
.0p; icia ion
Tmtle 5 Off" m I Inspect" Form
Not for Vol untaryAss,essments
Subsurface Sewage Disposal System Form
Ruisanchez, Antonio
Property Address
507 Salem Sit,
......................
Owner 0 w n e r's Name
information is No Andover MA 01845 04-19-2019
required for every —---1--- -- "`-,-,--,- ,-,------, -'' , ,-,
page. CitytTown State Zip Code Date of Inspection
C. Inspection Sum ar c t.)
El Cesspooll or privy is within 50 feet of a, surface water
Cesspool or privy is within 5 feet,of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (arid Public Water Supplierjf any)
determines that the system is furilc born ng in a manner that prot cts the public health,
safety and environment:
0 The system has a septic tank and soil absorption system (SAS) and the SAS, is within
100 feet of a surface water supply or tributary to a surface water supply.,
El 'The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply,
[] The system has a sepitic tank and SAS and the SAS is withilln 50,feet,of a private water
supply welL,
[:], 'The system has a septic tank and SAS and the SAS is less than 100 feet but 50,feet or
more from a private water supply well".
Method used to determine distance:
This system passes, if the well water analysis, performed at a DEP certified laboratory, for fecal
cloliform,bacteria, indicates absent and the presence of ammo nia 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 must
be attached to,this,form.
c. Other:
14), System Failure Criteria Applicable to All Systems:
You must indicate "Yes"' or"'No" tio each of the following for all,inspections,,,
Yes No
Backup of sewage into,facility or system component due to overloaded or
clogged SAS or cesspl l
Discharge or nding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or ces,spoo,l
ffifnsp.doc-rev,7/26/2018 Title 5 Official:Inspection Form,Subsurface Sewage Disposal,Systeni-Page 4 of 18
uommonwealth of Massachusetts
ion Form
Totle
Offmici'al
M. � �Voluntary�, h ace Sewage, Disposal System Form
Ruisanchez, Antonio
Property Address
07 Salsa,St
information is
IVIA, 845.
ru�irl �for every .. .. _...._And _ - .....ver __..._..__.._._....
City/T ry State Zip Code Date ofInspection
F
C.
1
Inspection Summa,ry (cont.)
4), System, Failure Criteria Applicable to All Systems: (cont.),
Yes No
StaticEJ N liquid i level in the distribution boxy above outlet invert,due to are overloaded
r clogged SAS or cesspool
Liquid i Iie thu in cesspoolis less than 6" below invert or available lu me is less
than 1 flow
Required pumping more than 4,times, in the last year NOT due to clogged or
'obstructed l s . Number times pumped:�I
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion ofcesspool or privy is within 100 feat of surface water supply,l r
tributary tar to a surface,water supply.
Any portion of a cesspool or privy is within a Zone a public water supply
l 1
Any portione s o 1 or privyis within 50 feet a private water supply well
Any portion a cesspool r privy is lens than 1,00 feet but greater than 50 feet.
from a private water,supply well with no acceptable water quality,analysis. [This
system asses if the well water analysis, performed at a D,EP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen, and nitrate nitrogen is equal to or less than 5
provided that no other failure criteri'a aretriggered. A copy of the n l sis
and chain of custody must be attached to this form.]
The syst r is a, cesspool serving a,f'a ility with a design flow of 2000,
gpd-
101000n
'The system fails. l have determined that one or more of the above failure
criteriaexist as described in. 310 CAR 151.3103, therefore the system ails. The
system owner sih uldcontact the Board of health to determine what will be
necessary to correct the failure.,
LargeSystems: be considered a large system the system must serve a facility with
design flow of 101,000g pd 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 C. .
Yes, N
the s ster i is within 400 feet of a, surface drinkilng water,supply
"
0 E] the system is within 200 feet f'a tributary to a sunrtace rir kin rater supply
the system is located in a nitrogen sensitive area Interim Wellhead r t ti+
El 1:1 Area IW r a mappedZone 11 of a public water supply well
t5ira , 'oc•rev. 1 1 1 Title 5 Official Inspection F ri ,Subsurface Sewage Disposal System Bags 5 of 18
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Commonwealthac
T'Itle 5 Official
Form
w � q
Subsurface SewageDisposal System rirr� � �"� l rat r �Assessments
w�
'. ,� Ruisanch ez 'Antonio,
Property Address j
Owner Owner's,Name
information,is MA 01845
required for every ___..�__. _ ___..._. �. _...._.___.._. �m,„�_ _._ _.._.__ �..„_..._. _20 1,9
page, City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
�
l It yes"' any y re a significant
u answered rr u���tNrr �� "��tur� . he system � considered,w �t
threat, or answered yes"'to any question in Section C above the large . The
owner or operator of any large system considered a significant threat u n r Section G.5 oir failed
under Section C.4 shall upgrade ud the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional! office of the Department.
. You must indicate `yes" or"no" for each of the folIllowing for a "Inspections
Yes No
Pumpinginformation was provided by the owner, occupant, or Board of Health
01 1Z Were any of the system components pumped out in the previous two weeks?
0 El Has the system received normal flows in the previous two week period'
El H Have large volumes of water been introduced to the system recently or as part of
this inspection?.
Were built plans of the system obtained and examined?. (If they were not
available rote as 1
Was thie facility r dwelling inspected for signs sewage back up?
Was the site inspected for signs of brash out?
Were all system commoner tr>, excluding the SAS, located on site"
Were the septic teak manholles uncovered,, openied, and the interior of the tarp
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depths of scum"
0 E] Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of su surface sewage disposal systems.?
The size and location the Soill Absorptilon System on the site has
been determined based n
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 1 .3 2 5 ]
i
i
l irm ,'oc-rev.7126/2018 Tille 5 Official Inspection Form,,Subsurface Sewage Disposal System.Paige 6 018
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................' '" ic"
" ia
Subsurface Sewage C i s � sal System Form Not for Voluntary Assessments
Ruisanchez, Antonio
Property
57 Sale S
....._ ..........._
Owner Owner's Name
Nrrrtrl is
. Andover M 5 - 21 9
;r u fired for __._.... _ _.._._._._._ _...
pale, City/Town State Zip Code Date of Inspection
U, System Information
u R,esidential RowCon,ditions,.-
Number of bedrooms, (design):
Number of bedroomsc al
DESIGN flow based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): _._.__._..._. _..__..
Description,
Number of current residents:
Does residence have a garbage grinder? Yes E] No
Does residence have a water treatment unit? 'Yes _El No
Is laundry on a separate sewage system? (include laundry system inspection Yes N
information in this report.)
Laundry system boast Yes [I No
,S sonal use? El Yes M N
Water meter readings, if available (last 2 years usage , " �
tI
Sump pump? Yes No,
cu �qd
Last date occupancy: ___ ®._._.__..n..
t
15insp,doc rev.'712612.018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System 4 Page 7 of 1
Commonwealth ' a sac a
ic" I Inspect"
N �. "''d I e 5 Offm' i a ion Form
r Not6'j
Till
for Voluntary Assessments
Subsurface Sewage Disposal System
Ruisanchez,p nt ni
Property Address
507 Sim Sit
Owner Owner's Name
information is
No
MA 0-,1814-5
required for every Andover City/Town State t Zip Code Date ofInspection
M System Information (cont.)
2. Commericiallindustrial Flow Conditions:
Type,of Establishment:
Diesign flow(based, on 310 MR, 15,203)-
G NN n peri day(gpd)
Basis of designflows is rs ns s . t., etc.)
Grease trap present?" El Yes No
Water treatment unit fires nt es No
Industrial waste holding teak present? El Yes El No
n sianitary waste disichargied to the Title 5 stem" Yes 0 No
Water meter,readings, if available:
Last date,of occupancy/use: __._... —...
Date
Other(describe iw .
3. Pumping
Stewrt's
Source of information,".
Was system pumped as part of the inspection? Yes N 15,00
If yes, g io n
How was,quantity pumped determined?.
maintenance
Reason for pumping,-.
i 1 ®retie. Official Inspectionrn Sir urf sewage Disposal terra.P of 1
i
Commonwealth
'y7y T"Itle 5 Off"icial.......... ion
Form
I M A r
Subsurface Sewage Disposal System Form
1 W N
Not for Voluntary Assessments
Ruisanchez, Antonio
Property Address
5,07 Salem
Owner Owner's Name
information't's N . Andover M 1 �5 --`�9-2 9
requiredfor ever �_ ..._..________..... .___....._ __._._.._.______....____..._.. _._., _ _ ........ _._.__._..__._.._...... ........
page City/Town State Zip Code Date f hi e tion
D. System Information (cont.)
. Type of System:
Septic tank, distribution box, soil', absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (des or irno) (if yes, attach previous inspection records, if any),
Innovative/Alternative technology. Attach a, copy of the current operation and
m iint nand contract(to, e obtained from system owner and a copy of latest
inspecti n of the I system y system operator under contract
'Tight tank,, Attach a copy of the E approval.
Other(describe):
Approximate age of all components, date 'In talled' (,if l a wn and source of information:
Were sewage odors detected when arriving at the site" El Yes X No
5, Building Sewer(locate on site plan):
1
Depth below grade- fe 11 et-"I-,,-,,
Material of construction:
cast iron 40 PVC other(explain):
Distance from private water supply well or suction lime:
t
Comments, m condition of joints, venting, evidence of leafage, etc.
1
1 cast iron thr floor
thin ,d -rev.7/2W20,18 Title 5 Official Inspection Form,Subsurface wage Disposal System.Page 9 of 1
hCommonwealth of MassachusettsP icia
T"tleInspection
1
� � Subsurface Sewage D'I"Isposall Sys,tem Form Not,for Voluntary Assessments
Ruisanchez, Antonio
Property Address
507 Salem St
Owner Owner"s Naas
information is . Andover M - 9 2 19
r u it for even _.._._ _.____._... . _..._._____...... . _._.._.
page, City/Town State Zip Code Date of Inspection
D. System Information (cont)
6, Sept'lic Tank (locate on site plan):
Built to grade
Depth below grade: feet
Material of construction:
concrete El metal El fiberglass polyethylene other(explain)
Is age confirmed by a Certificate of Compliance? (attach a copy of'certificate) El Yes [:] N
1 011F
Sludge depth:
22
Distance from top of sluidge to bottom of outlet tee or batty _ __..._ n._._._._._ __...._.. ... __..__.._..._�....m_._...
ist nce tr rn top of scum to top of outlet tee or baffle
1611
Distance from bottom of scum to 'bottom of outlet tee or baffle
Sludge,j q /tape measure
How were dimensions determined _.__ .
Comments (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity,
liquid levels as related to outlet invert, evidence of lelakage, eta.):
Both baffles are in good shape. leafage,, liquid levels are good. Filter on outlet tee should be
cleaned trig" a ear..ry
t ire , -rev.7/' 1 1 itl iffi i l Inspection Forma:Suibsur,f rageDisposal System.Page 10 of'l
Commonwealth
M Tmtle 5 Offincial pAl 'p m
Inspect"ion
Subsurface Sewage Disposal System Form Not for' lunt ry Assessments
Rui,sanchez, Antonio
_ _. ....._ _... �� _. _...._
Property Address
7 Salem St
Owner Owner's Narne
informiation,is
9
require � r .._MA 0 1 845 ..
page. t own Stag Zip C Date f I s ti l�
U., System Informationcoat.
'. cease rap (locate on site lace:
Depth below grade:
feet
Material of c s rUction:
El concrete metal fiberglass polyethyl neother lain),:
Scum,thickness
Distance from top of scum to top of outlet tea or � ' �m�. _.__._.-___._._.._....,��rv------
Distance from bottom of sicum to 'bottom of outlet tea or baffle
Date! of last pumping:
t
Commentspumping recommendations inlet and lutl t tea or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence,of leakage, etc.)
81. Tight or HoldingTank tank,. lust.be pumped' at time of inspection) on site wlan)-
Depth below grades .......
Material of construction:
i
concrete, metal fiberglass polyethylene other(explain):
Dimensions: ....m W . .m ., �� n. w w_....r.._.__...._ m_....__m_ .. ., .m ..............r._._.. _..__.... � ... .__...__�_
Capacity:
gallons
Il ns.per
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Uommonwealth
Tmtle 5 Official Inspect" Form
ion
ry +ih Subsurface wage Disposal sa y's r�10
Ruisanchez �� for Voluntary Assessments
. w
Rroperty,Address
507 Salem S'
Owner Owner's Name
Information is MA 01845
m _..__._ _______.....m...._..___. __..._._ _....___
requiredevery _ _._ . _.._.__....
.itI/T n State Zip Code Date of inspection
page „
D. System Information (cont)
8. Tight or ''Un (coat.,).
Alarm present. "des,
Alarm _._..._.:,....__ _.... _.__ ._ in working Yes N
Date,of last pumping-. Date.1
Crneats (condition of alarm and float switches, tc.,
Attach copy of current pumping contrast required). Is copy attached? Yes N
9. Distribution x (if present must be opined) (lociatie on siteplan):
Depth of liquid level above outlet invert .........
Comments (note if box is level and distribution to outlets equal, any evidence of solids carry er, any
evidence of leakage into or out of box, etc.)
� al distribution, no no solids carryover
G
v
Title Official In pie don'Forums:Subsurface Sewage Disposal System Page 12 of 1
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icia
Tl"tle 5 Off"' 1 %v o n F'o rm
Ins
�" .. SubsurfaceDisposal System Not for Voluntary Assessments
,u
i
Property Address
507 Salem St ......
Owner Owner's Name
infor�m tion is No Andover MA 01845 9 9
required for every
City/Town
Zip Cody
p t � twrm
_
D, System Information (cont.)
. Pump Chamber(locate on site plan):
Pumps in workingorder'.
Yes
Alarms in working order: Yes 1
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.),.
Tested alarm & pump by lifting up floats manually in pump chamber. Both the,alarm and pump are
workinn..__q at_ the_ time.. ......_.inspection. - .
l r alarms are not in working order, s ste is a conditional pass.
11. S, lil AbsorptIN
ion System (SAS) 11 at on Site plan„ excavation ni t r ��ired):
It SAS not located, eXplain w
Type,.,
leaching: pits number: �����.._..__.........
El _.__
leaching chambers number-
'El
leaching galleries number:
El leaching trenches number, length: _....__. _.. _.._.
- 25X 40,
leaching fields number, imensi ns-
Ej overflow cesspool number:
_..___........ .., .�.....
innovative/alternativesystem
V
Type/name of technology* _... _.. _._ __... ..._
t5insp.doc•re w 712612018 Title 5 Official'Inspection Form:Subsurface,Sewage Displosal System w Page 13 of 1
Commonwealth of Massachusetts
Y
Tmtle 5 OffolIc"lall Ins ecti'an i"orm
M" q
-- Subsurface Sewage Disposal System Form - Not for Assessment
77 .
Property Address
..............
Owner Owner's Name
information fori everyNo, Andover Andover 9 2 9
requiredCity/Town
Mate Zip Code Date f Inspection
p'
M System Information (cent.)
11. ll Absorptibn (SAS) (coat.),
Comments (note condition of soil, signs of hydraulic failure, legal of pondinig, damp soil, condition ition f
vegetation, etc.):
Nq hy raulic faillure, no_p ipg, no,4@mR soils
12. Cesspools (cesspool must be pumped as part of Inspection), (locate on site plan)-.
Number and configurationDepth—top,
f liquid to inlet invert ...�--_w_ ....__.._... .. .-r_._...___ ....____...........
Dimensions of cesspool,
Materials, of'construction
Indication of groundwater'inflow Yes
Comments,+ nts (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t51nsp.do .rev®71 /,2018Title 5 Official InspectionForm:Subsurface Sewage Disposal System-Page 14 of 1
commonweaith of Massachusetts
.............
ion icial Inspect
TIt.le 5 O,ff'm
Form
� . :..
DisposalSubsurface Sewage Not four Voluntary
Assessments,
� " isac
Grp
Property Address
507 Salem ,
....... ...........
owner Owner's Name
Inf rrnnt"n veNo
M 9-2
fo 0,19
r . Andover _._. _.__.. _.___ _ . _ ...
__._ _ state Zip Code Date of Inspections
page. City/Town
D, System Information (cont.)
3" Privy (locate on site plan):
afionl-
Dimensions
Depth of solids
Comments (note condition, soil, signs hydraulic i l , 'l l ling, tl �� g t t a
etc.
Tillie Official,inspection Form-SubsurfaceSewage�p �system��"� �
115insp,Aoc rep.7/2612018
. ^mmonwealth of Massachusetts,
ion
officiall, Inspec Form
Tmltm,
NSubs
le 5,
rf ce Sewage Dilsposall System, Form Not for Voluntary Assessments
AntonJo
Property Address
5,07 Salem
Owner Owner's Name
No. Andover
C't y/Towrn State Zip Code Date of Inspection
D. System Information (coat.)
14. Sketch, Sewage D ispos 1 y 't+ r :
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks, L c to all wellswithin 100,feet, Locate,bare public water supply enters
the building. Check one of the boxes, below:
El hand-sketch in the area below
drawing attached separately
I
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t5inspAcc r 1 Tftl Official inspection Forte;Subsurface Sewage Disposal S tern. '� 16 f 1
Commonwealthash a e
III Nt
-==-7.711 ection Form
icia tie 5 Off
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�_ T 0 *�
Y S u &urf ce Sewage Dilsposal System Form Not for Vlater ssessments
Lo
Ruisanchez, Antonio
Property,Address
507 Salem St
..... ............
Owner n r°s Warne
requiredinformation is MA 01845
19-2019
Andover
fir „_.._.._.. _._.... ___ ___ _.____.__... __._.._ .__ _..__
page.
fit /To State ,dip Code Date In tion
D. System Informaltion, (cont.)
5. Site Exam-
Check Slope
Surface water
1
Check cellar
Shallow wells
Estimated depth to high griound watery _..._ _.._... . __..__._._._......
feet
Please indicate all methods used to determine the high ground water elevation,
Obtained from system design pleas can record
plan,If checked, date of design reviewed:
----.-
Observed site abutting propertylobservation hole within 150 feet of SAS)
Lq Checked with local Board of Health -e l in:
u lied file
El Checked with local excavators, installers- (attach documentation)
Accessed USES database explain:
Essex c+c n�ty_s 'il m
You must describe how you established the high ground water elevation:
Esex country soil �� , suet#30., Canton soil, water r 76' deep---,
Before filing this In,splection Report, please see Reportr Completeness Checklist nex�t page.,
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Commonwealth of Massachusetts
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Complete all applicable I sections, this for �r��� i N
A. Inspector Information: Complete allfields In this section.
B. Certification-, Signed & Dated and 1, 2,,, 3, or 4 checked
G., Inspection Summary:
Y 2, 3, or 5 completed as appropriate
(Failure Criteria) and 6 (Checklist) completed
, System Information:
' r ight/Molding Tank Pumping contract attached
For : Sketch of Sewage Disposal System drawn on pg. 16 or attached,
For 5: Explanation of estimated depth to high groundwater included
.7/2612,018 Title 5 Official,InspectionForm:Subsurface sewage Disposal systern Fags 18 of 1
AL
Commonwealth of Massachusetts
mom's tle 11 a spect 5 0�ffw 0 1 In ion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
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Property Address
Mark Perry
Owner Owner's Name
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required for
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R. System Informat'lion (cont)
Sketch,Of Sewage Disposal Systern: Provide a,view of'the sewage disposal system, Including ties to
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hind-sketch i In the area below
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