HomeMy WebLinkAbout- Title V Inspection Report - 60 ROCKY BROOK ROAD 6/4/2019 Commonwealth of Massachusetts
licia tie 5 off I Inspect-10
n Form
Subsurface Sewage Disposal System Form Not for Voluntary ssess ent
60 Rocky Brook �I
q, r»srfl�Yrro 'w b,,a,.
Um
Property Address,
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Owner Ownef's Name
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Andover A 01845 3 9
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required'for every � d �m .rv�.�m ... �.d mm...d.m W M d� ....w , .....
page,i, Cityl(Town State Zip Code Date of Inspection
1 I
Inspection results must u mitt d on this form. Inspection forms may not be altered in any
way. Please,see completeness checklist at the end olf the form.
Inrtlnt When
A. Inspector Information
tilling out forms
on the om ut r,
use only the tab John DiVincenzo ......
key to move your Name of Inspector ...w d
cursor-do not & S r l rent Stew rt's Septic Service
use the,return �,,�dd� dd ,,� .��"
Company Naas!
5 S Kimball St.
M...,,.� mmrvrv.�.�.m.�. _
Company Address
Bradford �1 5
..... � �
Cityfriown State Zip Code
� .� ���..�.. �d.
Telephone Number License Number
B, Certification
I certify that: I am a DEP approved system inspector in Full compliance,with Section, 15.340Title
(310 C1 , . a 1 have Personally inspected the siewagle disposa,l system, at the property address
lusted above; the information reported below is true, accurate and complete as of the time of nay.
inspection* and the inspection was performed based on my training and experience in the proper function
and m int n n e ofon-site sewage disposal systems.After conducting tiing this inspection I have determined,
that the system,
w Passes
2, Conditionally Passes
3. El Needs Further evaluation by the Local Approving Authority
4. El Fa
00,
I Cr' Cate
'he system i t r s submit a copy of this inspection report to the Approving Authority(Board
f Health or 30 days f completing this inspection. If the system has a design flow of
g d or g ireater'„ the inspector and the system owner shaII s u bmit the repoirt,to the appropriate
regional office ofthe DER The original form should be sent to the,system owner and copies,sent t
the buyer, if applicable, and the approving authority.
Please in ter This report only,describes conditions at the time of'ins t'i n and asunder the
conditions use at that time. Thilsinspection does not,address how the system ril'l perform
in the future lnid r the same or different Conditions of use.
Mnsp.d -rev.7/2612018 Title ffi l A inspection 1=ors:Subsurface Sewage Disposat System•Page I of 1
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Commonwealth of Massac
TI Ll�w ff I C 1.11,11w,
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
r
6 Rocky Brook R
Property Address
Vaughn
Owner r
Owner's Nameinformation is
gyred for every North Andover MA 0 1845 04-30-19 —-..
pages City/Town State Zip Code Date of Inspection
C. Inspection
Inspection Summary- Complete 1, 21 3, or 5 and all, of 4 and 6.
1) System asses:
l have not found any information which indicates that any of the failure criteria described'
in 310 CMR 15.303 or in 3101 CMR 15.3104, exist. Any failure criteria not evaluated are
indicated below.
i
2)
System n tlonzl "asses;
0 one or more system components as described in the,"Conditional Pass section reed to be
replaced or repaired. The system, upon cor l ti n of the replacement Ir repair,, s approved by
the Board of Health, Will pass
Check the box for 11 yes", "no" or"not determined"' , 1 , for the following statements. It"n t
determined,"ined," pleas pleasle 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 tarok failure is Imminent. System will peen
inspection it 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 i ►structurally sound,, not leaking and if a Certificate of
Compliance indicating that the tams is less than 20 years old is available.
EJ Y [:1 INI ND (Explain below),-
.
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Commonwealth f Massachusetts
Ammon
Moft
Tit 5 ITTIcia
le 0 1 Ins ectmion Form
mm . Subsurface Sewage Disposal System Form Not,for Voluntary Assessments
60 Roick Brook Rd
- "a
ro,p e rty Ad dr ''
V , h n
Owner s Name
information is
North Andover MA 01845, 3 -1
required + r eviery
Cu wn State Zip Code Cake of Inspection
,C. Inspection Summary (cont.)
2) System Conditionally Passes (coat.):
Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
0 Observation of'sewage backup or break out or high static water level ire 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, ofBoardf Health):
broken i e(s) are replaced N 0 IND (Explain below)*
] Destruction 'is removed E:1 N (Explain below):
E] distribution box is leveled or replaced 01 Y Ej N 0 ND (Explain below):
w :
The system; required r in more than 4,times a year due to broken or obstructed pipe(s). The
system will pass inspection if(wide approva,l of the Board of Health):
El broken, pipe(s) are replaced N E] ND ( Main below)-
obstruction is removed Y Ej N Ej N lain below:
3 Further Evaluation is Required by the Board of fi lth
El Conditions exist whi h require further evaluation by the Board of Health in order to determin if
the,system is failing to protect public health, safety or the environment.
a. System will pass unless. BoardIHealt,h determines In accordance with 310 MR
1 -3 3 that,the system is not functioning iin a, manner which will protect public health,
safety and the environment:
t5 p.d .rev.7/26/2018 Title 5 Official Inspection Form:;Subsurface Su e Disposal' term-Fags 3 of 1
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Commonwealthass c west
An MR
"it,le 5 wt, '���l I Sp t n Fo
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments,
60 Rocky Brook F
P rop e rty Address
Va u g hen
Owner Owner's turns
information a l" rth� �' A 5 3 19
required r err ..., _ Ott � � � Inspection City/T w Date
C. Inspection Summary, (ct.
El Cesspool or privy is within 50 feet of a surface water
[:1 Cesspool or privy is within 50 feet ofa bordering vegetated wetland or a salt marsh
. System will fail unless the Board of Health (and Public Wat r Supplier, If any)
determines that the system is functioning in a manner r Nr t c the public l eafth,
safety and environment:
E] The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributaryto a surface water supply.
F] The system has a septic tank and SAS and the SAS is within a,Zone 1 of a, li�cwater
supply.
[:] The system has,a septic tank and SAS and the SAS is within 50 feet of'a private welter
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 t a, DEFT certified laboratory, for fecal
c lif rm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogien is equal
to or less than 5 ppmei, provided that no other failure,criteria are triggered. A copy of the!analysis mast
be attached to this f rm',
. Other:
4) System Failure,Criteriar 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 overloadedr
cloggeld SAS or cesspool
E] M, Discharge r ponding of effl ent to the surface of the ground, or surface waters
due to an overloaded, or cloigged, SAS or cesspool
t l p,d •rev, / /2018 Title 5 Official Inspection Form-,Subsurface Sewage Disposal tem-Page 4 of 1
%,ommonwealth
4,
" i
, tle 5 Offmicnial lnsmw ection Form
H
0 Subsurface Sewage D111'sposal System m Not for Voluntary Assessments
Iq
610 Rocky Brook Rd
Property Address
VaughnOwner .
Owner's Name
.rvm mm...
information is North Andover _ .. . mm M �.� 1 � 30 11 9requi '
age. r City/Town State ZIP Code Date of inspection
C. Inspection Summary (cont.
4) System Failure Criteria llc l! to All Systems: i it.
Yes No
Static lilquid level in,the istri ti n box above outlet invert due to an overloaded
r clogged SAS or cesspool
E] N Liquid depth, in cesspool i's less than 6" below invert or available volume is less
than 1 flow
Ej N Required uir ur inn more than 4 times in the last year NOT due to clogged or
obstructed i e s . Number of times , :
Any portion of the SAS, cesspool or privy is below high ground',water l ati n.
Any portion of cesspool I r privy is within 100 feet of a, su rfacie water su pplyr
El 19
tributary to a surface water supply.
El N Any portion of a cesspool or privy is within!iin Zone 1 of a public,water supply
well.
El N Any portions of a cesspool or privy is,within 50 feet f'a private water supply well,
El N Any portion of a cesspool, or privy is less than 1010 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis, [This,
system passesif''the well water analysis, performed at a DEP certiffied
laboratory,for Ifecal coliform bacteria 11ndicates absent anid the presence
f ammonia nl r g , a and nKraten1trogen Is equ i l to or less than 5 p,pm,
provided thalt no other failure criterila. are triggered. A,copy of the air l sls
and ch,allan of custody must be attacMdto this forma.]
The system is a cesspool 1 serving a facility with a design flow of 2
gpd-
107000,gpid.
El N The system falls. I have determined that one or more of the above failure
criteria exist as described ire 310 CM R 1 5.303, therefore the system fails. the
system wn r should nt t the Board of Healthy to determinewhat will be
necessary to correct the failure.
Large Systems: 'To be,considered Dirge systemi the system must serve a facility wrth
For large systems you must indicate either" e DA r "no"to each of the following, i,n addition to the
questions in Section CA.
Yes No
El F-1 the system is within 400 feet of a surface drinking water supply
El 1-1 the system is within 200 feet of a tributary to a surface drinking water supply
El Eli the system is faceted in a nitr g na sensitive area Int rir r Wellhead Protection
Area —IWP r a mapped Zone 11 of a public water supply"well
t in .d' .rev. 126/2018 Title 5 Official Inspection Forn Subsurface Sewage Disposal Sys,tem.Page of 18
Commonwealth ofMassachusefts.
TI*tle 5 OffOL;00 I Inspectn'� Form
M1
M
.. Subsurface Sewage Disposal, System Form -Not,for Voluntary Assessments,
J , 60I� Brook Rd
Property Ader
Vaughn
Owner Owner's Name
information i
North Andover MA 01845 04-30-1 9j
required for eves ,
City/Town �i d tInspection f
page
C. i coat.
If you have answered "yes," to any question in ,Sections C.5 the system is considered a significant
threat t r answered "yes"to any question in Section; C.4 abovethe large system has,tailed. The
owner or,operator of anyUrge system considered a significant threat under Section C.5 or failed
under Section Cw shall upgrade the system in accordance with 310 CIVIR 15.304. 'The system owner
should contact the appropriate regional office of the Department.
16. You must indicate "Yes,"'or"no"for each of the Following for ali inspections:
Yes No
Z El Pumping information was provided by the owner, occupant, or Board of Health
0 Z Were any ofthe system components pumped out in the re i u; two weeks?
z El Has the system; received normal flows in the previous two week period'
Have large volumes of water been introduced to the sst+ rn recently or as part of
this inspection?
Were as built plans of the system obtained and examined? I they were not
Z El available note as A
z 1:1 Was the facility r dwelling inspected for signs of sewaige back ups
Z El Was the site inspected for signs of break outs
z 1:1 Were all system components, excluding the SAS,, located on site?
0 "ere the septic tank rn nh lies, uncovered, opened,, and the interior of the tank.
inspected for the condition of the battles or tees, material of construction,,
dimensions, depth of liquid, depth of sludge and depth of s uer
ED Was the facility owner Ind o cu l nts if different from owner) provided with
information on the, r r maintenance o" subsurface sewage disposal systems?
The size and location of the Sold Absorption System (SAS) on the site has
been determined, based n
Existing information., For example, a plan at the Board of Health.
z 1:1 Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [31 CIVIL 15,302(5)]
tfln p.do rev,,7/26/2018 Tittle 5 Official Inspection Forme Subsurface Sewage Disposal System rage 6 of 18
i
i
Commonwealth w Massachusetts
T"tie 'm Offoicoial Inspectmion Form
Subsurface Sewage Dilisposal, System Form - Not for Voluntary Assessments
60 Rock Brook Rd
Property Address
Vaughn
Owner Owner's Name
information i
Forth Andover MA Oi 0-19
required for ever
page., City/Town Zips Code Date ofInspection
D. System Information
e i en i t Flow Conditions
f bedrooms s actual
4
440
DESIGN floes based on 310 CMR 15,203 (for example,
Description:
Number of current,residents:
Does residence have a garbage grinder,.? Yes N
Does residence have a water treatment unit? El Yes N
If yes, discharges-to-
Is laundry on a separate sewage system? (Include laundry system inspection El Yes E, No
information 'in this report.
Laundry sfrn Inds ' El Yes N
Seasonal use? Yes No
Water meter rails, if available (last 2 years, usage M „ ...�
Detail-
Sump pa Yes N
Ocq4i,ed
Last date of occupancy: Date
t in pall .rev,712612018 Tifle 5 Official l Inspection Form-,Subsurface Sewage Disposal System,-Page 7 of 1
I,
Commonwealth of Massachusefts
. .. MENEM, u'ff"ic'ia'1 'inspect"i1on
11t,le 5
.m Subsurface System Not for VoluntaryAssessments
A
60 Rocky Brook, Rd
u �n
Property Address
Vaughr�
Owner Owner's Name
informati In is North Andover
requilred for every
pads, CityfTown, State Zip Code Date of Inspection
Di. Sys,tem Information (cont.)
2. lr r c l/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310, MR 15. 3);
GalIns per day
Basis esig,n flow(seats/ rs ns s .fit, tcj:
Grease trap reed Yes Igo
"eater treatment unit,present? El Yes Ej I
If yes, discharges . ., .. „.,.
to-
Industrial waste holding teak present? E] Yes, No
Non-sanitary waste discharged to the Title 51 system? [] Yes l
Water meter readings, if available-
Last data of occupancy/use: Date
Other(describe below):
3. PumpIng Records:
Sea r"s
Was system pumped as part of the inspection.? Yes N o.
15,00
If yes, volume pumped,- gia .pan
arr°nir�a " � truck
w was anti l pad dad
nain
Reason for pumping: I' ain .... anca „
t in p.d .r v.'1 /01 Title Official inspection Forn Subsurface wage Disposal System.Page 8 of 1
Commonwealth of Ma,ssachusefts
t n
a .
. ttle
T Subsurface Sewage Disposal System Firm -Not�f r"� I rat r s ss �e ��
A
6 Pr R
Property Address
Vayg_o,,,n
Owner Owner's Name,
information is North Andover MA 01845 -3 - '9
page.required for every
Cit /Town State Zip Code Date f In tion
D. System Information (cont)
F Type&System:
Septic tank, distribut,ion box, soil absorption system
Single cesspool
❑ Overflow cesspool
El Privy
El Shared system (yes,or n if yes,, attach previous inspection records if ►n
El Innovative/Alternative technology. Attach a copy of the current operation and
maintenance ntr t(to be obtained from system owner) and copy oflatest
inspection of the l A system by systems operator under contract
F-I Tight tank. Attach a copy of the DEP approval.
El Other(describe):
Approximate age of all components, date installed if now and, source of information:
996
Were sewage odors detected when arriving at the site' 0 Yes Z N
5. Buildilng Sewer(locate on site plea)*
1811
Depth below, rl feed ... .. _.m
Material f construction:
oast iron Z 40 PVC other(explain,):
Distance from private water supply well or suction line feet
. . .
Comments (ors condition of joints, venting,,, evidence of leakage, etc.)*
ffinsp.doc rev.71 18 Title ffi a 'I Inspection,Form.Subsurface Sewage IDisposal System*Page 9 of 1
Commonwealth of Massachusetts
T otle 5 0 ff is a nsp i oct" Form
V
Subsu�rface Sewage Dllsposa! System Form ,- Not for Voluntary Assessments
60 Rocky, rook 6 R ...........
d:
Property,Address
Va h n
Owner Owner's,Name,
information is North Andover IVIA 01�845 04-30-19
required for everyrv,
page,. City I fflown State Zip Code Date of Inspection
D, System Information (cont,.)
6,. Septic Tank (locate on site pilan),
811
Depth below grade: feet..
eet.......
Material of construction:
Z concrete El metal fiberglass polyethylene E], other(explai,n)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) E] Yes E] No
65"X 1 10'X 4811
Dimensions-
�,.:.,1211
Sludge depth*
Distance from top of sludge to bottom of'outlet tee or baffle 2211rc
Scum thickness
611
Distance from top of scum, to top of outlet,tee,or baffle
Distance from bottom of scurn to bottom of outlet tee or baffle
Tape measure/sluldge jud,,,,, e
How were dimensions determlined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,, eitc.'.
Both baff les 9 liquid, leve od
_?�rein�o� leaka e L9—o
t5insp.doc-rev,712612018 Title 5 Official Inspection Form",Subsurface Sewage Disposal System Page 10 of 18
Commonwealth of Massachusetts
,r litle 5 official Inspect*ion Form,
em
tip T
. ......................
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
......................... 610,5,oc�y Brook Rd
Property Address
Va h n,
.............
Owner Owner"s Name
informat"Ion is required for ev North Andover M A 01845 1041-111113-0-1 9
ery
City/Town State Zip,Code Date ofIns pection
page.
D. System Information (cont)
7. Grease Trap (locate on site plan),
Depth below grade,, feet
Material of construction:"
0 concrete [I metal El fiberglass polyethylene E:1 other(explain):
Scum -thickness,
Distance from top of scum to top of outlet tee or baffle
Distance from bottorn of scum to, bottom ofloutlet tee or baffle,
Date of last pumping: gate
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 (tare: must be pumped at time of inspection) (Iocate,on site plan),-.
Depth below grade:
Material of construction:,
El, concrete El metal D fiberglass F] polyethylene other(explain):
Dimensions-.
Capacity'., gallons
Design Flow:
gallons per day
t5lnsp.doc-rev,7/2612018 Title 5 Official Inspection Form,Subsurface,Sewage Disposal System-Page 11 of 11'8
Commonwealthch u
,. tion Form
mm. Subsurface Sewage Disposal System Form Not for Voluntary Assess tints
6
, o r0 ...............
Property Address
Owner Owner's Name
i rm tion is North Andover MA 01845 3 - 9
page.required for every C ity[Town State Zip Code Date of Inspectio"I n—
D. System Information c t.
. Tight or Holding Tank(cont.,)
Alarmpresent* El Yes �E] No
I rml bevel: ..., .�, Alarm in working order: El Yes
Date of last pumping-
Date
Comments (condition alarm and float switches, etc.),
Attach copy of current pumping, contract(required). Is copy attached? El Yes No
9. Distrib,ution Box(If present must be opened) (locate on site plan)
Depth of Ili quid level above outlet in rt
C oats (note if box pis level and distribution to outlets,equal, a,ny e il or ice of solids carryover, any
evidence of Leakage Into or out,of box, etc.):
_��qu distribution, no leakage,"no sllsrrr
i
i
Tine 6 Official Inspection Form.: u b rf` Sewage Disposal System-Page 12 of 1'
l,"
uommonwealth of Massachusetts
'i it o u icia ion
I Insw%ect" F'olrm
� Subsurface Sewage Disposa! System Form Not for Voluntary Assessments
6 f� rqqk Rd
Property Address
ay b
Owner Owner's Nerve
information is North Andiover MA 01845 04-30-19
required for every
m... . gym. t Ir .... ��
C it own ti ro
D. System Information (cont)
10. Pump Chamber (loofa on site plan):,
Pumps in working order: D Yes El No*
Al rmis in working order. 0 Yes 0 I'
Comments (note condition ofpump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working over, system is a conditional pass.
. oilAbsorptions e SAS (locate n site plan, excavation not required).
If SAS not located, explain Tlype-
El,
leaching pits number-
E] .mm
leaching chambers number*
El leaching galleries number:
w r�u.�rnb�r l� r� 1 ; r �n�b�,
lea i�ng trenches � � � . ....
El leaching fields number, i m nsi ns
overflow cesspool number: mmm m.
ED inn va i altern i e system
Type/namie of technology: ..
k i wdo rev.7/2612018 Tide 5 Deal Inspection Forte;Suibs,urface Sewage Disposal,System Pugs 13,of 1
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L.0111monwealth of Massachusetts
T"tie 5 icia Insp orm
I e ction
E— 0 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
60 Rocky Brook Rd
.......... ......
Property Address
Vaughn
Owner Owner's Name
information is North Andover MA 01 8�45 04�-30-19
required for everymm�
page. City/Town State Zip Code Date of Inspection
R. System Information (cont)
11. Soil Absorption System (,SAS) (cont.)
Cornments (note condition of soll, signs of hy'draulic failure, level of ponding, damp so�il, condition of
vegetation, etc.):
_No h draulic failure, no, pond,i,pg, no damp it
12., Cesspools (cesspool must be pumped as, part of inspection) (locate on site plan)*
Number and configuration
Depth —top of liquid to intet invert
Depth of'solids layer
Depth, of scum layer
Dimensions,of cesspool
Materials of construction
Indication of groundwater inflow El Yes [:1 N o
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of've get ation,
etc.),-
.............
t,5i,nsp,do c rev.71261,2018 This 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
<�L Commonwealth of Massachusetts
licia
e n s p e c t'i o n o r m
16P,
S
- Not for Voluntary Assessments ubsurface Sewage Disposal System Form
610 Ro Brook Rd
Property Address,
Vapop
Owner Owner's Name,
information'is North Andover MA 0118415 04-30-19
required for every City/Town, ---------- State Zip Code, Date of Inspection
page.
Di. System Informat'on (cot)
13. Prilvy (locate on, site plan):
Materials,of construction'.
Dimensilons
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc,):
t5lnsp,doc-rev.7/26/2018 Title 5 Offi:cial Inspection Form,Subsurface Sewage Disposal System-Page 15 of 18
mmonwealth of Massachummw
setts
in
Itle 5 uJ""fficial Inspection Form
94'
M, Subsurface Sewage Disposal System Form w Not for Voluntary Assessments
L4
610 Peck Brook Rd
Property Address
Va hn
Owner Owner's Name
information is North Andover �MA 01845, 04-30-19
required foir every I
Ipage�., City I[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.-
E:] hand-sketch in the area below
Z drawing attached separately
t in . r ,'7 18 Page 16 o
Title 5 Official In Form,Subsurface Sewage Dip System f 185� spdoc- ev /26120
Commonwealth of Massachusetts
ion
T'Itle 5 Oifficial Inspectu Form
%
Subsufface Sewage, Disposal System Form Not for Voluntary Assessments,
. ......... 6 lI rook, Rd
Property Address
Vaug�n
Owner neir's Name
information is North Andover MA 018,45 04-30-19
required for every
page. City/Town, State Zip,Code Date of Inspection
D. Systern Information (cont.,)
15. Site Exam:
2 Check Slope
D Surface water
E Check celliar
El Shallow wells,
Estimated depth to high ground wiater, 518114
feet
Please indicate all methods, used to determine the high ground,water elevation:
Obtained from system design plans on record
05-20-1993
If checked, date of design plan reviewed: Date
D Observed site (abutting property/lobservafin hole within 150 feet of SAS)
Checked with, local Board of Realth - explain:
Pulled file
Checked with, local excavators, installers - (attach documentation)
El Accessed USGS,database -explain:
You m ust describe how you established the high g rou ndi water elevation
'Taken from deep hole lapp, 05-20-1993. Witnessed,,b Sandra Starr, Heallth-A rat.
Y 9
Before filling this Inspection Report, please see Report,Completeness Checklist on next page.,
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 if 118
Commonwealth of Massachusetts
an Ann, M SEEM
MENEM
P itie otticial 1nsEp4%&e,ction Form
j
Svbs rf ice S age Disposal, System Form - Not Voluntary Ass ssments
60 Rocky Brook Rd
Property Address
Owner Owner's Name
inf rmati n is North Andover MA 845 4®3 9
required for r �. mM .. State � I C I lute of Inspection
page. �it �r "
E, Riepoirt Completeness Checklist
Complete all applicable t o i form *inclusiveofi-
A.
Inspector Information: Complete all fields in this section,.
B. Certification 1: Signed & Dated and 1� 21 3, or 4 checked
G. Inspection Summary:
4 (Failure Criteria) and 6, (Checklist) completed
f . System Information:
For : Tight/Holding Tank Pumping, contract attached
For 4: Sketch Sewage Disposal System drawn on pg. 16 or attached
For 5: Explanation of estimateddepth to high groundwater included
t5insp.doc rev,7/2612018 TitteOfficial Inspection Form Subsurface Sewage Disposal Systerni•Page 18 of 18
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