HomeMy WebLinkAboutPass - Title V Inspection Report - 33 SHERWOOD DRIVE 6/19/2019 Commonweal ts D
REC
I T Inspectioon Form witle 5 Off"icia. pp
T �� 'rdM
. Subsurface Sewage Disposal Syst rn, Form - Not for VoluntaryAssessments
.10*4 OF
iiiia
33,Sherwood Dr
qu en, Thin
Owner Owner's it
information is
MA 0
2019
required for everyd over .... .mmmm.m.. ..... .. .m ,
page, City/Town State Zip Code Date f Inspection
Inspection r s ilt , must be submitted on this,fora., Inspection forms may not be altered in any
way. lea a see completeness checklist at the end, of the form.
ImpartA. InspectorInformation
tilling out form m
on the computer, DiVincenz
use only the tadJohn
key to move u r Name m of Inspector
cursor r-do notDevet . m n.m 'tic ;service
use the return Company Name
58 So. Kimball St.
Company Address
r f r 35
..�.. ......m. r
City/Town State Zip Code
„
Telephone her License m r.mm
B., Certification
certify that, I am, a DEP approved system inspector in,full compliance with Section 15.340 of Title
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above, the information reported below is tree, 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 fon-site sewage disposal systems* After conducting this inspection I have determined
that the ;system'.
Passes
2. Conditionally Passes
31. El Needs Further Evaluation y the Local Approving authority
.1 Fall
Ins tr'� iimt t
T e system inspector „T submit a copy of this inspection report to the Approving Authority (board
of Health or D ' within 30 days of completing this insp !cti n�. 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 DES'. The original form should' be sent to the system owner,and copies sent t
the buyer, if applicable, and the approving authority.
Please note. This report,only describes conditions at the time 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.
t iin ,d' .rear,7126/2018 Title fpi i l Inspection Form.,Subsurface Sewage Disposal Systiern.Page I of 1
Commonwealth of Massachusetts
MI
I Inspection Form
T"Itle 5 O,ff"icia
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
33 Sherwood Dr,
.................Property Address
,Nguyen, Thim
Owner Owner's Name
information is, No, Andover MA 01845 05-14-2019
requ ired for every
page. Cityffown State Zip Code Date of Inspection
C, Inspection Summary
Inspection Surnmary.: Complete 1, 21 3, or 5 and all of'4 and 6.
11) System Passes:
Z I have not found, any information which indicates that any of the failure criteria described
in 310 CIVIR 15.303 or in 310 CMR 15,,304 exist.-Any failure criteria not evaluated are
in below.
Comm nts*
..........
2) System Conditiio�niallly, 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, as approved by
the Board of Health, will pass.
Chieck.the box for"yes", "no$) or"not determined"' (Y, N, ND)for the following statements. If"not
determined,$1 please explain,
The septic tank is metal and over 20 years o,ld* or the septic tank (whether metal or not) is structurally
I 1
unsound exhibits substantial infiltration or exfiltratioln or tank failure is immi11 nent. System will pass
inspection if the existing tank is iteplaced 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 a Certificate of
Compliance indicating that the tank is, less than 20 years old is available.
N Ej ND (Explain below):
t5lnsp.doc rev..7126)2018, Tiff e 5 Official Inspection Form,,Subsurface Sewage Disposal System Page 2 of 18
Commonwealth of Massachusetts
Ti
ion
tle 5 Official Inspecta Form
Subsurface Sewage GIs s it System ` wr Not for Voluntary Assessments
,� V 33 Sherwood r
o
Property Address
NgUy� , Thin, „ro
OwnerOwner's Name
information is . Andover mm mmm � ,
required for ►r . . .� mmmm.
fit To n State Zip Code Date of Inspection
C. Inspection Summary (cont.)
System2) onditi all ► Passes (cont,).:
Pump Chamber pumps/alarms not operational. System will pass with Bard of Hey altl approval if
pumps/alarms,are repaired.
Observation f sewage backup or break out or high static water level in the distribution box due
to broken or obstructed piple(s) due to o broken, settled r uneven distribution box* System will
pass inspection if(with r ► al of Board of Health):
broken pipe(s) are replaced l (Explain below),
obstruction is ramov"e 0 Y N Ej ND (Explain below)*
0distribution box is leveled or replaced Y l (Explainbelow'),
The system required pumping more than 4 times a year due to, broken or obstructed i a s . The
system will pass inspection i with approval of the 'Board of
Health)-
broken i a s, are replaced [:1 l (Explain below):
w
obstruction is removed N (Explain below):
3, Further 'ale i Is Requited by the Board &Health:
El Conditions exist which require further evaluation by the oars of Health in order to,determine if
the system is failing to protect public health, safety or the environment.
a.
SystemIII unless r �' l determines �Ireaccordance with31 CMIR
16.3 3(1)(b),that the ya i ri ot ro c i n 1 1 a manner wh Lic h w 111 protect pu blic h ea,Ith
safely and the environment:
1:5 on s p.d .rev. /2 6/2018 Title 5Official Inspection;Form.Subsurface Sewage Disposal Systern-Page 3 of 1
Commonwealth
Title o" Official Inspect"ion Form
.m_ .
Subsurface Sewage Disploisa,l System Form Not for Voluntary Ass ssments
33 Sherwood Dr
P rop e rty Add ress
erg, Thin
Ownier Ownerts,Name
information is, . Andover � .5-' -2 9
required foir r . u.„ „.. ._m Ott �a
page.
City own ate f Inspection
C. Inspection (conk.
[:1 Cesspool or privy is within 50 feet of a surface water
r
[:1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a silt marsh
. System will fall unless the Board of Health (arid PubIlic Water Supplier,, if any)
determines that the system is functioning In a manner that protects the public health�.
safety and nvir nmenit:
E] The ,system has a septic tank rind soil absorption system (SAS) and the SAS is within
100 feet of a surface waiter supply or tributary to a suirfiace water supply.
Ej The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The system has, septic tank and SAS and thie SAS is within 50 feet of a private rater
supply well.
Ej The,system has a septic tank and SAS and the,SAS is less than 100 feet but 50 feet or
more fro private miter supply well".
Method used to determine distance:
This system passes if the well water analysis,, perforrned at a DEP certified laboratory, for fatal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or lass than 5 ppr , provided that no,other f wil ura criteria are triggered. A copy of the analysis rust
be attached to this forums.
c. ther.,
4) System Fallure,Criteria Applicabie t ,All st r I
You must ire l wt "' e " or"No" to eachof the following for all inspections:
Yes No
Backup of sewage into facility or,system component due to overloaded or
El E clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface raters,
due to an overloaded or clogged SAS r cesspool
t5insp,doco rev.7126/2018 Tide 5,Offidat Inspection For w Subsurface Sewage Disposal System W Page 4 of 1
Commonwealthc
„. ion Form
,µSubsurface Sewage, Disposal System Form Not for Voluntary ntar Assessments
33 Sherwood Dr ...m
Property Add it' s
l en, 'Thin
Owner Owner's Name
information is No., Andover MA 01845 05-14-2019
required for every City/Town State Zip Code Date of Inspection
C. Inspection Summary (ct.
4) System iulu r Criteria Applicable to All ems: (cont.)
Yes
El 0 Static liquid, level in the distribution box above outlet Invert due to an overloaded
r clogged SAS or cesspool
Liquid depth ire cesspool is less than °" below invert or avallable volume, is less
El 01 than 1/2day flew
Req uired pur iin more,than,4 times ire the last year,NO T dine to clogged or
obstru cted i s X Number of times urn + d
Any portion of the SAS, cesspool or privy is below high ground nd water elevation.
El z Any portion of cesspool or priory is within 100 feet of a surface water supply r
tributary to a surface grater,supply'.
El 0 Any ;portion of a cesspool r privy is rithiru a Zone, I of a public water supply
well.
E:] 2 Any portion, of a cesspool 1 r prier is within 50 feet of a private water supply well.
E] E Any portion f acesspool or r� u� less ss than 100 feet but greater than 50 feet
from a private grater supply well with no acceptable water quality analysis. his
system passes if the,well,water analysis, erf rirm dd! at,a D,EP certified
laboratory,,for decal ciollform bacteria indicates absent and the presence
f ammonia nitrogen and nitrate nitrogen is equal'to or Less than
r+ "d d that n other failure criteria are tr g red. copy the an l i
and chain of custody must be attached to this form.)
El 0 The ssteru is a cesspool serving a facility with a design flow of 2
1 ,, pd.
E] 0 The system fide. I have d tarmiined that one or more f the ab era failu.ur
r*teria exist as described in 3 Cl �15.3 3 therefore the s stern ails. The
system owner should contact the Board of Health to determine what will b
necessary to,correct the failura.
Legge Systems-. To be considered a large system the system must sears a facility with a.
design flow of 10,000to 15,000 .
For barge systems, your rust indicate either 14yes' or"no to each, of the following, in addition to the
u esti rus ire Section C
Yes No
E] 1-1
the system is within 400 feet of a surface drinking niter supply
El 1:1 the system is,within 2010 feet of a tributary to a,surface drinking grater supply
the system is located in a ruitr ru sensitive area (Interim"wellhead Protection
El Area— IWP r a mapped Zone 11 of a public water supply well
t 1 rev.7/26/2018 Title 5 Official Inspection F r :Subsurface Sewage Disposal,system•Page 5 of 1
Commonwealth of Massachusetts
Form
O'tle 5, Olff ct,m n
Ti %,.iiai inspe i ,
ot foir y A
Subsurface Sewage Disposal System Form ® N Voluntar ssessments
33 Sherwood Dr
Property Add r �
N9njhirn ......
Owner Owner's Name
information is No., Andover MA 01845, 05-14-2019
requ ired for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.,)
Ifyou have answered liyes" 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 f ail led, The
owner or operator of any large system considered a significant threat,u nder Section C. or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15w 304. The system owner
should contact the,appropriate regional office of the Department.
in it
6. You must indicate 11yes" or"no" for each of'the following for all inspections"
Yes No,
E 0 Pumping information was pro Sri dedby the owner, occupant, or Board of Health
Were any of the system components pumped out in the pirevious two weeks?
Has the system received normal flows in the previous two week pleriod
i
Have large volumes of wat r been introduced to the system recently or as part of
this inspection?
E El Were as, built plans of the system obtained and' exiamined? (If they were not,
available note as N/A),
Was the facility or dwelling inspected for signs of sewage back up.?
E El Was the site inspected for signs of bireak out?
E E] Were all system, components, exc,luding the, SAS, located on site?
H E] Were the septic tank manholes uncovered, opened, and the, interior of the tank
inspected for the condition of'the baff les or tees, material of construction,
d
I imensions, 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 systerns?
The s,ize and location of the Soil Absorption System (SAS) on the site has
bleen, determined' based on:
El Existing information. For example, a plan, at the Board of Health,
Determined in the field (ifany of the failure criteria related to Part C is at issue
a p proxi m ation of'd ist am e 'is u n acc e pta b le), [310,CI R 15.3102(5)]
Mnsp.doc-rev.7/2612018 Title 5 Offidal Inspection Form-Subsurface Sewage Disposal System-Page 6,of is
Commonwealth�L\\, of Massachusetts
rq
Title 5' Official Form
Subsurface 'sewage Disposal System Fore � � for Assessments
�. 33 Sherwood Dr
Property ress
Nguye n, T h,i
fir �. �....�.,.. .... ,.. m� ,.. „ .. .
Owner �' Name
requiredinformation is No.,
MA
5
2019
for ^�i�t � 1..�,. ���mm.�, ,,�..�mm�m , ,. �� te .� , . mm , .
,dip Code Date of Inspection
D. System Information
1. Residen'tial Flow Conditions:
Number of bedrooms (design): 4 Number er f bedrooms (actual):
1440
DESIGN flow based on 310 CMR 15.203 (for example: 110,gpd x#of bedrooms):
s
Description:
2
Number,of current residents:, . m.
Does residence have a garbagegrinder? Yes E No
Does residence have a,water tr atm e nt unit? El Yes No
If yes, discharges to'. ....
Is laundry on a separate sewage system? (Include, laundry system inspection El es H No
information In this report.,)
Laundry system, inspected.? Yes El l!
Seasonal use? Q Yes
Water meter readings, if ll ' l (last 2 years usage �m.
Detail:
Sump pump? EJ Yes E N
Ocqu ,
ied
Last date of occupancy. Date .....
f5in p.doc rev„7/2612018 Title 5 Official Inspection Fora:Subsurface Sewage Disposal System•Page,7 of 1
Commonwealth Massachusetts
KPA""'p le Off'icial Inse� �ion "
r
. . Subsurface Sewage is + s 1 Sys Form Not for Volluntary Assessments,
33 ,Sherwood Dr ..
Property Address
Ng
lea Thin
OwnerOwner's Name
information is . Andover MA 01845 05-14-2019
required for every
page. City/Town State Zip Code rate of Inspection
tion
D. System Information (cont)
2. CommercIallindustriall Flow Conditions,-.
Type of Establishment".
Design 'i w(based on 310 CIVIR 15.2 3)': Galtl�ons per day '
Basis of design flow(seats/persons .ft., etc.),: . M.. m. ........�.�
Grease trap present? El Yes No,
Water treatment unit present? El Yes El No,
i 'yes, discharges tot, , w, .m .m.. „ ..... „
Industrial waste holdIng teak present? EJ Yes [:1 NO
Nora-sanitary waste discharged to the'Title 5 system? El Yes Ej No,
Water meter readings, if available:
Last date of occupancy/use: te .mm. mm
Other(describe below)*
3. Pumping Recotrd'sx.
Board of information: Stewart'
Was system pumped as, part of the Inspection Yes E] No
If yes, volume : N�
gallons
How was
tit u tr ,ir� ld' Si but c , ,.
Maintenance
Reason,for pumping,
t in ..do •rev.71261/20118 Title Official Inspection Form-,Su rfaceSewage Disposal System-Page wf 1
Commonwealth ofWassachusetts
'icial Inspection t�
orm
t 1 0 ff
I e
Subsurface Sewage Disposal System Form - Not for VoluntaryAssessiments
33 Sherwood, Dr
P ro pe rty Address
.„ '-yen, Thin
Owner Owner's Name
information rmation is d A No. Andover w
required42019
for �r�r � � ���I
s City/Town State Zip,Code Date of Inspection
page
U, System Information (cont.)
. Type of System:
Septic tank, distribution boy, soil absorption system
El Single cesspool
E] Overflow cesspool
Privy
F1 Shared system (yes or n if yes, attach previous inspection records, if any)
E] 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 system by system operator under contact
Tight tank., Attach a copy of the DE,P approval.
E] Other(describe):
Approximate t age of all components, date installed (if known and source, f information.
99
Were sewage odors detected when arriving at the situ Yes P�, No
5. BuilldIng Sewer(locate on site plan)-.
2211
Depth below grade: feet
,mm
Material f construction*
El cast iron M 40 PVC 01 other e pl in *
Distance nce from private water supply well or suction lire: ...
t
Comments r tints n condition of Joints, venting, evidence of leakage etc, .
t5insp.doc rev.7/26/.20,18 Title, Decal Inspection Fornt Subsurface Sewage Disposal System• 'age 9 of'18
Commonwealth of Massachusetts
Title b OHICIal inspection F 0 U In
..........
I Subsurface Sewage MsposM System Form Not for Vol untary,As,sessments
33 Sherwood Dr
Property Address
NgLqen, Thin
Owner Owner's Name
inf,ormati'on is No, Andover MA 01845 05-14-20191
required for every City/Town State Zip Code Date of Inspection
page.
D, System Information (cont.)
6. Setc Tank,(locate on, site plan):
1011
Depth below grade'.
feet ................
Material ofconstruiction:
concrete l metal El fiberglass polyethylene other(explain)
list age-
If tank is metal, years
Is age confirmed by a Certificate of Compliance,,? (attach a copy of certificate) El Yes No
5 X 10 X 4'
Dimensions-
Sludge depth, 8111
Distance from top of sludge to bottom of outlet tee or baffle 2611—11,
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"
I?Rq,�me asure/sllqqq��,.e
How were dimensions determined?
Comments (on, pumping recommendations 5 inlet,and outlet tee or baffle,condition, structural integrity,
liquid levels as, related to outlet invert, evidence of leakage, etc il.),
Both baff les'jpb�ood",, a q. No leak,pp�ri _uJe levels good.,
...............
...........
..........
t5i nspi.doc-rev,7/26120 18, Tifle 5 Officials Inspection Form:Subsurface Sewage Disposal,System-Rage 10 of 18
Commonwealth of Massachusetts,
..................
............... NOW&Aft&
UTTIcia io I"orm
O' l, 5 11 ns t
-ts
Subsurface Sewage Disposal System Form A Not for Voluntary Assessimen
33 Sherwood Dr
Property Address
Ng in py T h i
............
Owner Owner's Narne
information is, No. Andover MA 01845 05-14-201 9
required for every
City[Town State, Z,ip Code Date of Inspection
page.
D. System Information (coint.)
7. Grease Trap (locate on site plan):
Depth below grade:
feet
Material of construction*.
El concrete El meta I fiberglass E:1 polyethylene other(explain):
Dimensions*
Scum, thickness
Distance from top of scum to top of outlet tee,or baffle
Distanc from, bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations,, inlet and outlet tee o r baffle condition, structural integrity,
I
liquid levels as related to outlet invert, evidence ofleaka,ge, etc.).
..........
8. 'Tight,,or HollidMgi Tank(tank, must be pumped at time of inspection) (locate on site pla,n).-
Depth below grade:
Material ofconstruction-
El concrete El metal F] f i berg lass El polyethylene Ej other(explain):
Dimensions:
Capacity: -gallons
Design Flow, gallons pe r day
I
t5insp,doc rev.7/26,12018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page I I of 18
Commonwealth
7 Title 5 Official Inspect'ion Form,
YA
. Subsurface Sewage Disposal System Form Not for Voluntary Assessment
5
33 Sherwood Cyr,
�Property Address
Owner Owner's Nam
information is 1 . Andover NIA 1 5- -2
required for even _ mm .
paged City/Town State Zip Code Nate of Inspection
D, System Information (cont
e Tight or bolding Tank (cont.)
Alarm present El Yes l
Alarm level: Alarm in workingorder.* El Yes El l
Date of Bast uin !: ..m.,,,,
Date
Comment, cnlin of alarm and float switches, .)
Attach copy of current 1 contract, r � it �. I copy attached? Yes N
9. Distribution Box (If present must be opened) (locate on site, plea)*
Depth of l'i level above outletinvert .01
Comments (noteif box is level and distribution to outlets equal, any evidence solids carryover, any
evidence of leakage into oir out of box, etc.):
gqu 1,1.1.11"Idlistribution, no solids car yver, no leakagIn
e
t5insp.doc,rev.'7/261/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System fags 12 of 1
Commonwealth of Mass
T le !) Officia�l Inspect'ion Form
I e
ram' NIF
Subsurface Sewage Disposal System Form Not for'Voluntary Assessmients
.a 33 Sherwood Dr mm. ......
Property Address
Ng qe Thin
Owner Owner's Nam�e
informiation is
2019
required for every
„� State Zip� Date.....MA 01845 051 ............. �.
page. it n f Inspection
D, System, Informatillon, (c .
10. Pump Chamber(locate, siteplan):
Vamps ire w r inn order. 0 Yes El I'
Alarms in working order. [], Yes Igo*
Comments (rote clondition of pump chamber, condition dumps and appurtenances, etc.):
If pumps or alarms are not in work,ing order, system is a conditional pass.
1 +gill',Absorption System (SAS) (locate on site plea,, excavation not required).
If SAS not located,, explain why:
Type.
leaching pits number-
leaching chambers number*
leaching galleries number. �....
0 leaching in reel s number, length- 2 -5 '
El leaching field's nurn r, dimensions:
1-1 overflow cesspool number.
El innovativelaiternative system
Type/name of te,ichnoillogy*
t5insp,doc rev,7/2612,018 Title Official Inspection Form:Su iurface Sewage Disposal System.Page 13 of 1
Commonwealth of Massachusetmm ts,
I t FU
T'tIe 5 ion, Ur
Subsurface Sewage Disposal System, Form Not for Voluntary Assessments
33 Sherwood Dr
Property Address
Nguyen, 'Thin
Owner Owner's Name
information is No. Andover MA, �01 845 015-14-2019
r,equi,red for every
............. Date of Inspection
page. Cityffown State, Z,ip Code
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.)*
Nq hy_qraulic failure, solls
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan)*
Number and configuration
Deptl 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 0 No
Comments (note condition of soil, signs of'hydraulic failure, level of,ponding] condition of'vegetation,
etc.
t5jnsp,.doc-rev.7/2612018 Title 5 Official Inspection Form-,Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth, of Ma,ssach,usetts�,
tie 0 TTIcia -Ak'e et 1 Insp imm
on FORIMM
0 Subsurface Sewage Disposal System Form, Not for Voluntary Assessments
33 Sherwood Dr
Property Address
N9, fir, iu ........
Owner Owner 11 s Name
information'is No. Andover MA 01845 05-14-2019,
required for every ......
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13, Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, sig,nis,of hydraulic failure, level of ponding, condition of'vegetation,
at .
..........
t5insp,doe-rev.7/2612,018 Title ffi'cial inspection Form.,subsurface Sewage Disposal Systm-Page 15 of 18
Commonwealth chin .
tle u iciai, insp
ection Form
ubsu ace Sewage deposal System ors � Voluntary Assessments
,* 33 Sherwood Dr
Property Address
U1 y
ens 'Thin..................
Owner, r°s Name
information is
01845
2 0 19
required for even ..m ..Andover w.m ,..rv... ...mm. W, .
Page. City/Town State Zip Code Date of Inspection
D, System Information (c .
g Sketch Of'Sewage Dilsposall System:
.
Provide e view of the awes disposal systems, including din tiesto at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet, Locate where public water supply eaters
the building. Check one of the boxes below:
FI hard-sketch, in the area below
drawing attached se ra el"
t in p.d .rev.71 /01 Title 5 Official inspection Form Subsurface Sewage Disposal System-Fags 16 of 18
�C Commonwealth of Massachusetts
0
Form
tie 5 Official inspection
Subsurface Sewage, Dilsposal System, Form Not for Voluntary Assessments
Lo
33 Sherwood Dr
Property Address
Nguyen, Thin
Owner Owner's Name
information is No, Andover, MA 01845 05-14-2019
required for every City/Town State Zip Code Date of Inspection,
page.
D., System, Information (cont.)
15. S*It e Exami@
E Check, Slope
El Surface water
Check cellar
Shallow wells
Estimated depth to high ground water: I'll Beet
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- 051-12-11992
.......................D ---ate
Observed site (abutting property/observation holle within 150 feet of SAS)
Checked with local Board of Health - explain:
Pulled file
(attaich do )
Checked with local excavators installers cumentation
4
Accessed USES database -explain.
.......... ..........-
You must describe how you established the high ground water elevation:
Design water@ levation 140.7 Bottom of trench,,- 145.7
..........
Before filing this Inspect' Report, p4ease see Report Completeness Checklist on next page.
t5insp.doc rev.71261201 'Title 5 Officiat inspection Forn,Subsurface Sewage Disposal System-Page 17 of'18
Commonwealth
q
9P Arm M
tiefficial lnspection Form
lilt
:�
1Subsurface Sewage Disposal! System Form Not for Voluntary Assessments
33 Sherwood Dr
Property d r s
Owner Owner's Name
information is . Andover M 01845 5-� 2 19
required r eves �w . ,., .w.. ��
page.. City/Town Colde Date of Inspection
E, Report Completeness Checklist
Complete all applicable sectllons of this form 'inclusive :
Inspector Information: Complete all fields in this section.
B. Certification: Signed Dated and 1 p 2,1 3, or 4 checked
C. Inspection Summar
11 2$ 3,1 or 5 completed s,appropriate
(Failure Criteria) and 6 (Checklist) completed
C . System Information':
For : Tight/Holding Tank— Pumping contract attached
For 14, Sketch of Sewage 'Disposal System drawn, on pg, 16,or attached
For 11' : Explanation of estimated depth to high groundwater included
tl5insp.doc*rev.7126/2018 Title, Official linspection Forte;Subsurface Sewage Disposal System-Page 18 of 118
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S h - W i r, g
Julie Clark& "As—Built Sanitary Disposal System"
Miahael Cronizi Lot 19 — Sherwood Drive
Pre ct For
Timberland Builders, Inc.
Sccde.- 1 20' Oata September IR 0*97
22,-961 ;5&521
Zoning District: R-I
Re.5idence I District
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