HomeMy WebLinkAboutPass - Title V Inspection Report - 147 JOHNNY CAKE STREET 7/1/2019 i
Commonwealth of Massachusett's
*W � T tie 5 '"mffic a,l Inspection Form
w
...� �i Subsurface Sewage Disposal System Form Not for Voluntary Assess V
147 John
Property Address
Cavazza
Owner Owner's Name
information Is �c' �r l 1 � � 1 �1
page. �
r u aired for every N,o0 An .......� ..
t r ri State Zip Code Date f Inspection
Inspection results must be submittedn this fora. Inspection forms may not be altered in any
way. Please see completeness checklist at the f the form.
Important:When A Inspector forma i
filling out forms
on the computer, � lr� l 'i" ir��er�
use only thetaw .�.�,.�,�..... .............. ,... ..A.......
key to move your Name of Inspector
cursor do notJ &S Development/Stew its Septic Service
u.;M the return
n. �m,.
Company fame
58 So Kimball street
Company Address
Bradford MA 01835
City/Town State Zip bode
Telephione Number L,iciense Number
Bi. Certification
I certify that: I am a DEP approvedsystem inspector in full compliance with Section 1 .3 f Title
(310 MR ., 1 ; I have personally Inspected the sewage disposal system at the property,address
lusted 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 ofon-site sewage disposal systemis,, After conducting tin this inspection l have determined
that the system:
1 Passe
2. 0, Conditionally Passes
3. Needs Further Evaluation by the Local Approving Authority
. i
Date
T �w system insp d r shall submit a copy of this inspection report to the,Approving Authority (Board
f Health r 'E'P), `thin 30 days of completing this inspection. If the system has a design flow of
r 1 rn
p „n �eater, the inspector and the system,owner shall submit the report to the appropriate
regional office,of the ER The original form should be sent to the system owner and copies sent t
the buyer, if applicable, and the approving authority.
Please Hints: is report only describes conditions t the flime of inspection and under the
conditions, f use at that time.This, iris a fi w ; does not t address how the system will perform
n the future under the same or different conditions, of use.
t iro #d •rev.7/ /0118 Title 5 Official,in pecti�on Porno,Subsurface SewageDisposal SysterrI page'l of 1
i
Commonwealth of Mass,achusefts
mmn__s Ir am, a
6 r,
T"Itle 5 OTt
Suuffe Sewage Disposal System i= r ltforlitr ssessrrmt
147 Jo��qake st
Property Address �._...._
Cz
Owner Owner's Name
information is
19
rr�udred fir r�r .,, � '� � ��" �"
�, ,,..�.�� m, ,�� ...._._m, ,...,
ONt�r�orrn Ott+ Cat ��
ntion
C. ISummary
Inspection Summ r M Complete 1, 21 3, or 5 and all of 4 and 6.
System, Passe:
I have not fund any information which i�ndica es that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15,304 exist, Any fallure criteria not evaluated are
indicated below,
Comments:
System Conditionally "asses:
one or more system components as d s ri i d in the"Conditional Pass'° section need to be
replaced or repaired. The system, upon completion of the replacement r repair,; as approved by
the Board of Health,, will pass.
i
Check the box for"'Yes", no'
A r Mint determined" , , ll for the following statements. l w4nt
determin dt" please explain.
The septic tank is metal and over 20 years gild r the septic tank metal r riot) is structurally
unsound, exhibits substantial infiltration or e filtrati n ortank failure is imminent. System will, pass
inspection if the existing tank is replaced ith a complying septic tank s 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.
Ej Y [:1 ll ND (Explain below)-.
0
15insp,doc rev,712612018 Titre 5 Official Inspection Form,Subsurface Sewage Disposal ystem Page 2 of 1
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Commonwealth of Massachusefts
ion
Title 5 f'c"a I I n s 1p e ct" Form,
Subsurface Sewage Disposal System Form..Not for Voluntary Assessments
1 Johnny e st
.... Property r ss
Cz , E
information,
wn r
war n r' � a
required for even
City/Town State Zip Code Date of Inspection
C. Inspection, summary
2 System Conditionally Passes n,t. ,
El Pump Chamber pumps/alarms, not operational. System will pass with Board of Health approval if
puny s ilarrns are repaired,
El Observation, of sewage backup up r break out or high static water level iin the distribution box due
t l hr en r obstructed' pi s,or due to hir l na settled r uneven ii tri �uti n . .�System will
pass inspection if(with approval of Board of Health):
broken pipes) ire,replaced _ [ IN ND (Explain below):
obstruction is removed N E] (explain below):
Ej distribution box is leveled or replaced 0 Y Fj N F] N (Explain below):
El The system required pumping more than 4 times a year due to broken ken r obstructed pipes . The
system will pass inspection if(with approval of'the Board of Health):
[:1 broken pipes)are replaced ll (Explain below):
El obstruction is removed l (Explain below):
Further Evaluation is Required by the Board of Health:
EJ Conditions exist which require,further evaluation by the Board of Health, in order to determine if
the system is Billing to protect t public health, safety or the environment
. System will pass, unless Board of Health determines in accordance with 310,C R
.3 3 ( that the system is, not functioning in a manner which will protect public health,
,
safety and the environment
1:51n p.doe rev.7126/2018 Tifpe 5 Official inspection ection Form:SUbsurfaea Sewage Dii p osat system-Page 3 of 1
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I itle 5 tiff icial Inspecti F
mn -
m.. i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y Y147 Johnny
�-yM�mmyr,fi 'r
Property Address
i
Ca Ivry f/'41F azz
{
Owner + n r°s Name E
inf+ rm till rp i . n over 1 5 5/1 19
�l re �red fir every ........... .mm .�..mm. � _ ..----......_.......- I
page. it i own ;state Zip Code Date of In do
C. Inspection Sa y (cont)
Cesspool or priory is within 50 feet of a surface water
Cesspool or priory is within 50 feet of a bordering vegetated wetland orasalt marsh
1 . System will fall unless the Board of Health (and Public Water Supplier, if any)
et+ rr ines'that the system is,fun ti rrir i,n a manner r that protects,the public health,
safety and environment
El, The system has a septic tank and loll absorption system (SAS) and the SAS is within,
100 feet of a surface grater,supply or tributary to a surface grater supply.
[:1 The system has a septic tank and SAS a,nd the SAS is within aZone 1 of a public water
supply,
El The system has septic tank and SAS and the SAS, is within 5,0 feet of a private water
supply well.
E] The system has a septic tank and SAS and the SAS is,less than 100 feat but 50 feet or
more from a private rater supply well".
Method used to determine distance.
This system passes if the well water analysis, performed at a DEP certified laboratory, fir fecal
lif rrn bacteria indicates absent and the presence f ammionia, 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.
Other:
i
System Failure Criteria Applicable to All Systems;
You must Ind icate"'Yes" r"No"to each of the following for all,inspections:
des No
El z backup of sewage into facility or system component dine to overloadedor
clogged SAS or cesspool
1:1 E Discharge or pining of effluent nt to the surface of the ground or surface graters
due to n overloaded or clogged 'SAS or cesspool
t5insp.doe rev,712612018 Title 5 Official Inspection Form-,: ubsurt sewage C ispo l System«Page 4 of 1
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Commonwealth of Massachusetts
� f
T'Itle 5 V'"I"cial
m T"t
Inspect*ion,
I> Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
e
�. 147 JohnnyCake st
Property Addresis
Cavazza
Owner Owner's Name
information i 1Andover 1 � � 1
r uire for err -No,,� �. . mm. mm w.. . .....m.
page Cityffown State Zip Code Date of Inspection
. Inspection Summary (cont.)
,system Failure Criteria a Applicable to All Systems: (cont,.),
Yes No
El 0 Static liquid level in the distribution box above outlet invert due to an overloaded,
r clogged SAS or cesspool
Liquid depth in cesspool is less than 6" 'below invert or available volume is less
El H than 1/2day flow,
El N Required pumping more than 4 times in the last year NOT due to clogged or
obstructed i . Number of tines pumped:
0 N Any portion of the SAS, cesspool or privy is blow 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.
0 S Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
El N Any portion of a cesspool oir privy 'lls within, 510 feet of a private water supply well.
Ej E Any portion of a cesspool or privy i feet
1 �thin feet but greater thin 5
from riv to water supply well with no acceptablewater quality analysis. [This
systemsses if the well water analysis, performed ter DEP certified
laboratory,for fecal c litorm bacteria indicates absent and the presence
of ammonia nitrogen n nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria pure triggered. A copy of the analysis
and,chain of ustol y rust be attached to this fora.]
El ED The system is a cesspool serving a facility with a design flow of 2
gpd-
10,000,gpdM
El M The s stem fails. I have determined that one or more of the above failure
criteria exist as described in 310 CIVI R 15.303, therefore the system fails, The
system owner should contact the Board of Health lth to determinewhat will be
necessary to correct the failure.
Large Systems,, To be consideredlarge system the system must t serve a facility with a
design flow of101;0100 gpd to 151 gpd.
For,large systems, you must indicate either"yes' or"no" to each of the following, in addition to the
C
questions in Section C.4.
Yes No
1:1 El the system is within 400 feet of a surface drinking water supply"
D Ell i
the system is within 200 feet of a tributary to a surface drinking water supply
1:1 El the system is located in a nitrogen sensitiv area Int rim Wellhead Protection
Area IW r a mappedZione 11 of a public water suppily well
t5in p.doc rev.,712612018 Tifle 5 Official inspection Fora-,SUbsurface Sewage Disposal sttem,page 5 of 18
_ ...
Commonwealth assac ses
Odom a
6 Title 5 Official Inspection Form
yi
w.. SubsurfaceSewage Disposal System Forte � � � lu r ss ents
, hnn Cake st
Property Address
r
CaZz
r
Owner
Owner's Name
information Is No Andover
required for every,
_........ ... . MA 01845 5/14/19
..
Page. C,ityfTown State Zip Cache Date of Inspection
C. Inspection Summary
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 n 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 C.4 shall upgrade e the system in accordance with 310 CIVIR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" r"no"for each of the following for all inspections:
Yes N
0 1 Pumping information was provided by the owner, occupant, or Board f Health
El E, Were any of the system components pumped out in the previous two,weeks?
0 1-1 Has the system received normal flows in the previous two,week period?
El E Have large volumes mes f water been introduced to,the system recently or as part of
this inspection,?
N El Were as 'builtplans of the system obtained andexamined? If they were not
available note as
E E] Was the facility or dwelling inspected for signs of sewage back up?
E El Was the site inspected for signs of brash out?
N EJ Were all system components, excluding the SAS, located onsite?
Were the septic tank manholes urncovered, 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
Ej El information on the proper maintenance of subsurface sewage,disposal systems?
The size and location of the it Absorption System (SAS) on the site has
been determined based n*
r5i El Existing information. For example, a plan at the Board of Health.
Determined in the field if a'n r of the failure criteria related to Part C is at issue
approximation f distance is unacceptable) [310 CMR 153 2(5)
i
t wry ,do -rev..7/2612018 Title Official inspection Form-Subsurface Sewage Disposal System Fags 6 of 1
"N Commonwealth of Massachusetts
Tit-le 5 U'T'Tfi,cial Inspection Form,�
Subsurface Sewage Disposal System Forrn- Not for Voluntary Assessments
147 Johnny Cake st
Property Address
C ' ,zz
OwnerOwner's Name
information I J
required for ever
, Andover 5 1
,.,...mm...� � �te�e- ., i�� � � �r Inspection. . .......mm......m.
pipe,
i� r
D. System Informat
1. Residential Flow Conditionsla.
Number of bedrooms(design: ., Number of bedrooms(actual):
440,
DESIGN,filler based can 3101 CMR 16,203 (for eum iw 1110 gpid x#of bedrooms)"
Description:
Number f current residents �.. �.
Does residence have a garbage ringer' Yes 0, 1
Does residence have a water treatment unit Yes Z No
If yes, discharges to: �.. .
Is laurildry n a, separate sewage stern' In llui e laundry system inspection El Yes Z No
information in this report.)
Laundry system inspected' Yes ! N
Seasonal use? E-1 Ye s Z, No
,aver meter readings, if arailialla(last year " re
Detail:
i
Sump pump? Yes
No
Occupied
Last,date of occupancy: rate
i
t5insp.,doc rev.7/2612018 Title frfi 6 1 Inspection Form;Subsurface SewageDisposal System-Page 7 of 1:
uommonwealth of Massachusetts
.. IInspection
T 'Form
i
.._ 1�, Subsurface Sewagle Disposal System Perm Not for Voluntary Assessments
147 Johnny Cake st
Property Address
i
Czz
Owner Owner1,s Name
information is
rir for rr , Andover 5 5/ 1 9
page. CitylTown State, Zip Code Date of Inspection
D. System Information (cont.
2. Commer6l'all/Industrial Flow Conditions,.,
Type of Establishment: -
Design flow (based on 31.0 CMR, 1 e2 3): Gallons per ip
Basis of design flow(seats/persons/s .ft.,b etc. : m.... .mm. .. m
Grease trap resent " El Yes
Water treatment rent present" Yes lido
If yes, discharges to, ... ..
Industrial waste holding tank present"? El Yes El l
Non-sanitary waste discharged to the Title 5 system? El Yes [:1 No
Water meter readings, if available:
Last date of occupancy/use,- ���.mm. �.
Other es rribe below)-
3. Pump i ,gi records:
,Source of information: Last pump 1
Was system pumped as, part of the Inspection? M Yes
00
If s volumepumped* �
aIles
s quantity pumped itern�in site nwtrr.r
How ck .......
l
Reason for pumping„ lintene� .
i
t u p,.d / 1 'Title, Official In p ti n Fore:Subsurface +w� Di pia I terra«Page 8 of 1
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Commonwealth, of Massachusetts
T tle 5 UTTicial Inspection orm
o Subsufface Sewage Disposal System Form Not for Voluntary Assessments
� Johnny Cake st
Property Address
Cavazza
Owner .®
information i
required for every w Andover 5/14/1
page. ��t '� wn n
1
Dl,, System Information (coat,.)
, Type of System:
Septic tank, distriltin box, slil absorption system
Single cesspool
El Overflow cesspool,
Eli Privy
Shared system (yes or,n if yes, attach previous inspection records, if any)
C] Innovative/Alternative technology'. Attach a copy of the errant+np rati n and
maintenance contract t e obtained from System o ner end f l t t
inspections of the I/A system by system operator under contract
Tight,tank. Attach,a copy of the DEP appr val.
Other(describe):
Approximate agie of all components, d to in t llled (if' nown and source of information:
1996
Were sewage oldors detected when arriving at the site? 0 es No,
5. Building Sewer (locate on site plan):
2011
Depth bellow grade:
Material of c nstrueti n:
El cast iron , FCC El other(explain), �ry
Distance from, private water supple well or suction, line: .
yet
Comments on condition f joints, venting, evidence of leakage, etc.):
15insp.doc•rev.7/2612018 Till Official inspection Foirml:Subsurface Sewage Disposal System Page 9 of 1
1
Commonwealth of Massachusefts
Title 5 Off"locial Inspection Form
:...... SubsurfaceSewageDisposal System Form
� Not t for Voluntary
� mm
•u��.r .....,,. ..� -,���.,, a������„�� �..m. ,,.,.��� ��,�„�,
Property Address
Czz
Owner Owner's Name
information is No, Andover
MA 01845
9
required for every
������...�.. ��������. ���.m. St i ..��� inspection
page. CitylTown
p Code Date of
D, System Information
. Septic Tank (locate on site plea),
Depth below grade, 611
feetMaterial of construction:
0 concrete El metal fiberglass polyethylene other(explain)
If tank is metal,, age* year
Is age confirmed a Certificate f'Corn li nce? (atta,ch a copy of certificate) El Yes El l
5'X 'X1 '
Sludge depth- 1011
Distance from top of sludge to bottom of outlet tee or baffle 2211
Scum thickness 01
61111
Distance from top of scum,to top of outlet,tee or baffle
1611
Distancefrom bottom of scum to bottom of outlet tee or baffle
measure & sI e'ug
How
were dimensionsdetermined? ..... .m mm.
Comments n pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid i levels as rellated to outlet invert evidence of leafage, etc.)*
Both baffles good no leakage liquid level good.
__......rr�nn rw.mmwmrrrrnr mmunuumnmr ...... vauwumnmmmnrmemmm uunummmmmrmmmmrr 'mnmewrnnnnrmmnnnnmmr uuum. iiiii.i..P-..._...
t5insp,doc rev.712612018Title 5 Offidat Inspection Poem:Subsurface Sewage Disposal (em Page 10 of 18
am
Commonwealth of Massachusefts
1-0, T le 5 U'fficial InspectionFE orm
w...., i Subsurface Sewage Disposal System, Form Not for'Voluntary Assessments
147 Johnny Cake s,t
Property Address
1
Cava z
Owner Owner's Name
information o. Andover MIA5 5/1 /19
required for every ..m.w ..mmm �. State
Zip
�....---
City/Town
page
p ode Cate of Inspection
D. System, Information (cont.
7. Grease Trap (locate on site plan):
Depth below gr l feet
....m _...m.
Material of constructions
El concrete rn eta I ] fiberglass p l et 'l ru' other,r(explain);
Dimensions,
S unn thickness
ness ...�. �.
Distance from top of scum, to,top ofoutlet,tee or baffle _ .._ ...m.
Distance from bottom of scum to bottom of outlet tee or baffle
Tate of last pumping: Datemm... � ...n
Comments (ors, purnpingi 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 Tangy (tank roust be pumped attime of Inspection) (locate on site p�lan)-
Depth below grade:
Material of construction,,,.
El concrete E] metal El fiberglass Oi polyethylene El ot o r(explain),-,
Dimensions:
capacity .............................
M n
Design Flow: gallons per day
t5insp,do •rev,.7,126/2018 Title Official Mspection Form:Subsurface Sewage Disposal System-Page I I of'1
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m
Commonwealth of Massachusetts
=�
I Inspection
T'it
q "'It 5 Off i,cia
MA
Subsurface Sewage Disposal System, Form Not for Voluntary Assessments
147 JohnnyCake st
Property address
r
r
Czza
Owner Owner's Name
i . f
information w �. Andover MA 01845 5/14119
required for every
page City/Town S tate Zip
Code Date of Inspection
D. System Information (corats
8. Tight or Holding Tank(colt.)
Alarm present: El Yes l
Alarm l lw .,.,,, alarm in working order: El Yes El N
Cate of last pu ping# Date
Comments (condition of alarm,and float switches, etc.):
Attach copy of current pumping contract(required). is copy attached' Yes El l'
9. Distribution Box if present tint be opened) (locate on site plan):
Depth f liquid level above outlet invert
Comment (note if box is Ilevel and distribution to outlets equal, any evidence of solids carryover, are
evidence of leakage into or out of box, etc.)*
Equal dish no ioao no solids carryover
i
f
i
t5insp,do w rev.'7/2612018 Title 5 Official Inspection Form.,Subsurface Sewage Disposal system*Page 12 of 1
Commonwealth of Massachusetts
Tnt,le 5 Offolci,al
f
Subsurface Sewage Disposall System Form Not for Voluntary Assessments
147 Johnny Cake st
Property Address
Cavazza
Owner Owner's INanne
information is
,M Are � � r AMA 5 5/ 9
required f �r r .��w� �� m�� �.,.... ��t t t �.�.�..n.-mm
page. CityfTown
Inspection
D. System Information (c wt)
10. Pump Chamber(locate n site plan):
Pumps in working in order: �El Yes 1 �
Alarms in working in order: EJ Yes El No*
Comments (note condition of pump chamber, condition, of pumps n urter antes etc.);
It pumps or alarms are not in working in order, system, is a conditional pass,
11. Soil Absorption System (SAS) (locate on site plea,, excavation not required).-
If SAS not located,, explain why:
Type
El leaching pi'lts numbeir:
El leaching chambers number: ..__............................ .... _�
El' leaching galleries number:
leaching trenches number, length: 3-57t
leaching field's number, dimensions:
El overflow cesspool number: �mm
innovat,ive/alte�rnative system
Type/name of technology:
t5insp.doc rev.V2612018 Fills 5 Offi�c al inspection Form:Subsurface,Sewage Disposal Sy stern, .Paige 13 of 18
Commonwealth of Massachusefts
T t I e 5 Om"� TJrTr 8 i nIForm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
Cavazza
Owner
information is
No.-Andover 45 5 4 9
required for � mm� Ott .......
paged Cit Zip Cade Date of Inspection j
D. System Information (cent.)
1. Soil ,absorption System (SAS) (cont.)
Comments (note condition of soil signs hydraulic failure, legal of ponding, damp soil, condition of
vegetation, etc.):
No'hydraulic failure no pondingno, damp sails.
2. Cesspools (cesspool must be pumped as,part of'inspection), (locate on site it n):
Number and configuration
mm mm
Depth top of liquid t , inl+ t invert
Depth s I�i slayer _ .�.......
Depth of scum layer
Dimensions,of cesspool
Materials of construction ...
Indication of groundwater inflow 0 Yes [:1 N 0
Comments (note condition of soil,, signs of hydraulic failure, level ending, condition vegetation,
tv
M
t in , b •rev.7/26)2018 Title Official Ira peutilon Form-Subsurface sew Disposal System 4 Page 14 of 1
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Commonwealth �of Massachusetts
Title 5 O�ff icial Inspection For�m
Subsurface Sewage DilsposaI System Firm INo�t for Voluntary Assessments
7 Johnny Cake st
Property Address
Czz
Owner Owner's Name
information is
required for eves . MA '� 5 " "�
age, City/Town State Zip Code Date of Inspection
D. J
System Information (
13. Priiv (locate on siteplan):
Materials f construction:
Depth of solids
Commme is (note condition of s i,i, signs of hydraulic,failure, level! f ponding, condition of vegetation,
eta.):
t 'In p.do rev. / 1 Title Official Inspection Form Subsurface Sewage Disposal Systern Page 15 of 1
Commonwealth of Massachusetts
01
Title 5 utnicia ftection, Form
I Ins&
a' Pi
Subsurface Sewage Disposal' System Form Not for Voluntary Assessments
147 Johnny Cake,st
Property Address
i
Cana r
_...... �.. .,
Owner Owner's Name
information is MA 5 5 9
required for eves 1 �Andover
page CI�t /T rn Sate Zip Code Date of Inspection
D. System Information (coat.)
1 , Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks r benchmarks. 'Locate all welllls within 100 feet. 'Locate where public water supply enters
the building. Check one of the boxes below*
El hand-sketch in the area below
drawing attached separately
i
ffiinsp.doc r �7126/2018 Tilde 5 Official Inspection Fora;Subsurface Sewage()jsposal System.Page 16 of 18
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i
Commonwealth of Massachusefts
Title 5 Offi
Inspect'ion
Form
� I
"2
-- ,Subsurface Sewage Disposal System Form Notfor Voluntary Assessments
k 147 Johnny Cake t
Property Addr
Cz
Owner Owner's Name
information I
4/19
requirpage.ed fir . �.� m���.�. ���.�.��Andover �4 � � 1 ...................
City/TownState Zip Code Date of Insp ti...on
D. System, InforII (cont.)
15. Site Exam:
Check,slope
Surface water
Check cellar
El Shallow wells
ww,
Estimated depth to high ground water: 66
,..... �rvm
feet
Maass indicate all methods used to determine the high ground water elevation.
Obtained ned from system design plains on record
If dr i ed data f design plan reviewed:
m 4/5/96
Date
Observed site (abutting property/observation hole within 150 feat of SAS)
Checked with local Board of Health -explain*
-Pulled file
E] Checked with local excavators, installers-(attach documentation)
Accessed USGS database- plain:
You must descrilbe how you established the high ground water elevation:
Taken from diesign plans on record water at elevation 159.40, bottom oftrench at elevation 163,40
Before,filling this Inspection Report, please see Report Completeness Checklist on next,page.
tiro . -rev,70612018 itl Official IInspection Form,Subsurface Sewage Disposal posal 'tem.Page 17 of 11
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Commonwealth Massachusetts
...........- p Title 5 Utticial Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1 J n n Cake st
Propertydd des
C
Owner Owner:'s Name
information,is No, Andover MA 01845 5/14/1 9,
requiredfor every
r F Cit /T, Stint Zip Code Cate of inspection
E. Report Completeness Checklist
Complete III app,ficable sections of this form iinc'[us v
., Inspector Information: Complete all fields in this, section.
i
1
., Certification* Signed & Dated and 1, 2, 3 r�4 checked
t
IZ C, Inspection Summary:
11 21 3,, or 5 completed as appropriate,
(Failure Criteria) n (Checklist) completed
D. System Information*
For M T'�i ht 1 l i g Tank—Pumping contract attached
For : Sketch of Sewage Disposal sal System drawn on , 16 or attached
For 15, Explanation estimated depth to high groundwater included
t in p.do rev.7/2612018 Tide 5 Offidial Inspection Form:Subsurface Sewage Disposal System 4 Fags 18 of 18
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OFFICIAL
PART C
SYSTEM INFORMATION SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
(continued)
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Woperty Address:
,Jobimy Cake Street
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Inspection:'Date of **"
SKETCH OF SEWAGE]DISPOSAL SYSTEM
Provide,a sketch of the sewage disposal,system l fie to at,least,two permanent reference landmvks or
bencbmarks.Locate all wells,vifidn, 100 feet.Locate where public water supply to build' .
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MassageEl -active
11 Offal(Septic) l
11 Recreational
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11 s iinming Pooh
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' TrashlSolid Waste Hauler
11 Well Construction $
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Septic Soil Testing
11 Septic-Design Approval
Septic Disposal Works Cons ction WC
Septic Disposal Works 111 l s,
Title 5Inspector
title 5 Report
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