HomeMy WebLinkAboutPass - Title V Inspection Report - 25 ABBOTT STREET 9/3/2019 Commonwealth of Massachusetts
�� m Title lForm
Subsurface Sewage Disposal System l m Not for Voluntary Assessments
25 Abbott Street
Property Address
Owner Owner's'Name
information is, Andover ,.,..,. .,,.„, m� �, �0,1845m� - -01
9
required for every
page® City/Town, State Zip Code [date of Inspection
Inspection results must be subm!itted on this torah. Inns ec'tion t+ rms, may not be altered In any
way. Please es see completeness hecklist at the end of the firm.
Important:When
�Iof o ionfi1�1 + t forms A. Inspector
n the muter, John DiVincenzo
use only the tab
1
key to more your Name of Inspector Ell,
N
cursor-do not � Service, �I���w �d
J ` l n earl St w nrt s Se tic
u thereturn Company NaN1�1
key.
68 So. Kimball St.
Company address
Bradford �1 35
m.... m mm.mmm...�.m.m.. ry m m m�,,,,�..� .w. u, �, ,,,,,.., � mm....�...�.....
City/Town State Zip Code
AM
Telephone Number License Number'
B. Certification
certify that: I am a DEP approved system inspector in full compliance ►it u Section ,3 of Title
(310 CIVIR 15., ; 1 have personallyinspected the sewage disposal stern at the property address
listed above" the, information reported below is true; accurate and complete as of the time rrn
inspection; arn the inspection was perforrned base on my training and experience in the,proper function
and maintenance of on-site sewage d.isposal systems. After conducting this inspection I have determined
that the s °stern
1. Passes
2. Conditionally Passes
3. Needs F ,,er Evaluat,ion by the Local Approving Authority,
. i1
ddV
Y
< .
w
e,to Signa Date
Tyµ s sta inspector sly 1' subm" copy rat this irnsp ti rn report t the Approving uth Authority B nr
of 1 alt n r E within s of omplat ng this J�n�spa ti rn. I tine system has a diasi rn t�l of
p 0010 g pd or greater, the inspector and the system owner sl alll submit the report to the appropriate
regional office of the DER, The original form should be saint to the system owner and copies sent t
the buyer, it applicable, and the approlving authority.
Please note: This report only describes conditions at the time of linspection and inner the
condiflons of use at that timie Tanis inspe ti n,sloes not address how,the system,will , ert rrn
Ilan the futurehinder the same r different,conditions of use.
t6insp.do,c rev.712612018 Title 6 Official inspection Fora:Subsuffacm Sewage disposal System-1 gage 1 of 1
Commonwealth of Massachusetts
ANN.
IFFEle 5 Offic'I'al! InsupAn-ecuon Florm
Subsurf ce Sewage Disposal, System Form Not,for Voluntary Assessments
26 Abbott Street
---—---- ............
Property Address
Nicol alsen I j oseph
Owner Owner's Name,
informationis No. Andover MA 01845 08-01�-20,19
required for every
page. it State Zip Code Date of Inspection
G. Inspection Summary
Inspection Summary. Complete 1 2� 3,, or 5 and all of 4 and 6.
1) System Passes,*.
I have not found any,information which indicates that any,of the failure criteria described
in 310 CMIR 15.303 or iin 310 CIVIR 16.304,exist. Any failure criteria not evaluated are
indicated below.
Comments:
..........................................................
2) System Conditionally Passes:
El
"Conditional Pass"section needto be One,or more system cornponents as described in the
replaced or repaired. The,system,, upon completion of the replacement or repair, as approved by
the Board of Health, will pass,.
I" (Y' N, ND) for the foll ow ing statements,. If"n ot
Check the box for,it yes", "no"or"not determined ,
determined," please expla,in.
The septic tank is metal and over 20 years,old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial,, Infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing taut is replaced with a complying septic tank as approved by the, Board of
Health.
*A metal septic tank,will pass inspection if it is structurally�sound, not leaking and if a Certificate of
Compliance indicating that the,tank is, less than 20 years old is available.
El Y E] N El ND (Explain below):
............
15insp.doc-rev.7126Q018 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page f 18
Commonwealth of Massachusetts
...........
TI 0 UTTIcta ion mA
I Insp%ect" Form
Subsurface,Sewage Disposal System Form Not for Voluntary Assessments
25 Abbott Street
Property Address,
Ni�,colaisen, JostLh........
,Owner rs Name
infbrmation is No. Andover MA 01845 08-01-2019,
required for every
page., Cityrrown, state Zip Code Date!of Inspection
C. Insplection Summary (clon�t.)
21) System Conditionally Passes (cont.)n.
Pump Chamber umps/a,larms not operational., System will pass with Board of Health approval, if
pumps/alarms are repaired.
Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed ipe(s)or duet o a broken, settled or uneven distributIon box�. System will
pass inspection if with appr val,of Board of Heialth):
0i broken pipe(s) are replaced Ej Y N E] ND(Explain below):'
obstruction is removed 0 Y N [:1 ND (Explain below):
distribution box is leveled or replaced F-I Y 0 N El NID(Explain below):
The,system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
,system willl pass inspection if(with approval of the Board of Health)*
broken p1pe(s) ire replaced [:1 Y [:1 N F-1 ND (Explain below *
El obstruction is removed El Y El N El ND (Explain below):
........................—..-...................................... ........... ................
3) Further Evaluation is Reqdfed by the Board of Health:
El Conditions exist which require further evaluation by the Board of Health In order to determine if
the system is failing to protect public health, safety or the,environment,.,
a. System will pass unless Board of Health determInes in accordance with 310 CMR
15-303(l)(1b),that the system is not functioning In a manner which will protect public health,
safety and the environment:
t5insp,doc rev,7/2612018 Title 5 otficial inspection Foirm,Sub,surface Sewage Disposal System-Page 3 018
Commonwealth of sac u e
I" tle 5 Oa�TAmmoscoal,IJ
Inspect'ion Form,
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
25 Abbott Street
Property address
l is laisen, Joseph
Owner Owner S Name
information is, . Andover M � 5 - -2 9
required',for even � � �..,�.
page City/Town state. .._ Zip Cade Cate of Inspection
C. rat.
Cess,pooli or privy is within 50,-feet t'a surface water
Cesspool r privy is within 5 feet ofa bordering vegetated wetla,nd or a stilt marsh
b. System will fail unless the Board of Health (and Public Water Supplier,, if
determines that the system is functioningin a manner that protects the publIc.he It ,I
safety and +envitr nn nt.
El The system, has a septic tank and soil absorption system (SAS),and the SAS i's with'in
1 feet of a surface water supply r tributary to a surface,water supply.
E] The system ss a septic tank and SAS and the SAS is within a Zone I of s u,bli water
Supply.
[:], The system has ai septic tank and SAS and the SAS is within 5,0 feet,of a private water
supply well.
El The system has a septic teak and SAS and the SAS i's less than 11 feet but 50 feet r
more from a private water supply well".,
Method used to determinedistance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
c lit rrn bacteria indicates absent and the presence of ammon'lia 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,attachedto this form.
cHOther,:
System. Failure Criteria Applicable to All Systems.
Your must indicate"Yes" r"'No""to each of tb,e following for all inspections.
Yes No
Backup of sewage into,facility or system component due to overloaded or
clogged SAS or,cesspool
Discharge or poniding of effluent to the surface of the ground r surface waters
dine to an overloadied or clogged SAS or cesspool
i5insp.doe rev.7/26/20181 Title 5 Official Inspection Form,Subsurface Sewage Disposal Systern-Fags 4 of 18
Commonwealth of Massachusetts
.......................................................
I,, lie 5 ufficial Inspection Form
Subsurface Sewage Dilspozal System Form Not for Voluntary Assessments
25 Abbott Street,
Property,Address
Nicolaisen, 'Joseph
Owner Owner's Name
information is, No., Andover MA 01845 08-01-2 019
required for every
pa,ige. Cityffown state Zip Code Date of Inspection
C. Inspection Summary ('cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
El E Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6�j below invert or availabl volume is,less
than %day flow
Required plumpling more than 4 times in the last year NOTdue to clogged or
obstructed plipe(s). Number of times mes pumped:
Any portion of the SAS, cesspool or privy is below high. ground water,elevation.
Any portion,of cesspool or privy is within 100 feet of a surface water supply or
M tributary to a,surface water supply.
Any portion of a cesspool or privy is,within a Zone I of a public water supply
well.
Any portion of a cesspool or privy is within 5,0 feet of a, private water supply well.
El E Any portion of a cesspool or privy is less than 100 feet but greater than 5 feet
frorn a private,water supply well with no,acceptable water quality analysis. [,This
system passes if tyre well water analysis, performed at a DE P certlfied
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogien and nitrate nitrogen is equal t'o or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be,attached to this form.]
E] M The system is,a,cesspool serving a,facility with a,design flow of 2,000 gpd-
10,000 gpd.
El E The system,fails. I have determined that one or more of the above failure
criteria exist as described in 310,CM R 15.303, therefore the system fails. The
system owner should conta ct the Board of Health to determine what will' be
necessary to correct the failure.
5) Large Systems,., To be considered a large,system the systern must serve a facililty with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must,indicate either"yes,"or"'no" to each of the following, In aiddition to the
questions in Section CA,.
Yes No,
1:1 El the system is within 4001 feet ofa surface drinking water supply
1:1 EJ the system is within 200,feet of'a tributary to a slurface drinking water supply
El 1:1, the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IIWP,A)or a mapped Zone 11 of a public water supply well
t5insp,doc rev.7/26/2018 Title 5 Official Inspection,Form,Subsurface Sewage DisposaI System-Page 5 of IS
Commonwealth of Massachusetts,
P%r-ra 0 0
11'"Itle 5 UTTIcia 1 Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
25 Abbott Street
Property Address
Nicolaisent Joseph,
Owner Owner's Name
information is No. Andover MA 018,45 08-01-2019
requiredfor every ......................................................................................................
page. Cityffown State Zip Code Date ofins pection
. I Summary (con�t.)
If you have answered "yes" to any,question in Section C.5 the system is considered a si�gnificant
threat,, or answered It yes"to any question in Section CA above the large system has failed. The
owner or operator of any large,system considered a significant threat under Section C.5 or-failled
under Section CA shall upgrade the system in accordance with 310 CIVIR 15.3104. The system owner
should contact the appropriate regional office of the Department,
6. You must indicate"Yes" or"no"for each of the following for all inspections:
Yes No
0 1:1 Pumping inf6rmation was provided by the owner, occupant, or Board of Health
El 0 Were any of the system components pumped out in the previous two,weeks?
M F-1 Has,the system received normal flows in the prevlious two week,period?
Have large volumes of water been introduced to the,system recently or as part of
this inspection?
Were as built,plans of the,s stem, obtained and examined'? (if they were not
available note as N/A)
Was the facility or dwelling 'Inspected fir signs of sewage back up?
Was the site inspected for sigris of break out?
M � Were,all system compo non entsIt excluding the SAS, located on site?
Z El Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or teen material of construction,
dimensions, depth of Iiquid, depth of sJudge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
information on,the proper maintenance of subsurface sewage disposalsystems?
The Mize and location of the Soil Absorption System (SAS) on the,site has
been determined based on*
Existing information. IF or example, a plan at,the Board of Health.
Determined in the field if urn of the failure criteria related to Part C is at issue
approximation of d1stance is unacceptable), [310 CIVIR 15.302(5)]
t5nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form,Subsurface Seviage Disposal System s Page 6 of 18
Commonwealth of Massachusetts
Amon 0MI
icesl Inspection, Form
Subsurface Sewage Difsposall System Form Not for Vol untaryAssessments
25 Abbott Street
Property Address
Nicolaisen,
Owner Owner's Fame
informat ion is No. Andover MA 018,45 018-011-2019
required for every ...............................
page. Cityrrown State Z,ilp Code, Date of Inspection
D. System Information
11. ReWdentiall Row Conditions:
3 3
Number of bedrooms (design)* ............... ........... Number of bedroomis (actual).,
DESIGN flow based on 310 CMR 15.203 (for example: 110 g,p,d x#of bedrooms): 604 G.P.D.
Description.-
..................... .......
Number of current residents-. 2
Does residence have a garbage grinder? Yes No
Does residence have a water treatment unit? Yes No,
If yes, discharges,to:
Is laundry on a separate sewage system? (Include, laundry systern inspection Yes No
information in this report.),
Laundry system inspected? El Yes No
Seasonal use El Yes M No
Water meter readings, if available (last 2 years usage(gpd),)*,
Detail:
...........
Sump pump? E] Yes E] No
Last date of occupancy, Occu pi e d"'Date
t5insp.doc rev.712612018 Tille,5 Official Inspection Form Subsurface Sewage Dsposal System,-Page 7 of 18,
Commonwealth of Massachusetts
w 5 u Ial, Inspectmion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
25 Abbott Street
Property Address
Nicolaisen, Jos h
.............
Owner Owner S,Name
information i's No.Andover MA 01845 08-01-2019
requiredfor eivery ..........r ............................................................................................................................
page. City/Town State, Z,ip Code Date of Inspection
D. System Information (cont.)
lots
2. Commer0fal/Industr'll'al, Flow Co,ndi ions,,.'
Type of Establish ment:
Design flow(based on 310 CMS 15.203):
Gallons,Per day(gpid)
Basis of design flow(seatslpersons,/sq.ft, etc.):
Grease trap present? El Yes E] No
Water treatment unlit present',? El Yes No
Ifyes, d:1scharges to'.
Industrial waste holding ta,nk,present? El Yes C No
No
1 Yes Fj No,n-sanitairy waste discharged to the Title 5 system —1'.? E
Water meter readings if available,
Last date of occupancy/usie: -,D-a 111.t 11 e
Other(describe below):
3,. Pumpling Records:
Stewart's-Last pu M 9-13-2:018
Source of information: ........... ...p 0
Was system pumped as part of the inspection? Z Yes Ej No
If yes, volu 1500me pumped:
gallons
Sight ge,,,o au n truck
,
How was quantity pumped determined? ........................
Reason for pumping, Ma*ntenance
Mnsp.doc rev.7126/2,018 Ti ille 5 Official inspection Fora Subsurface Sewage Disposal Systern-Page 8 of'18
�^l
Commonwealth scs
Viti Otticial, 1,
e 5 nspection, Form
.... .. . Subsurface Sewage Disposal System Form Not for Voluntary Assessments
® 5 Abbott Street,
Property address
...............................................................�p............................................ ...................... ........ ............................ ...................................
Owner Owner's Name
information is . Andover 5 8-01-2019
r uired for e ��i r ......ww.�....�...... - ..w .� - -
State Zip Code Date of Inspection
D. System Information (cont.)
. Type of System:
2 Septic tank,, distribution box, soil absorption system
Single cesspool
1:1 Overflow cesspool
Privy
El Shared system (yes or n cif yes, attach previous Inspection records, it any)
Innovative/Alternative technology., Attach a copy of the current operation and
maintenance contract(to,be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
Tight tank., Attach a copy of the DEP ai ro 1.
Other(describe,),:
Approximate ague of all components, date installed it known) and source of int r , ti m
95
Were sewage odors dete�cted ,when arriving at the site's El "des 0 No
5: Buildoing Sewer(locate on site plan):
1811
Depth below grade, . ...
feet,
Material of construction.*
past iron PVC other(explain),
Distance tr rru, privatewater supply-well or suction n lire
fet
Comments n condition of joints, ventlng,, evidence of leakage,,, etc,
t5insp.dcc rev.7,12612018 Title,5 Official inspection Form,Subsurface Sewage Disposal System Pa,qa 9 of 18
CommonwealthofMassachusetts
�Otle 5 Official Inspection Form
Subsurface Sewage Dis,posall System mom Not for Voluntary Assessments,
x
25 Abbott Street
Property d dr
Nicolaisen,, Joseph,
Owner s Name
information is No. Andover MA 0`1845 08-01-2019
required for every
,,age. City/Town State Zip Code Date of Inspection
D. System Information (cont)
6, Septic Tank(locate on site lan):
w
Depth below grue. feet ---
Material of construction:
concrete El metal F1 fi erglass polyethylene other(explain)
If tan is metal, list age. yelar .� ..
Is,age confirmed by a Certificate of Compliance 7, (attach a,copy of certifi at , Yes No
l
Dimensions,nsions, X 1
11
Sludge depth:
11
Dist cl from top sludget bottom of outlet tee r ale �.
Scum thickness
Distance from top of scum to top of outlet tee or baffle 611
.��..�.m.
611
Distance from bottom of'scum to 'bottom of'outlet tee or baffle ,
How were 'imensi s determined? Tape s r /sl j � e
Comments pumping, recommendations inlet and outlet tee oir battle,condition, structural Integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.).',
Both baffles in food shape. No leak ,, liquid level good.
t5insp,doc rev.7126,12018 Title 5 Official,Inspection Form,:Subsurface Seviage Disposal Syste -Page 10 of 1
Commonwealth a
TwItIb 5 Official Inspectmion Form
. Subsurface Sewage Disposal l Systm Form Not for' luntar ssessments
25 Abbott Street
Property Address
Owner fir s Name
information is
1
�� '"�Pfl Ott ��� � � � � ,
required ��
page. f Inspection
D. System Information
T. Grease Troup (Iodate on site plan);,
Depth e l oar grade:
feet
Material f constructiom
El concrete metal fiberglass [:1 polyethylene Ej other(explain):
Dimensions.*
Scum thickness
Distanice from top of'scum to top of outlet tee or baffle
ist ara from bottom f scum to bottom of'outlet tee or baffl•! ..
Date of lastpumping: Date
�.
Comments pumping recommendations 5 inlet and outlet tee,or,baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leafage, etc.);
8. TIgM or Holding Tank(tankrust be pumped gat time of inspection), (locate on:site lain):
Depth bellow grade:
Material of construction'.
El
art metal fiberglass polyethylene other(explain):
Capacity: ...........
a
gallons
Design low: � ...mmm... . . .. _.,.....,�
gallons per dad'
t5ins ed .rein.,71261,20,18 Title f loll Inspection Form:Subsurface S viage Displosal System.Page 11 of'1
Commonwealth of Massachusetts,
T"Itle 5 Offmcial Inspect"ion, Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
25 Abbott Street
Property Addr�ess
Nico�laisen, Joseph,
................................................
Owner Owner's Name,
information is required for eve No-Andover MA 01845, 08-01-2,019
ry
p�age. City/Town State ZIP Code Date of Inspection
D. System Information (cost.)
8. T'ilght or Holding Tank(cont.)
Alarm, present: El Yes Ej No
A
I . N o larm level: Alarm in working orde�r Yes
Date of last purnping: Date
Comments(condition of alarm and float switches, etc.).
...............
Attach copy of current pumping contract(required). Is copy attached? El Yes
9. Distribution Box (i�f'present must be,opened) (liocate on site plan):
0
Depth of liquid level ablove outlet invert
I
Comments (note if box islevel and distribution'to outlets equal, any evidence ofsolilds carryover, any
evidence of Ileakalge into or out of box, etc.):
Equal distribution no leakage, nio solids car�over .....
................
l5insp.doc rev.,712U20,18 T'rill'e 5 Official Inspection Form,Subsurface S�awage Disposal Systern-Page,12 of''18
Commonwealth of Massachusetts
n 5 o, ictal 1nsr%ec1t,'ion Form
..................
Subsurface Sewage Disposal System! Form Not for Voluntary Assessime rat
s
I njv 25,Abbott Street
Property Address
Nicolaisen,,,, Joseph
Owner Owner's Name
information is No. Andover MA 01845 08-0 1-�2 0 19
required for everym.
page., City[Town State Zip Code Date of Inspection
D. System Information (cont)
10. Pump, Chamber(locate on ,site plan)*
Pumps in working order: El Yes N o*
Alarms in workilng order: M Yes 0, No*
Comments (note condition of'pump chamber, condition of pumps and appurtenances, etc.):
..........
If pumps or alarms,are riot ire working order', system is a conditional pass.
11. Soil Absorption System (S,AS,)(locate on site plan,, excavation not requ tred
If SAS not located, explain why&
'Type:
El leaching pits number*
leaching chambers number"
leaching galleries number'.
leaching trenches number, length: 2-45'
leaching fields number, dimensions:
over,flow cesspool number:
innr tive/alternative system
Type/name of technology:
t5insp,dw-rev,.7/2,612018 Title 5 Official Inspection Form.,Subsurface Sewage Disposal System-Page 13 of 18
w
Commonwealth of Massachusetts
F= -... -1 0 A" 0 E
T icia on,e 5 Off I Inspect i" �Form
Subsurface Sewage Disposal System Form Not for Vol untary,Ass esera ents
25,Abbott Street
Property Address
Nicollaisen, Jose h
.............O
wner Owner's Name
information is No. Andover MA 011845 08-01-2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS,)(cont.)
Comments(note condition,of soil, signs of hydraulic failure, level of poindingl, it soil, condition of
vegetation, etc.),*
No hydraulic failure, no )oTnqTi:nq, no„damp soils
.............
........
...........................................................................................................................................................................-.......................................-................ ....... .............................
12. Cesspools (cesspool must be purnped as part of Inspection) (locate on site plan):
Number and, configuration
Depth—top of liquid toinlet invert
Depth, of solids layer
Depth of'scum layer
Dimensions of cesspool
Materials ofconstruic tin,
Indication of groundwaterinflow El Yes N o
,Comments(note condition of soil, signs of hydraulic failure, level of pondin,g,, condition of vegetation,
etc.):
..........
t5insp.doc-rev.7/26?2018 Title 5 Offidal Ins,pection Form,Subsurface Sewage Disposial System-Page 14 of 18
Commonwealth a se
",-le 5
Titc uttiia ion
�. Insw%ect"
%
mm�mm.�mm
Subsurface 'Sewage Disposal System Form Not for Vol untaryAssessments
25 Abbott Street
Property Address
.... m....._. ...mm....... ., .,,,.,,,,,.
Owner Owner's Name
information 4 ,
1 9,
required for eves � Andover 5 - -2 "
page., City own State Zip Code Date of Inspection
D. System Information (cent.)
13. Privy(locate on site plan):
Material's of construction.: .m�.. ..m............ mm. mm ..
..................
Dimensions
Depth of solids
Comments (note condition of sold, signs of hydraulic f iillure level of ponding, condition of viegetat,ion,
t h p,d rev, / ,1 g18 Title 5 Official Inspection Form:Subsurface Sewage iDi posail System-Page 15 of 18
Commonwealth of Massachusetts
T'"Itle 5 'ff"c al I 1 1, nspection Form
Subsurface Sewage DiSposal System Form Not for Voluntary Assessments
25 Abbott Street
Property Address
Nicolaisen, Joseph
Owner Owner's Name
information is No. Andover MA 01845 018-01-2019
required for every
page. Cityffown State, Zip Code Date,of Inspection
D. System Information ('con�t.)
14. Sketch Of Sewage D11sposal System:
Provide a view of the sewage disposial systemt 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*
are s,ketch in the area below
drawing attached separately
1:5 in sp.doc,-rev.,7/26120 18 Title 5,Official Inspection Fofm Subsurface Seviage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspecti'"on Form
.........................
Subsurface,Sewage Disposal System, Form Not for Voluntary Assessments
"."1 25 Abbott Street
Property Address
Ni la,isen, Joseph,
� W 0) ner Owner's,Name
information,is No�. Andover MA 01845 08-01-2019
requiredfor every ......................................... .........................................
page. Cltyffown State Zip Code Date of Inspection
D. System Information (cunt.)
15. S'Ite Exam:
2 Check,Slope
F] Surface water
E Check cellar
0 Shallow wells
3011
Estimated depth to high ground water: feet
Please,Indicate all methods used to determine the high ground water elevation."
Obtained from,system,design plans on record
If checke 05/30/1985d, date of design plan reviewed, Date!
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked,with Ilocal Board of Health:-explain,
Pulled fi'le
Checked with, local excavators, installers,-(attach documentation)
Accessed USES database®explain:
..............
You must,describe how you established the high ground water elevation,
Taken from qti ,,,,,p,,,Ian on file,,.,, System, rai�sed approximately41"'from on final soil
.........._..........................................................
Before filing this Inspection Report, please see Report Completeness Ch,,ecklilst on next page.
t5insp.doc-rev.7126,12018 Title 6 Official Inspection Form-,Subsurface,Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
.................................................... i icial Inspection Form
Subsurface Sewage Disposal System Form� Not.for Voluntary Assessments
25 Abbott Street
...........
Property Address
Nicolaisen, Joseph ....................................................
Owne�r �Owner's Name,
information is No. Andover MA 01845 08-01-2019
r�equired for every .......................
page. Cityffown State Zip Code Date of Inspection
E. Repart Completeness Checkl ist
Complete all applicable secti,ons of this form inclusive of':
Z A. Inspector Information: Complete all fields in this section.
0, B. Certification-., Signed & Dated and 1, 21, 3, o,r 4 checked
C. Inspection Summary:
ill 21 3, r 5 completed as appropriate
4 ('Failure Crilteria)-and 6 Checklist completed
D. Systems Information:
Fir 8:1 Tight/Holding''Tank— Pumping contract attached
For 14: Sketch,of Sewage Disposal System drawn on pg. 16 or attached
For,15-1 Explanation of estimated depth to high groundwater included
t5irtsp,doc-rev.712612018 Title 5 Official Inspection Form Subsurface Sewage,Disposal System w Page 18 of 18
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