HomeMy WebLinkAboutPass - Title V Inspection Report - 267 OLD CART WAY 7/10/2020 r
r Commonwealth of Massachusetts Recejvl
Title 5 Official Inspection Form,
j Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen
HEAL �PRPY
267 Old Cart w 'a
Property Address
Vander rr af, Peter
__......
_
Owner .. _....
Owner's Name
information is No. Andover MA 016415 ..._....._ 067.297.210121 0 ..._..____
required for every . ..... .. _...._. ..._...
page. �tylTown. Mate Zip code Date of Inspection
Inspection results must be submitted on this form. Inspection farms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
Mkng out forms
on the computer, John Ii"w/inceno
use only the tab ......n_.__.
key to move your Name of Inspector
cursor-do not J & S Development/Stewart"s Septic Service
use the return _ ___-_- ..
key., Company Name
— 58 So. Kimball St.
r company Address
Bradford MA 01635
wty/Town State Zip Code
976-37 -7471 S113366
Telephone Number License Number
... .___....._.......
B. Certification
I certify that: I am a IM P approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16. 00); l have personally inspected the sewage disposal system at the property address
listed 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 of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. 0 Passes
2, El Conditionally Passes
3. F1 Needs Further Evaluation by the Local Approving Authority
4, ❑ Fails,
61,
Inspect s igna)ui� ✓ [late
The s stem inspector shall submit a copy of this inspection report to the Approving Authority (Board
of IH Ith or EP) within 30 days of completing this inspection. If the system has a design flow of
10,0 6 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regi nal office of the DER The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority,
Please note: This report only describer conditions at the time of 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.
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Commonwealth of Massachusetts
yJ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
267 Old Cart Way
Property Address
Vandegraaf, Peter
Owner Owner's Name
information is required for every No. Andover MA 01845 06-29-2020
page. Cityrrown State Zip Code Date of Inspection
C. 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 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Distribution box was replaced
2) System Conditionally 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.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
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 tank 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.
❑ Y ❑ N ❑ ND (Explain below):
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