HomeMy WebLinkAboutconditional pass/pass - Title V Inspection Report - 89 CHRISTIAN WAY 7/10/2020 Commonwealth of Massachusefts
a T A,
xIlle 5, Officia,l For
SystemSubsurface Sewage Disposal Form Not for Voluntary Assessments
89 Christian
Property Address
Kirk, Robert
Owner
Owners ame
information is
06-24-2020
required for eves ., � .m.._
page. City/Town State Zip,Cade Date of Inspection
Inspection results must,be submitted on thilis form. Inspection forms may not be altereldin any
way. Please see compiiletene s checklist at the end of the form.
Ir oitar t When A. Inspectornfor tionfilling,outf rms
on the computer, John iVincenzo
use nl,y the tab --, ,,,.,,, �. .
key to,move your Name of
cursor-do not S De el a r�rat/Stewart's " �icgerviguse tl ratlurr „. .�
key. Company Name
58 So. Kimball St.
tab
Company Address
Bradford A 01835
City/Town State Zip Cade
few 978 3 2- 4711 1133 6
_ . _ ,,,,,,,.. .��.�. ,,..,.,.._..4. . __ _._.._ .,.u.,u,, , _._.
Telephone Number License Number
1311,
I certify that: I am a DiEP approved system lnspector in f'urll compliance with Section 5.34 of Title 5
(310 CMR 16- 1 1 have personally Inspected the sewage disposal system at the property address
listed above the information reported below is trace, 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 orr-site sewage disposal systems After conducting this inspection I have determined
that the system:
1. E Passes
2. Conditionally Passes
3. Needs Farther Evaluation by the Local Approving Authority
. Fails
,
r ,d,
w,
,W
Inspe or's Signature Date
h system inspector s rafl suhmlit a copy of this inspection report to the Approving Authority
t ealth or REF')withlin 30 days of completing this inspection. It the system has a,design flow t'
1,01000 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, it applicable, and the approving authority.
Please note-. This report only describes conditions at the time cif inspection and under the
conditions of use at that time.This inspection dues not address, how the system will perform,
in the future under the same or different conditions of use.
t5in . o «rev.7/2612018 Title 5 Official'Inspection Form"Subsurface,Sewage Disposal System.Page 1 of 1 ,
Co�mm�on ealIth o Mias,s,achulsetts
'a I Ins,pecti"on Tatlie 5 UA01h6TTIcia
For
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
89
Property Address
Kirk, Robert
Owner wirer"s Name
information is No. Andover MIA 8 6-24-2 2
r �u�i�r for every M ...� . �..
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary.: Complete 1 1 21 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 CAR 15.,303 or in 3110 CAR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Distribution box was change
2) System Condlitilonally Passes,.,
El one or more system, components as described in the"Conditional ditional ass" section need to, be
replaced or repaired. The system, upon c m le�tion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for It yes", It no"'or"'not determined" Y, N, ND for the follow ing statements.. If"not
determined,,11 lease explain...
The septic teak is metal and over 2 ,years old* or the septic teak (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or teak failure is imminent. System will passe
inspection if the existing tank is replaced with a compu lyir septic tank as approved the Board o
Health.
A metal)septic tank gill pass inspection if it is structurally sound, not leaking and if a Certificate o
Compliance indicating that the tank is, less,than 20 years old is available.
El Y INI El ND (Explain below)*
t5ins , a .r /6/2,18 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page "cif 18
N
Commonwealthil of MassachusettsA.
nle 5 Officia,l Inspect"ion For
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
w 89 Christian
Property Address
Kirk, Robert
Owner Owner's Name'
information is
MA 01845 06-16-2020
red for every
� _ � .
page. City/Town State Zip Cade Date of Inspection
ection
InspectIon results must be submitted on this form. Inspection forms may not be altered In any
way. Please see completeness checklist at the end of the form.,
Importaft When
II'il� out formsA. InspectorInformation
on the computer, John l iVinc nzo
use on:ly the tab �
key to move your Name of Inspector
cursor-do not d & S evel r nt/Stewart's � �c Service
use the return ..�_. . �—e-1,��,,,. . .,..,, _.. ,,,, �. ,. ,ro
key. Company Name
58 So. Kimball St.
Company Address
Bradford MA 01835
City own State Zip Code
113386
"eIeph �ne ~ .... _A....... ,.m...w. a_...�..... . .__... ._.. .. ... .y.._._._ ._.. ........_.
Number License Number
Bl,, Certification
I certify that. I am a EP approved system 'Inspector in fulfil compliance with Section 15.340 of T"Itl+ 5
(310 CMI 15. 1 I 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 r maternal f n-site sewage a disposal systems. After conducting this inspection l have determine
that thile system:
1 El Passes
2. Conditionally Passes.
3. Needy Further Evaluation by the Local Approving Authority
4. El Fails
„ VF
Inspector' I nature '' Date
The s t m inspector shall submit a copy of this inspection report to,the Approving Authority(Board
of H Ith or DEP")within 30 days of completing, this inspection. If the system has a design flow olf
g1pld or greater, the inspector,and the system owner shall submit the report to the appropriate
regional 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 not+ : This report only d aorl wlaa conditions at the time of Ina aotlon and under the
oonditlona f uaa at that time.This, Inspection does not address how the system Mild perform
in
the future under the same or different condltl r�s o use.,
t5insp,d .rev,7/2612018 Title5 Official Inspection Form:Subsurface Sewage Disposal System.Page 1 of 18
Commonwealth of Massachusetts
ww OffoInspectn Tatle 5 icia ion
Subsurface Swage Disposal System Form - Not for Voluntary Assessments
89 Christian"may
Property wddress
Kirk, Robert
Owner Owner's Name
information is
required for even ., �., .�.�,M.MA 45 _
page. CIt rrown State Zip Code Date of Inspection
Go Inspection Summary
Inspection Summary*. Complete 1 f 21 , or 5 and all of 4 and' 6.
1) System Passes
l have not found any information which indicates that any of the failure criteria described
in 3101 C R 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated baler,
2 System C rn l l maally Passe
one or more system components as described in the"Conditional Pass" section untied to be
replaced or repaired. The systerm, 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, l 1, NCB) for the following staterments, If"not
determined,11 please explain.
The septic tank is metal and over 20 years cldl* or the septic gunk (whether metal or,not) is structurally
unsound, exhibits substantial infiltration or exfiltraticn or tank fai,l�ure is imminent,. System will puss
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 leafing and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
Y loll N Explain below
t5insp d -rev.712 " 1 Tiitle 5 Official Inspection Forrw:Subsurface Sewage Di p s I System.Page 2 of 1
M M YTIcial Inspecti'mon'P TUEle 5 0
For
Subsurface Sewage Dilisposall System Form Not for Voluntary Assessments
89 Christian Wa
Property Address
Kirk, Robert
Owner Owner's Name
information is
` 06-161-20,20
required,for every _. ...__., �._ �.
page. City/Town State, Zip Code Date ofinspection
C, Inspection Summary (cont)
2 System Con diufio nally Passes (cont.):
Pump Chamber pumps/alarms not operational. System will pass with Bard, of Health approval if
um s wlarrns are repaired.
Observation of sewage backup or break out or high static water level in the distribuition box due
to, broken or obstructedpipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection i (with approval of Board of Health)-.
0 broken pipe(s) are replaced 0 Y El NEI ND (Explain below
[_1 obstruction is removed E1Y 0 l l (Explain below)*
distribution box is leveled or replaced Z Y ED N 0 ND (Explain below),:
lei tribuutrion box nod Le l�cin because there is leakgw e around the outlet inverts
The system required pumping more than 4 tines a year due to broken or obstructed l ilex The
system will pass inspection if'(with approval of the Board of Health
E] broken 1 s are replaced F1 Y N ND Explain below)-.
obstruction is removed Y El N E] NCB Expl in below)-.
3 Further Evaluuuafiioun is Required by the, Board of Health:
El Conditions exist which require further evaluation by the Board of health in order to determine i
the system is failing to protect puubilio health, safety or the environment..
. System wilill pass unless Board of Health determilines i�n accordance wl hi 3110 CMIR
16.3 3 b that the system pus not fuunotl+ nlung in a manner which will protect public h ealfhw,
safety"and the environment.
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Commonwealth of Massachusetts
�Z;I"I
....wemmmmrrrurv.mmmmmmexr
Tille 51 Oiffici,al Inspect"ion F'olr
Subsurface Sewage Dirsposal System Fora Not for Voluntary Assessments
89 Christian
MC
Property Address,
Kirk, Robert
Owner Owner's Name
information is N . Andover M 18 5 6- 6 2 2
required for ever �,... � m ,w �. .
page. City/,Town State Zip Code Date of Inspection
C,i Inspection Summary (cont.)
E] Cesspool or privy is within 50 feet of a surface grater
[:1 Cess ol1 or parr is within 510,feet of a hoirdering vegetated wetland or a salt marsh
b. System will tall uniless,the Board, of Health (and Public Water Sup pller, 'if any)
t rmlr es that the system 'ls functioning in a manner that protects the p ubllc health,
,
safety and r ulrrarrmen�t��
E] The system has a septic tank and, s ill absorption system (SAS) and the SAS is,within
100 feet of a surface water supply or tributary to a surface grater su lly.
[:1 The system has a septic teak and SAS and the SAS is within a Zone 1 of a public grater
supply.
Ej The system has a septic teak and SAS and the SAS is within 50 feet of a private grater
supply"well.
0 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 at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to r less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this fora.
c. Other:
You mustiIndicate,"Yes" or No"' to each of the following for all lr sp ectlon
mKoxi
Yes N
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground, or surface waters
E] E
due to an overloaded or clogged SAS or cesspool
t5insp. o -rev. /26/201 Title 5 Mill Inspection Form-Subsurface Sewage Disposal System.Page of 1
Commonwealth of Massachusetts
T otle 5 rm
Offilcia
I Inspect6i'on Fo
10 Subsurface Sewage Disposal posal System Form Not for Voluntary Assessments
Property Address
Kirk, Rohe
Owner me
information is No,. Andover MA 01845 6-16-2 2
required for eves ...__. . .. .. .,.,..,,, _.�
age. City[Town State Zip Cede rate of Inspection
C. Inspection Summary (coint.)
System Failure Crlferla Applicable to All Systems: (coat.),
Yes No,
,
Static liquid legal in the distribution box above outlet Invert due to,an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 dauy flowEl 0 .
Required pumping more than 4 tunes in the lust year NOT due to clogged or
obstructed i e s . Number of times 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
tributary to a surface water supply.
Any portion of a cesspool or,privy is within a Zone 1 of a public water supply
well.
El 11 Any portion of a cesspool or privy is within 510 feet of'a private water supply well..
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply"well with no acceptable water quality analysis. [This
system passes If the well water analysis,, performed of a DEP certified
laboratory,for fecal conform bacteria, indicates absent and the presence
of ar urrronia nitrogen and nitrate nitrogen is equal to or less than, 5 ppim,
provided that no other failure c riferl r are:triggered. A copy of the analysi'
and chain of custody mr a rsf be attached to this fours.)
The system is a cesspool servir a facility with a, design flow of 2000 gpd-
1010001 gpd.
The system fails. 1 have determined that one or more of the above failure
criteria xi t as described in 310 C R 15.3 3 therefore the system Boils. The
system owner should contact the Board of Health to determine what will he
necessary to correct the failure.
5 Large Systems-, To be considered a large system the system must serve a facility with a
design flow of 10,000 gpid to 5�, 1 gpd
For large systems, you must indicate either"y,es" r" o"tc each of the following, in addition to the
questions in, Section CA.
Yes No
the systems is within 4,00 feet of'a surface drinking water supply
the systems is within feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (interim W'ellIh ad Protection
1:1 El
,Area--IW " ► or a mapped Zone 11 of a public water supply well
t5insp.doc-rear,7/26/2018 Title 5 Officials Inspection Form:Subsurface Sewage Disposal System-Page 5 of 1
Commonwealth of Massachusetts
Title 5 Official In,spect,mion For
M Subsurface Sewage Disposal saI System Form Not for Voluntary Assessments
89C,.hristian q
Property Address
Kirk, Robert
Owner Owner's Name
information is No.. Andy er MA 011845, 6-1 2 2
s
required for eve
page Ci�t frown State Zip Code Date of inspe tion
C. Inspection Summary (coat.)
If you have answered 41yes" to any question in Section C.5 the system is considered a significant
threat, or answered Uyes" to any question in Section 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 the system in accordance with 310 CMR 15.3014. The stern owner
should, contact the appropriate regional office of the Department.
6 You miluisf indicate"Yes" r"no"for each of he following for all nspecti" s
Yes, N
El E] Pumping information, 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?
0
Has the system received normal flows in the previous two weekperiod?
Ej IE Have e large volumes of water been introduced to the system recently or as part of
this inspection,?'
'
Were as built plans of the system obtained and examined' (If they were not
available note as loll
Z E] Was the facility or dwelling inspect,ed for signs of sewage back up?
Was the site, inspected for signs of brash uat
Were all system components, excluding the SAS, Iodated'', on,s,ite "
Were the,septic tank manholes uncovered,, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction)
dimensi, ns, depth of liquid, depth, of sludge and depth of scums'
Was the facility owner(and occupants if different from owner) provided with
information, on the proper maintenance of subsurface sewage disposal systems?
The size and l c t1l"on of the Sol Absorption Sy�sfe (SAS) n the site has
been determined based on
Existing information. For example, a plani, at the Board of Health.
Determined in the field if any of the failure criteria related to Part C is at issue
approximation of distance is u�naccepta,ble) [310 CMR 15.302(5)]
f ire .dr -rear.`/26/201' TitleOfficial Inspection rmi:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 UTTICIal Inspect'i0on For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Dirk, Robert
Owner
i�nformation is No
ver MA 01845 06-1 6-2,020
required for every
page. Ci'lty/Town State Zip Code Date of Inspection
D, System Information
. Residential Flow Conditions:
Number of bedrooms (design).- Number of bedrooms (actual):
DESIGN flow based on, 310 CMR 15.203 (for example: 110, g�pd x#of bedrooms): 4! �....
Number of current residents.
Does residence have a garbage grinder? es Z No
Does, residence have a water treatment unit? Yes Z No
If yes, discharges to.:
Is laundry on a separate sewage system? (Include laundry system Inspection El Yes Z, No
information in tb�is report.)
Laundry system inspected.? El Yes El No
Seas nal us ? Yes Z No
Water meter readings, It available(last 2 years usage g d ,),� . .... .._ . _ _.._ _..._ ....
Detal'l:
Sump pup Yes Z No
date occupancy.* ���� ��
ed
Last �y. Date
t5ins ,do .rev.7/26/2018 Ti le 5 Official Inspection Form:Subsurface Sewage Disposal sal System-Fags 7 of 18
< as,sac
Commonwealth of M, husetts
A.
TTICI
Totle 5 al Inspect0ion For
Subsurface Sewage Disposal System Form! Not for Voluntary Assessments
' 89 Christian"tea
Properly Address
Kirk, Robert
Owner Owner's Name
information Is
required'
Waage. City/Town ate dip Code Date of Inspection
D System Information (cont.
2. Commercial/Industrial Flow Corndi ioirrs
Type of Establishment-
Design flow(used on 310 C R 5.203): Gallons per day(gpd)
Basis of design flow seats ersons/sq.tt., etc. :
Grease trap present's El Yes No
Water treatment unit present' El Yes El No
If yes, discharges to:
Industrial waste hoilding tank present's El Yes N
Non sanitary waste discharged to the Title, system? Yes No,
Water meter readings, if avail leiLast date of occuipa,ncy/'u:se:
Date
Other(describe el w)w
3. Pumping Records*,
Source of information: Stewar 's
Was system pumped as part of the inspection? YesN o
1
If yes, volume pumped: 5,00.
gallons
How wasquantity pumped determined? §9qgAuge on in true
Reason r um in g M a tenance and to i�n st II boy
t5i,nsp,do w rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal Sir -Page 8 of 18
Commonwealth of Massachusetts
'Tai�t'doile 5 U"0"&1Tfi*Tfi"wIC*IaI Insvp%ectmion Foir
Subsurface Sewage Dilisposal System Form Not for Voluntary Assessments,
8,9 Christian
Irery Address
Dirk, Robert
Owner 6W_I r i I
information is No.
required for even Andover _ .M. ,.,. MA 01 845 06-16-202,0
page. City r own State Zip Code Date of Inspection
D. System Information (cont.)
4,. Type of System:
Septic teak, distribution box, soil absorption system
m
ing,le cesspool
Overflow cesspool
Privy
El Shared system (yes or no) (if yes, attach previous inspection records, ifany)
Innovative/Alternative technology. Attach a copy of the current operation are
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 teak. Attach a copy of the DEP approval.
Other(describe)-.
Approximate,age of all components, date installed if known) and source of information:
7
Were sewage odors detected when arriving at the site? El Yes Z No
5. Bair Sewer(locate on silte plan):
Depth below grade:
feet
Material of construction:
S cast iron [:] 40 PVC El other(explain):
Distance from private water supply well r suction line:
feet
Comments on condition of joints, venting, evidence of leakage, etc.)-
t5insp.d -rev. /26/2,31 "title 5 Official,Inspection Form,Subsurface Sewage Disposal System.Page 9 of 1
Commonwealth of Massachusetts
a T A.
I'Lle 5 Offilicial Inspection l Form,
Subsurface Sewage Disposall System, Form Not for Volun!tary�p
Assessments
rr
14
8 C ristian Way
Property Address
Kirk, Robert
Owner Owner's Name
information is No. Andover M 8 12 6- 6_2
required ired for every
�. ��.. � ,.. _ ... ...
page. CityfTown State Zip Code Date of Inspection,
D, System Information (coat.)
6. Septic Tank(locate on site plan):
Depth below grade: 411
Material of construction
ED concrete El meted 0 fiberglass pollyethylene other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Com liiarace? attach a,copy of certificate) E] `des No
Dimensions 5 X 10 X
511
Siludg,e depth:
9 11
Distance from top,of sludge to bottom of outlet tee or baffle
Scum thickness►
Distance from top ofscum to top of outlet tee or baffle 611
Distance from bottom of scum to bottom of outlet tee or baffle 2411 ..., ....__.,Tqpt_Measure/sIu,d j ...........
How were dimensions,determined?
Comments on pumping recommendations11 inlet and outlet tee or baffle condition,, structural integrity,
liquid id levels,as related to outlet invert, evidence f leakage, etc.):
Both baffies in wed_0 , no 1e*a q, lu��uud le el o d
t5in p.d -rev,7/26/2011118 "title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 10 of 1
Commonwealth of Massachusetts
A.
Offimcia■
IEle 5 T I Inspecti*on For
Subsurface Sewage Disp olsaIl System Form Not for Voluntary Assessments,
IIA
9 Christian
Property Address
Kirk, Robe's
Owner + '�r�er`�N
information is
0 1845 016-16-202,0
required for eves Nq. Andover MA� ._
page. City/Towns State Zip Code Date of Inspection
D. System Information (conit.
7. Grease Trap locate on site plan),.
Depth below grade.-
feet
Material of construction:
El concrete El metal tl,berglass polyethylene other(explain):
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bloftom of scum to bottom cat urtl t tee or baffle
Date of last plumping: ....�, . .._._. ..__. mmw®_.__.�... .._ .... �_.. .. .m. M .
Date
Comments on pumping recommendations, inlet and outlet tee or baffIle condition, stru�cturral integrity,
liquid levels as, related to outlet invert, evidence,of leakage, etc.)..
M Tight or,HoldI Tank(tank must be pulmpeld at time of inspection) (locate on site plan),.
Depth below,grade-.
Material of construction.:
El concrete Ell metal fiberglass pol' etl yle'n other(explain).
gallon
Flow,.-
gallons per day
t5i . oc-rep!.7/26/2018 Title 5 Official inspection rm'Subsurface Sewage Disposal System-Page 11 of 1
w
Commonwealth of Massachusetts
"T A.
itle 5 Officiial Inspect"ilon Fo,r
i Subsurface Sewage Dlisposall system Form Not for Voluntary Assessments
89 Christian Wa
Property Address
Kirk, Robert
Owner Owner's Name
information is N . Andover M 5 06-16-202,
requ�ired for even , „ _ ®. .,
a ea City/Town State Zip Code Date of Inspection
System, Inf torsi (cont.
8* Tight or Holdling Tank(cant.)
Alarm, present... D Yes El N
Alarm levlw ....... Alarm in working;order: El Yes N o
Comments(condition of alarm and float switches, etc.).
Attach copy of current purrs ling contract(required). Is copy attached": Yes No
. Dilstribution Box %f present must be p ne (locate on site plan).-
Depth th of liquid level above outlet invert
Comments note if box is level and d'istributi n to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No solids carryover. Box needs r pl� cin bqcause 9f le*a ground the outlet inverts
t5ln p.duo .rear. /26/20,18 "title 5 Oifficiall Inspection Fora.Subsurface rf Sewerage Disposed System-nag!e 12 of 1
Commonwealth, of Massachusetts
icial,
� � � � � � � ww� � � Not for Voluntary Assessments,
y
89 Christian
Property Address
Kirk, Robert
Owner Owner's Dame
information is
required for ever ,�.� � � � „,.�. ....
Page. City/Town State Z,ip Code Delta of Inspection
D. System Information (cont.
10. Pump Chamber(locate on site plan):
Pumps in working order: El Yes E No
Alarms in working order. Yes [] o*
Comments (note condition of plump chamber,r, condition of pumps and appurtenances, etc)".
If dumps or alarm is are not in working order, system is a conditional pass.
Soil Soill Absorption System SAS (locate on site plan, excavation not required):
If SAS not located, explain why.
Type:
leaching, pits n r � r:
leaching chambers number: �..,.�.,�,...,, ,...,, -----
El
leaching galleries numbers
leaching trenches number, length: 1 X 40
leaching fields number, dimensions.- -2
overflow cesspool number
in,nova i e al err a i e system
t5r ..d -rear.7/261201Title 5 Official Inspection tion Form:Subsurface Sewage Disposal System.Page 1 3 of 1
p
Commonwealth of Massachusetts
T"tie 5 Off"ic'imal Inspect"ioin For
Subsurface Sewage Drs osall System Form Not for Voluntary Assessments
819,Christian
Property Address
Kirk, Robert
Owner Owner's Name
information is
MA 01845 0161-161-2020
required for even _ ,. ..._ �. . . � ..
page, City/Town State Zip Code Date o inspec tior
D. System Information
11. Sol ll Absorption System (SAS) (cont.)
Comments (note condition, of soil, signs of hydraulic faillure, level of ponding, damp soil, condition o
vegetation, etc,
N o I drq lic taui�lure no pqq i a, no daMp soils
12. Cesspools (cesspool must be pumped as part of inspection) (louts on site plan)..
Number and configuration
Depth 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 N o
Comments (note condition of soil, s,i ns of hydraulic failure,, level, of plonding, condition of vegetation,
etc.):
t5in p.do rev.7' 12018 Title 5 Official Inspection " rani;Subsurface Sewage Disposal System.Pugs 14 of 18
Commonwealth of Massachusetts
A.
a
i�cia
T le 5 Off I Inspect"ion For
1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
wa
9 Christian
Property address
Kirk) Robert
Owner Owner's Name
information is No. Andover MA 01845 06-16-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. stem Information (cont.)
13. Privy (locate on site Noun :
Materials of construction: . .� ..��._ .._..��....� ._ ..__._. , ._ ,.
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.
t5ins ,+d rev.7'/26/2018 Title 5 Official Inspection Form:Subsurface Sewage[deposal System•Page 15 of 1
ry
Commonwealth of Massachusetts
Tive 5 u icial Inspect"ilon For,
.. Subsurface Sewage Diosposall System Form Not for Voluntary Assessments
89 Christian,n WaAl
Property Address
Kirk, Robert,
O mer 6�r is
information is
6-16-2020
required'car even _.And ......._.
age. Cit (Town State Zip
C ode Date of Inspection
D. System Information (cont.)
14. Skate 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, i hin 100 feet. Locate where public water supply enters
the building. C1 ck one of the bore below:.
han -sket,c r in the area below
drawing attached separately
t5 n pm o .rev. /26120 8 Title 5 Official Inspection Fora,Subsurface Sewage Disposal System,•Page 6 of 18
Commonwealth of Massachusetts
IP Tille 5
Official For
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
89 Christman Wail
Property Address
KlrK Robert
Owner Owner"s,Name
information is No. Andover A 84 6 �-2 2
required or eves � , , ,. .�..,_ ._ .. . ., .�.., .... �.
page. City/Town ,State Zilp Code Date of Inspection
D. System, Information (cont.)
15. S1e Exam:
Check Slope
Surface water
Check cellar
EJ Shallow wells
1
eet
Estimated 'e h to high ground water: �. .
Please indicate all methods used to determine the high ground water elevation..
Obtained from system design plans on record
If checked, date of design, pilan reviewed,,* �_ _... M_ _ .,m m. ....�...�. .... ...-..----_----
Date
Observed site (abutting property o'hservati n hole within 150 feet o SAS)
Checked with local Board of Health - explain:
Checked with local excavators, installers- (attach cu entation,
Accessed USES database -explain-
You must describe how you established the high ground grater elevation:
No,sum uym in basement. Bottom of bed is a al 5 above basement floor
P-
Before fifing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.d .rev.7/26/2018 Title 5 Official Inspection,Fermi:Subsurface Sewage Disposal Systern.Fags 17 of 1
Commonwealth of Massachusetts
low, T
1I
e fficial, Inspection 11 0
For
qA Subsurface,Sewage Disposal sal System Form Not for Voluntary Assessments
89 Christian Wa
Property Address
Kirk, Robert
Owner Owner's Name
information is No. Andover A 84 + 6 16-2 2
reap u i red for ever � �rv. �.� .�,. � � �.,
page. City/Town State Zip,Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of thisform incl as v o '
A. Inspector Information'. Complete all fiel�d,s in this section.
.
.. Certification- Signed & Dated are 1, 2$ 3 r 4 checked
C. Inspection Summary:
11 21 3, or 5 completed as appropriate
4 (Faillure Criteria) are Checklist completed'
D. System Information.-
For 8 Tight/Holding TankPumping contract attached
For : Sketch, of Sewage Disposal osal ystem drawn on pg. 16 or attached
For 5: Explanation of estimated depth to high groundwater included
t5ins .d r •rev,7/2612018 Fitts 5 Official'Inspection Forn Subsurface,Sewage Disposal Sy term Page 18 of 1