HomeMy WebLinkAboutFail - Title V Inspection Report - 463 WINTER STREET 11/16/2021 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for\4oluntary Assessments
v
463 WINTER STREET
Property Address
JOHN & JOAN BENINCASA
Owner - ---- - .. ._-__----
Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
page. City/Town State Zip Code Date of Inspection
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.
Important:When A. Inspector Information
filling out forms
on the computer,use only the tab JAMES H. CURRIER II
key to move your Name of Inspector
cursor-do not TS SEPTIC & DRAIN
use the return Company Name
key.
131 FOREST STREET
" Company Address
MIDDLETON _ MA 01949
City/Town State Zip Code
978-774-6685 S12327 _
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 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. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approvin,g Authority
4. ® Fails
11/4/21
�gpector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. 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 DEP. 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 describes conditions a-t the time of inspection and under the
conditions of use at that time.This inspection dotes not address how the system will perform
in the future under the same or different conditio,ns of use.
t5insp.doc•rev.7/2 61201 8 Title 5 Official linspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
w Subsurface Sewage Disposal System Form - Not for Yoluntary Assessments
463 WINTER STREET
Property Address
JOHN &JOAN BENINCASA
Owner e
Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all cif 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:
2) System Conditionally Passes:
❑ One or more system components as described i n 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 thie 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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Commonwealth of Massachusetts
+� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
cw / 463 WINTER STREET
u�
Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
_
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. :3ystem will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or h igh static water level in the distribution box due
to broken or obstructed pipe(s) or due to a brokein, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Hesilth):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 timer a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of tl�ie Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Hiealth:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safE ty or the environment.
a. System will pass unless Board of Health dletermines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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C Commonwealth of Massachusetts
i- Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
463 WINTER STREET
Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a btordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Healthy (and Public Water Supplier, if any)
determines that the system is functioning in;a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ 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 or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems;:
You must indicate "Yes" or"No"to each of the fcollowing for all inspections:
Yes No
® El clogged
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
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
463 WINTER STREET
Property Address
JOHN & JOAN BENINCASA
Owner - _ - -
Owner's Name
information is NORTH ANDOVER MA 01845 11/4/21
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ❑ 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" below invert or available volume is less
El ❑A3
than 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Dill Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water sup ply.
❑ ElAny portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ❑�� Any portion of a cesspool or privy is within 50 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 at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitirate nitrogen is equal to 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.]
❑ ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ❑ The system fails. I have detenmined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact trie Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large systen i the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or'-no" to each of the following, in addition to the
questions in Section C.A.
Yes No
❑ ❑ the system is within-4 feet of:'a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitroc3en sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zorie II of a public water supply well
t51nsp doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c ' Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for V oluntary Assessments
463 WINTER STREET
Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
__. _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
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 CA above the large system has failed. The
owner or operator of any large system considered a Eyignificant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the C)epartment.
6. You must indicate"yes" or"no"for each of the fcAlowing for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ❑'Vr Were as built plans of the systenn obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes u incovered, 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
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Sail Absorption System (SAS) on the site has
`?6een determined based on:
❑ ❑ Existing information. For example, a plan 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 unacceptable) [310 CMR 15.302(5)]
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Commonwealth of Massachusetts
,e Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for V oluntary Assessments
463 WINTER STREET
Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
_
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): NA I Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example e: 110 gpd x#of bedrooms): NA
Description:
Number of current residents:
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 eat indry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: DCaURRENT
t5insp.doc•rev.7126/2018 Title 5 Official Ins{ oection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
463 WINTER STREET
Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
- - -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: —--
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: - -
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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c Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
463 WINTER STREET
Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil abst orption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, att,;ach previous inspection records, if 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 syster n operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
NA
Were sewage odors detected when arriving at the Site)? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: NA
p g feet
Material of construction:
❑ 40 PVC NA
❑ cast iron other(e explain):
Distance from private water supply well or suction linE:: NA PUBLIC H2O
feet
Comments (on condition of joints, venting, evidence c)f leakage, etc.):
PLUMBING IS BELOW CELLAR FLOOR, PRIOR TO i EXITING HOUSE
t5insp.doc•rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for"Voluntary Assessments
s � 463 WINTER STREET _
Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
-
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 12"feet
Material of construction:
® concrete ❑ metal ❑fiberglz3ss ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 GALLON
Sludge depth:
24"
Distance from top of sludge to bottom of outlet tee o,r baffle
10"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? SLUDGE JUDGE
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK HAS EXCESSIVE SOLIDS AND NEEDS TO BE PUMPED, CONCRETE BAFFLES IN PLACE,
LIQUID LEVEL IS CORRECT.
t5insp.doc•rev.7/26/2018 Title 5 Officiall Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for"Voluntary Assessments
463 WINTER STREET
Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping 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 Tank(tank mus �epumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
°l Subsurface Sewage Disposal System Form - Not for"Voluntary Assessments
463 WINTER STREET
Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
---- -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: -Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required).. Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 3" — ---
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
LIQUID LEVEL IS HIGH, DBOX IS 35" BELOW GRADE.
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Commonwealth of Massachusetts
+� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6",
463 WINTER STREET _
Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845- 11/4/21
--
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, systenn is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
LIQUID LEVEL HIGH IN DBOX
Type:
❑ leaching pits number:
❑ leaching chambers number: ----- —
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
NA
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official hnspection Form:Subsurface Sewage Disposal System•Page 13 of 18
1-^1 Commonwealth of Massachusetts
Title 5 Official Inspection Form
o
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
............« 463 WINTER STREET
L�
Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
-
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 ponding, damp soil, condition of
vegetation, etc.):
SOILS WET, SYSTEM APPEARS TO BE HYDRAULIC FAILURE, VEGETATION NORMAL
12. Cesspools (cesspool must be pumped as part of in;3pection) (locate 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 ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official linspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for`Voluntary Assessments
463 WINTER STREET
u Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
page. Cltyrrown 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, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5insp.doc•rev.7/26/2018 Title 5 Official Unspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspectic) n Form
11, Subsurface Sewage Disposal System Form -Not fo r'Voluntary Assessments
z � 463 WINTER STREET
Property Address
JOHN &JOAN_BENINC_A_S_A_
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
__
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, inc lu ding ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 'I DO feet. Locate where public water supply enters
the building. Check one of the boxes below:
hand-sketch in the area below
® drawing attached separately
�A- 3I• Qr/ Lo,
z -2 Z'Y z .
t5insp.doc-rev.7126r2018 Title 5 Offici.at Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for'Voluntary Assessments
463 WINTER STREET
Property Address
JOHN &JOAN BENINCASA
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: NA
feet
Please indicate all methods used to determine the h igh ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observiation hole within 150 feet of SAS)
❑ Checked with local Board of Health -exlplain:
❑ Checked with local excavators, installer;3-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
SYSTEM NEEDS TEST PITS FOR NEW DESIGN
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
463 WINTER STREET
Property Address
JOHN &JOAN BENINCASA _
Owner Owner's Name
information is required for every NORTH ANDOVER MA 01845 11/4/21
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in ttiis section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4- checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official inspection Forth:Subsurface Sewage Disposal System•Page 18 of 18
Of NORTH,h I
O
Town of North Andover
HEALTH DEPARTMENT
SS^C NUStS
CHECK#: DATE:
LOCATION: /,_3l
H/O NAME: Ao /)1.af n
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
a
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Tras4lSolid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer