HomeMy WebLinkAboutPass - Title V Inspection Report - 23 TANGLEWOOD LANE 5/31/2022 .�
Commonwealth of Massachusetts RECS\vw
�� Title 5 Official Inspection Form 3v011-
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Subsurface Sewage Disposal System Form -Not for Voluntary Assessments PN
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Property Address
ELLEN MCINTYRE �D
Owner Owner's Name
information is NORTH ANDOVER
required for every — _ MA 01845 MAY 25, 2022 _
page. Cltyfrown 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 filling out forms A. Inspector Information
on the computer,
use only the tab Todd James Bateson
key to move your Name of Inspector - - ---
cursor-do not Bateson Enterprises Inc.
use the return
key. Company Name
111 Argilla Road _
ra3 Company Address -
Andover _ MA 01810
City/Town State Zip Code
978-475-4786 SI-16
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 Approving Authority
4. ❑ Fails
j �-
Inspector'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 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
I s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c 23 TANGLEWOOD LANE
Property Address ---- - -
ELLEN MCINTYRE
Owner Owner's Name ---
information is NORTH ANDOVER
required for every _ MA _ 01845 MAY 25, 2022
City
page. /Town 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.-
PERMIT BOARD OF HEALTH
INSTALLED NEW H-20 D-BOX
SYSTEM NOW PASSES TITLE V INSPECTION
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):
t5insp.doc-rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18