HomeMy WebLinkAboutPass - Title V Inspection Report - 67 FOSTER STREET 2/16/2023 Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 '�023
67 Foster Street F AN°pVE
Property Address jo\N 1 O'F TVA°�pAR�
Rivet, Pam HEAD
Owner Owner's Name
information is No. Andover MA 01845 02/13/2023
required for every __ __--- _—
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 John L. DiVincenzo
key to move your Name of Inspector
MIMr-tVIVI J & S Development Corp. d/b/a Stewart's Septic Service
use the return
key. Company Name
Co Kimball St.
_._
Company Address
Bradford MA 01835
City/Town State Zip Code
iehan 978-372-7471 S113386
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
t ��? 02/1 312 02 3
I pe or's Signature Date
The system inspec 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 Form,Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
iI; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 Foster Street
Property Address
Rivet, Pam_
Owner Owner's Name
information is required for every No. Andover MA 01845 02/13/2023
— — —
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
r r�1ivr 'i^R 1� 1l13.nur it I(1 (`�AR`1� 2fld o.Vi�7Jz'�h jf.:., RrrL!{PLrJ?�L1Qt Phi --
v r..♦ I..i.vliv i v vrn v.av-T
indicated below.
Comments:
Replaced distribution box and added one riser
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18