HomeMy WebLinkAboutPass - Title V Inspection Report - 373 SALEM STREET 3/13/2023 Commonwealth of Massachusetts °
Title 5 Official Inspection Form �
P Y y 0 �
�. �r� Subsurface Sewage Disposal System Form ..Not for Voluntary Assessments
373 Salem Street
Property Address �w
Nadler„ Mike
Owner Owner"s Name
information
equiredd for every is No. Andover MA 01845 03/07/2023
re _.
page, City/Town Mate Zip Cade 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 Jahn L DiVincenzo _
key to move your Name of Inspector
cursor do not J & S Development Corp. d/b/a Stewart"s Septic Service
use the return key. Company Marne _
_....._ 58 So. Kimball St.
4z Company Address
Bradford MA 01835
City/Town State Zip Code
978-372-7471 S113386
"telephone Number License Number
,_........ __........._.._. ...._... _..... _ .__ _................ v,_,__...� .._... �._... ....._
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15. 40 of Title
(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. Z Passes
2. F� Conditionally Passes
3. [l Needs Further Evaluation by the Local Approving Authority
4. 0 Fails
V
03/07/2023
In ° SI . ..,
ector s q i�ature irate
The system inspector 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 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 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.
6tnain.doc•rev 7D?662018 11A S Officmu 9rrgr,Dwllom poor ry "rs.sb urface Se e Disposal;System-Page t of 18
Commonwealth of Massachusetts
TOtle 5 official Inspection Form
TT Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
373 Salern Street _
Property Address _ _
Nadler, Mike
Owner Owners Name
infOrrequired
is No, Andover MA 01845 03/07/2023
regwired for every _
page. CityfTown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 11 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:
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.
[l Y ❑ N [I NIA (Explain below):
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Commonwealth of Massachusetts
r,p Title 5Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4r�e
r y, 373 Salem Street
�r
Property Address
Nadler, Mike
Owner C7 vner's Name
information is
No. Andover MA 01845 03/07/2023
required for every - _
page. City(Town State Zip Code Gate of Inspection
C. Inspection Summary (cant)
2) System Conditionally Passes (cant.):
E] Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
[l Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
broken pipe(s) are replaced D Y D N ❑ ND (Explain below):
obstruction is removed D Y D N F] NC (Explain below):
El distribution box is leveled or replaced E] Y 0 N Ej ND (Explain below):
[� The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health)
[ broken pipe(s) are replaced F`1 Y F� N ❑ ND (Explain below):
obstruction is removed 7 Y N ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
[W1 Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines 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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Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
�. 373 Salem Street
Property Address
Nadler„ dike
Owner -...
owner"s Dame _
information for
is No Andover MA 01545 03/07/2023
required for every
page, cityPrown Mate Zip Code Date of Inspection -.-----
-..__.__ -__.,_ ...... __.... _.........
C. Inspection Summary (cant.) ......_.._._ ..
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (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 1€ 0 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 following for all inspections:
Yes No
❑ 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
due to an overloaded or clogged SAS or cesspool
t`itunsp.dix; rev.7/26J2018 'Title 5 Official inspection Pon Subsurface Sewage DisposW System-Page,4 of 18,
Commonwealth of Massachusetts
= lY Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm Not for Voluntary Assessments
ra"
373 Salem Street
Property Address
Nadler, Mike.
owrne€ Owner's Name
inforrrfor every is
required
fo No Andover MA 01845 03/07/2023
_._...._.... ._ ..
page. City/Town State Zip Code Date of Inspection
C. Inspection_.... _-_.e__. __ _._ ..... __.._.... ...._ __..... __..._... ...w. ._.._.._...._
Summary (Cont.)
4) System Failure Criteria Applicable to All Systems: (corn.)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El E Liquid depth in cesspool is less than 6°" below invert or available volume is less
than '/2 day flow
Required pumping more than 4 times in the last year Nor due to clogged or
obstructed pipe(s). Number of times pumped.
Q ME 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.
n z Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well,
0 2 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
n gip, 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 nitrate 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.]
El 11 The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
0 Z The system fair. I have determined 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 the Board of Health to determine what will be
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 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 CA.
Yes No
[] 11 the system is within 400 feet of a surface drinking water supply
F1 the system is within 200 feet of a tributary to a surface drinking water supply
❑ 1-1 the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
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i
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1
i
Commonwealth of Massachusetts
Title 5 Official Inspection Farris
` Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
373 Salem Street
�w
Property Address
Nadler, Mike
Owner Owner's Larne
information is
No Andover MA 01845 03/107/2023
required far every
paage. CVty/Town State Zips Code Date of Inspection
_... .,
C. Inspection Summary (cant.) _.._....__.... _ _. ..
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 significant 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 Department.
6, You must indicate"yes" or"no" for each of the following for all inspections:
Yes No
F—] Pumping information was provided by the owner, occupant, or Board of Health
❑ Z Were any of the system components pumped out in the previous two weeks?
Z E] Has the system received normal flows in the previous two week period?
El Z Have 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 NIA)
Z D Was the facility or dwelling inspected for signs of sewage back up?
D Was the site inspected for signs of break out?
El F1 Were all system components, excluding the SAS, located on site?
Z 11 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,
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 Soil Absorption System (SAS) on the site has
been determined based on:
0 E Existing information. For example, a plan at the Board of Health.
Z F-1 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)]
t5inslip idoc.•rev 02612018 1 Itle 5 Official Inspection Form aubsufl ace Sewage Disposal Syslerm•Pogo 6 of 18
Commonwealth of Massachusetts
= 6P Title 5 official Inspection Form
11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
73 Salem Street
Property Add ress
Nadler, Mike
Owner Owner's game
information is
required for every No. Andover MA 01845 03/07/2023
page. Cwty/Town State Zip Code Cate of tnspection
. ......_ ..... ...._ .„. _._...... .w....._ ._ _ _........ _.. _..,,...___.... ..._...Mw.......... ...__ ...
D. System Information
1, Residential Flow Conditions:
Number of bedrooms (design): ? Number of bedrooms (actual): 3 _
DESIGN flow based on 310 CMR 1 . 03 (for example: 110 gpd x#of bedrooms): 330
Description:
......
Number of Current residents: 4
Does residence have a garbage grinder? Z Yes ❑ No
Does residence have a water treatment unit? El Yes Z No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection F Yes No
information in this report)
Laundry system inspected? El Yes [:] No
Seasonal use? Yes Z No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? E, Yes "`I No
Last date of occupancy: Occupied
Date
t51nspa d(W-re+v."7126,P 016 T]Ue 5 Official k1spection Form Subsurtacm Swage DtspcpsaV Sycstern-Page 7 of 18
Commonwealth of Massachusetts
Tide 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
K
a 373 Salek°n Street
Property address
Nadler, Mike
Owner Owner"s Name
informationrequired for
o. over MI
r every is require N Andover 01845 03107/2023
r ..
,page. Cltyrrowrt State pup Clyde Gate of inspection
D►. System Information (cont.)
2. Commercial/industrial Flaw 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? 0 Yes [_1 No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Nan-sanitary waste discharged to the Title 5 system? ❑ Yes El No
Water meter readings„ if available:
Last date of occupancy/use:
Ga 11 te
Other(describe below).
3. Pumping Records:
Source of information: Last pump: 05/25/2022
Was system pumped as part of the inspection? Yes No
If yes, volume pumped: 1500
gallons
Now was quantity pumped determined? Kght gauge on trunk _
Reason for pumping: Inspect tank
t5insp.dur,,.�i ev.7d 60201.E Totle 5 Official inspecton Form Subsurface Sewage Dtsposel Sydlem.Page 6 of 16
Commonwealth of Massachusetts
,r Title 5 Official Inspection Form
l Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
,M
373 Salern Street
Property Address
Nadler, Mike
Owner Owner's Name _
reLion is
required for eve No. Andover MA 01845 03/07/2023
e aulre
Rage, City/ own State Zip Code Crate of Inspection
.......------ ..., ._.__.., ..... _.m .... .......... _..... ...__._ ._..
D. System Information (cost.)
4. Type of system:
z Septic tank, distribution box, soil absorption system
7 Single cesspool
[-1 Overflow cesspool
[� Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
El 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 system operator under contract
Tight tank. Attach a copy of the DEP approval.
El Other(describe).
Approximate age of all components, date installled (if known) and source of information:
1985
Were sewage odors detected when arriving at the site? Yes 7 No
5. Building Sewer(locate on site plan);
Depth) below grade:
18"
feet
Material of constructil
Z cast iron [1 4C PVC other(explain):
Distance frorn private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5inisp dor,.iev.7126/2018 'Title b{,^ffn al Insperijon For"i Subsu f ce liewag e Disposil So en1-Page 9 of 18
Commonwealth of Massachusetts
"Title 5 Official Inspection Form
w Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
.a `" 373 Salem Street
Properly Address
Nadler„ Mike
Owner Owner's Name _
information is required for every No. Andover MA Q1845 03/07/2023
page City/Town State Zip Code Date of Inspection
_..,... ............ _.,w.____._... .,....,....._,_...,..._-M.__...
D. System information (cons.)
6. Septic Tank (locate on site plan).
Depth below grade: 4kr
feet
Material of construction:
Z concrete El metal [-1 fiberglass F� polyethylene other(explain)
_ _----------
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes Cl No
D mensions 5 6 4
Sludge depth: _
Distance from top of sludge to bottorn of outlet tee or baffle 29,
Scum thickness 6
Distance from top of scum to top of outlet tee or baffle 6<<
Distance from bottom of scum to bottorn of outlet tee or baffle 6
e measure/sludge judge
How were dimensions determined? Pap
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert„ evidence of leakage, etc.):
Both baffles are in good shape. No leakage, liquid level is good.
thdrtsp doc rev '71261201 B TiVe"5 Ofriani inspection Form Su.ohseur aee Sewage Disposal Syso .Page 10 0 16
Commonwealth of Massachusetts
* Title 5 Official Inspection Form
�� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
373 Salem Street _
Property Address _
Nadler„ Mike
Owner's Narn e
inforrequired
equiire dfor is No Andover MA 01845 03/07/2023
required for every ... .. ..
page State Zip Code Date of Inspection
D. System Information (coat.)
7. grease Trap (locate on site plan):
Depth below grade: feet _
Material of construction:
El concrete 0 metal [I fiberglass ❑ polyethylene El 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 Nast 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 must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
E] concrete F' metal ❑ fiberglass ❑ polyethylene other(explain):
Dimensions:
Capacity: gallons _
Design Flow: 11 _
gallons peg day
t5inspx a,:Wc rev.7t2d'ed2016 f tie 5 Of k',,al In"et orr Forrrr Subsurface Sewage Dis,prr W,Symwfem-Page 11 of 18
Commonwealth of Massachusetts
�ryw 4 ` Title 5 Official Inspection Farm
ff
Subsurface Sewage [Disposal System Form -Not for Voluntary Assessments
P 373 Salem Street
Property Address _
Nadler, Mike
Owner Owner's Warne
information
equ nati for
No. Andover MA 01345 03/07/2023
requored far every _
page. cityrrown State Zip Code Date of Inspection
_. _.. ....._.._ ........ —..... ... ...........
D. System Information (cant.)
3. Tight or Holding Tank (cant.)
Alarm present: 0 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
0. Distribution Box (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert
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.):
Equal distribution, no leakage, no solids carryover.
r5nsp doc•ci.v 7t26/2018 I"ole 5 l;ff ciao f€`ispr;Momn For,ri Subsra ace Sewage DiSpOW sysPoul�Page 12 of 16
, Commonwealth of Massachusetts
Tile 5 Official Inspection Form
w '"„ Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
r ` 373 Salern Street
4.,
Property Address
Nadler, Mike
Owner Owner's Nerve
information is No. Andover MA 01845 03/07/2023
required for every ._ _.
page, City/Town State Zip Code Date of Gnspection
D. System Information (cant.)
10. Pump Chamber(locate on site plan):
Pumps in working order: Z Yes El No*
Alarms in working order: Z Yes Ej No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc,):.
Lifted floats manually at the pump chamber. Pump& alarm were working correctly at the time of
inspection.
" If pumps or alarms are not in working order, system is a conditional pass.
11, Sail Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
El leaching pits number:
0 leaching chambers number;
EJ leaching galleries number:
0 leaching trenches number, length:
leaching fields number, dimensions: 1 -25" X 40"
El overflow cesspool number:
innovative/alternative system
Type/name of technology: -
15 naaW.doc•rev.70261210'18 'rifie 5 C ft4 hspeacton rorm Subsurl ace"age P36aposal„System•Page 13 rv6 18
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
" 373 Salem Street
Property Address
Nadler, Mike
Cher _.. _ _
C1wr�er"s Name
information is
No. Andover ___.. MA 0134 03/07/2023
required far every
page. City/Town State Zip Cade Crate of Inspection
_...... _.._.n_. ....... _ _.. .._
D. System Information (cant.)
11. Soil Absorption System (SAS) (cant.)
Comments (note condition of soil, signs of hydraulic failure, level of pending, damp soil, condition of
vegetation, etc.):
No hydraulic failure, no pending, no damp soils _
12. Cesspools (cesspool must be pumped as part of inspection) (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 [ j No
Comments (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation,
etc,):
t,�.msp doc-i ev 772W2016 Title 6 Offir,4{Yr@Bypection Form Subsurface tSwwage r spxsae System-Page 14 of 18
Commonwealth of Massachusetts
Ix� ; Title 5 Official Inspection Form
.° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
, ,;w
73 Salem Street
Property Address
Nadler, Mike
Owner
owner s Nstrre
information is No. Andover MA 0184 Cl3/C17/2C123
required for every __ _ ...
r o.p
City/Town State Zip Code Date of Inspection
__.w.... _._....... ._.. _...._ . ..... .. ......_...ry .... ............ ..........._,. _.._. ...__..... ........
D. System Information (cant,)
11 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.),.
M5fn,%r x.dcwc:«re, 7/:6r2018 Ti06 S CYrlciaaf inspaev(on Form. ubsdurfauu Sewage Disposal o°ysYem-Page 15 0 18
Commonwealth of Massachusetts
_. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments
373 Salem Street
Property Address
Nadler, Mike
Owner ..-..... ...
Owner's Nane _.
information is
o. Andover MA 013 03-07 202.
requiredfor every _ _....__._.__......__.. ..__....... ...._...._._ _._.....,.._....._.._ _ _. ..._._.__ ____._...w__._..__.._ ..._.._.__._.._...
page, CItyJTown State Zip Code Gate of Inspection
D. System Information (cons.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at beast two permanent reference
landmarks or benchmarks. Locate ail wells within 100 feet. Locate where public water supply enters
thee b'u�ilding. Check one of the boxes below:
ff nand-sketch in the area below
�] drawing attached separately
et
e,
15�invp Pdor-rev 712&2018 1"o-4 e 5 Offurria€R spechon Form Subsurface Sewage Df8p asaf System•Page`16 at 16
°N\ Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
373 Salem Street
property,4ddress
Nadler, Mike
Owner Owner's Name
information
for every
oration i
re No. Andover MA 018�45 03/07/2023
a e
p City/Town State Zip Code Date of Inspection
_........ _M.... ......... ..____.._ ._..._._w...............___w._._._.w.. ..... _...
D. System Information (cant.)
15. Site Exam:
Ej Check Slope
0 Surface water
#6keck cellar
Shallow wells
Estimated depth to high ground water: >61
feet
Please indicate all methods used to determine the high ground water elevation:.
Q Obtained from system design plans on record
If checked, date of design plan reviewed: Date
E] Observed site (abutting pro pertydobservation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Pulled file
El Checked with local excavators„ installers- (attach documentation)
�] Accessed USES database- explain;
You must describe how you established the high ground water elevation:
Taken from Title V in 2006. There is a brook approximately 400' away.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
EraorrL,^ga.dor,•rev.772CV2018 I106 5 offr.,,W trrspeclion Fur„n Subsurface Sewn Disposal Sys'terrs.Page 17 of 18
`* Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
37 Salerri Street
_.- _
Property Address
Nadler, Mike
Owner Owner's Name _
require tifo is No. Andover MA 01345 03/07/2023
required for every _ _
page. City/fawn State Zip Code Date of Inspection
__......, ...,.... ..__._.,.......__., .... _. __,..._,... _ __......_.m, _.. ...
E. Report Completeness Checklist
Complete all applicable sections of this form Inclusive of:
E A. Inspector Information: Complete all fields in this 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 5 (Checklist) completed
I D. System Information:
For& Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 15 or attached
For 15: Explanation of estimated depth to high groundwater included
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