Loading...
HomeMy WebLinkAboutPass - Title V Inspection Report - 920 JOHNSON STREET 11/1/2023 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 920 Johnson St Property Address _.._._ _......... ... Whitehead Owner ..__-. ...._...... Owner s Name information Is required for every N. Andover MA 01845 11/1/2023 ....,.. ..._.,_, ..... Pa9a• 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 farm. Importfling outfoxWhenA. General Information tilting out forms on the computer, use only the tab 1. Inspector key to move your cursor-do not Chad Jablonski use the return _.._ _... .... ._,.. _._ _........_... _ .,......_ . . .... key. Name of Inspector CJ Jablonski § tic lnspectron & Ftepalr Company game 237 Merrimac St Company Address Newburyport _.....a....._ MA 01950 City/Town State Zia Code 978-360-9358 4574 -----__.._.,_ m'ber-----'—" _ _ .._.........._ -__...__._ .. .... ......._. Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DP approved system Inspector pursuant to Section 16.340 of Title 5 (310 CMR 16.000). The system: E Passes R Conditionally Passes 0 Fails Needs Further Evaluation by the Local Approving Authority tt Imps s i nat a Date The system ' ipector shall submit a copy of this inspection report to the Approving Authority (Board of Health o CEP)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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. l5ins.doe•rev,6/16 Title 5 Official trispectton Foam:Subsurface Sewage Disposal System-Page 1 of 17 -------- -........ ...... _ __ Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Farm -Not for voluntary Assessments 20 Johnson St. Property Address Whitehead Owner . --.__._. _...._ owners Name Information is N. Andover MA 01845 11/1/2023 required for every m....__..._...___ _.._.._...__......., .. page, Cttyll own StaCe Zip Code Date of Inspection B. Certification (cent.) _...._ Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: Ej 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: SAS and all components were in good working order. D-Box was replaced October 2018 ------------ B) 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): t6lns.doc-rev.6/16 Tkt&e 6 Offiew Inspection Farm:Subsurface Sewage D aposel System•Page 2 of 17 Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Johnson St Pr6perty Address .......... _.._. . ... ....... ..._, ._.._ _....... . ... _.._ ., . .. ...._..____.._ Whitehead Owner ..... ...... a_....... _... .........._. Owner's Name information is N. Andover MA 01845 11/1/2023 required for every ..,_ _....._._.. _.__w ,. . ......._w.._. . ._,.... ..__. _.._m...,.._ page. CftylTown State Zip Code D,ate of inspection B. Certification (cant.) ... ..____ ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cant.): ❑ 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 ❑ Y ❑ N ® ND (Explain below); obstruction is removed ® Y ❑ N ❑ ND (Explain below); ❑ distribution box is leveled or replaced F1 Y ❑ N [3 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y n N © ND(Explain below). C) Further Evaluation is Required by the Board of Health: Q 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. 1. 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: ❑ Cesspool or privy is within 50 feet of a surface water F1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t6fns.doc•rev.6116 Title 5 Official Inspection rearm:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Johnson St. Property Address Whitehead Owner ._ _....... . .... ....... ........._ ... owner's Name information is N. Andover NIA 01845 11/1/2023 required for every __.... . _._.__ __.,... .__...... page. GitylTown Sta_te Zip Code Date of Inspection B. Certification (cone.) 2. 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 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 D P 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. 3. Other;. D) 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 ® 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 _pthan "/ day flowm t5ins.doc R rev.W16 Title 5 Off i al Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts kTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments V4,��. 920 Johnson St. Property Address Whitehead Owner information,is required for every N, Andover MA 01845 11/1/2023 page. ity/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No 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. M E 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 I of a public 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 nitrate nitrogen Is equal to or less than 6 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 2000gpd- 10,000gpd. The system falls. 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 11 of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304, The system owner should contact the appropriate regional office of the Department. t5ins.doc rev.6116 Title 5 Offidal Inspection Form:SUbSurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 920 Johnson St. Property Address —------------- ------ Whitehead Owner dwrwr°"im"e—,— ........ information is required for every N. Andover MA 01845 11/1/2023 page. State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No Z M Pumping information was provided by the owner, occupant, or Board of Health El Z Were any of the system components pumped out in the previous two weeks? El Z Has the system received normal flows in the previous two week period? M Z Have large volumes of water been introduced to the system recently or as part of this inspection? M Z Were as built plans of the system obtained and examined? (If they were not available note as N/A) Z M Was the facility or dwelling inspected for signs of sewage back up? Z M Was the site inspected for signs of break out? E El Were all system components, excluding the SAS, located on site? Z El 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: Existing information. For example, a plan at the Board of Health. Z M 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): No aidesign Number of bedrooms (actual): -5 avlab I e DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): No desig..-- _n,, Mns.doc-rev.6/16 Tittle 6 OfWal In"dion Forn Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts VK�01; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Johnson St. Property Address Whitehead Owner C7__.._e__r`s__f«l_—arar-.e____....-.. . _..... . wn information is N. Andover MA 01845 11/1/2023 requiredfor every _.�_ _ -.,.._._... _.. ..._ ..._..... ......M_..__...._._ ._ . ..._,.-.... ___._______...........__ ......-.__....�..... .......... page. City/ n ate Zip Code Gate of inspection D. System Information Description: Number of current residents: - - Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ® Yes No easonaluse? ❑ Yes ® No Water meter readings, if available last 2 years usage d 130 gpd....._.. Detail. Sump pump? ® Yes No Last date of occupancy: Qccupied„ LL _._-._---- _....... Date 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 Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ® Yes F] No Water meter readings, if available: -.-_ _.__... _._...__.... Mns.doc-rev.6116 TAW 5 Offir-ial tnapeclion Form;Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 920 Johnson St. Property Address Whitehead Owner w" ....__�_.____ OtiMfner"�hlae required fo is N. Andover MA 01845 11/1/2023 required for every ._....__..._. ...... . .. . ... _ ......__..._._.. . page. rtylTan State "rp Cade bate cif Iroapectran D. System Information ....(Cont.).._.__....._..._....�.,�.�.._._���. ..... ... ..w........w...m.......................�w.._.__._.__._._. ...ww...__..._....m_._.....___.._._n Last date of occupancy/use: oIie Other(describe below): .. General Information Pumping Records. Source of information: Nome Owner Was system pumped as part of the inspection? Q Yes 57, No If yes, volume pumped: na ----- gallons Flow was quantity pumped determined? na Reason for pumping: na Type of System: 0 Septic tank,, distribution box, soil absorption system El Single cesspool El Overflow cesspool 0 Privy El Shared system (yes or no) (if yes, attach 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 system operator under contract [� Tight tank, Attach a copy of the CIFP approval. El Other(describe): a6ns,dcc.rev,W16 7"9W S Offmiai fi,4Wumi r'wm Skfibsuqace Sewaige DiaposW Systorn•Wage 8 0 17 Commonwealth of Massachusetts . . =c Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm Not for Voluntary Assessments 920 Johnson St. Prirrty Address Whitehead Owner Owner's Name information is N, Andover MA (l1_ 11!1/2C123__ ______.. required for every _�... ....._.... ....____ , ......._ _,_..._ page, di rovwn state a ip Code Gate of Inspection D. Syterr�......I..r�fcrrmatic►wl�..�(cont,.)...�._w... ....___......u_..........�._ ._.�.�._.._...� w._... ._�......_.....� Approximate age of all components, date installed (if known) and source of information: Septic Is the or in I septic Were sewage odors detected when arriving at the site? El Yes Z No Building Sewer(locate on site plan):. 28" Depth below grade. _....__.._......-_.-____.._......m feet Material of construction. cast iron fl PVC other(explain): Distance from private water supply well or suction line: _......__...... ... ............ .. __ feet Comments (on condition of joints„ venting, evidence of leakage„ etc.): Watertight at foundation Septic Tank (locate on site plan): Depth below grade: 15 feet Material of construction: M concrete ❑ metal © fiberglass polyethylene ® other(explain) If tank is metal, list age: n years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No 10.6x5.5x55 Dimensions: Sludge depth: „r V&ns dX.rev.6d66 Us 5 orb hapection Form Sulaaonxfaca Sewage Do posa3 System•page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Johnson St. Property Address Whitehead Owner _..._. __., . .,__m.__.....w._.. Owner"s iVafne .._....._...__.... ......... . ........_._...._....._ required for N. Andover MA 01845 11i1/2 23 required for every .w,.. ._. ............. ._ . ..____..._.. .._..__.._._.___ _._.� .. page. CityCTown State Zip Code Clete of Inspection D. System Information (cant.) Septic Tank (cant) 301w Distance from top of sludge to bottom of outlet tee or baffle --.-..-..-._.___.___ __._.._...__.__._ _._....._......_. 1"" Scum thickness ___... _.........._ __. ._...____._._._....._._ Ski Distance from top of scum to top of outlet tee or baffle _. ......,. _ _,.. .. ___........_ __......... .._.......e. Distance from bottom of scum to bottom of outlet tee or baffle . _- How were dimensions determined? Nleasurin,tape 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 was structurally sound. Inlet and Outlet tee"s were in goad working order. Crease Trap (locate on site plan): Depth below grade: _,f......_......._........ .__.._ eet Material of construction: concrete Q metal (1 fiberglass ❑ polyethylene n 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: _........... .....w....._. _.... .._.... Date tsins.doc•rev,6116 7if e 5 official Inspection Form;Subsurface Sewage Disposal System Papa 10 of 17 ° Commonwealth of Massachusetts Tit'le 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 920 Johnson St, Frraperty Andreas Whitehead Owner Owner's Name in formation is required far every N. And __.».w MA. .. 01845 11/1/2023 regrler �. over ....._.. _. .......... ... ...... page, City/Town State Zip Code mate of Inspection D. System Information (cons.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet Invert, evidence of leakage, etc.). Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: El concrete E] metal fiberglass ❑ polyethylene other(explain): Dimensions: _...w...... _. . ...._ Capacity: _ ......._ gallons Design Flow. _.. gallons per day Alarm present. n Yes No Alarm level; _... Alarm in working order. ® Yes n No Coate of last pumping: _ _,... gate Comments (condition of alarm and float switches, etc.): __.....__. ..... _ _ ... Attach copy of current pumping contract(required), is copy attached? ❑ Yes No tNns c^rev,W16 'rWe 5 OfficWl hype"ton Faarrm Stftswrsce Saw age Disposal System PKW 11 of 17' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form _Not for Voluntary Assessments 920,Johnson St PropertyAddress _. _..... _..... .._....__.....__._..._.._._._.__.___._...... ._ ...... Whitehead Owner _._._.. .._._...... _..._.. .. ...... _ . ................... Owner'stVarrfe information is N Andover MA 01845 11/1/2023 required for every .............. .. . .. _..... .. page. Cl iy fo'wn _. ...,. . State Zip Code Date of Inspection D. System Information (cont.) _ Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert I�''.. _ ..._..__ _....._...... _._.._. __ _.......... 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.): Box was replaced October 2018. Pump Chamber(locate on site plan):. Pumps in working order: ❑ Yes ❑ o* Alarms in working order: ❑ Yes n No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Mns.doo-rev.6/16 Title 6 Official Inspection Form,Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts m. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments gQ Johnson St,. Property Addreae Whitehead ...�_.._.. __... _............. _..... . .. ....._._._ ....._.._...... _..._. ... Owner owne(s Name m oIrequlred for every N. Andov.e.r...._. MA 01845 11/1/2023 page City/Town State Zip Code Date of Inspection ___.............. .._ .. ...._M_..._____.w__.___ D. System Information (cant.) Type: El leaching pits number: El leaching chambers number: - ❑ leaching galleries number: El leaching trenches number, length: __._.. leaching fields number, dimensions: 1-25" x 35' El overflow cesspool number; _ _... ....... ... _. Q innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.). o sign of hydraulic failure, ponding or vegetation infiltration . 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 Q Yes F-1 No C&r¢s'ckc•rwv,W16 "rift 5 CaWPoW In born Form Subswface Sewage Dmposal Systems w Pogo 13 of 17 ._ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 920 Johnson St. ..... ..... .. _ ......... f�rrlperty.. A.ddress.. . .. ._ . . ...... Whitehead Owner _..Cl.. .__._. wner"sN.a.me _.. ._... .. .__._ _.._..._... ....... information is l�l. Andover required for every _ A 01848 11/1/2023 page. llyrrow- _..... Mete _.... Zip Code . _.. Date of Inspection D. System Information ( ,� ._�,_ .... Comments mote condition of soil, signs of hydraulic failure, level of ponding„ condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: ___. __.._.. _....._....._ __ _._... _.._.._.._... Dimensions _.. ....... .... . _ _.._. Depth of solids Comments(note condition of sail„ signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5tns.doc•rare.5i15 Title 5 OffiriAl Inspection ction F'oana.5ambarrrfarco Sewage Usp oral g1stern M Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 920 Johnson St. iii perty Acidness Whitehead Owner 6Wn_e'r`s'"Nem'"e'__ ............ . .... ......... Mornrlafion is required for every N,,,,.An.dover- .......... MA 01845 11/1/2023 page, Cfty/Town State Zp Code Date of Inspection stem Information (cont.) Sketch 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 within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: Z hand-sketch in the area below drawing attached separately tz' C B�> Mns doc-rev,6116 TO,16 5 Offic&W h"amn Form Subsuffere Sewage Disposal Sysjea -Page 15 of 17 w ". Commonwealth of Massachusetts Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments m , 920 Johnson St. _ Or-operty Address Whitehead Owner Owner's.dame information or is N. Andover MA 01845 11/1/2028 requiredtcrre�ery _ . _._ _.__........._w.. ... ___-... __......., page, dityCrown State Zip Code Date of Inspection D. System Information (font.) Site Exam: 0 Check Slope ® Surface water ® Check cellar Shallow wells Estimated depth to high ground water: }4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 11 gate Observed site (,abutting property/observation hole within 150 feet of SAS) Q Checked with local Board of Health -explain: Checked with local excavators, installers - (attach documentation) (� Accessed USOS database-explain: You must describe how you established the high ground water elevation: System was built in fill, Water damage in cellar came up 12""-15". Soils test performed at 910 Johnson St, Before filing this Inspection Report, please see Report Completeness Checklist on next page. k,5kns.doc-rev.6116 Tale 6 C?b+'6a[Insp --toi F'o(m,SLbsk0are Sewage Disposai System•Page 16 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm Not for Voluntary Assessments 920 Johnson St. Orape' rty+4ddrees -......_ ... Whitehead O Owner ,_w._ner"...s Name""- _.... _ ......_...... required for is N. Andover (`wIIA 01545 11/1/2023 required fareleery _._._....... .._._..... _....... ._..... ...._. ...._..,_ ._,,_........ page. 0 It P Pawn -state........ Zip Cade Cate at Irtipeattan F. Report Completeness Checklist Inspection Summary, A, S, C, D, or E checked '. Inspection Surnmary D (System Failure Criteria Applicable to All Systems)completed Z System Information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t60r,doe•rev 6116 Title 5 Official h erection 6'cann S4 mm,face Sewage Disposal System•Page 17 of 17