HomeMy WebLinkAboutPass - Title V Inspection Report - 453 FOREST STREET 11/21/2023 ° Commonwealth of Massachusetts
, 4 T idle 5 Offi al In pecUon Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments>" y`v'
453 Forest Street
Property Address
Herald, Daniel
Owner Owner's Name
regUired information is No. Andover MA 01345 10/041/20123
re�hulred for every
page cityrrown State Zip Code mate 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 ................_._.._ _ __ ....... _.___......._..___._..__.....
fillingAora forms
A. Inspector information
on the computer,
use only the tales .Kohn L. DiVincenzo
key to move your Name of Inspector
cursor-do not J & S Development/Stewart's Septic Service
use the return key. Company Name
__. 58 So. Kimball St.
Company Address
Bradford MA 01835
0kyrrow ri State Zip Code
reaa?a
978-37 - 4 a 1 S113335
Telephone Number License Number
..................... _._._......,_..... _,_.. ._.,_m..._...._,_............__. .........,_........_, ._._._..—___ -
B. Certification
I certify that. I am a DEP approved system inspector in full compliance with Section 15.340 of Title
(310 CMR 1 .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. E] Conditionally Passes
. Deeds Further Evaluation by the Local Approving Authority
4. Fails
Z 10/04/2023
In e.,or's signature rate
he system inspector submit a copy of this inspection report to the Approving Authority (Board
of HeaBth 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 systern owner shall subrnit 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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
453 Forest Street
Property Address
Herald, Daniel
Owner Owner's Name
information Is No. Andover MA 01845 10/04/2023
required for every ._ _ ...... _ _
page. Cety/Town State Zip Cade Cate of ftpecticn
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 CIv1R 15,303 or in 310 CIVIR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
one or more systewn components as described in the "Conditional Pass" suction 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):
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x Commonwealth of Massachusetts
,}p Title 5 Official Inspection Form
�) Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
�k r
453 Forest Street
Property Address
Herald„ Daniel
Owner Owner's Name
information
for every is
No Andover MA 01545 10/04/2023
e
pace, CityfTowwn _ State Zip Code Date of Inspection
_.._... ..._...._.. ......... _..._.... _... . .,_...,._..._,.___w __._. ... ....._,.,._......_ ..._....
_ _
C. Inspection Summary (cant)
2) System Conditionally Passes (coat.):
El Pump Chamber pumps/alarrns not operational. Systern will pass with Board of Health approval if
pumps/alarms are repaired.
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):
0 broken plpe(s) are replaced Y 7 N [] ND (Explain below);
F] obstruction is removed Y F1 N [I ND (Explain below):
distribution box is leveled or replaced F- Y E3 N El 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):
[-j broken pipe(s) are replaced 0 Y 7 N 0 ND (Explain below):
El obstruction Is removed ❑ Y El N [I ND (Explain below):
--------
3) Further Evaluation is Required by the Board of Health:
] 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
f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w'x 453 Forest Street
Property Address
Herald, Daniel
Owner Owner's Name
information is required for every No Andover MA 01845 10/04/2023
. . . ..._....,. __ _--- ----- --------- _ ._ ..,,,......
page City/Town State Zip Code Date of Inspection
_. ..._. .. ....___, _ _,._ - ____..._... ....... _..._... _......._a...... ................. .. ......a.._ _....... . _..... _ .._..,,,.__ ..............._
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.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
F� 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 following for all inspections.
Yes No
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El El Discharge or ponding of effluent to the surface of the ground or surfooe watore
due to an overloaded or clogged SAS or cesspool
t5inspxdor.-rev.7126=18 'Title 5 Officet Inspection Form.Subsurface Sewage Disposah System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
453 Forest Street
Property Address
Herald, Daniel
Owner _
Owner's Name
information is No. Andover MA 01845 �t7/04t2023
required for every ._..__._ _._
page. City/Town State Zip Code Date of Inspection
_,._....__...._....._._......_...__......._._.......__.W..._.__..0._._....._ _.....------_._._._..................._..._.........._.._._.............._.....__.
C. Inspection Summary (cant.)
4) System Failure Criteria Applicable to All Systems: (cant.)
Yes No
❑ El Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Z liquid depth in cesspool is less than 6" below invert or available volume is less
than °/a 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.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ E Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
El ❑ 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 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 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
❑ ❑ 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
• ❑ 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
t5msp.dor,-iev.7Q612015 Title 5 Offieml Inspection Ferro:Subsurface Sewage DispasM System-Page 5 of 18
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
.... Subsurface Sewage Disposal System Form Not for Voluntary Assessments
° 453 Forest Street
Property Address
Herald, Daniel
Owner owner's Name
information is required for every No. Andover MA 01845 10/04/2023
_ ..
page. Cltyown State Zip Code Date of Inspection
...._._._ ..............._._._._...,_......,m...,........_...........__...... _......_...._.__..__...___,.,_.__..._,__..._.._ ._.............
/T _...__. .._...._......__...___
C. Inspection Summary (coat.)
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 C.4 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
7 ❑ Pumping information was provided by the owner, occupant, or Board of Health
El 0 Were any of the system components pumped out in the previous two weeks?
Z ❑ Has the system received normal flows in the previous two week period?
0 Z Have large volumes of water been introduced to the system recently or as part of
this inspection?
M ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Q ❑ Was the facility or dwelling inspected for signs of sewage back up?
Z ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
❑ 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:
Z ❑ Existing information. For example, a plan at the Board of Health.
Z 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)l
t5irtmp doc rev.712612018 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
�rN Title 5 Official Inspection Farm
_.= Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
453 Forest Street
Property Address
Herald, Daniel
Owner owner's Name
Information is No Andover MA 01845 10/04/2023
required for every _...� �....... _
page. City/Town State Zip Code Date of Inspection
_.. ___ n_.........._...w.._.._._.._. _..w._._. _...__......_......_..............._......._ _...........__. ......._.............
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660
Description:
- ---------
-
Number of current residents: 5
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? El Yes 0 No
If yes, discharges to: _
Is laundry on a separate sewage system? (Include laundry system inspection El Yes Ej No
information in this report.)
Laundry system inspected? 0 Yes [I No
Seasonaluse? ❑ Yes M No
Water meter readings, if available (last 2 years usage (gpd)): ------- ....
Detail:
Sump pump? F-1 Yes M No
Last date of occupancy: Occupied,
Date
t5insp doc-rev.7l2612018 'Vitle 5 om,a a0 inspector Form Subsurface Sewage Disposau System•Page of 18
,
"°, Commonwealth of Massachusetts
1 ,N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
453 Forest Street
Property Address
Herald, Daniel
Owner Owner's.Narne
atYan is o Andover 10/04/2023
page
inform
for every _
requiredN Ad MA 01345
aee CityfTown estate Zip Code Date of Inspection
_ _ ................ _ ...._,..._ _w...... _......_ ...._ _....,,__..., _._.w.._....-_.___-_..._ ............
D. System Information (cant.)
2. Commercialllndustrial Flow Conditions;
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day.C9 11 pd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes No
Water treatment unit present? El 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; Stewart"s
Was system pumped as part of the inspection? Yes [ } No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Sight gauge on truck
Reason for pumping: Inspect tank_
t°'gimsp d c•K'ev,'712612018 1'iUe 1 Offit,€ual to spec,tma i"oim Subwfacc Sewage CJs&sosW Sy1cdwn.Page 8 ox 18
Commonwealth of Massachusetts
- Al- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
w , .,, f 43 Forest Street
Property Address
Herald, Daniel
Owner Owner's Name
information is
required for every No Andover MA 01845 10/04/20213
Page CctyfTown State Zip Code Crete of Inspe(lion
D. System Information (coiit.)
4. Type of System.
°" Septic tank, distribution box, sail absorption system
C] Single cesspool
7 Overflow cesspool
F� 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 frorn system owner) and a copy of latest
inspection of the I/A system by system operator under contract
F-1 Tight tank, Attach a copy of the DFP approval.
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
1996
Were sewage odors detected when arriving at the site' 0 Yes Z No
5. Building Sewer(locate on site plan)
Depth below grade. feet'
Material of construction;
EI cast iron Z 40 PVC El other(explain`:
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp doo•rev.712612018 1 uw 5 official InsPectron Form Subsurface Sow age Disposal Systeir.Page 9 of 18
ram° Commonwealth of Massachusetts
Title 5 Official Inspection Form
w' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
453 Forest Street _
Property Address
Herald, Danietl
Owner 67 ner's Narne
inforrnafion is
regeslred for every No Andover MA 01645 10/04/ 0 3
ed
page, Cetyfl"own State Zip Code Date of Inspection
_... _._ _..... ...._..__..... _. ._. .. ..__ ..... __..u......__....w _.
D. System Information (cant.)
6. Septic Tank (locate on site plan):
Depth below grade: 6
p g feet
Material of construction:
Z concrete El metal fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, fist age: _
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes No
Dimensions: X 10 C 4
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 8°"
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 16
How were dimensions determined? "ape measure/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.):
Both baffles are,in good shape. No leakage, liquid levels are good.
t5i4nsp doc•rev'7f6f2018 Tafe 5 Ufi°,4 hr¢pe tion Form Subsurface Sewage Disposal"yst rn.Pegg t0 of 16
° Commonwealth of Massachusetts
Title 5 Official Inspection Form
s' Subsurface :sewage Disposal System Farm - Not for Voluntary Assessments
483 Forest Street
Property Address
Herald, Daniel
Owner Owner's Name
inforrequired
is o Andover MA 01845 1 f1/.g412023
rega�tred far every ........... ...
page, City/Town State Zqp Cade Date of Inspection
_._...... __. ................. ....._. .....--------- _ _._....
D. System Information (cant.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
concrete metal F-1 fiberglass 7 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 must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
[l concrete El metal [I fiberglass E:1 polyethylene other(explain):
Dimensions:
Capacity: gallons _
Design Flow:
gallons per day
15 nsp adr..•rev.712G12018 1 q1e 5 OfficiN Insraama.wn Form Sijbskm`tace 4'mage Disposal Sysilern-Page age 11 of 18
Commonwealth of Massachusetts
rF Tide 5 Official Inspection Form
^V lii Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
s 458 Forest Street
Property address
Herald, Daniel
Owner Owner's Name
requirn*n required
is No. Andover MA 01845 10/04/202
regruired for every __ ...
page. clty[Town Mate Zip Code Date of Inspection
............. _ _.... _....._.. __.. __........._w
D. System Information (cent.)
8. Tight or Holding Tank (cant.)
Alarm present: ❑ Yes 0 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 0
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.
C5(rrspa ckw•reey.712612016 16 1u 5 OffICba I nsped6 oI 4'0r111"SIfr.9Ldf"GICe Sowar„e Dispar;MN SyF.tea T Page'12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
453 Forest Street
Property Address
Herald, Daniei
Owner Owner's Name
information is No. Andover MA 51€345 10/04/2023
required for every ---— - .. _.
page. Cptyriow n State Zp Code Clete of Inspection
D. System Information (cant.)
10. Pump Chamber(locate on site plan):
Pumps in working order: D 'Yes 7 No*
Alarms in working order: 0 Yes 7 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.
11, Soil Absorption System (SAS) (locate on site plan„ excavation not required):
If SAS not located, explain why:
Type:
E leaching pits number:
E] leaching chambers number:
El leaching galleries number: _
El leaching trenches number, length:
z leaching fields number, dimensions:
1 -3625
0 overflow cesspool number:
L-1 innovative/alternative system
Type/name of technology:
ttiimqs d c,•rev 7l26f2018 Title 5 Official 1i rspedion F ocrn .Subisav,lace Sewage 6: sposak Sys�efn•Flage 13 d 16
Commonwealth of Massachusetts
=, Title 5 Official Inspection Form
`
I Subsurface Sewage [disposal System Form -Not for Voluntary Assessments
453 Forest Street
Property Address
Herald, Daniel
Owner Owner's Name
information is No Andover MA 01845 10804/2023
required far every � _ ..__. --..._.. _..__.._. _..-_..
page, Cityrrown State Zip Code Date of Inspection
_.........................................._.._.........................._..._....._..._..___._........_...._._._.__........_.___.._..__._.....__..__...____._._______w.............._....._._................._._.................._..._._............._.....
_�
D. System Information (cant.)
11. Soil Absorption System (SAS) (cant.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil„ condition of
vegetation„ etc.):
N10 hydraulic failure, no ponding, 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 ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t51nsp doc-reu.7/261 01 B Title 5 OffEc(al Inspection Form Subsurfare Sewage Uisposaw System•fags 14 of 18
Commonwealth of Massachusetts
wb, Title 5 Official Inspection Farm
�,l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
453 Forest Street
Property Address
Herald, Daniel
Owner .......-_
Owner's Name
information is required for every No. Andover MA 01845 1 0/04/2023
page. Cityrrown state Zip Code Date of Inspection
__.--.-.............................._.. ---
_._...__....._-. ......_..........
D. System Information (cunt.)
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.):
t5inspa dac.rev.7/26/2015 Title 5 O ficiai Inspection Forme Subsurface Sewage Dispcsa�System w Pere 15 of 18
Commonwealth of Massachusetts
"Tide 5 Official Inspection Form
°� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t�
453 Forest Street
Property Address
Herald, Daniel
Owner Owner's Name
information is
required for every No Andover MA 01845 10/04/2023
page. City9Towrn State Zip Code Date of Inspection
........._.......... ..... ...... . ..__... ._. ....._ ._.....w _ __..._... . _....... , ,_..w_..ww....._.._.........w ,..... ....
D. System Information (cont.)
14. 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;
F1 hand-sketch in the area below
F; drawing attached separately
t5ws p do rev '7127612018 Ti6e 5 Offi aV Pnsp!bdian Form Subswface Sewvrag4 Hoag sSM System•Page'6 of'18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
5ryI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
453 Forest Street
Property Address
Herald, Daniel
Owner awnei s Name _
information as No Andover MA 01545 10/04/2023
required for every _
page, CctyfTown State Zap Code Clete of 4nspection
D. System Information (cant.)
15. Site Exam:
Check Slope
Surface water
Check cellar
Shallow wells
Estimated depth to high ground water: freeak` et to 4"
Please indicate all methods used to determine the high ground water elevation:
Obtained frorn sy tern design plans on record
If checked, date of design plan reviewed: Date 1996
Date
El Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Pulled file
( Checked with local excavators„ installers - (attach documentation)
[� Accessed USGS database -explain:
You must describe how you established the high ground water elevation;
Taken from design plans on record.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5 nrp doc°rev '7/261201 H Tit k>5 nfCrri of fnrMpa cton Form Subsurfa:w.re.Sewage M µnraal 9wsyszwn•Page 17 of 18
Commonwealth of Massachusetts
°0 Ville 5 Official Inspection Farm
b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
453 Forest Street
Property Address
Herald,. Daniel
Owner owner"s Nerve
information as No Andover MA 01645 10/04/2023
required for every
page. Cdtyrro wn State Zip Cade Date of 9nspectncn
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E. Report Completeness Checklist
Complete all applicable sections of this form Inclusive of:
Z A. Inspector Information: Complete all fields in this section.
Z B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
Z C, Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
Z D. System Information;
For 6: 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
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