HomeMy WebLinkAboutconditional pass - Title V Inspection Report - 476 JOHNSON STREET 12/11/2023 Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
478 Johnson Street
art Y
Property Address
Erler, AnnMarie
Owner Clwner s Narne
information is No. Andover. MA MA 11/02/2023
required far every
page City/Town State Zip Code Cate of Inspection
Inspection results must be submitted on this form. Inspection farms may not be altered in any
way. Please see completeness checklist at the end of the form.
.. _.......... ..........
.__... _ ..._._... __. ... __...�._....
iil,ng out
A. Inspector Information
filiunr�out forms
on the computer,
use only the tab John L. DlVincenzo
key to move your Name of Inspector
cursor-do not J & S Development/Stewart's Septic Service
use the return Ivey. Company Name
58 So. Kimball St.
Company Address
-- Bradford MA 01835
City/Town State Zip Code
978-372-7471 S113388
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
(310 CIVIL 16.000); I 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 basses
] Needs Further Evaluation by the local Approving Authority
4. Fails
F
f, 11/02/2023
Ins//S?, natu Gate
The system inspector /30days
mit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) with 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 farm 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 Form
,t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
` 476 Johnson Street
Property Address
Erler, AnnMarie
Owner Owner's Name
tinfcrrrnatuan is No Andover MA MA 11102/202�3
required for every
page. CityrTowrt State Zip Cade Date of Inspection
.._......... _ .... ....._,.,_..._..._.......___ _ _ _... ....... _ ...._....._. _........
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3„ or 5 and all of 4 and 6.
1) System 'passes:
El 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:
System is working, but is 65 years 60,, No ponding in the stone. Single trench.
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 of 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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Commonwealth of Massachusetts
Titl+ 5 Official InspccUon Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
476 Johnson Street
Property Address
Erler, AnnMarie
Owner awwner"s Name
required
is No Andover MA MA 11/02/2023
cegt�irecE for every ............ .
page Cly/Town State Zip Cade Date of Inspection
..._._.................. .... ...... __.
C. Inspection Summary (cant.)
2) System Conditionally Passes (cant.):
Ej Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
F,_] 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 El Y 7 N 0 ND (Explain below):
obstruction is removed ] Y N ND (Explain below):
distribution box is leveled or replaced Y N ND (Explain below):
Needs new outlet baffle
(_ 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 7 N ❑ ND (Explain below):
obstruction is removed Y 7 N El ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
E.1 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
16.303(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
A NO
Title5 Official Inspection Form
R
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
476 ,Johnson Street
Property,address
Erler, AnnMarie
Owner Owner's Narne
information is No. Andover MA MA 11f0 620 3
required for emery _
page. C4ffowwn State Zip Cade Gate of Inspection
_. __......... - ...__._n..._... . ........ ....._...
C. Inspection Summary (cant.) _.... _....
El Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fall 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:
El 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.
0 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.
E_ 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 weal".
Method used to determine distance:
" This system passes if the well water analysis, performed at a DE " certified laboratory, for fecal
conform 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
❑ z Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or porwc inn of effluent to the surface of the ground or ourfeco watc"re
due to an overloaded or clogged SAS or cesspool
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�. Commonwealth of Massachusetts
I, Title 5 Official Inspection Farm
µ: r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
tt ..
�M
` . 476 Johnson Street
Property Address
Frler, AnnMarie
Owner
Owner's Narne —
infontrat6on is
required for every No. Andover MA MA 11/021 023
page. City/Town State Zip Cade Cate of Inspection
C. Inspection Summary (cont.) _.w_._._.w_.................__ ...._.._.
4) System Failure Criteria Applicable to All Systems. (cant.)
Yes No
z 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
than 1/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or
w obstructed pipe(s). Number of times pumped:
[l Z 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.
❑ z Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
El Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El 1 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.]
1:1 z The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
1:1 z The system fails. I have determined that one or more of the above failure
criteria wrist as described in 310 CMR 15,303, therefore the system fails. The
system owner should contact the hoard 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
❑ [l the system is within 400 feet of a surface drinking water supply
(l ❑ 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
C6trpwp du'rc^iev 7(26r?018 I t're 5 Qu'frcaal Irrw„„rricti n N-crrr.Subsurfac# Sewage Dr4ruwsaf Sy4 err•Page 5 0 18
Commonwealth of Massachusetts
l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
` 476 Johnson Street
Property Address
Erler, AnnMarie
owner Owner's Name
nfrarnration is No Andover MA MA 11/02/2023
required for every
page, City/Town Mate Zip Code Date of Inspect=
---_ m m .......... _ .. ......... __.. ..................... _,_,.,._...._---
C. Inspection Summary (cons.)
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 regiona6 office of the Department.
6. You must indicate "yes" or"no" for each of the following for all inspections:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
E Z Were any of the system components pumped out in the previous two weeks?
El Has the system received normal flows in the previous two week period?
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 N/A)
l 0 Was the facility or dwelling inspected for signs of sewage back up?
E El Was the site inspected for signs of break out?
Z ❑ Were all system components, excluding the SAS, located on site?
Z ❑ 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 11 Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.362(5)]
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 476 Johnson Street
Property Address
Erler, AnnMarie
Owner Owner's Name _
required information is No Andover MA MA 11/02/2023 required for every ....... . _.... .. _ ._
page. City frown State Zip Code C1ate of Pnspection
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):
Description:
No plans on file
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Does residence have a water treatment unit? Yes No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection Yes No
information in this report.)
Laundry system inspected? ❑ Yes No
Seasonal use? Yes [ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? Yes [] No
Last date of occupancy: Occupied
Crate
t5irisp doc•rev '7/26/.0 t8,„i ri0ea 5 Official Inspar,,bon r'oiru Subseto ace Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
476 Johnson Street
Property Address
Erler, AnnMarie
Owner owner's Name
information is Na Andover MA MA 11/02/2023
required for every _... .._.... _ ......... ------- ------ -- .- _
- -
page. City/Town State Zip Code date of Inspection
__.._..._...,, _._.._ .._,....,__,_., _...,.. ........... _.__..__.__...._..._.._..........._._........_,.. __......__..___.._........_.........
_._.__._
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flaw(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? ❑ 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: Last pump 08/31/2018
Was system pumped as part of the inspection? Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Sight gauge an truck
Reason for pumping: Inspect tank
t5msp.doc-rev 7126/2,118 F'itie 5 Official Inspection Form Subsurfare Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
476 Johnson Street
Property Address
Filer„ AnnMarie
Owner Owner's Narneinformati _
required for
No Andover MA MA 11/0212023
rer,�uired for every ...
page, Prcavun y state Zip code Date or Inspection
Git
D. System Information (cant.)
4. Type of System:
Septic tank, srbrrr soil absorption system
[ Single cesspool
[ ] Overflow cesspool
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 l/A system by system operator under contract
E] Tight tank. Attach a copy of the I FP approval.
0 Other(deschbe):
Approximate age of all components, date installed (if known) and source of information
6yr
Were sewage odors detected when arriving at the site? ❑ Yes Z No
5. Building Sewer(locate on site plan):
e
[depth below grade: f "
test
Material of construction:
Z cast iron R 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.',
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Commonwealth of Massachusetts
I Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
476 Johnson Strut
Property Address
Erler, AnnMarie
Owner Owner's Name
information Is No. Andover MA MA 11/02/2023
required for every
Pape City(Town Mate Zip Code Date of Inspection
_.w........ ._._._.._ _ ._..... _ _ ..._... _ .n...............
._.
D. System Information (cant.)
6, Septic Tank (locate on site plan):
Depth below grade: Built 3"to grade
feet
Material of construction.
Z concrete ❑ metal ❑ fiberglass F-1 polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes El No
Dimensions: )t 3
Sludge depth: °
Distance from top of sludge to bottom of outlet tee or baffle N/A
Scum thickness
Distance from top of scorn to tap of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
How were dimensions determined? Sludgeudge/tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Outlet baffle needs replacing
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
� � I� Y Y
476 Johnson Street
Property Address
Srler, AnnMarie
Owner Owner's Name
inforegUired for
is
o. Andover MA MA 11/02/2023
rqufr�+d for every
page City/Town State Zip Coda Date of inspection
_.._...e..._.__... ..,... .. . _..._a _.._ _.....
D. System Information (cant.)
7, Grease Trap (locate on site plan);
Depth below grade; feet
Material of construction:
❑ concrete El metal [ fiberglass ❑ 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 _
Gate 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.):
Tight or Molding Tank (tank must be pumped at tirne of inspection) (locate on site plan):
Depth below grade;
Material of construction:
El concrete ❑ metal 0 fiberglass polyethylene other(explain):
Dimensions;
Capacity: iioris
Design Flow;
gallons per day
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
476 Johnson Street
Property Address
Frler, AnnMarie
Owner Owner's Name
information
for every over
nation is
re Na And MA MA 11/02/202
a .. _
4
p City/Town State Zip Code Date of Inspection
......_......................_....._........- _,_..w_w______ .......w...__ ....
D. System Information (cent.)
8, Tight or Holding Tare (cant.)
Alarm present: Yes [ No
Alarm level: _ Alarm in working order: [l Yes E-1 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
g, Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.);
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Commonwealth of Massachusetts
o Title 5Official Inspection Form
nI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
476 Johnson Street
Property,address
Eder, AnnMarie
Owner Owner's Name
required
is No. Andover" MA MA 11/02/2023
regtairP,d for every _. .
page. City/Town State Zip Code Gate of Inspection
_ ...... ....... ..... ...m........ .._....__ _..m. .... .. . ..... ......._._._................... . .......
D. System Information (coot.)
10, Pump Chamber (locate on site plan).
Pumps in working order; Yes Noy
Alarms in working order: E] Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):.
......._.
If pumps or alarms are not in working order, systern is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan„ excavation not required):
If SAS not located, explain why:
Type:
El leaching pits number:
E....� leaching chambers number: .......
El leaching galleries number;
z leaching trenches number, length: 1 - 70" - 20' solid
ED leaching fields number, dimensions:
D overflow cesspool number;
❑ innovative/alternative system
Type/name of technology: _
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v,u Commonwealth of Massachusetts
Title 5 Official Inspection Farm
fF�
Subsurface Sewage disposal System Farm - Not for Voluntary Assessments
,,. ..,
476 Johnson Street.
Property address
Frler, AnnMarie
Owner
Owner's Name
information ie No Andover MA MA 11/02/2023
required for every .............. _ _ ,,._._.. ....... ... ..........
page, City/Town State Zip Cade date of Inspection
.................._.._ ___._..___ __.._.__.._....._..___._____.._.._......_....__.......,,,.,._._..._..._.__..------._._.___________.____.._..__.__.
D. System Information (cant.)
11, Sail Absorption System (SAS) (coat.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No 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.):
t5insl doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1121 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s. 476 Johnson Street
.„ . .......
Property Address
Frler„ AnnMahe
Owner Owner"s Name
ro is
required far every No Andover MA.. MA 11 f_0. f 0 �page CctyPTown State Zip Cade Crate at inspection
... .....................__............ . ......,,,. . ... ......... _ _.. ._...._... ...._.__...._....._.__ ....._.__.. __.._�_._._. ,__ .. ...........
D. System Information (cant.)
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.).
.._..................
t5rrwsp.doc irw„,rw.'7125Z72018 Titte 9 Officaaal Inspea,bw Forrp'r:Subsrurtace Sawa Dhspce',asrrrf Syskem pages 15 a',t8
y' Commonwealth of Massachusetts
Title 5 Official Inspection Form
r
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
;A
475 Johnson Street
Property Address
trler, AnnMarle
Owner
6wner's Name .
information is No Andover MA 01845 11/02/2023
required for every ...._...._._ _. ._ ..._ _ .._._._._.._..m
gage, ity✓Town State Zop oo�te Date of(nspectflon
D. System Information ( __._..�.._..��.._.�_ _.._.__ .. cent.)
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:
hand-sketch in the area below
drawing attached separately
1,
6
w�
f �
E
t5insp doc-rev,yP'?k"rf2018 1"Me 5 Official Yn pecUon Form.5ubsuffaWl Sewage Dispcssel uyskel" Page 16 vC 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
c
f ` Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
476 Johnson Street
Property Address
rler, AnnMarie
Owner
Owner's hJart"te
information f" No, Andover MA MA 11/02/2023
required tcrr every _ _ _
pace. CftydTown State Zip Code rate of Inspection
___.,.._.._.___,......_._............ . ..... ...._____ ___ _.,.
D. System Information (cent.)
15. Site Exam:
Check Slope
E1 Surface water
Z Check cellar
L1 Shallow wells
6"
Estimated depth to high ground water: ----.--
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:
Date
E] Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Only pumping slip on record
El Checked with local excavators, installers - (attach documentation)
El Accessed USGS database _ explain:
You must describe how you established the high ground water elevation.
No water in basement, dry hole 10' from end of the trench No water at 7'._
Before filing this inspection Report, please see Report.Completeness Checklist on next page.
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Commonwealth of Massachusetts
l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
476 Johnson Street
Froprty'address _
rler, AnnMarie
Owner owner's flame
inforequired
is No, Andover MA MA 11/02/2023
reo;;aired for every ...
page City/Town State Zip Cade Date of Inspection
_._ w. ___..... ...._ _....... . __ . .... ... �........._........ ....
E. Report Completeness Checklist
Complete all applicable sections of this farm inclusive of:
7 A. Inspector Information; Complete all fields in this section,
Z B. Certification: Signed & Gated and 1, 2, 3, or 4 chucked
Q C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: 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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