HomeMy WebLinkAboutPass - Title V Inspection Report - 476 JOHNSON STREET 3/26/2024 Commonwealth of Massachusetts
,x Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t
475 Johnson Street
Property Address
Filer, AnnMarie
Owner's Nar�Ye
Owner
information is No. Andover MA MA 12/21/12023
11,
required far every
page, City/Town State Zep Cade gate 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.
_. _r..__..._.__._. ..... .......... .-.....-.. . ......._.
Important:When
filling out forms A. Inspector Information
on the computer,
use only the tab John 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
1 So, Kimball St,
Company Address
Bradford MA 01335
� 1 r Cityrsawn State Zip Cade
F 73-372-7471 S113386
_:._.._ _...a.... Telephone Number License Number
_....._, _.._.-..... _ ........_._....... . .. ............. ....... ------........_._._._ ...,..,.,..._ .w..........._........
B. Certification
I certify that: I am a DFP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 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. r Passes
2. Conditionally Passes
3, Needs Further Evaluation by the Local Approving Authority
4. ] Fails
d
1. 12/21/2023
I ector's Signature Date
The system inspect r°""hall 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.
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° Commonwealth of Massachusetts
Title 5 Official ial n p►ec can Form
im Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
476 Johnson Street
Property Address
Erier, AnnMaroe
Owner Owner's Name infor
required ation
is No. Andover MA MA 12/21/2023
requre�t for every _.
pace. CCtylTown State Zip Code Cate of Inspection
_.._..w...__,.r ....._._._.. _ _ _ _.. ._._........__ .w. . .,... _....._.._..... .... ._._ ._.........__..........v..._.._
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes.
Z I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CLIP. 15.304 exist, Any failure criteria riot evaluated are
indicated below.
Comments:
Replaced outlet baffle. System is working, but is 65 years old. No ponding in the stone. Single
trench.
2) System Conditionally Passes:
El 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.
El Y O N El ND (Explain below)
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