HomeMy WebLinkAboutConditional Pass - Pass - Title V Inspection Report - 102 LACY STREET 5/28/2024 Commonwealth of M1Aassachusett
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm -Not for Voluntary Asslnts ib
102 Lacy StreetPro �
CopesAddress
Thomas
Owner Cawr7es" Name _
information is o Andover MA 01845
required for every
page. city/Town 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.
_....... .._... ...................
Irmportant:When _.__ .. ..._...._--- _......_.__. ....
Mling out forms A. Inspector Information
on the only
the bJahn L. DiVincenzo
use onry the tab
key to move your Narne of Inspector
cursor-do not J & S Development/Stewart's Septic Service
use the return Company Name
key
58 So Kimball St
Company Address
Bradford MA 01835
p, City/Town State Zip Code
w 978-3 72-7471 SH 3388
Telephone Nurmlaer License Number
B. Certification
I certify that: I am a DBP approved system inspector in full compliance with Section 15.340 of Title
(310 CMR 16.000); 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. ' masses
2. Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4 EJ Fails
m 05/09/2024
In, ec.tor's Signature Cate
The system inspector sh ubmit a copy of this inspection report to the Approving Authority (Board
of health or DFP) 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 DBP. The original fon'n 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
�g:i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Lacy Street
Property Address
Coppa, Thomas
Owner Owner's Namehfor
requrired o as No. Andover MA 01345 05/09/2024
required for every
page, Uty/Town State Zip Cade Gate of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6,
1) System basses:
" I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMIR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Distribution box was replaced
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 ex'filtration 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.
C ) Y ❑ N El NCI (Explain below):
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Commonwealth of Massachusetts
i1 Title 5 Official Inspection Farm
. ^is, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
k
102 Lacy Street
Property Address
Coppa, Thomas
Owner Owner's Nameinform
required
is No. Andover CIA 01845 05/01/2024
rertuired for every
page, City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be a + iµny
way. Please see completeness checklist at the end of the form. "°
Important:When .. .................._,.__.......
...
_.__ ............_. .. ...___.___..._._ _..........._.._ .__._.___._____.....__ 4�,,�
filling out tars A. Inspector Information
key to move your Name of Inspector
_.. � .
on the computer,
� o�me� i
J S revel ncenZ
cursor_do not i "
p t/Stewart s Septic Service
use the return
us Company Name - ,
y 58 So. Kimball St. rt,� 1_N
r Company Address
Bradford MA 01835
City/Town State Zip Code
978-372-7471 S113386
Telephone Number License Number
_._._..._..............m...m.__a...._.................._.. _ _..._..__ .._.__..._.._..........._..._.__.._.__._.._................_....._.............
...............__............._......
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.000); 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. M Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. F� Fail
05/01/2a�4
/ector's Signature Dateem inspector sh ubmit 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.
h;Sinsp,doc•rev 7126r)018 Titk3 5 OfP ctW Inspect on Form:Su:rsurfaw Sewage rt6swrS Sysewn-Page f M its
° Commonwealth of Massachusetts
Title 5 Official Inspection Form
? I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Lacy Street
Property Address
Coppa, Thomas
Owner Owner's Flame
information is No Andover MA 01845 05/01/2024
required for every =
page Cityrrown 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:
[-] 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:
Z one or more system components as described in the"Conditional Fuss" 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 F� N Q ND (Explain below):
r5insp doc rev 7t26/018 TAW 5 C1YEOM Inspection Form Subsurface Sewage MsposaB System•Page 2 of 18
� Commonwealth of Massachusetts
❑ � Title 5Official Inspection Form
k _.:" j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Lacy Street
Property Address
Coppa, Thomas
Owner Owner's Name
information is No. Andover MA 01845 05/01/2024
required for every _ _.
page. C ty/Town State Zip Code Date of Inspection
.........____.............._....._..-_.........__ � . _.. _.._....._.._....-_._... ...._ ...... _._...._...._.......................v.................._.,,.,...a...,.._,._._._....__.,._.,......._-....
C. Inspection Summary (cant,)
2) System Conditionally Passes (cant.):
❑ Pump Chamber pumps/alarms not operational. System 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):
[l broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
Distribution box needs replacing due to leakage around the outlet inverts.
❑ 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):
El obstruction is removed (❑ Y ❑ N ❑ 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:
t5insp doc.rev.7�26=18 TWo 6 OffIcjaE Inspection Form:Subsurface Sewage Disposal System�Page 3 of 18
Commonwealth of Massachusetts
�M�r Title 5 Official Inspection Form
p = Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Lacy Street
Property Address
Coppa, Thomas
Owner Owner's Name
required fo is No. Andover NIA 01845 05/01/2024
required for every
page, CityfTown State Zip Code Date of inspection
C. Inspection Summary (cant.)
❑ Cesspool or privy is within 50 feet of a surface waster
(� 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:
F 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. 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
❑ El 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
t5uns p doc rev Me 2018 Titles 5 Official Gnapoction F O,M:,Subsufface Sewage Disp�asal Sys Sam-Page 4 of'18
Commonwealth of Massachusetts
Y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
"... ' 102 Lacy Street
Property Address
Coppa, 'Thomas _
Owner Owner's Narne
rerequor r ed for every et un is
No Andover VIA 01545 05/01/2024
gt� _
page, City/Town State Zip Code Date of Inspection
C. Inspection Summary (cant,)
4) System Failure Criteria Applicable to All Systems. (cant.)
Yes No
11 z Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
EJ ® 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: __.
0 z Any portion of the SAS, cesspool or privy is below high ground water elevation.
0 z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
E-1 z Any portion of a cesspool or privy is within a Zone I of a public water supply
well.
C] z Any portion of a cesspool or privy is within 50 feet of a private water supply well,
EJ Z Any portion of a cesspool of,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 CLEF' 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 forma
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 C MR 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.
) 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
E] (l the system is within 400 feet of a surface drinking water supply
El 0 the system is within 200 feet of a tributary to a surface drinking water supply
0 ❑ 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
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Commonwealth of Massachusetts
� 9 i T1"LI vial Inspelabon "oCI""1'""1
Y ( '^
�, Subsurface Sewage Disposal System Form Not for Voluntary Assessments
102 Lacy Street
Property Address
Coppa, Thomas
Owner Owner's Name
informationis
requiredNo. Andover MA 01845 05/01/2024
�
a
p for every
e CrtylTown Mate Zip Code Date of Insperfion
C. Inspection Summary (cant.)
If you have answered"yes" to any question in Suction C.5 the system is considered a significant
threat, or answered "yes" to any question in Suction 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
E E] Pumping information was provided by the owner, occupant„ or Board of Health
❑ E Were any of the system components pumped out in the previous two weeks?
E [._ 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)
[ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
� ] Were all systern components, excluding the SAS, located on site?
El 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?
IZ ❑ 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:
EJ Existing information. For example, a plan at the Board of Health.
Z 0 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)]
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Commonwealth o,f Massachusetts
*'4 ( Title 5 Official Inspection Form
RI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
" 102 Lacy Street.
Property Address
Coppa, Thomas
Owner Owner's Name
info
rmation
star every tlon Is No Andover C IA 0134 05/01/2024
required
page, City/Town State ,dip Code rate of Inspection
_ -- _.. .......,. ._..._..m.... .
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual');
DESIGN flow based on 310 C MR 15,203(for example: 110 gpd x#of bedrooms) 600
Descriptiom
Number of current residents: 2
Goes residence have a garbage grinder? F] Yes Ej No
Does residence have a water treatment unit? E-1 Yes E1 No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection 0 Yes E No
information in this report.)
Laundry system inspected? ❑ Yes E] No
Seasonaluse? El Yes No
Water meter readings„ if avaifable(last 2 years usage (gpd)):
Detail:
Sump pump? El Yes Z No
Last date of occupancy: Occupied
Date
t5in sp'r drs•r'ev 7"26r,,'018 Il"We 5 4C'bflkiW Inarp;wtuaan F r>rrvr ftutiraurface Sewage[)Isrosaaf„iy^Ms"emm•page 7 of 18
< ' Commonwealth of Massachusetts
Title 5 Official Inspection Form
? Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t _I
102 Lacy Street _Property Address
Coppa, Thomas
Owner Owner's Name
information is required for every No. Andover MA 0184 05/01/2024
.... ............
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes 0 No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes F-1 No
Water meter readings, if available;
Last date of occupancy/use: Date
Other(describe below):
..... ...
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? El Yes ❑ No
If yes, volume pumped: 1000 ..
gallons
How was quantity pumped determined? Sight gauge on truck
Reason for pumping: Inspect tank
t5insp.doc•rev.7126 fi}1 8 TrW 5 Offimal Inspecfllrar*Form.Subsurface%w&age Disposal WSyMern•Page 8 of 18
Commonwealth of Massachusetts
�4h Title t" ff dal Inspection Form
Subsurface Sewage Disposal SystemForm - Not for Voluntary Assessments
10 Lacy Street
Property Address
Coppa, Thomas
Owner Owner's Name
informatrequired for
is No. Andover MA 0184�5 05101/ 024
rectuured for every _.
page, Cityffown State Zip Code rate of inspection
D. System Information (cant.)
4. Type of System:
z Septa tank, distribution box, soil absorption system
Single cesspool
�] Overflow cesspool
[ Privy
[.,.. 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 CEP approval,.
Other(describe):
Approximate age of all components, date installed (if known) and source of information:
197
....
Were sewage odors detected when arriving at the site's E] 'Yes Z No
5. Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
Z cast iron 40 PVC El other(explain):
Distance from private water supply well or suction line: <1 CM(1"feet
Comments(on condition of joints, venting„ evidence of leakage, etc.):
t5insps r8oc•rev 7/265//,201 S Trt6e 5 Official h4waro;;^ton I°cnm wt4 bsurfiace`.,a'awage Disposal Sptern t Page 9 of IS
r Commonwealth of Massachusetts
fii�tl 5 ►firil Inspection �' rrn
, Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
,,. 102 Lacy Street
Property Address
Coppa, Thomas
Owner Owner's Name
mformaton is
required for every No. Andover 01 1 05/01J C1 4
gage CityOTow n estate dip Code gate of Inspection
___... _._.w_...,w..._ _.., ........ .............
.. .... . .....
D. System Information (cons.)
Septic Tank (locate on site plan):
Depth below grade: 6"
feet
Material of construction:
Z concrete El metal El fiberglass El polyethylene ❑ other(explain)
if tank is metal, list age: year
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes ❑ No
Dimensions: a X 8 X 4
Sludge depth: °
Distance from top of sludge to bottom of outlet tee or baffle 27"
Scum thickness1„„
Distance from top of scum to top of outlet tee or baffle
1 „,
Distance from bottom of scum to bottom of outlet tee or baffle
fog+were dimensions determined? Tape measure/sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition„ structure& integrity,
liquid levels as related to outlet invert, evidence of leakage„ etc.):
Both baffles are in good shape. No leakage„ liquid level is good.
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Commonwealth of Massachusetts
Title 5 Official Inspection Farm
w. 1,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
` 102 Lacy Street
Property Address
Coppa, Thomas
Owner Owner's Name
infrequired
is No. Andover MA 01845 05/01/2024
required for every _ _
page. City/Town State Zip Code Date of Inspection
m .............______._.........____.....__..._._...._._....._._.._._....._.........._-_.__._____w_._...._____._.____..._____............. ...._.._.__.__._._.._.
D. steminformlatio y n (cant.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass 0 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:
concrete F-1 metal ❑ fiberglass ❑ polyethylene other (explain):
Dimensions;
Capacity:
gallons
Design Flow: -
gallons per day
€FiInsp.doc,•reay.7/2612018 Title 5 Offhcpaal lnspecti n Forcer Subsurface Sewage Disposal Systaroorp•page 11 of 18
Commonwealth of Massachusetts
TPELle 5 Official Inspection Form
� 7, " . i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Lacy Street
Property Address
Cpppa, Thomas
Owner Owner's Name
information is No. Andover MA 01845 05/01/2024
required for every
pause City/Town_ _ State Zip Cede Date of Inspection
D. System Information (cant.)
5. Tight or Holding Tank (cant.)
Alarm present: El Yes [ No
Alarm level: _ _ Alarm In working order: E
.1 Yes ❑ Na
Cute of lest pumping: gate
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required), Is copy attached? Ej Yes Q No
g. Distribution Sox (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.):
Box needs replacing due to leakage around the outlet inverts. One side of box has fallen inward.
t8an r.r 0c,•rev.'rP;,fSo":018 Ti%5 Offiu W Irmfwei:imn Forn SUbs yface Sewage D6du@re saf systern.Page 12 of 18
Commonwealth of Massachusetts
r
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Lacy Street
Property Address
Coppa, Thomas
Owner Owner's Narne
information is required for emery No. Andover PEA 01845 05/01/2024
page. Clty/T`own State _ Zip Cade gate of Inspection
D. System Information (cant.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ..] Yes E No*
Alarms in working order: El Yes E.� 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:
] leaching pits number: _
�] leaching chambers number:
w..
leaching galleries number:
�] leaching trenches number, length:
leaching fields number, dimensions: 1 -20 45
] overflow cesspool number: _
innovative/alternative system
Type/name of technology:
tflnsp,doc•rev.706120'18 'T 190 5 OffidW lnspact4rrco Form.Subsurface cA w«agaw Cbumµa sal SyF6flem•Page 13 of 18
Commonwealth of Massachusetts
T I-le 5 Official Inspection Farm
is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,." Z7102 Lacy_Street
Property Address
Coppa, Thomas _
Owner Owner's Name
required information is No Andover MA 01845 05/01/2024
required for every �
page. City/Town 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.):
No hydraulic failure, no ponding, no damp soils. Used a camera in the lines and there is no ponding
in the lines.
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 sail, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
tk'msp doc•rev 71,1612018 Tft 5 OfficiW Inapkwwfion Form Subaeaft e Sewage Disposal System•Page 14 or 10
Commonwealth of Massachusetts
x T*11ELle 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
102 Lacy Street
Property Address
Coppe, Thomas
Owner Owner's Nar'ne
inforrequired
is No. Andover MA 01845 05/01/2024
rev�uired for every _
page. Cetyflrown State Zip Code Cate of Inspection
........... ........ ........_ ._... ..... __._,....._.. ....... _._.. _ ......
D. System Information (cont.)
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.)
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Commonwealth of Massachusetts
........ . ..........
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
/r.
102 Lacy atrt
Property Address
C;oppa, Thomas
Owm' Owner's Nw3rne
r nfonro for every is No Andover MA 01845 05/01/20 4
required
for
page, City/1-own State Urfa Code Date of 4nsrr Llion
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:
hand-sketch in the area below
Z drawing attached separately
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`- k Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
11
102 Lacy Street
Property Address
Coppa, Thomas
Owner Owner's Name
information is required for every No. Andover MA 01845 05/01/2024
page. City/Town State Zip Code Date of Inspection
.............__._._.._...,_. _.......w._.. _............ ...._...
D. System Information (cant.)
15. Site Exam.
Check Slope
Surface water
Check cellar
(l Shallow wells
"'72
Estimated depth to high ground water: 72
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: 12/01/1976
Date
❑ 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)
El Accessed USCS database - explain:
--------
You must describe how you established the high ground water elevation:
Taken from design plan on,record.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
f5 nsp.doc rev f126/2. 18 'rifle 5 Off*al Inspection Form S61bsurlace Sewage Disposal System-Page 17 of I$
Commonwealth of Massachusetts
Title .� �► iCia Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 lacy Street
Property Address,
Coppa, Thomas
Owner Owner's Name
required is No Andover MA 1545 05/0112024
required for every
page, City/Town State Zip Code Date of hispectron
E. Report Completeness Checklist
Complete all applicable sections of this form Inclusive of:
A. Inspector Information: Complete all fields in this section.
B, Certification: Signed & bated 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
D. System Information:
For 3: 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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