HomeMy WebLinkAboutPass - Title V Inspection Report - 1005 FOREST STREET 7/1/2024 Commonwealth of Massachusetts
yw =art= T ill YTI InspecUon Form , - ,-:, "
Subsurface Sewage Disposal System Form - Not for'Voluntar)t,, s s rents
1005 Forest Street
Property Address
Stewart, Georgia
Owner Owner's Name
information a No Andover MA 01845 )b6/2024
page,ored fc'rc every ,
City/Tow n State Zip Code Cate o�f Inspection
Inspection results must be submitted on this farm. Inspection forms may not be altered in m1
way. Please see completeness checklist at the end of the form. "
y
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Important.When
filling out forms A. Inspector Information
on the computer,
use only the tab John L. DMincenzo_
key to move your Narne of Inspector
cursor-do not J & S D eve lopment/Stew�a Service rt's Septic Servi
use the return _
key. Company game
-- 58 So, Kimball St.
Company Address
Bradford MA 01835
City/Town State Zip Code
as 978-372-7471 S113386
_._ Te4ephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CIVIL 15.000); l 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 l have determined
that the system:
1. Z Lasses
2, F Conditionally Lasses
3. Deeds Further Evaluation by the Local Approving Authority
4. Z,t
r
f
06/06/2024
in Sic�'�,' re Gate
he system inspector srallsubmit a copy of this inspection report to the Approving Authority (Board
of Health or DEL) w ithf" 30 days of completing this inspection. If the system has a design flows of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEL. 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 Form
" Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1005 Forest Street
Property Address
Stewart, Georgia.
Owner Owner's Name
information is required for every No. Andover MA 01845 06/06/2024
page. City/'town State Zip Code Date of Inspection
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C. Inspection Summary
Inspection Summary. Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
Q 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:
❑ 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 El ND (Explain below):
V)nsp doc-rev,7/26/201 H I'lle 5 Offic4 Inspection Form Subsurface''". age Dispcs,M System-Purge 2 of'18
Commonwealth of Massachusetts
{ , " Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
f� 1005 Forest Street
Property Address
Stewart, Georgia
Owner Owner's Narne _
information is No. Andover MA 01845 06/06/2024
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (coat.)
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):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed [,-1 Y F-1 N ❑ ND (Explain below):
distribution box is leveled or replaced ❑ Y Fj N E] 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 El Y F� N F� ND (Explain below):
0 obstruction is removed El Y ❑ N 0 ND (Explain below):
) Further Evaluation is Required by the Board of Health:
E] 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:
6.)msg:r.doe-row.'7126/3�018 TWe 5 OffOc4 lnspectvi Fcem SubgUrf&ace Sewage Disposal Sys^ em.Pwge 3 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
` i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1005 Forest Street
Property Address
Stewart, Georgia
Owner Owner's Name
information is No. Andover MA 01845 06/06/2024
required for every
page. City/Town State Zip Cade Date of Inspection
.....__,._.._ .........__..__... ...._..............._....... _............ ...... ......
C. Inspection Summary (coat.)
0 Cesspool or privy is within 50 feet of a surface water
[l 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.
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.
0 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
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 ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.dov•resv.712612018 T're 5 Officral Insped.on Form Subsurface Sewage Disposal S,ystern•Page 4 of'9 B
< , Commonwealth of Massachusetts
Title 5 Official Inspection Form
511 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I��
1005 Forest Street
Property Address _
Stewart, Georgia
Owner Owner's Name
information is required for every No. Andover MA 01845 06/06/2024
_
page. Crtyaown State Zip Cade Date of Inspection
..__.._.............a.a.................. .__ ......_ _ ______.._____
C. Inspection Summary (cant.)
4) System Failure Criteria Applicable to All Systems: (cant.)
Yes No
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 1/2 day flow
❑ Required pumping more than 4 tirnes 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.
F Q 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 1 of a public water supply
well.
❑ 0 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 CM 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 fallowing„ in addition to the
questions in Section CA.
Yes No
0 ❑ 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
t5 rxsp.eYoc mv.7/26/2018 1 RYe 5 Official Inspection Form SUbsurfaue Sewage a6sposaf Syseern•Page 5erf 18
Commonwealth of Massachusetts
i � -*J Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1005 Forest Street
7`
Property Address
Stewart, Georgia
Owner Owner's Name
information is No. Andover MA 01845 06/06/2024
required for every _
page. City/"Gown State Zip Cade Date of Inspection
........_.,.. _ _.. _..m_.m ... .....__. _,_......._
C. Inspection Summary (cant.)
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 regional office of the Department..
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
Z ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Z Were any of the system components pumped out in the previous two weeks?
Z 1:1 Has the system received normal flows in the previous two week period?
11 Z Have large volumes of water been introduced to the system recently or as part of
this inspection?
Z Q Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z ❑ Was the facility or dwelling inspected for signs of sewage back up?
Z ❑ 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?
Z ❑ 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 1:1 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)]
t5msp doc rev.'7P;6/2018 Title 5 GffocVaB Insr,*c4ron S=carry Subsurface Sewage DispausaB System,Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
j>; Subsurface Sewage Disposal System Form: - Not for Voluntary Assessments
1005 Forest Street
Property Address
Stewart, Georgia
Owner Owner's Name
infrequired
Is No. Andover MA 01345 0 /06/2024
rectulred for every
page, CityfTow n State Lp Code Date of Inspection
_e.._.. . . . ....... ......w .w.w ... __.__... _....._._. _.
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design) Number of bedrooms (actual)
DESIGN flows based on 310 CMR 15.203 (for example 110 gpd x##of bedrooms) 440
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes E No
Does residence have a water treatment unit? Yes 0 No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes [-I No
information in this report.)
Laundry systern inspected? ❑ Yes El No
Seasonaluse? ❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)):
Detail
Sump pump? D Yes Z No
Last date of occupancy: Occupied
Cate
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` Commonwealth of Massachusetts
�w Title 5 Official Inspection Form
ai Subsurface Sewage Disposal System Farm • Not for Voluntary Assessments
1005 Forest Street
Property Address
Stewart, Georgia
Owner owner's Name
information ks required for every No. Andover MA 01845 06/06/2024
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commerciallindustrial Flaw 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 ❑ 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? Z Yes ❑ No
If yes, volume pumped: 1000
gallons
Haw was quantity pumped determined? Sight gauge on truck
Reason for pumping; Inspect tank _
tE5in sp.'b.dcc-rev.7126t2'018 T'rtle 5 Offictial Inspector Form Subswfaca Sewage Dsposel System.Page 8 of 18
Commonwealth of Massachusetts
n
Title 5 Official Inspection Form
} Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1005 Forest Street
Property Address
Stewart, Georgia
Owner Owner's Name
information is required for every No. Andover MA 01845 06/06/2024
page. City/Town State Lp Code Date of Inspection
.......... ................ ... ...... .. _.........
......_,,..,,,._.._..... .._w..._,_,._ ....._,..._ _,w_,._...,. .._.,__,....
D. System information (cont.)
4. Type of system:
E Septic tank, distribution box, soil absorption system
El 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.
El Other(describe):
Approximate age of all components, date installed (if known) and source of information:
June, 1977
Were sewage odors detected when arriving at the site? Yes FA No
5. Building Sewer(locate on site plan):
Depth below grade: 36" ....... -_— -
feet
Material of construction:
E cast iron F1 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
&Fjinspldoc-rev.7126/2016 Title 5 Offbaa�Inspedron Form Subsurface Sewage Disposal Syskem-Pager 9 of 18
Commonwealth of Massachusetts
ry ;� Ti�tic fficial Inspection Form
r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t
1005 Forest Street.
Property Address
Stewart„ Georgia
Owner Owners Name
rrrtquirr dfotion tis No. Andover MA 01845 06/06/2024
required for every
page Crty(Town State Zip Code Date of Ir7spectaert
D. System Information (cunt.)
6, Septic Tank (locate on site plan):
Depth below grade; Suitt to grade
ffee4
Material of construction:
Z concrete D rnetal ❑ fiberglass ❑ polyethylene other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes E] No
Dimensions: 5 x 8 x 4
5'
Sludge depth
Distance from top of sludge to bottom of outlet tee or baffle 2
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 6"'
Distance from bottorn of scum to bottom of outlet tee or baffle
How were dimensions determined? Tape rmeasure/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 level is good.
t51nsp doc^rev "7P26t 018 Ti7twe 9 Offv'oai Irmrtrwr',toi i l'crrn w;ti losuffeco-r Sewage Disposal Syskwn•Page'10 of'78
Commonwealth of Massachusetts
s
Title 5 Official Inspection Form
y Subsurface Sewage Disposal System Form - Not for Voluntary .Assessments
1008 Forest Street
Property Address
Stuart, Georgia
Owner owner's Name
iinformaaatZ is No. Andover MAC 01848 06/06/2024
required for every
page. City/Town State Zp Corte bate of inspection
D. System Information (cent.)
7. Grease"Trap (locate on site plan):
Depth below grade: feet
Material of construction
E concrete D metal E-1 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
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:
.J concrete F1 metal fiberglass polyethylene El other(explain):
Dimensions,
Capacity:
gallons
Design Flow:
qah8ans per day
t5nsp do<° -re,v 7126Q018 Tifle 5 Offifl rwf Pnspa!aa,',,on Fan'n $ubsurfac'e Sewage Disposal l System•Page 1 Y of is
Commonwealth of Massachusetts
Ti"'Ede 5 Official Inspection Form
r ti Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.. 1005 Forest Street
Property Address
Stewart, Georgia
Owner Owners Name
information as No Andover MA 01845 06/0 /2024
reytsrrec9 trar every .. _
page. cityrrown state pup rate Cate cif Gnspentiocb
D. System Information (cant)
& Tight or Holding Tank (cont.)
Alarm present: 0 Yes 0 No
Alarm level: Alarm in working order-, Yes Igo
Bate of last pumping: gate
Comments (condition of alarm and float switches, etc.):
`Attach copy of Current pumping contract(required). Is copy attached? 0 Yes E] No
9. Distribution Box (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.):
Equal distribution, no leakage, no solids carryover. Box is down 20".
C"aor sp doc•i ev '7126/2018 tl`d[A 5 Ciflir W Pn nq"ecuon r omr, Subsurface'Sewago 4':f(yp jai SyMc »Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
r i�, Subsurface Sewage [disposal System Form - Not for Voluntary Assessments
1005 Forest Street
Property Address
Stewart, Georgia
Owner bw-ner`s N me
information is No. Andover A 01845 06/06/2024
required for every
page. City/Town State Zip Code Late of rnspection
D. System Information (cent.)
10. Pump Chamber (locate on site plan):
Pumps in working order: El Yes E] No*
Alarms in working order: El 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):
It SAS not located, explain why:
Type:
leaching pits number:
El leaching chambers number:
Ej leaching galleries number:
E] leaching trenches number, length:
[_ leaching fields number, dimensions:
(� overflow cesspool number:
innovative/alternative system
Type/name of technology
t5insr7.d; K..*rev '7t"26 2018' rr Ie 5 Offinaf fins roectiw` r'crrn Si.ibwwface E,^'Amag a Ms pcimv Symem.Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1005 Forest Street
Prapeily Address
Stewart, Georgia
Owner Owner's Name
information�s No. Andover MA 01845 06/0 /20 4
regWreed for every
page C+tyll'aw n State Zip Cade Date at hispectraa"r
D. System Information (cant.)
11, Sall absorption System (SAS) (cant.)
Comments (note condition of soil, suns of hydraulic failure, level of ponding, damp sail, condition of
vegetation, etc.'):
No hydralic failure, no ponding, no damp soils. All of the pits are dry. The stone on the bottom
appears clean and loafs good.
12. Cesspools (cesspool rnust be purnped 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.):
45,rrrrp dur,•rev '7r2&2018 T Ole 6 Offic.a�4rvuiemv'rn Firm 1Subskwfrxvr Sevr'�ge[)rs osW;aywern•Page 14 r1P 18
Commonwealth of Massachusetts
+ i
tle 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessrrlents
!w�
1 005 Forest Street
Property Address
Stewart, Georgia
Owner Owner's Name
information is
every ti is
required tea No. Andover MA 01845 06/06/2024
_
page CatyfTowmr State pep code Cate of Inspection
.......... . _._ _.... ........_. ..... .......... . ......... ..... _...__........._.__. _._._
D. System Information (coat.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Cornments mote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)-,
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rto�.
we Commonwealth of Massachusetts
e .
.x. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1005 Forest Street
Property Address
Stewart, Georgia
Owner __.
..._._ _. . _ _.._..._ _„__ .._....
Owner's Name
information is
No. Andover _....... MA 01845 06/06/2024
required for every __. ....,.—. .........
page. iif6wn Mate Zap wade Date of lnaped6on
SyS$el'n Information (cont.)
14, Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, incWding ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the buRding. Check one of the boxes below:
the
in the area below
E] drawing attached separately
d;-
F �
a
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� Commonwealth of Massachusetts
° � rTitle 5� 'ff dal Inspection Form
ri � subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
✓ 1005 Forest Street
Property Address
Stewart, Georgia _
Owner Owner's Name
infor
required
for fo 6every over
requ No And MA 01845 06/06/2024
_
page. Cetyl"@"own State Zip Code Date of Inspection
a .._�_.w..._.. .... .w�....... ._..w.w.,_ ,.,....._.. ..........._ ..__ ......_...... ........_ ___.......... .....__....__....� ..�..._�._.......... .......__.__...... ____
D. System Information (cant.)
15. Site Exam:
E Check. Slope
0 Surface water
Z Check cellar
Shallow wells
Estimated depth to high ground water: lea water, p 72'"
feet
Please indicate all methods used to determine the high ground water elevation:
z Obtained from system design plans on record
If checked, date of design plan reviewed: 04/02/1977
Gate
El Observed site (abutting property/observation hole within 150 feet of SAS"
z 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 plan on record.
Before filing this Inspection Report, please see Report Completeness Checklist can next page.
tnirnsp doc my 712612018 1 itfe 5 OfPr araI Orrrspection f cm wn Subsurface Sewage 01 tapos W Sysbery i M Pasps 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�tw
}i Subsurfaces Sewage Disposal System Farm - Not for Voluntary Assessments
1005 Forest Street
Property Address
Stewart, Georgia
Owner Owner's Nan7e
required
is No Andover MA 01845 06/06/2024
rer�trured for every
page. City/Town State Zip Code Cate of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this farm inclusive of:
A. inspector Information: Complete all fields in this section.
S. Certification: Signed & Dated 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
C. System Information:
For 8: 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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