Loading...
HomeMy WebLinkAboutConditional Pass / Pass - Title V Inspection Report - 296 BOSTON STREET 8/8/2024 Commonwealth of Massachusetts Title 5 Official Inspection Form 0, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments rw 296 Boston Street Property Address Hartford, Annie Owner Pawners Name information is required for every No Andover MA 01845 07/25/2024 page. City/Town State Zip Code Date 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 _. v..........___.._.._ ................. filling out forms A. Inspector Inforlmation 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 Company Name key. Uj[,_ _._ 58 So. Kimball St.re .. Company Address Bradford MA 01835 CityfTcwn State Zip Code 978-372-7471 S 113386 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 5 (310 CMR 15.000); 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. Z Passes 2. ❑ Conditionally Passes 3. F-1 Needs Further Evaluation by the Local Approving Authority 4. E] Fails 1 ,� 07/25/2024 In t s ign ure _ Date he system inspector s I 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. Viinsp dor,-rev.7126/2 18 Nle 5 UWfxcA Nn3pectdr,n Form Su.b a alike Sewage Disposal System•Noe 1 of 18 , .. Commonwealth of Massachusetts 1„r Title 5 official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Boston Street Property Address Hartford, Annie Owner Owner's Name information is No. Andover MA 01$45 07/25/2024 required for every _ page, City/Town State Zip Code Date of Inspection 1-.---Inspec.tion summary _...._._..._....._.._._..._..._._d._......._._._.......__.w_....._ww_.._.__.__. _.._.w__.._._..._..w_.__._.._....__...._._ C. 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 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Replaced distribution box 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. D Y ❑ N ❑ ND(Explain below): t5dmsp,doc.rev 7126/2018 Title 5 Official Inspection Form Subsurface Sewage DispanM System*Page 2 of 18 Commonwealth of Massachusetts w4sw ra\ Title 5 Official Inspection Form = " w Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 296 Boston Street Property Address Hartford, Annie Owner Owner's Name information is required for every No. Andover MA 01845 07/10/2024 page, City/Town State Zip Code Date 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 _..__...__ 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 Company Name key. 58 So. Kimball St H Company Address Bradford MA 01835 City/ 'own State Zip Code 978-372-7471 S113386 Telephone Number License Number _.. .___.__ _ _.... ..._... ..... ____.____ __.___...._.....w_..__.__._._._.......___._._.... ., .......... ,_......,. _,....._. B. Certification I certify that: I am a DBP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15,000); 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. F� Passes 2. Z Conditionally Passes 3. E) Needs Further Evaluation by the Local Approving Authority 4. [J Fails 07/10/2024 tar"s Sigrtdf _ Date The system inspector stiff 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. tbinsp.rloc rev.7/261'2018 7 lit r 5 Official Inspection Fcim Subsurface Sags DisposM Syste rn.Pngea 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage disposal System Form - Not for Voluntary Assessments 296 Boston Street Property Address Hartford, Annie Owner Owner's Name information is required for every No. Andover MA 01845 07/10/2024 page. Clty[Town State Zip Code Date of Inspection .._..._.... ..............e_................. __- _ __..._._... C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6, 1) System passes: D 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: E 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 E] N E] ND (Explain below): 4S6nsp.doc rexv.e'P2S'2018 Title 5()'ifi da3 Inspection Form Subsurface Sewage I:)IispcsW Sys tern-Page 2 0 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ry� Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 296 Boston Street ,.ems Property Address Hartford, Annie Owner Owner's Name information is regWred for'every No, Andover MA 01845 07/1012024 page. �CityfT'owrm_ State Zip Code mete of Inspection _.... ..,...._..... . ........__... .w .., ._ .........,.._._., _.,.__. __w...,_ . ...,.,...,...._..... C. Inspection Summary (cant,) 2) System Conditionally lasses (wont.); Pump Chamber pumpslalarms 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 F [ N ] ND (Explain below): [] obstruct%an is removed [.-1 Y F� N [I NIA(Explain below'): distribution box is leveled or replaced ; Y 0 N El ND (Explain below): Box needs replacing due to corrosion 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 0 Y n N 0 ND (Explain below) obstruction is removed [ Y 0 N D ND (Explain below): ) Further Evaluation is Required by the Board of Health: M Conditions exlst 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. 1 ,303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: C51nvkr dr,„c rev '7f26=18 5 orf,�"w frruropwrom,,,tion Fonn S'ub%urfw*Sewage Disrosa� Sys1wrii,Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Boston Street Property Address Hartford, Annie Owner Owner's Name information is No. Andover MA 01845 07/10/2024 required for every _ _ page City/Town State Zip Code Date of Inspection 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: 0 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. E' 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 0 M 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 surface waters due to an overloaded or clogged SAS or cesspool 9�inspa.doc rev.7Q612.01 8 Titian 5 Offiaas Inspection Form Subsurface Sewage MsposW System-Page 4 of 18 Commonwealth of Massachusetts r ,g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 296 Boston Street Property Address Hartford, Annie Owner Owner's Name information is required for every Na Andover MA 01845 07/10/2024 pane. Cly/Town State Zip Code Date of Inspection .....................____.____ 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 El N Liquid depth in cesspool is less than 6°" below invert or available volume is less than /2 day flow El N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El Z Any portion of the SAS„ cesspool or privy is below high ground water elevation. El Z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El Z Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. El 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. El z 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 collform 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 d The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. El Z 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 following, in addition to the questions in Section CA. Yes No 1:1 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 El © the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area_ IWPA)or a mapped Zone II of a public water supply well fiFjmspaxdor-rev 7/261 018 TMe 5 C1tf cW Inspedbn Form &;bsu f@M(Se Sewage DrsposM Systain.Page 5 of 18 Commonwealth of Massachusetts fmy �� lk r Tile 5 Official Inspection Form F ° } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 296 Boston Street Property Address Hartford, Annie Owner Owner's Name information is required for every No Andover _ MA 01845 07/10/2024 page, CityB1 own State Zip Code fate of kispectlon ...................M....._. .__._._......... _....._.. ......... _............ _ .......,..._.w._.--____. 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 CMIR 15,304, The system owner should contact the appropriate regional office of the Department, . You must Indicate "yes" or"no"for each of the following for,all inspections: Yes No H 0 Pumping information was provided by the owner, occupant, or Board of Health L1 El Were any of the system corponents purnped out in the previous two weeks? LEI 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 ma ® this inspection? E] Were as built plans of the system obtained and examined? (If they were not available note as NIA) 'A^ Was the facility or dwelling inspected for signs of sewage back up? E El 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? Z 1:1 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 Existing information. For example, a plan at the Board of Health. Z El Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMIR 15.302(5)) f'11a ,rr 1drrr e w.7M.2 8,17,71,8 Tire 5 7.'SM'fca,l Ilan"mrApun r am Subbsu rfece Sewage Disposal SyMaa,m•Page 6 of 18 Commonwealth of Massachusetts Ifw� Title , t ff1 1 Inspection n Form �. ", Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments q t ,Fua 296 Boston Street F roperty Address Hartford, Annie Owner Owner's Narne information is No. Andover MA 01645 07/10/2024 required for every _ pare. CftyCowrr State Zip Cade Date of Inspection D. System Information 1. Residential Flaw Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example, 110 gpd x#of bedrooms): 440 G l'_D _ Description: Number of current residents: 2- Does residence have a garbage grinder? ❑ Yes Z No Does residence have a water treatment unit? D Yes Z No If yes, discharges to: _ Is laundry on a separate sewage system? (Include laundry system Inspection El Yes Z No information In this report.) laundry system inspected? Yes [:] No Seaonalue? Cl Yes Z No Water meter readings, If available (last 2 years usage (gpd)); Detail: Sump pump? El Yes Z No Last date of occupancy: Occupied _ Date Vvigi doc rev 71261r.'c) 6 °ni o 5 orfif'kal Iri,;,ac^w t r"mrn Subsurface;Sewage Dispsrt i,W Sy%hdrn•Page 7 of 1S ° Commonwealth of Massachusetts =ry Title 5 official Inspection Form Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 296 Boston Street Property Address Hartford, Annie Owner owner's Name information is No. Andover MA 01845 07/10/2024 required for every page. CatyiTown State Zip Code Date of Inspection ______._..._.._.._.__._ _w.__ __ _ ._..._....rw..._...,v____..___..._...__-._____._.._.__.._._....__.__.__.__..,....,._......._,,,,_._,m..M.............w.__..,_,._............,_..._......,,._._ D. System Information (cant.) 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? [l Yes ❑ No Water treatment unit present? ] Yes ❑ No If yes, discharges to; Industrial waste holding tank present? El Yes Ej 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 10/25/2023 Was system pumped as part of the inspection? EJ Yes El No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Sight gauge on the truck _. Reason for pumping: lnspot tank t5insp.doc•rev.'7'd",c6/'2018 'nice 5 off�cief knspeebon Form Subsurface Sewage MsposW System•Page 8 of 18 ................ Commonwealth of Massachusetts zW" Tide 5 Official Inspe+ct"on Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21916 Boston Street Property Address Hartford„ Annie Owner Owners Name requiredf information is No. Andover MA 01845 07/10/2024 required for every page. cwtyfTown Stag Zip code Date of Inspection __...__ _. _ ......., ......._,.......... . _....._,_w._.._..._...,.w .rv.._.._.. __._,_ D. System Information (cant.) 4. Type of System: M Septic tank, distribution box, soil absorption system El Single cesspool El Overflow cesspool E] Privy EJ 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 E"] Tight tank. Attach a copy of the DEP approval. El Other(describe): Approximate age of all components, date installed (if known)and source of information: 04/23/1997 Were sewage odors detected when arriving at the site? EJ Yes Z No . Building Sewer(locate on site plan): Depth below grade: 22 feet_. Material of construction: F cast ironZ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting„ evidence of leakage, etc.): t?`mnsp ckx•rev 'AFCMIO r a 5 Oftlaar hspsx on Farm Subsurface'Scmarjo Iu1sporrat fnY'WAM•page 9 V le Commonwealth of Massachusetts Title 5 Official Inspection Form ;w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments n 7 296 Boston Street Property Address Hartford,Annie Owner Owner's Name _ information is required for every No. Andover MA 01845 07/10/2024 _ _ page. City/Town State Zip Code bate of Inspection ..........____.......,.....__-___...._....____, .......... .. ................ _....... D. System Information (cent.) 6. Septic Tank (locate on site plan): - built to grade Depth below grade: 3"'feed Material of construction: E concrete El metal E] 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 El No Dimensions: 10 X 5 4 Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 28" _ Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6'- Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape 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 level is good. t5insp.doc•o'ev.V2612018 T1RVe 5 Oftk,,,W ln,4.*dran Form:Ss.bSUrface Sewage Disposal System•Page 10 ch`'18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 296 Boston Street Property Address Hartford, Annie Owner Owner's Name information is No. Andover MA 01845 07/10/2024 required for every _ page. City/Town State Zip Code Date of Inspection .._......._. __..,a..,. _„__..,_, _.mm,,..,..._. _,........,_.,,, D. System Information (cant.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: C] concrete metal 0 fiberglass El polyethylene E] 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.): & Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: EJ concrete [l metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day ffwisp.doc-rev '706/2018 Title 5 MOM Insp ecticm Form Subsaurfacau Sewage Mspa mM System Page I 018 Commonwealth of Massachusetts SIP Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments . " 296 Boston Street F rnperty Address Hartford, Annie Owner Owners Name information Is required for every No. Andover MA 01845 07/10/2024 page C tyr yawn State Zip Code fate of lrispection _. _.._............,,.........._ _...... .... ....._. _ ..,....._ D. System Information (cont.) . Tight or Holding Tank(cant.) Alarm present: EI des No Alarm level: Alarm in working carrier: El Yes No Date of last pumping: date Comments (condition of alarm and float switches, etc.): Attach copy of current purnping contract (required). Is copy attached? Ej "yes �_ No g. 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 solid's carryover, any evidence of leakage into or out of box, etc.):. Box needs replacing due to leakage around the outlet inverts._No solids carryover. Vmnsp u.Rcoc•i n,v '7(2612019 Tito 5 Offioal h m parldon Faarn Yaubsudare SeAe pe MspisW System,Page 12 of 10 Commonwealth of Massachusetts wI,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 296 Boston Street Property Address Hartford, Annie Owner Owner's Name information is No. Andover MA 01645 07/10/2024 required for every _ page. City/Town State Zip Code Date of Inspection _............. _.....,. - ..... D. System Information (cant.) 10. Pump Chamber(locate on site plan): Pumps in working order:. ❑ Yes El No* Alarms in working order: ❑ Yes ❑ 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: [l leaching pits number: --- El leaching chambers number: El leaching galleries number: z leaching trenches number, length: 3-60' F1 leaching fields number, dimensions: ] overflow cesspool number: innovative/alternative system Type/name of technology: 1.lfrrasp doc•rev.7/26f2018 1'itlle 5 Otfcdal Inspection Form Sutnurfaace ukiwaage Msposal syMern-Page 13 of 18 ° Commonwealth of Massachusetts Title 5 Official Inspection Form w i�" Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M) 296 Boston Street Property Address Hartford, Annie Owner Owner's Name information is required for every No. Andover MA 01$45 1 07/10/2024 page. City/"town State Zip Cade Gate of Inspection _., .....,, ___._.._,......._____ .,.............. ............_._......________.___...._____..____ ................. 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. 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.): _ __ t5msp doc-iev.7/2612018 TYUe 5 OffkdM H4s ech an Form r SuN swlace Sewage L'Nsposat System-Page 14 of 18 Commonwealth of Massachusetts fx Title 5 Official Inspection Farm ' i° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 296 Boston Street Property Address Hartford, Annie Owner Owner's Name information is No Andover MA 01845 07/10/2024 required far every _ _ page, Cltyf Town State Zip Code 'Cate of Inspection _._.__.. _....__ .._...._u._..._._.........._.. .__...._....... ._.................... _ ,....,.m._,a._ ..__..... ._..._...._._......_ ..._ D. System Information (cant.) 11 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.): t5irR sp doc•rev.712612018 'T'iMe 5 dffiict4 Inspection on rvaun Suta„urfar..e S«vrrage DrsTaos al SyMern-Page 15 of 18 Commonwealth of Massachusetts Mills 5 Official Inspection Form R its Subsurface Sewage Disposal Systems Form Not for Voluntary Assessments 296 Boston Street property Address Hartford„Anna Owner rJwner s hJme requiredotre No,Andover._ _. .. �°�`....__. 0184.�.._....._.. 07/10/2024 required for every .__ page, City/Town state Zip Code Date of Inspection 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 7/'�, hand-sketch ilding. Check one of the boxes below: in the area below draping attached separately Tl E5 . A -- T - Pg -- A n , 52. i ' 2 ~D ',b - pY _ -� V 30 7 til IAIV-Z6 C� Vp t5insp.doc-ray,7!G!23,;a Tits 5 OPftdtl hspsation Farm:,Subsurface Se,,vage Disposal Systarn•pap'E6 at 18 Commonwealth of Massachusetts 1� r Title 5 Official Inspection Farm w p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ww , 296 Boston Street Property Address Hartford, Annie Owner Owner's Narne Information is No. Andover MA 01845 07/10/2024 required far every page. Cltyr own State Zip Code Date of Inspection .. _...,,._.. ................._._._ _ _._._. .......,_._ D. System Information (cant) 15, Site Exam: Check Slope Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: fe 42"' et 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: Dat 1 1/1 911 996 e [� Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Pulled file [l Checked with local excavators, installers- (attach documentation) E] Accessed USES database-explain: You must describe how you established the high ground water elevation: Taken from approved plans at No. Andover!3,0,0.. ---- Before filing this Inspection Report, please see Report Completeness Checklist on next page, f."insiip doc•mW.7126/2018 Title 5 Official Inspection Foram:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 256 Boston Street Property Address Hartford, Annie owner Owner's N arne information is required for every No. Andover MA 01845 0711012024 page City/Town State Zip Code Date of inspection _...._... ... ._..__... ________.m_.._..a.._.._.-...v_ E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: E A., inspector lnformation: Complete all fields in this section. B, 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 6 (Checklist) completed D. System lnformation: For 8: Tight/Holding Tank-- Dumping 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 f revmp r9rx my '7Y2WO18 7iWe 5 Official Inspection Farm oSp&ArlPn4lff}b,e S(-Aagn 0.isspa rw[ #yWwn^Pago 18 of 18