HomeMy WebLinkAboutPass - Title V Inspection Report - 64 STANTON WAY 8/19/2024 V^7,
Cornrnonw,ealth o�t Massachusetts �w
OR � i!o T itle 5 Off ici; ll Inspection FormEE;El �
a
Subsurface Sewage Disposal: System Porr>It, . Not for Voluntary Assessr �it
n54 Stanton Way
Property,address
Moody, Kwesj
owner Owner's Name
equireticn rs
r d for enemy No Andover A 01345 08/06/2024
rcea�Iullre _
purge. cityrrown State dip Code bate not Inspection
Inspection results must be submitted on thlis form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
trrrpomtarrt.When _._.. _ _.... ...._. ............ .._____..___�.__...._ .....,.._.. ...
fr99ilrug out forrns A. Inspector Information
on the computer,
use only the tab Jahn L. Di`Vd'incenzo
key to move your Name of inspector
cursor-do not � ptuc Service
use the ret�urc� C�n�ny Nam(a ��°nt6teVa�r"c�ft' E'
key
n 53 So. Kimball St,
air as C o,m—perry address ..
Bradford MA 01835
CIlty/To wn State lop wade
s r 978-3 m'2-7471 S1133186
-relephcne Number Ucense Number
B. Certification
I certify that: I am a D'EP approved system inspector in full compliance with Section 15.340 of Title
(310 CMR 1!S 000), I have personally inspected the sevwalge disposal system at the property address
listed above; the information reported belovw,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 oin-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. Passes
2. ond4ionally Passes
3, Needs Further Evaluation by the Local Approving Authority
4. Fail
08/06/2024
Ins p - Signr� y C��te
T d system) inspector s subi it a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 33 days of completing this inspection. If the system has a design flow of
15,333 glpd 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, iif applicable,, and the approving auuthority.
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 uise.
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Commonwealth of Massachusetts
Title 5 Officialion Fob'
Subsurface Sewage Disposal System, Form - Not for Voluntary Assessments
X `
` ma;
64 Stanton Way
Property Address
Moody, Kw!esi
owner Owner's Name
information is No. Andover MA 01845 08/06/2024
required for every
page, CityfTown State Zip Code date of Inspection
__..,._ ___._-- _____ __.. w...w.w_..._....._w.__..____w._... _.._..., ._.........,_, ___..,_.,_.,. _.._...,_......._._.___.
IC. Inspection, Summary
Inspection Summary: Coimplete 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 CMIR 15.303 or in 310 CMR 15 304 exist. Any failure criteria not evaluated are
indicated belowd.
Comments:
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 26 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 26 years old is available..
El Y ❑' N ❑ ND (Explain belovv):
€5iirvsp do r^r°w.7126001 B TiUe 5 Of6lmal Inspaea.ron Form Subsurface Sewage rPmpnsm System Page 2 of 18
Commonwealth of Massachuuisetts
l
° i ll fil+ ul Inspection Form
Subsurface Sewage disposal System Form - Not for Voluntary Assessments
54 Stanton Way
Property A dAess
Moody, kwesi
rw inir it Owner's Narne
information,is
required fw every No. Andover MA 01845 5105/ 4
page OtyfI C)Wn state Zip Code Date of Mspection
C. Inspection Sun Mary (cont.)
) System Conditionally Passes (cont.):
[, ] Pump Chamber purrnpslalarms not operational. Systern will pass with Board of Health approval J
pumps/alarms are repadired.
[ 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 bracken, settled or uneven distribution box. System will
pass inspection ref(with approval of Board of Health):
broken pipes' are replaced I.m. N ] NCB (Explain beiow);
E]', obstruction is removed [. 1 N 0 ND (Explain below):
El distribution box is leveled or replaced �w_� Y L1 N E] NIID (Explain below)�
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection it(with approval of the Board of Health);
I;. ] broken pipe(s) are replaced 0 Y 0 N E NID ('Explain below):
El obstruction is removed y N ND (Explain below).
3) Further Evalluation is Required by the Board of Health:
[ ] Conditions exist which require further evaluation by the Board of Health in order to determine if
the systems 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 .3d13(1)(b)that the system is not functioning in a manner which wviill protect public health,
safety and the environment:
6,r p doc rey rM201 6 1 W 5 lnspectm r Fonv °irknbSL)ffacm Sewage ID vpu mI.y.a err,•Page 3 cyP 18
Commonwealth of Massachusetts
Title 5 Off' i a' Inspection
4"
iI' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� F
54 Stanton Way
Property Address
Moody, Kwesi
Owner Owner's Name
information is No. Andover MA o1545 Cl5/05/2024
req�rAred for every
page 0tyrTown State Zip code Gate of Inspection
_._.,..... .. .__....., ..........._.__..--------- __ ._. ....................._.......
._.____
C. Inspection, Summary (cont.)
El Cesspool or privy is within 50 feet of a surface water
D Cesspool or privy i`s within 50 feet of a bordering vegetated wetland or a salt marsh
b. System w 111 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:
El The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
El The system has a septic tank and SAS and the SAS its within a.Zone 1 of a public water
supply,
E The system has a septic tank and SAS and the SAS is wfthlin 50 feet of a private water
supply well.
E] The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply 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 its equal
to or less than 5 pptm, 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:
Your must indicate "Yes"or"No" to each of the following for all inspectiions:
Yes No
0 z Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
1:1z Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
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Commonwealth of Massachusetts
T"tie 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Stanton, Way
Property Address
Moody,Kwesi
Owner Owner"s Name _
information fn is No. Andover MA 01645 08/06/ 0 4
required for every _
page. City/Town State Zip' Code Date of inspection
.._.
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cant.)
Yes No
El Z Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
E] z Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'lz day flow
El I, Requiired pumping more than 4 tunes in the last year NOT to clogged or
obstructed pipe(s). Number of times pumped:
❑ z Any portion of the SAS, cesspool or privy is below high ground water elevation,
❑ z Any portion of cesspool or privy, is within 100 feet of a surface water supply or
tributary to a surface water supply.
z Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well,
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 coliiform 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
0 z The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
z The system fails. I have determined that one or more of the above failure
criteria exist,as described in 310 CMR 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.
) Marge Systems. To be considered a large system the system must serve a facility with a
design flow of 10,0010 gipd 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 C.4.
Yes No
El the system is within 400 feet of a surface drinking water supply
El D the system is within 266 feet of a tributary to a surface drinking water supply
El El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area IWPA) or a mapped Zone ll of a public water supply well
�50sp dac.,rnv.706�2018 Tie 5 Offj i al MnspaecRiori Form Subsurface Sewage Di9posaal SyMein�Page 5&18
................. ... ........ ................ ......... ......_ __....
Commonwealth of I" a a huu e
W:f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for'Voiuntary Assessments
54 Stanton Way
Property Address
Moody, Kwesi
Owner Owner's Name
infrequiretiond
is Nlo. Andover MA 01845 03106/2024
required for every
page. Crty(Town State Zip Code Date of Inspection
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.
5. You must indicate "yes" or"no for each of the following for all inspections;
Yes No
E El Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks?
�] 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 NIA)
El Was the facility or dwelling inspected for signs of sewage back up?
El Was the site inspected for signs of break out?
E 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"?
El 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.
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 15.30 (5)]I
t5msp d 7a•i ev '712 Jr/20. 8 T1kla 5 Officlal h1p1*ction Faatrri Sukr5„a la,:.Sewage"Disposal Sy�tem•Page ir,of 18
Commonwealth of Massachusetts
,a Title 5 Official Inspection Form
w
l-,6 SubsurfAce Sewage Disposal System Form - Not for Voluntary Assessments
1 84 Stanton Way
Property Address
Moody, Kwesd _
Owner Owner's Name
information ie No Andover A 01845 08/06/2024
required for every �
page. City/Town state Zap Cade Date of inspection
.. ._.._
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms (actual); 3
DESIGN! flow based on 310 CMR 15,203 (for example, 110 gpd x of bedrooms): 333
Descripbon,
Number of current residents: 2
Does residence have a garbage grinder? El Yes H No
Does residence have a water treatment Unit? El Yes Z No
If yes, discharges to:
Is laundry on a separate sewage system' (Include laundry system inspection E Yes Z No
information in this report.)
Laundry system inspected' [l Yes E' No
Seasonal use? 0 Yes ZI No
Water meter reactrigs, if available(last 2 years usage (gpd)):
Detail.
Sump pump? El Yes Z No
Last date of occupancy: Occupied
Date
cdcm-nay.7P26l'y218 Tr49u 5 Official Insyacwr.;ddran Form Sit surface Sewage Msposa� System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 m Official _ Form
,rw
h :Subsurface Sewage Disposal System Form Not for Voluntary Assessments
0
64 Stanton 'Way_
Property Address
Moody, Kwesi
Owner Owner's Warne
reformation is required for every No. Andover MA, 61845 08/06,2024
page, Cityd"rown State Zip Code Late of Inspection
D. System Information (coat.)
2. Commerciallindustrial Flow Conditions:
Type of Establishment:
[design flow(based on 316 CMR 16.203),
Gallons per day(9pd)
Basis of design flow (seats/personslsq.ft., etc.): _.
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? 7 Yes ❑' No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Fast date of occupancy/use,
Late
Other(descriibe below);
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? Yes No
1500
If yes, volume pumped: gaucsns
How was quantity pumped determined? Sight gauge on truck_
Reason for pumping: Inspect tank
patensp doc•raw 'i 126120184 Ti1Ie 5 Offleii al Icespaad,w Fvr i Sur, uoracea Sewage Disposal Spiern•Page 8 of 18
Commonwealth of Massachusetts
rr Title 5 Official Inspection Form
1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Stanton Way
Oropeny Address
Moody„ Kwes�
Owner Owner's Narrne
equ rronis
rquilreded for every o.NAnover MA
Andover 01845 08/06/2024
e _
page,. Cuty/Town state Zip Code date of Inspection
D. System Information (cant.)
4. Type of Systems:
Septic tank, distribution box, soil absorption system
Single cesspool
El Overflow cesspool
El Privy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
[� Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the IlA system by system operator under contract
Tight tank. Attach a copy of the DEP approval.
El father(describe):
Approximate age of all components, date installed (if known)and source of information:
10/08/2014
Were sewage odors detected when arriving at the site? El 'yes E No
5. Building Sewer(locate on site plan):
Depth below grade: 16"feet
Material of construction:
❑ east iron 40 PVC ] other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
@5'insp dou,,-rev.V25120'15' "rifle 5 Offi al Irrsperfton F'trrrrr.aubsui{ace Sewage Disposam frysRattm Page 9 of 18
�g Commonwealth of'Massachusetts
=f, Title 5 Official cial Inspection Form
Subsurface Sewage Disposal Systern Form -Not for Voluntary Assessments
RI w„
64 Stanton Way
Property Address
Moody, Kwesi _
Owner Owner's dame
informationmire for
No. Andover 01845 08/06/2024
rewired for every _
page. City/"own State Zip Code Date of Mspectkon
D. Systern Information (cont.)
Septic Tank (locate on site plan):
Depth below grade: feet _
Material of construction:
Z concrete ', metal ❑ fiberglass ❑ polyethylene El rather(explain)
If tank is metal, list age; years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes No
Dimensions: 4-
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 29`
Scum thickness
D. stance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 1
Now were dimensions determined? Tap ,measureisludgejudge
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.
tl 3insp doc.ray.'7F261201116 7ode 5 Of oal Inspedw Form,Subsurface Sewage Disposal SysEem-Page 10 of 18
Commonwealth of Massachusetts
„ `1F) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 Stanton Way-
Prolperry Address
Doody„ Kwesi
Owner Owners Name
information is No .Andover MA 01845 018/0 /20 4
rrw�uaured tcvo a�wrwry
garage City/Town State ,Zip Cade Cate or dnsp �lioaa
.w ..._. _._...__.w......................_........__..........
.., _ _.. __ ....., .....,.
D. Systems Information (scant)
7, Grease Trap (locate on site plan):
Depth below grade. reed
Material of construction"
concrete ' metal F] fiberglass El polyethylene [:1 other (explain):
D rnensions.
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
Cate of last pumping: Dot
Corn ments(on pumping recommendations,, inlet and outlet tee or baffle condition, structural integrity,
li1puid'I levels as related to outlet invert, evidence of leakage, etc.):
Tigiht or Holding Tank (tarok must be pumped at time of inspection) (locate on site plan).
Depth bellow grade:
Material of construction:
EJ concrete D metal ❑ fiberglass polyethylene other(explain):
Dirrnensiorns:
Capacity: galwora
Design Plow:
gaHons per tray
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Commonwealth of Massachusetts
YZ
Title 5 Official Iris ecti ►on Form
Subsurface sewage (Disposal System Form - Not for Voluntary Assessments
s gym`
84 Stanton Way
Property Address
pMoody, Kwesu
Owner Owner's Narne
Wormation 8s
rertWred for every No. Andover MA 0184 08/1016/ 024
for
page, City/Town stag Zip Cooke Date of Inspection
D. System Information (cone)
8, Tight or Holding Tank (coat.)
Alarm present �.... Yes El No
Alarm level: Alarm in working order: (71 Yes Ej INo
Date of last pumping: ate
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required!). Is copy attached? El 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 egtualI, any evidence of solids carryover, any
evidence of leakage into or out of box, etc,):
Equal distribution, no leakage, no solmds carryover.
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Commonwealth of Massachusetts
Title fficial Inspection Form
r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°a w. 4 Stanton Way
Property Address
Moody, K wesi
Owner Owner's Name
informregUtredoi�is No Andover MA 01845 08/0 �l�024
regcwtrw'�tt tw�r every _ _ _ _ _
page Oty/Town stat(l, Zip code Date of tln%pection
D. System Information (cons.)
10. Pump Chamber(locate on site plan)i.
Pumps in goring order El "yes F o*
Alarms in working order; 0 Yes El o*
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:
leaching galleries number;
leaching trenches number, length:
leaching fields number, dimensions:
overflow cesspool nlumber
zI innovativelalternatve system
Type/name of'technology rrviro ystema- ' Imes
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
l
dry
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Stanton Way
Property Address
Moody, Kwnresi
Owner
wner"s MJame
required for
No. Andover MA 011845 08/06/2024
required frar every _
page. Cityfrown State Zip Coale Date of tnspeotton
D. System Information (coat.)
11. Sail Absorption System (SAS) (cant.)
Comments(note condition of sail, signs of hydraulic failure„ level of pending, damp soil, condition of
vegetation, etc.):
No hydratalip 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.)-
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Commonwealth of Massachusetts
W
UE
�rNl a Subsurface Sewage Disposal System Form _Not for Voluntary Assessments
4 Stanton Way
Property Address
Moody, Kwesi
Owner Owner's Narne
infonraCron Hs
requared for every, o. Andover _ MA 018,415, 00' l? 4
page, City/Town state lip core Cute of Inspection
D. System Information (cons.)
13 Piriivy (locate on site plan'):
Materia9s of construction:
Dirnens�ons _
Depth of solids
Comments(note condition, of sail, suns of hydraulic failure, level of ponding, condition of vegetation,.
etc.):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
.. Subsurface Sewage Disposal System Forum - Not for Voluntary,assessments
' 64 Stanton Way.
,pry
Property Address
Moody, Kwesi
Owner Owner's Name
information is.
required for every No. Andover MA 01845 08l66/2024
page. City/Town State Zap Code Gate 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
the building. Check one of the boxes below:
Ej hand-sketch in the area below
Z drawing attached separately
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Commonwealth of Massachusetts
Title 5 Official Inspection Fora
� Subsurface Sewage Disposal sal System Form
-Not for Voluntary,Assessments
64 Stanton Way
Property Address
Moody, Kwesi
Owner Owner's Name
requr ata is No. Andover MA 0184 08/06/20 4
reyu�red for every _
Page Cutyl-rowni Stake Zip Cade Date of Inspection
D. System Information (cont,)
18. Site Exam:
Z Check Slope
0 Surface water
Z Check cellar
0 Shallow wells
Estimated depth to high ground water: <61
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: bate gl M�14
r�;�te
Observed site (abutting property/observation hole within 150 feet of SAS)
z Checked with loicail Board of Health -explain.
Pulled files
El Checked with local excavators, installers - (attach documentation)
Accessed US S database_ explain:
You must describe haw 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.
k 5snsp dac rezw.71;,°612018 T i91e 5 official Inspection Form Sutnurtace Sewage Dispas al Sy Morn-Page'17 W 18
............. ....... .... ..... ..... .... ... .... ....,. .... .... ,._..
Commonwealth of Massachusetts
Title 5 Official Inspection Form
lr', Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
� 64 Stanton Way
.h
Property Adldress
Moody, Kwesi
Owner owner's Name
required on is o, .Andover MA. 01845 08/06/2024
required for every
page. City/Town Mate Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this forma inclusive of:
E A. Inspector Information: Complete all fields in this section.
B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
, Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
D. System Information:
For& Tight/Holding Tank Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 16: E xpianation of estimated depth to high groundwater included
CSins;p doc°rev.7t2&201 S Title 5 Offi al Inaptrq.Clrrrs Form Subsurface Sewage Dispcsae 5y'men)-Page 18 or 18
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APPROXIMATE LOCATION OF p
UNDERGROUND UTILITIES
LCIT 16-3 DRIVEWAY NOT PAVED-
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AT THE'TIME OF THE
AS-BUILT SURVEY
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LIMITS Of PRESBY- C)RAINAGE � �
SYSTEM SAND1 EASEMENT A PROXIMATE
L)CATION CDF
11:i.8 TER SER ICE
APPROXIMATE
LOCAD N OF
ION --.—s 2 1 GAS SERVICE
. "� j 1 Cf0 GALLON
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1 "4 ti S�':PTIC TANK
,°PVC PIPE 22 f
;ESERVE , ,
(TYP.) "
AREA
TP —12� BENCHMAI D4 .W
TP 28 CUT SPIKE IN 12"OAK,
P'T 24 ,,. A
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ENVIRO-SEPTIC`PIPE: � 2 ,�ua SLAB. .�
6 LINES WITH 5 VENT'
SECTIONS dSGD`)PER LINE � FNCD` TOP FNCD.=95.97`
p
FNI).WSW! p
BASMENT
LOT 16-5