HomeMy WebLinkAboutPass - Title V Inspection Report - 60 BEAVER BROOK ROAD 9/6/2024 ; Commonwealth of Massachusetts
Title 5 Official Inspection Form
`I Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
50 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owner's Name
information ie No. Andover MA 01845 08/08/2024
required for every _
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 A
filling out forms . 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.
Company Address
Bradford MA 01835
City/Town State Zip Code
r,n 078-372-7471 S113386
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. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
08/08/2024
�ry
I pe or's Signature Date
The system inspe o shall 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 DEP. 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
-T, Title 5 Official Inspection Form
-m: Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owner's Name
information is required for every No. Andover MA 01845 08/08/2024
page. Qty/Town State Zip Cade Date of Inspection
__...._....._ ._.... ..... _._......._,__._._......_ _. __„ .,,..__W..._,....... ._.__ _.... , , ,,....,_,.. _ .._.w.._,,, ............._ ... _. _.__...._
C. Inspection Summary
Inspection Summary: Complete 1, 2„ 3, or 5 and all of 4 and 5.
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:
FI 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 yearn old is available.
El Y ❑ N [ ND (Explain below):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
�.... 50 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owner's Name
deformation is required for every No. Andover MA 01845 08/08/2024
page. City/Trown State Zip Code Date of Inspection
_........................_..._.._...................._........_.._._............................_._..._._._._..... _..... _.__.. _._...._..._._......_.__.- _.._ __.... _u.__..........._
C. Inspection Summary (cont.)
2) System Conditionally Passes (cant.):
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
F} 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 0 Y (Q N El ND (Explain below):
F� obstruction is removed F� Y M N ❑ ND (Explain below):
❑ distribution box is leveled or replaced 0 Y [1 N El 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):
El broken pipe(s) are replaced ❑ Y ❑ N F ND (Explain below):
Q obstruction is removed ❑ Y ❑ N F 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:
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Commonwealth of Massachusetts
h Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�v
>t x 60 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owner's Name
information is No. Andover MA 01845 08/08/2024
required for every _
page. CltyfTown State Zip Code Date of Inspection
...................._. .... .. .._...__..m._....__....___.._-.__...,.....__..........._.__.................._.__..___..__....___._.___._..__..__._ _.__.._....
C. Inspection Summary (cant.)
(l 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:
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.
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.
F 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 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
t5€nsp,docr•rev,712E'J2.018 Tithe 5 Official Inspection Form Subsurface Sewage D:sposal Systern•Page 4 of 18
" Commonwealth of Massachusetts
,ror Title 5 Official Inspection For
177�� Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
60 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owner's Marne
informrequired
is No Andover MA _ 01845 08/08/2024
required for every � _
page. City/'Town State Zip Code Date of inspection
__.._.._......._._,_e__.__..__.,___._._- ..._..._..
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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
El E 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.
❑ Z 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.
❑ 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.]
C-1 ED 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 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.
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 C.4.
Yes No
❑ [l the system is within 400 feet of a surface drinking water supply
❑ [l 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 11 of a public water supply well
tsinspa do,c-rev 'Afaf 204 8 Title 5 Official Inspw,,tion Form Subsurface;i ry ge DiiW osm System•F aWa 5 W 18
Commonwealth at Massachusetts
" Title 5 Official Inspection Form
4 Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
m 60 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owner's dame
requa required
is No, Andover MA 01845 08/08/2024
ret�ulred for every
page. City[Town state Zip Cade Date of Inspection
_.....__,_.. .,.,_.,__________....m.....m ........... ._ ..._..m_......._........ ......_..._,.
C. Inspection Summary (cent.)
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 systern 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-11 E Pumping Information was provided by the owner, occupant,. or Board of Health
El ..._ Were any of the system components pumped out in the previous two weeks?
11 Has the system received normal flows in the previous two week period"
El Z Have large volumes of water been introduced to the system recently or as part of
this inspection"
F11 El Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
0 Was the facility or dwelling inspected for signs of sewage back up?
Z 0 Was the site inspected for signs of break out`
E] Were all system components, excluding the SAS, located on situ
'] El 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 determuned based on:
Existing information. For example, a plan at the Board of Health.
Z F-1 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)]
eSfnsp elm i,ey 7/26120 1 8 "GNA 5 Offir l Nrruspeeton Fwm suhsurface Sewage Diqpr,we Systarn•Page 6 0� 18
r Commonwealth of Massachusetts
�, Ef Title 5 Official Inspection Form
a-.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Beaver Brook Goad
Property Address
Lombard, Vanessa
Owner Owner's Name
information is required for every No. Andover MA 01845 08/08/2024
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow 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.P.D.
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes Z No
Does residence have a water treatment unit? Yes No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection F1 Yes M No
information in this report.)
Laundry system inspected? ❑ Yes [:j No
Seasonal use? ❑ Yes M No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? F1 Yes R] No
Last date of occupancy: Occupied
Date
t"insp rice^i°aw 7126/2�018 Ttle 5 official Mpecticcr Form Subsurface Sewage Disposal System•Page of 18
Commonwealth of Massachusetts
Tide 5 Official Inspection Farm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
60 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owner's Flame
information is No. Andover MA 01845 08/08/2024
required for every _ _
page. Crtyffown State Zip Code Date of Inspection
__..._._....._..._................_........._.....__.........._.__...._....._w__._...--_..._.w_w_.........._..__.._... _.. ..____.......... ...............m........._.................._........ ..._.....
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.ff., etc.): _
Grease trap present"? El Yes No
Water treatment unit present? El Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? 0 Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? El Yes ❑ 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? ❑ Yes 0 No
If yes, volume pumped: gallons
Now was quantity pumped determined?
Reason for pumping:
f.5insp>.d=•rev.'U261201 8 1 t e 5 O fic;al Insptniion Fann Subsurface%, W ago€isposw systom.Page 8 of 18
Commonwealth of Massachusetts
-' Title 5 Official Inspection Farm
Ft'I
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` 60 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owner's Name
information is No. Andover MA 01845 08/08/2024
required for every _
page, Cl State Zip Code Gate of Inspection
_....._....._.........__..........................._._.............................................._..........___.........._.._.__.._..__......_......_......._._.........._._......._.........._...... -___._..._........_..._...__......._.._.__._..... ...._..
D. System Information (cant.)
4. Type of System:
® 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)
El 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
El Tight tank. Attach a copy of the DBP approval.
F1 Other(describe):
Approximate age of all components, date installed (if known)and source of information:
October, 1998
Were sewage odors detected when arriving at the site? ❑ Yes F No
5. Building Sewer(locate on site plan):
Depth below grade: 22
feet
Material of construction.
cast iron M 40 PVC 0 other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.71.2662 18 Tilie 5 Official Inspection Form Subsurface Sgwarga Disposal Systern•Page 9 of 18
Commonwealth of Massachusetts
w,a Tine 5 Official Inspection Form
�1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
60 Beaver Brook Road
Property Address. - - - -
Lombard, Vanessa
Owner Owner's Name _
information is No. Andover MA 01645 08/08/2024
required for every
page. City/Town Mate Zip Code Date of inspection
.............._,_._.......... ._......___ ___. ------_._-_
D. System Information (coat.)
6. Septic Tank (locate on site plan):
Depth below grade: feet
feet
Material of construction:
0 concrete ❑ metal C] fiberglass ❑) polyethylene El other(explain)
If tank is metal, list age: year_ _
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes 0 No
Dimensions: 5 X 10 X 4
3"
Sludge depth:
31
Distance from top of sludge to bottom of outlet tee or baffle _
Scum thickness 0
6"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 14"
Now 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.
l&nsp boc-rev M612016 'Title 5 Official Inspectmn Form:Subsurface Sewage DfszpasW System^Page 10 of 18
Commonwealth of Massachusetts
=1 . Title 5 Official ial Inspection Farm
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owners Name
Information is No Andover MA 01845 08/08/2024
required for every � _ __ ..
page. y.. _.._... .._ __........_ ._.. _.............................................._ ._.._.............
Cit /Town State Li Code Date of Inspection
D. System Information (cent.)
T Grease Trap (locate on site plan):
Depth below grade: feed
Material of construction:
El concrete ❑ metal n 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:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5ins p doe•rev 712612018 Tvttle 5 Of4n4mn,0 Inspection Form.Su bsroface Swwage Disposal System-Page 11 W8
Commonwealth of Massachusetts
Tide 5 Official Inspection Farm
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
p Y Y
�r
60 Beaver Brack Road
Property Address
Lombard, Vanessa
Owner Owner's Name
information is No. Andover MA 01845 08/08/2024
required for every _ _ _
page. City/Town State Zip code hate of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cant.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ 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.
tF"nsp.doc•rev.7f 612018 TlEVe 5 C7tiic at Inspection r(yrrt:Subsu,*ace Sewage Msposal System•Page 12 of 18
Commonwealth of Massachusetts
i` Title 5 Official Inspection Farm
V., Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owner's Name
informationeuirequired
is No. Andover MA 01845 08/08/2024
required for every
page. City/Town State Zip Code Date of Inspection
._.._...._....._..................................__.__..___._.._.._---------------- ___ __..._.._,_. _,_.,_....._.._..........._..._m.___._......._........,_........a._,_...,.._,__,_...._......................_....................
_._._...__._..
D. System Information (cant.)
10. Pump Chamber(locate on site plan):
Pumps in working order: El Yes [I No*
Alarms in working order: ❑ 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:
�] leaching galleries number:
Q leaching trenches number, length: 2 -541 x 4'W_
leaching fields number, dimensions:
❑ overflow cesspool number:
El innovative/alternative system
Type/name of technology:
tr„insp.doc•rev.7126/2018 Title 5 Official inspection Forrnr,SukSrrwfacn Sewage Disposal l Syste n+-Page 13 of 18
Commonwealth of Massachusetts
y Yetis 5 Office l Inspection Farm
P � d
'.
'1k Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
60 Seaver Brook Road
Property Address
Lombard, Vanessa
Owner Owner's Narne
information is mertOed for every No Andover MA 01645 08/08/2024
_ _
page, crtyrrown State Zip Cede rate of fnspeebon
_... _ . ._ ....... _ .._......
D. System Information (cant.)
11. Soil Absorption System (SAS) (coat.)
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.
1 . 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.):
v";vi srj r1ne.•va% 7.26Y,'"i„018 7W'0 5 Of'fbal kIsp ection F ivin Susswlac'e Sewage Disposal wyyTwn-Page 14 0118
. `� Commonwealth of Massachusetts
Title 5 Official Inspection Form
y Subsurface Sewage Disposal System Form
- Not for Voluntary Assessments
60 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owner's blame
informarequire fo is No. Andover MA 01845 08/08/2024
required for every _ _
page. City/Town State Zip Code Cate of Inspection
........._...._.w__. _._..._.._w.__.........._....._......w..............
D. System Information (cant.)
13. Priory (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
y � Title a Official Inspection Form
i Subsurface Sewage Disposal System Farm Not for Voluntary Assessments
� 50 Seaver Brook goad
Property Address
Lombard, Vanessa
Owner Owner's Narrte _
unrformatiar"r is
required for every No. Andover MA 01845 08/08/ 0 4
page, C ity/Town :Mate leg Code Date of Inspection
D. System Information (cant.)
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 eaters
the building. Check one of the boxes below:
hand-sketch In the area below
drawing attached separately
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DiS„'rraxsal 'nywVum Page V6 of IS
Commonwealth of Massachusetts
lhk6VpJffN �f�� ■
`C"1 1+� 5 Of dal Inspec t'AR
on Farm
Subsurface Sewage Disposal System Form -Not for VOluntary Assessments
f �
,.T 69 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owners Name
information os
required for every No Andover MA 01845 08/0 /2024
page. C�ityfTown State Lip Code Dane oif 6nspc�GtOrr
... ....._ _.a......._ _ _... _ __.,_... .............
D. System Information (coot.)
15. Site Exam:
, Check Tape
Surface water
Check cellar
Shallow wells
Estimated depth to high ground water: No water at 90
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: Date ..f1994 08/ 5/1994
Date
EJ Observed site (abutting property/observation hole within 150 feet of SAS)
z Checked with local Board of Health -explain:
Pulled file
El 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 on next page.
I",nsp doc°paw 712M"a'?02 8 Nis s 5 Offical VrRpecMion P of imp Sakmwface Sewage Dis„'rss+tiW System,Page 17 cal IS
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form _Not for Voluntary Assessments
66 Beaver Brook Road
Property Address
Lombard, Vanessa
Owner Owners Name _
required or'6 is No Andover MA 01845 08/08/2024
required for every _
page, ityf f'owrl States Zip Code Date of hi pectiorr
_,...... ... __._-------- ...__.._ .........w. _ ._......... _._____.--__._.._...__._.. ...... _ _...... .... ... ... ._......._ .... .. ..... .....
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 & Dated and 1, 2, 3„ or checked
C. Inspection Summary:
1, 2, 3„ or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
f D, System Information:
For 6: Tight/Holding "dank_..Dumping contract attached
For 14: Sketch of Sewage Disposal Systern drawn on pg. 16 or attached
For, 15: Explanation of estimated depth to high groundwater included
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