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Home My WebLink AboutConditional Pass - Title V Inspection Report - 191 JOHNNY CAKE STREET 4/9/2025 uommonweafth of Massachusetts a 'It1e, 5 officia Inspecti"on Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 191 Johnny Cake Street ........... ................................................................... .................................. ................. ....... ................... Property Address McGinnis, Tom .......... ............... ...................... .......................... ..................... ......... r. Owner Owner's Name information is N . Andover MA 0,1845 O�4/01/20,215 ,required for every 1111111-__...................................... 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. A n\j lmportant When 0"11 rNVIV filling out f O'm A. Inspector Information 01 s on the computer, J�ohn L. DI'Vincenzo use only the tab ............................. ........... key to move your Name of Inspector cursor-ado not, J & S D eve I opm e nit/Stew art's...,Se.p,t,,ic,,_Se,ry ice use the return Company Name ................................ ............... .......... key., 5,8 So. Kim.. ball .St ent .................. ..............---------------------- _De03dM Company Address, Bradford MA 01835 .......-—----------.......... ... ........ . ........................ Cityfrown State Zip Code 978-372-7471............ ...............Telephone Number License Number B. Certification I certify that: I any a DEP approved system inspector 'in full compliance with Section 15.340 of Title 5 (310 CI 'II 15.000); 1 have personally, inspected the sewage disposal system at,the property address listed above-, the information reported' bellowl's true, accurate and complete as of the time of my inspection; an the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system,* 1. Passes 2. Conditionally Passes 3. El Needs Further Evaluation by the Local Approving Authority 4. El Fails ............... .......... ................. In I ector's Signa, re Da,te, The system 'Inspector shall submit a copy of this inspection report to,the Approving Authority (Board of Health or DE P) within: 30 days of completing this inspection. If the system has a design flow of 11010010 gpid 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 ad,d're,ss how the system will perform in the future under the same or different conditions of use. t51nsp.doc rev,7/26/2018 Title 5 Official Inspection Form-Subsurface Sewage Disposal system-Page I of 18 suummonwealth of Massachusetts A T le 5, Of'" I Inspect,"ion ti,cia �For�m Subsurface Sewage Disposal System Form Not for Voluntary Assessments w191, Johnn Cake Street d. Property Address Owner Owner's Name information is r MA 01845 04/01/2025 required'for eves . page, CityfTown State Zip Code Date f Inspection C. Inspection summary Inspection Summary: Complete 1 2$ 3,, or 51 and all of 4 and 6. 1) System aas, ;a I have not found any information which indicates that any of the failure criteria described i n 3101 C M R 1,5.3 03 or in 310 C M R 15.3 04 exist: Any faiIu re criteria riot e a lu ated are indicated below. Comments- 2), System ConditioniaRy Passes: [Z 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 r repair, as approved, by the Board Health, will pass. Check the, box for it s,, "no" r"not determined" , I , N for the,following statements. If Itnot determined,Ip please explain. The septic tank is metal and over 20, years old* or the septic tank her metal or not) is structurally unsound, exhibits substantial ntial infiltration or exfiltration or tangy faillure is imminent. System will pass inspection if the existing teak is replaced with a complying septic tank s approved the Board of Health. A instal, septic tank rill pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that thetank is less than 20 years old is available. N (Explain below); t5i s . ww .rep,712612018 Title 5 Official Inspection Perm"Subsurfaceevivage Disposal System-Page 1 Commonwealth of Massachusetts 07P '10 tl,e 5 O�ff i" c'iaal Ins ect'inon Form . .w Subsurface Sewage Disposal System Form Not for Voluntary Assessments wi 191 .J•4 she•• %'"!MN �.v...�._.._.®...m..Johnny ....q� Steet _...®._...�.._..._...__.._..__._._ .. ......................... .... Property Address McGinnis, _ _ .......... .,,.,.....�., __ „,.m,.. ..... �.,..,.... ,,,...... �....�,. ..,,.� ..�......... .................. . .............. ...................................... Owner Owner" m information is 025 required for even ....... y� .. _ _. ._.__ mrm ... page, City/Town State Zip Code Date of Inspection C. Inspection Summary (cent.) System Conditionally Passes (cont.),: E] Pump Chamber pumps/alarms, not operational. Sys Systern will pass with Board of Health approval i pumps/alarms,are repaired. El Observation sewage backup or break out or high static water level in the, istri uti a box due to broken r str cte l i s) or due to,a broken,ken, settled or uneven distribution box. System will pass inspection it(with ap�proval of BoardHealt,h)- Ej broken pi s are replaced D ('Explain below): obstruction is removed Ifs 0 ND (Explain below): w distribution box is leveled or replaced i (Explain below): fox needs replacing due to,corrosion around the outlet inverts El The system required um in more than 4 times s i year dui to broken or obstructed 'i e ,y The system will pass inspection it with ap�proval of the Board of Health),., room pi es are replaced, F1 Y El N R, ND (Explain below)- obstruction is remove l (,Explainbelow), 3) Further Evaluation 'is Required by the Board of Healt'h-:.i Con iti ns exist whi�E] c require urthier evaluation the Board of Health in order to determine, the system is failing to protect public e l't a safety or the en it numentw a. System ill pass unless Board of Health determines In accordance with 3 .3 3(1)(b)tat the system is not functioning Nun manner which will protect public health,, safety and the environment: r inu p,do -rev.712612018 title 5 Official Inspection Form,Subsurface Sewage Disposal System t Page 3 of 1 uommonwealth of Massachusetts, TI'tle 5 0,ffimctal lrispect,ion Form ...m .: Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1191 JohnnyCa....... .ke.........................Street ........................................ ......... ................................... Property Address, McGinnis, 'Tom Owner Owner's Name information is . Andover 5 !'1 25 required for eves _,w._. ,- ,-,,.___. m �.. .....F _.. .. page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cmt) [:1 Cesspool,or privy is within 50 feet of a surface waiter El Cesspool r privy is within 50 taut of a bordering vegetated wetland or a salt mars' . System will tail unless, the Dare of Health (and, Public Water Supplier, it any) determin that tl system is �r ttiig in a mianner,that protects the public health, safety and environments. El The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply ortributary 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 hias a septic tank and SAS and the SAS is within 50 feet ofa private water supply well. The system as 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 determinedistance" This system passes i 'tl e well water r l sis, 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 51 ppm, provided that no other failure criteria,are triggered. A copy of the analysis must be attached to this form s c. Other, 4) System Failure Criteria Applicable to All Systems: You last indicate "Yes" or"No" to each of the following for all inspections: Yes No Backup of sewage into facility or system component dule to overloaded or cloggedSAS or cesspool Discharge or ponding of effluent to,the surface of the ground oir surface waiters dine to overloaded or cloggled SAS or cesspool t5insp.dot rev.7/26120118 Title,5,Official Inspection Form,Subsufface Sew g,e Disposal system-Page 4 of 1 kNCommonwealth Tal'tie 5 Off'ioc"ial Inspection Form r W� Subsurface Sewage Disposal System Form - Voluntary Assessments 91 Johan Cake Street Property Address McGinnis, Tom ... ................ wM _..... . , ............_..._... wner ' _ _. Owner arne information is, No., Andover MA 01845 04/01/2025 page. Cit n State Zip Code Gate of Inspection C. Inspection Summary (cont.) 1 System Failure Criteria Applicable to AllSystems: (cont.) Yes, No Static liquid level in the distribution box above,outlet invert due to an overloaded r clogged SAS or cesspool E] 0 Liquid depth, in cesspool is less than 6" below invert,or availabille volume, is less, than %day flow EJ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed ip . Number of tires pumped* Ell M Any plort,ion of the SAS, cesspool or privy is below h i h ground water elevation. El N Any portion f cesspool or privy is within 1 feet of a surface water supply or tributary to a surface water supply. 1:1 N Any portion of a cesspool or privy is within a Zone 1 of a public water supply ,well,, [j Z And portion of a cesspool or privy is within 50 feet private water supply well. 1:1 z Any portion of a cesspool or privy is less than 1 feet but greater than 50 feet from a private water supply well with no,acceptable water quality analysis. [This system passes if the gall water analysis, performed at a DEPcertified laboratory, ar fecal coliform bacteria indicates seat,and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 51 ppm, provided that no other failure criteria are triggered. A copy of theanalysis and chain of custody, must be attar ad to this form.] The system is a cesspool serving a, facility with a design flow of 2000 gpd, 101000 '. 0 The system fails. l have deteirm�ined that one or more of the above failure criteria, exist as described in, 310 CM,R 15.303, therefore the system fails. The system owner should contact the Board Health, to determinle what"will be necessary to correct the failure. 6 rge Systems,., To considered a large system the system must,serve a facility with For large systems, you react indicate either"yes" r"no," to each of the following, in addition to the Yes No El El the syste 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 sensiti ar (Interim Wellhead Protection Area—l' r a ' Zone 11 of a public ter supply well t5insp,doic rev.71 / 1 Title 5 Official,Inspection Firm:Subsurface Sewage Disposal System-Page 5 of 1 c lofMassachusetts u -�"tie 5. . officiaI Inspection Form Subsurface Sewage D121sposal System Form of for Voluntary Assessments ®. i reef .... ................._ _____.............. .......... Property McGinnis, Tom Owner _ „„.,.... __n_.. ........... .......... Owner's Name information,is * Andover A 5 2 25. required for err . page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont) If you have answered fIyes" to anyquestion in Section C.5 the system is considered a significant neat, or answered "eyes"' to any question in Section CA above the large system has failed* Tine owner or operator of any lail system considered a significant threat under Section CM.5 or failed under Section CA shall upgrade,the s st rn in accordance with 310 CMR 15.304. The, system owner should contact the appropriate regional office,of the Department. . You must* n kilt �"yes" r"no," 'r each thefollowing o �� Inspections: Yes No 9 0 npirng information was providedby thile owner, ccuparnt; or Board of Health El M Were any of the system components pumped out in, the r i ms two weeks? 0 El Has the system received normal al 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 plains of the system obtained and xamirn if they were not available mote as N/A) s the facility or dwelling inspected for signs,of sewage black,up? Was the site inspected for sibs of break out Were all system components,, excluding the SAS, located n: site? 0 El ere tine septic tank rn un covere ', opened, and the interior of the tank inspected for the n iti rn of the baffles or ties, material of construction, imensi �,, depth ►f liquid,rn tin of sludge and e t n of scum Was the facility,owner(and occupants if'different from owner) with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the wail Absorption System (SAS) on the site has been determined based on: Existing information. For xam l , a plan t the Board of Health. Determined in the field if any f the failure r t ri a related to Fart C is at issue approximation f dlistance is unacceptable),l 1 t5insp.doc#rev.7/26120,18 Vitus 5 Official Inspection Fora subsurface e Disposal System M Page 6 of 1 Commonwealth Massachusetts _ Inspection Subsurface Sewage Disposal s System orm Not folfVoluntary Assessments 91 Joh�nny Cake Street Proplertly,Address McGinnis, Tom Owner ......... Owner's Darns information is requir for every � W Andover 1 � �� ... ..............._ page City/Town State, Zip Code Date of Inspect,ioln D. System, Information 1., Residential Flow Conditions: Number of bedrooms (design)* Number bedrooms actual), _r� .... _............. DES G N flow based on 3 10 C M R 15- 3 (for exam wl - 110 g pd x#of bedrooms) Description- Number of current residents* _ _..w_._...._.. ,. ,.... Dues residence have a garbage grinder.? ] "des F] No Does residence have a water treatment nit'? Ej Yes i No If yes, discharges to, laundry on a separate sewage system? Inclo�! e, laundry system inspection information in this report.) Laundry system inspected? El Yes Ej No, Se son l use? Yes N Water aster readings! if available (last 2 years usage ' ' � _ __._... Detail,: Sump ? Yes N Last date of occupancy Occuied - ...._ .. Cate t5insp.doc rev.7126/2018 Mitre 5 Officiat Inspection Form,,,Subsurface Sewage Disposal System w Page 7 of 1 Commonwealthe a� 'i' le 5 a, �w 0!ff"ic'i,a1, Inspect,'imon Form r - Subsurface Sewn li sposall System Form Not for Vol u nitary,ASSressments 191 Cake Street . "..__.. Property Address O�wl" c innis, Tom . ....... _.......... _._ ... ,.. ... w.. .._.............. _ i t w n r' Naas n rr i t N .. n r ��1'802 required for every ........_._._....� m_...._..M�.,..,. �, .... ..............._._. page. Cit own State Zip Code mate of Inspection D. System Information (cola. 2. Commercial/Industrial Flow n1lons Type of Establishment, ........ ,F _.........._............._. Design flow(based ors 310 C M R 15. 3): .... ...... Gallons per day Basis,of design flow, seas ersons/s . t.1 etc.): _ .,., M. Grease,trip present? El Yes [:1 No Water treatment ni present',?� Yes Ej No If yes, discharges, to* . .. ............_ Industrial,waste holding,�tank present? s 0 No Nion-sanitary,waste discharged to theTitle 5 system? El Yes [:1 No Water meter readings,, if available'. __.._.... ................... Last date of occupancy/use: Othie�r(describebelow)". 3. Pumping Records: Las ; 2 2 2 Source information: _.. ._............._........ s system pumped as part of the inspection Yes N . If yes volume pumped: __._..Ym.—___.... _... . M m... gallons How was ant,it pumpeddetermined? ................................................ Sid -.a.u.� a n truck Reason for pumping: -1 . m:k _._........_ _....„ ..... t5insp.doc rev.712,6/2,018 Tillef'fi i l Inspection Form,Subsurface SewageDisposal Systern-Page 8 of 1 Puommonwealth of Massachusefts TwItle 5 Off'i*cmial, in t'O Form nspec ion imn r ., U s rf ce Sewage Disposal Syste�m Form Not for Voluntary ntar ssess ents r � 4 Property Address cGli nis, Tom -—------------- ..................................... ..........._............ ..... ....._.._ Owner Owner"s Name, information isN .. Andover A �18 5 2 5 required for even _...a,.. . _- .,.... _ .__., .-. _ _.. page. duty/Town State Zip Code Cate ofinspection D. System Information ( . System: Septic tank, istri ti box, soil absorption system Slagle cesspool, Overflow cesspool Privy tired system; (yes or n It yes, attach ,previous inspection records,, if tiny) �El Innovative/Alternative technology. Attach a copy of the current operation and maintenance e contract(to be obtained from system,owner) and a copy of latest inspection of the l A system by system operator under contract El Tight tank. Attach a copy of the, DEP approval. El Other(describe). Approximate age of'all complonents, date installle it known) and source of information: >30 years Were sewage odors detected when arriving at the site? Yes No 5. Building Sewer(locate n site plan):: 211 'Depth below grade. __ _ . Material of construction: east iron PVC El other(explain) _ ____._......___._..___ istance from private water supply well or suction line: . ..,,........ Comments n condition of'joints, venting, evidence lea agep te, t nsp -rev,N ,o"2018 Title 6 Orfi t l Inspection Forte;Subsurface Sewa,ga Disposal Sys,tem w Page 19 of 18 Commonwealth Massachusetts e T"Itle 5 Off,licial Inspect,i"on F�orm Subsurface Sewage Disposal System Form Not for Voluntary Assessments -1.9 n Cl,allke-S�tre,�e�t��-11,�-11'.11.��-'-"-'-"""-"----�.�. Property Address McGinnis,, Tom _...... " 'rile ....._._ ......._ ............. wrier° Name information is No. Andover 5 2025 required for every ......... ............... �. page Cityffown State dip Code Date of Inspection D. System Information (co nt 6. Septic,Tank (loots on ;site plea): Depth below graide, feet Material of construction: El concrete metal El, fiberglass El polyethylene E:1 other(,explain) If tank is,metal, list age: ears s age confirmed by a Certificate of Compliance? (attach a copy of cert� cate) E] Yes N 5,XX Dimensions, ....................._ 2tt Disitancle from top,of sludge, to bottom of outlet tee or baffle .......... .. ... Scum thickness _01 __ Distance from top,of scuim to,top of outlet tee or baffle Distancer r bottom of scum to bottorn of outlet tee or,battle 1414 How were dimensions determ�ined 'Tape, mleasure/sludge judge Comments pumping recommendations I inlet and outlet tee or baffle condition, structural Integrity, liquid levels as, related to outlet invert, evidence of 1 aka , etc. : Both baffles are ire shy ...........N leakage, liquid 'level i� d. t6hsp.doc rev.7/261/2W 'Title 5 Official Inspection Fora,Subsurface Sewage Di 1,System mega 10 of 1 Commonwealth ofMasIc etas Title 5 Official� lnspect,ion, Fiorm� w M Subs ac w w w l e _ N t for Voluntary Assessments, � a. 19 hnn Cake Street m� _ �.__..._._. Property Address McGinnis, Tom OwnerOwner's Name [Information N . Andover 15 25 required for every _,,,, __..__ —._ _....__ .......... _.... __..�.,, page„ City/Town, State Zip Code 'Date of Inspection D. System Information (cont.), . Grease Trap, (locate on site plan). Depth below grade: .. ................_m..... Material of construction.: El concrete instal El fiberglass [:1 polyethylene �E' other er(explain): Dimensions* Scum thickness __._............ ....................... Distance from told scum to top of outlet tee or batty °............m_.............._. Distance n From 'bottom of scum to bottom of outlet tee or bafflem.. _.-__m.µ_,.. _.__....._ .. .. C r menu (on pumping recommendations, inlet and outlet tee or,baffle condition', structural integrity, liquid liquild levels as related to outlet invert, evildencle of leafage,, etc,.) 8. Tight or HoldingTank (tarok must be pumped at time of ins ecti n) (locate on site Ilea Depth below grades , M�.� ..m ._.rv.. m.._. ,...,, , Material of construction: 0 concrete EJ metal E] fiberglass [:1 polyethylene E:1 other(explain): ,.—.... .,...........w . ....n .. ..H. .. gallons per day t in .do .rev.712612,018 Title ff i t Inspection Fofm"Subsufface Sewage Disposal System-Page 11 of 18 'aWCommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not fog V I r t it ssessments 91 ' q Street _ _ _.. ........_._._.......__..._._.w___..____. Property Address McGinnis, ,.,. ,., ... .,.w, ... ., ....� ,,....... ,,,,,,,,,,,,, ,,,,,,,,, �w... „....... .. „.,ry . .r� �....... .�.,,,....,. Owner nere ll Name information is page. on D. System Information (cont.) W Tight or Holding Tank (coat.) Alarm present'. El "des D 1 � ,Alarm level. _. .._... ............................_m....... . rm in working r rm El Yes l Date list pumping", Date Comments condition ofalarm and float switches, etc.). ,Attach copy of current plumping contract(required),. Is copy attached? Yes E] N 9. Distriblution 'Box i'present must be opened) (locate on site plea). Depth of liquid level above outlet inert Comments,(mote if box is level and clistribution to,outlets squab, any evidence of solids carryover, any evidence of leakage into it out f box, eta.): Box need's r� lac r� ._ t l� l � e around the outlet inverts. No,solid's carryover. t i'ns,p.do rev. 1' 1 01 'Title 5 Official Inspection Form:SubSUrface Sewage Disposal Systern-Page 12 of'18 uommonwealthi of Massachusetts 'T'Itle !'$ Off"ic"ial Inspection Form Sul,bisurface Sewage Disposal System Form Not for V l nt r Assessments 191 John Cake Street Property Address McGinnis, Tom Owner lnrws e information is, required for even MA 01845 � �� page. Inspection D. System Inflormatillon, 11 " dump Chamber,(locate on, site plea): Pumps in working order: Ej Yes, E] No* Alarms in working order, El Yes El N Gets (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. 1. So,11 Absorption System, (SAS) (locate on site plea, excavation not required), If SAS not located, explain why;. Type: leaching pets number,: .__.......__.._ E] leaching n tubers n berg 1'eaching galleries number* leaching 'trenches number, length: _. ................__...........__...... leaching fields, number,, dimensions: _.._... El overflow cesspool number: 0 El innovat / l ernati system Type/name ftechnology* ., f 5 j ns p.doc.re v.M61,12,018 Title 5 Official inspection Form:Subsurface Sewage l o al System w Page 13 of 18 kpommonwealt,h of Massachusetts "I'll T* orm 'Tlot,le 50mm Off'i'lc"ial 1n,spec!t'i2o,n �r, Suibsurface Sewage Disposall System Form Not r Voluntary Assessments 19 Johnny Cake Street _ ..w_ ....__.. ....... Property Address 'McGinnis, Tom Owner ............_____...... ....... ...... ............ ....................................................... ................... . ............................. ......... Owner's . . Name information is r � it � �r even + ! 2025 page. Ci tyff own State Zap Code Date of Inspection Di. System Information (c . 111. Soil Absorptilon System (SAS) (coat.) Comments note condition of soil, signs of hydraulic failure, Nagai of ponding, damp soil, condition vegetation, etc.),: No p Min no,,damp siolls, no hy rquIlic failure,,, 2. Cesspools c ss li must pumped as part of ins,pectilon (locate on site plan): Depth—top ofliquid toinlet invert _ � . Depth ofsolidslayer Depth ofs,curnlayer _...m ... Dimensions of cesspool Materials of construction Indication of groundwater inflow Yes 0 No Cornments (mote condition, of soil, sligns, r uiic falilure, level of ponding, condition vegetation, etc.),- . ffiinsp.doc►rev,71 6/ 018 'Titte 5 Official Inspection Forte,Subsurface Sewage Displosal System-Page 14 of 1 %,ommonweatth of Massachusetts It icia ion Form� T"'"' le 5 Off'� I I ns pect" Subsurface Sewage Disposal System Form Not for Vol untaryAssessments, 191 Jqh n; ake Street ...........Property address McGinnis, T.11-11,...........................................-""............om ......... .......................... Owner Owner's Name information is MA 01 4/01/2025 required for+��rr _._ page City/Town State dip bode Date f Inspection D . System Information (cont) 13. Privy (locate on site l n)w Materials of construction. _ _..w_ _._..... ... ... _......._.., Dimensions .______ ._- Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation,, etc, 15insp,doc rev.7/2612,018 Title! ffi as inspection Form;Subsurface Sewage Disposal System w Page 15 of 1 Commonwealth of Massachusetts, T'tie 5 Off" I Inspect"ocia ion Form Subsufface Sewage Disposall System Form Not for'Voluntary,Assn ants 191 Jo,hnn Cake Street, ............ Property Address McGinnis, Tom Owner Owner's Name, Information is No. Andover MA 01845 01/15/2026 required or elvery Page. City/Town State Zip Gode Date of Inspection D. System Information (cont.), 14. Sketch Of Sewage Disposal System: Provide a view,of the sewage disposal system, including tiles to at least two, permanent reference landmarks or benchmarks,, Locate all wells within 1100 feet., Locate where public water supply enters the building. Check one,of the boxes below: 0/1 and-sketc1 in the area below drawing attached separately, ve 1 AV V4 on Ith, t6insp.doic-rev.7/26/2018 Tifle 5 Offidal Inspection Form,Subsurface Sewage Disposal System Page 16 of 18 uommonwealth MM6 T"t,le 5 Offizial Inspect"ion �Subsurfa,ce Sewage Disposal System Forte Not for Voluntary Assessments 19 l ru Cake Street ... ..,,,.., ..._.m_ __...... Property Address Glaris, Tom Owner ........ .............. ......................................... ............... ............................. ..................... m. Owner" Name , information!is required for every __a.._.. page. �City/Town State Zip Code Date of Inspection D. System Information c . . SiteExam" Check Slope El Surface water 9 Check cellar El Shallow wells Estimated depths to high ground water: ....... t' t Please indicate all methods used to determine the high ground water elevationu Obtallned from system design plans on record If chiecked, date of design plea re lewe Date n... ,....... _ . m.. __ .... Observed site (abutting property/observation bole within 1 50 feet of SAS) Checked ed with local Board of Health - ex laim Pulled file Checked with local excavators, installer - attaich documentation Accessed USGS database -explain: You east,describe how you established the high ground water elevation: .No.pump In basement. Bottom et lout is _approximately 3 above the basement floor. � P l re filling this 1rispection Report,, please see Repot Completeness Cht,cklist on next page. t5insp. -riev.7126/2018 Tide 5 Official Inspection Form:Subsurface rf wage Disposal System,Page 17 o f"1' Commonwealth of Massachusetts W Title 5 Off'icial Inspection Form 0 Sub -n surface Sewage 131fists al System Form Not for Voluntary Assessi ents . ............... 191 Johnny Cake,Street .....................___....... ... ... ................................................... ............... ............................................................... .................... ............. Property Address OwnerMcGinnis, Tom, .................... ......... ............................... ...... ... Owner's Name information,is No. Andover MA 01845 014/0 1/210 2 5 reqUired'for every ....... ............................. page. CityfTown State Zip,Code Date of inspection E. Report Complete h li'list Complete all applicable sections of this form inclusive of-, A. Inspector Information,: Complete all fields in this section. B. Certification* Signed & Dated and 1� 21? 3, or 4 checked C, inspection Summary, 1, 21, 3, or 5 completed as appropriate ,4 ail Sri ri I ) and 6 (Checklist) completed(Fe tea D. System Information: For 8- Ti ling Tank— Pumping contract attached, For 11 Sketch of Sewage Disposal System id rawn on pig 116 or attached For 15, Explanation of estimated depth to high groundwater included t5insp.doc rev.'712612018 Title 5 Official Inspection Form-Subsurface Sewage Disposal System-Paige 18 of 18