HomeMy WebLinkAboutPASS - Title V Inspection Report - 191 JOHNNY CAKE STREET 4/9/2025 Commonwealth ofMassachusetts
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I ton Formi
T'tle 5 Off" 1, I J� spect"
Subsurface Sewage Disposal Systern Form Not,for Voluntary Assessments
191 n C Joh
............. .................................. .................................. ........................ ........................................................................ .................. .................. ............... -------
Property Address,
McGinnis, Tom.
...............
Owner Owner's Name,
information is No. Andover MA 01845 04/09/2025
required'for every ..............
page. City/Town State Zip Code at of Inspection
inspection results must,be submitted on this,form. Inspection forms may not, be, altered win any
way. Please see completeness checklist.at,the end of the form.
Important:When A,. Inspector, Information, npNodh Andover,
It fOTMS ow , of
on the computer, John L, incenzo
useonly thie tab ................-',............ ............................................ ..................................................................-.................... .......... ........................ ............. ...........-,......
key to,rove your Name of Inspector
�cursor-do not J &S Development/Stewart's'Septic Service MAY 19 2025
usethe return .................................................................................. ..................... .........................................................................................................................................................................................................................................................................................................................................__',.............--"-.........................................__,'____,_,...........................................
key. Company Name
58 So. Kimball St. t
Company Address ii-eafth-Depattmen
Bradford MA 01835
City/Town State Zip Code
978-372-7471 S113386
... ...................................................................................................................................................................
Telephone Number 'License Number
B. Certification
I certify,that". I am a DEP approved system inspector in full compliance with Section 115.340 of Title 5
(310 CIVIR 15.0100); 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
inspectiow 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, 1, have determined
that.the system"
1. Passes
2. Conditionally Passes
I F1 Needs Further Evaluation by the Local Approving Aluthority
4�. E] Fail,
Lj ai,
04/09/2025
�t�_
........................
IC pector's Signature Date
The system inspector all 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 s,ign flow of
101000 gpd or greater, the inspector and thie,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
a
in the future under,the same or different conditions, of use.
t5insp.doc rev.7/26/2,018 Title 5,Official Inspection Form Si)bsurface Sewage Disposal System-Page 1 of 18
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Commonwealth � c etas
It,le 5 O,ff" I InspecIt" Form
icia ion
,..�
,.� Subsurface Sewage Disposal Sy emForm Not for Voluntary Assessments
9 ' � Cake Str �t
_. rz. . ...... ....... __ _ __ -...,,, .... _... ._................ _...... �._�_.._ _ ......._ .. _ _ _ ........_w.._..,..
Property Address
McGirr is, om
I. .... ,, _......
OwnerOwner's Name
information is N . An r
required for every I.,,. ,"" � � ��
"age® City[Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary- Complete 1, 21 3, or 5 and all of 4 and6&
1) System asses:
1 have not found any information which, indicates that any of the failure criteria described
�in 310 CMR 15.303, r in 310 CMR5,,3 xist. Any failurecriteria not,evialuated are
indicated below,
Comments*
replaced distribution boy
2), SyS eM Conditionally Passes:
E:1 One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired'. Tie system, upon completion the, r l r rat or repair, as appir y
the ardi of Health, will pass.
Check the box for"yes", "no" r"not eterr inn "' , N, N for the following statements. I "not
deterrnined,,at Please explain.
The,septic tank is metal arid' over 20 years old* or the septic tank (whether metal or riot) is structurally
unsound, exhibits substantial infiltration or exfIltration or tank failure is im inn:nt. System will pass
inspection if the existing t n is replaced with a complying, septic tank as approved' by the +o r
Health.
* A.metal' septic tank will pass inspection if it is structurally sound, not leaking n 'if a Certificate t'
Compliance indicating 't Alt the tank is, 1ess than 20 years old is available.
F] Y l! I (Explain below):
1 in,p. o rev.7'126)2018 Title 5 Official Inspection Fon" l Subsurface Sewage Dis1posall System-Page f 1