HomeMy WebLinkAboutPASS - Title V Inspection Report - 285 RALEIGH TAVERN LANE 6/11/2025 0
Tu't,le 5 ffnicui'al Inspect,nion Form
u s irf a ew ge Disposal st Fore � �
s ssm is
m
, 2,85 R LEIGH TAVERN LAN
Property Address
KELLY PARKS SULLIVAN,
n r 6�er's Naas
information is
requi�red for every
CIt ffow n 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 lend t e fora.
lrntA. Information
filling out forms
on the computer, odd James teson
use it the tad .. _mwmm
key to move your Name of Inspector
cursor-do not Bates,on Enterprises Inc.
use the return Company,Name
l Ar u:Ila Road
ho Company r
Andover MA 01810
City/Town State, Zip C ' ,
NumberTelephone License Number
B. Clertif 10caltion
I certify that, 1 a DEP approved system lens t r In u]l compliance with Section 15.340 of Title
(310 CMR 1 . ; l e personally inspected the sewage disposal system at the property address,
listed' above; the information reported 'below is true accurate an � lit � � �� of my
inspection, and the inspection,was performed based on my training and experience in the proper function
and maintenance of on-silte sewage disposal systems., After conducting. this inspection I have determined
at the system,
1. Passes
2. EJ Conditionally Passes
3� Needs Further Evaluation by the Local Approving Authority
4. E] Fails
ns Date,
The system inspector shall submit a copy of this inspection report to,the ppr i u Authority (Board
Health or Ewithin 30 days of completingthis inspection, If'the system has a design flow of
101000 p r greeter,, the, inspector and the system owner shall submilt the report to the appropriate
regional office of the DE,P. Thy original form should be seat to the system owner and copies sent t
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 ghat dime. This inspection does not address how the system will perform
In the future under the same or different,conditions of use.
Mn p. o .rev.7/2-612018 Title 5+ ffo i l inspection Fora-Subsurface Sewage Di p l System Page I of 18,
'Coommionwealth of Massachusetts
Title, 5 Official Inspection Form
4. Subsurface Sewage DiisposaI System Form Not,for Voluntary Assess eats,
mm 285, RALEIGHTAVERN LADE
Property Address
KELLY PARKS SULLIVAN
Owner Owner's,Nees
informationis
required for eves
Page. fit lT wn state Zip Code 'Date out Inspection
C., Inspection
Inspection Summary-, Complete 1, 21 3, or 5 and all of 4 and 6.
System Passes 1
I have, not found any information which ire mates that any of the failure criteria described
in 310 CUIR 15.303 or in 310 CMR 153104 ist, Any fallurecriteria nit evaluated are
indicated below.
Comments-,
PERMIT OAR HEALTH
INSTALL NEW D-BOX AND RISER
2 System Conditionally Passes:
�El one or more,system components as described in the "Conditional', Passe section reed 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 �� �� r`not determined" (Y, N, N� for the following statements. If not
determined," please explain.
The septic tank is metal and' over 20,years,old* or the septic tausk (whether metal or nit) is structurally
ns nd, exhibits substantial infiltration or exfIltratilon or tank failure is imminent. System will pass
inspection it the existing tank is replaced with, a complying, septic tank as approved by the hoard of
Health.
metal septic tank will pass inspection if it is,structurally sound, not Ileaking and it a Certificate of
Compliance indicating, that the teak is less than 20 years old is available.
D
N Ej ND (Explainbelow):
t ire , . -rev.7126,12018 Title 5 Official InspectionForm:Subsurface Sewage Disposal Systeni-Page 2 of 1
MassachusettsCommonwealth of
TI"t1e, 5
Official Inspectsion
Subsurface Sewage'Disposal System Form Not forV Assessments
285 RALEIGHTAVERN LAN
Property Address,
LY PARKS SULLIVAN
Owner Owner's Name
information is
required r "�" A_ 01,845 MAY Id s 2025
page'„ Cli wn state Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage lSystem*
Provide a view of the,sewage disposal system, Including ties, least two permanent reference
lan,dmarks or benchmarks. Locate all wells within feet. Locate where public water supply eaters
the ilia. . Check one o boxes below;
hi and-sketch In the area below
El drawing attached separately
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t5insp,ldoc rev,7126018 Tille,5 offioal Inspection Form:x9ubsuiface,99wage Dilsposel.System-pagg,I e 011