HomeMy WebLinkAboutPASS - Title V Inspection Report - 80 CHRISTIAN WAY 6/5/2025 Commonwealth of Massachusetts, TovIn 0j Ndh Andover
IF I I " I Inspect"ion Form
T'"tle 5 Offoi'cia
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
JUN 0 Z025
80 Christian Way
Property Address alth iDepaiiment
Tait, Brad Imr
Owner Owner's Name
information is
required for every No. Andover _MA 01845 0 /05/2025
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. Inspector Information
filling out forms,
on the computer, John L. Di Vincenzo
use only the tab
key to move your Name of Inspector
cursor-do not _J & S DevelopM_��nt/Ste�Karf s S
use the return Company Name
key.
518 So. Kimball St.
..................
tab Company Address
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 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal' system at the property address
listed abo\je*, 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. Passes
2. Conditionally Passes
3. Needs Further Evaluation by the Local Approving Authority
4. E] Fails
06/05/2025
1 t r's a r 'OF Date
The system inspector shall su' m a
* a copy of this inspection report to the Approving Authority (Bord
of Health or DEP) within, 30 d 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 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
in the future under the same or different conditions of use.
t5insp.doc-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,-Page 1 of 18
Commonwealth of Massachusetts
Title 5 Offi"cial Inspection Form
Subsurface ewa a Disposal System Form: Not for Voluntary Assessments
80 Christian Way
Property Address
Tai't, Bradley
Owner owner's Name
information is No Andover MA 01345 06/05/2025
required for every
page. City/Town State Zip trade Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 21 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 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
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, I! , I 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, net leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y 0 N 0 ND (Explain below):
t in p.doc.rev,7/2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
T'Itle 5 Off"Ic"Ial Inspect'ion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
80 Christian Way
Property Address
Tait,
Owner
Owner's Name
information is No. Andover MA 01845 06/05/202�5
requ:i'red for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (coint.)
2) System Conditionally Passes (cont.):
El Purr p Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
El 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):
El broken pipe(s) are replaced El Y 0 N 0 ND (Explain below):
obstruction is removed E Y F1 N F1 ND (Explain, below):
El distribution box is leveled or replaced F1 Y F1 N ND (Explain below):
..............
El 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 F Y 0 N F1 ND (Explain below):
obstruction is removed El Y El N El ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
El 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 was unless Board of Health determines in accordance with 310 CMR
16.303(l)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/20118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
µ Commonwealth of Massachusetts
icia ion Form
T'tle 5 Off" I Inspect"
. Subsurface Sewage Dispiosal System Form Not for VoluntaryAssessments
o Christian
Property Address
rad leTait, � ._. _..�___ .
Owner ......--
owner's Name
information is fro, Andover MA 01845 0 /o5 2o25
req to ired for revery _
page. City/Town State Zip Code Date of Inspection
C. Inspection, Summary (co nt.,
[� 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
bSystem will fail unless, the Board of Health (arid Public Water Supplier, if any
determines that the system is functioning in a manner that protects the public health,
safety and environment:
EJ 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..
[:1 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
El 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
coliforrn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppmr provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form,
cT other:
System Failure Criteria Applicable to AllSystems-,
You, must indicate "Yes" or"No"to each of the following for all inspections:
"des No
El 0 Backup of sewage into,facility or system component due to overloaded o
clogged SAS or cesspool
El z Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded r clogged
d o SAS or cesspools
tan p®de •rear. 12 1 01 Title 5 official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 18
Commonwealth of Massachusetts
T I ion Form otle 5 Official Inspecto
>
Subsurface Sewage Disposal System Form Not for Voluntary Assessments,
80 Christian Way
Property Address
Tait,
...........
Owner Owner's Name
information is No. Andover MA 01845 06/05/2025
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4
I) System Failure Criteria Applicable to All Systems,-, (cont.)
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 1/2day flow
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pi'pe(s). Number of times pumped:
El E Any portion of the SAS, cesspool or privy is below high ground water elevation.
El E 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 I of a public water supply
well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El E 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. [Thi's
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.]
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 CM�R 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
1:1 1:1 the system is within 400 feet of a surface drinking water supply
El 1:1 the system is within 2010 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone 11 of a publ'ic water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
m5Commonwealth of Massachusetts
T"tle I
Off"icial Inspect"ion Form
Subsurface Sewage Disposal System Form Not for voluntary Assessments
wu"
o Christian Way
Property address
Tait, Bradley
Owner Owner's Name
information is No. Andover MA 01845 06/05/2025
required for every
page. City/Town State ,Zip Cade [date of Inspection
C. Inspection Summary (coat.)
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 C..4 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 C.4 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 ofthe following for all inspections.,
"es No
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?
N El Has the system received normal floes in the previous two creek period''
El N Have lame volumes of water been introduced to the system recently or as part of
this inspection?
El Were as built plans of the system obtained and examined" (If they were not
available note as
Was the facility or dwelling inspected for signs of sewage back up'
[ Was the site inspected for signs of break out'
N E] Were all system components, excluding the SAS, located on site"
[] 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'
Was the facility owner(and occupants if different from owner) provided with
information on the maintenance of subsurface sewage disposal systems?
proper p �
The sine 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.
N EJ Determined in the field if any of the failure criteria related to Part Cis at issue
approximation of distance is, unacceptable) [3,1 o C M R 15.302(5)]
t insp.do •rev, `l 1 D18 Title 5 Official Inspection Form Subsurface Sewage aispos,l System-Page 6 of 18
Commonwealth of Massachusetts
ion: Form
V4
X
Q Title 5 Off"icial Inspecto
>
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
80 Christian Way
Property Address
Tait, Bradley
Owner Own r's Name
information is No. Andover MA 01845 06/05/2025
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
4
Number of bedrooms (design): N umber of bedrooms (actual
4):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600
Description:
2
Number of current residents,:
Does residence have a garbage grinder? F1 Yes H No
Does residence have a water treatment unit? El Yes H No
If yes, discharges to,:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes H No
information in this report.)
Laundry system inspected? El Yes E] No:
Seasonal use? D Yes H No
Water meter readings,, if available (last 2 years usage (gpd)):
Detail:
Sump pump? D Yes H No
Last data of occupancy: Occu pied
Date
t5insp.doc-rev,7/26/2018 Title 5 Official Inspection Form,-Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth chusetts
riF4 Tmit,le 5 Official Inspect"ion Form
:aSubsurface Sewage, Disposal System Form Not for Voluntary Assessments
...........0 hr i s i a�I W ,.... ..�,�...m......m........,.
v y..
Property Address
Owner
Tait, brad
_ .._. _. ___.....__.. .....__� .. _ _._.._ ..
Owner's Nam
information is No. Andover "1� o 5 06/05/2025
required for ever _ .__
page. City Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day( p )
Basis of design flow(seats/persona/aq.ft. etc.):
Grease trap present? El Yea E] No
Water treatment unit present? D Yes 0 No
If yes, discharges to:
Industrial waste holding tangy present? El Yes No
Non-sanitary waste discharged to the Title 5 system Yea No
Water,raster readings, if available:
Last data of occupancy/use: Date
Other(describe below):
3. Pumping Records.:
,Source of information: Stowart'a
Was system pumped as part of the inspection? Yes No
If yes, volume pumped: __1500
gallons
_ ....�.
How was quantity pumped determined. Sight paAue on truck-
Reason
Insect tank
Reason for pumping:
t in p.d'o .rev,7/26/2018 Title Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 1
Commonwealth of Massachusetts
TI"tle 5 Off'icial Inspecti"on Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
-4; 80 Christian Way
Property Address
Tait, Bradley ......
Owner Owner's Name
information is No. Andover MA 01845 06/05/2025
required for every
page. City/Town State Zip Code Date of Inspection,
D. System Information (cont.)
4. Type of System:
z Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
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 IA system by system operator under contract
Tight tank. Attach a copy of the DEP approval.,
El Other(describe)l:
Approximate age of all components, date installed (if known) and source of information:
Tank &distribution box were installed in 2012 but the leachfield is from 07/23/1987
Were sewage odors,detected when arriving at the site? El Yes Z No,
5. Build!*Ing Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
Z cast iron Z 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
MI'ra
Inspect"ion
T"tle 5 Off'iciaForm
Subsurface Sewage Disposal System Farm Not for Voluntary Assessments
Christian Wp
Property Address
Tait, Bradley
Owner Owner's Name
information is No. Andover M 01845 6/05/2 25
required fair every fit brawn .. ._. _ __.� � .. . State �:i e Date of.lrls Inspection
page. y
D., System Information (cont)
6. Septic Tank(locate can site plan):
ww
Depth below grade: 811
Material of construction:
concrete El metal fiberglass polyethylene other(expilain
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes No
Dimensions-
Sludge Sludge depth:: _�
Distance fror top of sludge to bottom of cutlet tee or baffle 311
Scum thickness _ .
Distance from top of scum to top of outlet tee or baffle 811
_.. _.............. .._.._ _..___
Distance from bottom of scum to bottom of outlet tee or baffle 1311
�'a � rnea�urel�ludg�judge
Now were dimensions determined? � _p
Comments on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage" etc.):
re in d shape. No lleak�agje" lid level is good,......_....._
Both laffl._.._es a
t ins m.dee.rev.7l /2018 Title 5 Official inspection Form:Subsurface Sewage Disposal esal System•Page 10 of 1
Commonwealth of Massachusetts
./ _. T"tle
5 Offi"cial Inspectilon
Subsurface Sewage Disposal System Form Not for Voluntary Assessments,
80 Christian Wa
Property Address
Tait, B,radl�
Owner Owner's llama
information is No. Andover MA 01845 6 512 25
required for every
page. city own ;State Zips Cede Date of Inspection
D. System Information (cont)
?. Grease Trap (locate tin site plan):
Depth belay grade: feet
Material of construction:
0 concrete metal fiberglass El polyethylene other(explain).
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: �_. ..n _.....__
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 grades
Material of construction:
EJ concrete El metal El fiberglass El polyethylene El other(explain),:
Capacity: gallons
Design Flog: gallons per day _ �_.._....._
t5insp.doc.rev. 1 /2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Pace 11 of 18
Commonwealth of Massachusetts
T tie 5 Off I Ins tion Form I icia Pec
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
80 Christian Wa
y
Property Address
Tait, Bradley
Owner Owner's Name
information is No. Andover MA 01845 06/05/2025
required for every
page., City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: Yes No
Alarm level.- Alarm in wo rking Order El Yes 0 No
Data of last pumpi,ng: D. to
Comments (condition of alarm and float switches, etc.,):
Attach copy of current pumping contract(required). Is copy attached? El Yes El No
9. Distribution Box if present must be o ened) (locate on site plan),:
l epth of liquid level above outlet invert -0--.--.
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.):
No leakage, all lines distributing equally, no solids
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection,Form:Subsurface Sewage Disposal System-Page 12 of 118
Commonwealtmm
h of Massachusetts
lip
Tl"tle 5 Off"Ic'lal Inspecti"on Fo!rm
>
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
L
80 Christian Way
Property Address
Tait, Bradley
Owner Owner's Name
information is No. Andover MA 01 84�5 06/05�/2,025
required for every
page. City/Town State Zip Code Date of Inspection
D. System, Information (cont.,)
10. Pump Chamber(locate on site plan):
Pumps in working order: El Yes El No*
Alarms in working order: 0 Yes El 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 Absorptilon System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
El leaching pits numbers
leaching chambers number:
leaching galleries number:
El leaching trenches number, length:
I -25 X 44
leaching fields number, dimensions:
El overflow cesspool number:
El innovative/alternative system
Type/name of technology:
t5insp,doc«rev,7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealthtit
T"t,le 5 Offmicial Inspect"lon Form
Subsurface Sewage Dfisposall System Form Not for
Voluntary Assessments
80 Christian Wa
y
Property Address
OwnerOwner � it� �� lo
Owner's Name
information is MvA r ov No An _
required for every
Andover { °� 4� o�lo�l�o�
gage. City/Town �..�..��_.�.�.�. State Zip Code Date of Inspection
D. System Information (co r"Mt.
11. Soil Absorptilon System (SAS) cont.
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No ponding, no h draulic failure, no dam soils
2. Cesspools (cesspool roust be pumped as part of inspection) (locate on site plan):
Nunnher,and configuration _. ._
Depth—tops of liquid to inlet invert �_.....__._....
Depth of solids layer
Depth of scum layer _... .._ _
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes No
Comments (note condition of'soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5tnsp.dv ,rev.71 1201 s Title 5 Official Inspection Form:Subsurface Sewage[disposal System.Page 14 of 18
Commonwealth of Massachusetts
TItle 5 Offi'cial Inspecti"on Form
>
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
U
' MMr
80 Christian Way
Property Address
Owner Tait, Bradley ......
Owner's Name
information is No. Andover MA required for every
page. City/Town State Z,ip Code Date of Inspection
D. System Information (cont.)
13, Privy (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.):
t5insp,.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 16
Commonwealth of Massachusetts
Tl"tle 5 Off" I Inspectn icia ion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
80 Christian Way
Property Address
Owner Tait, Bradley
Owner's Name
information is No. Andover MA 0,1845 06/015/2026
required'for every
page. C ityfTown State Zip Code, Date of Inspection,
D. System Information (c nt.)
14. Sketch Of Sewage DISposall Systemll
Provide a view of the sewage dispoisal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet, Locate where public water supply enters
thelbuilding. Check one of the boxes, below,,
R hand-sketch in the area below
drawing attached separately
Fqw
...............
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11,6 of 18
L;ommonwealth of Massachusetts
Tiotle 5 Off'icial Inspect"
i,on Form
u u ace Sewage Dlisp System m Not or lu a y Assessments
c
` 80 ChristianProperty Address
Tait, radley
Owner ..........
Owner's Narne
information is I"o. Andover A 01845 6/ 5 2 25
required for every �. _ .. __......_ _.._ _ .
page. City/Town State Zip Code Cate of Inspection
D. System Information (cunt.
15. Site Exam:
Chock Slope
0 Surface water
Check cellar
Ej Shallow walla
r
Estimated' depth to high ground water: _.._. _..
feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked data cf dcsi n lan reviewed. 319119
84
� Gate
Observed site (abutting property/observation, hole within 150 feat of `AS
Checked with kcal Beard of Health - explain:.
Pulled files
El Checked with local excavators, installers_ (attach documentation)
El Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
d�esi n plans on record Tien from
Before filing this Inspection Report, please see Report CompletenessChecklist on next page.,
t5ins ,doc.rev.7/2 /2018 Title 5 Official Inspection Parr:Subsurface Sewage Disposal System.Pogo 17 of 18
TZ'11'X Commonwealth of Massachusetts
1,
V4 ion Form T"tle 5 Off"icial Inspect'm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M.
80 Christian Way
Property Address
Tait, Bradley .......
Owner Owner's Name
information is No. Andover MA 01845 06/05/2025
requi'red for every
page. City/Town State Zip Code, Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
Z A., Inspector Information.: Complete all fields in this section.
Z B. Certification: Signed & Dated and 1, 21 3, or 4 checked:
C. Inspection Summary:
1) 21 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
Z D. System Information:
For 8: Tight/Hol!ding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on, pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18