HomeMy WebLinkAboutPASS - Title V Inspection Report - 197 INGALLS STREET 7/29/2025 o o�nw alth of Massachusetts
�:,p TI"tle 5 0'"" 1 lnsv%ecti"on F'o,rmi
ire,
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� Subsurface Sewage e Disposal' System Form - Net for Voluntary Assessments
197 I GALLS STREET"
Property Address
Owner
Owner's lame
information is NORTH A NDOVE � MAC g1 45 J L "26 2025
required for every _ �...m.. r
page, City/Town State Zip Code Cate of Inspection
Inspection results must he:submitted on this form.. Inspection forms may not be altered in any
way. Please s completeness checklist at the end of the...f
rok of Nodh.,And vpr
Important:WhenInspector Informationfilling cut forms
on the computer, .�
use only the tab add Jamey Bate�CanAUG
key to move your Name of Inspector
I 2n25—
cursor-do not Bateson Enterprises Inc.
use the return y
key.
Company dame Health
_
111 Air i lla Road
Company Address
Andover IAA► .01810
City/Town
State Zip Code
97 -4?5-4786 SI-16
Telephone lumber �...� License Number
B. Certification
I certify that: I am a DEP approved ,system inspector in full compliance with Section 15.340 of Title
(310 C R 1 . , I 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
an
d maintenance of en-site sewage disposal systems. After conducting this inspection I have determined'
that the system:
1. 0 Passes
2. El Conditionally Passes
3. El Needs Further Evaluation by the Local Approving Authority
. El Fails
2025
es ec rs Si nawtur�°"
p g Date
In
The system inspector shall ,submit a copy of this inspection report to the Approving Authority (Beard
of Health or CEP) within 30 days of completing this inspection. If the system has a design flow of
1 0100�O gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DE,P. The original form should be sent to the system owner and copies sent to
the buyer, it 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 sane or different conditions of use.,
t5 nap.dcc.rev.7/26/2018 Title 5{official Inspection Farm:Subsurface Sewage Disposal System.Page`t of 18
Commonwealth of Massachusetts
tie 5, UTTIciai inspection Form
Subsurface Sewage Disposal System Form _ Not for voluntary Assessments
7'� I J GAL.L
Property Address
MATTH EW MCMAHON
Owner
Owner's Name
information is NORTH A D yER MA 1
JULY 2025requlred for every )
page. it /Town State zi—C o-de Date of Inspection
C. Inspection
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1 System Passes:
1 have not found any information which indicates that any of the failure criteria described
in 3 CMR 15.3 3 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
2 System Conditionally Passes:
El 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 th
e box for eyes", "no„ or `not determined" Y, I , l ' ) 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 201 years old is available.
El Y El N El ND Explain below):
t5ins .dcc.rev,7/26/2018 Title 5 Official InspectionForm:subsurface Sewage Disposal osal System-Page 2 of 18
L;ommonwealt,h of Massachusetts
�N
p"ection Form
tie !'5 oTticiai ins""
Subsurface Sewage Disposal' System Form Not for Voluntary Assessments
kq)
197 INGALLS STREET
Property Address,
MATTHEW MCMAHON
Owner Owner's Name
information i's NORTH ANC MA 01845 JULY 2612025
required for every —
page. City/Town State dip Code Date of Inspection
C. I nspection Summary (cont.)
2) System Conditionally, Passes (cont.),-
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)l or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
Ej broken pipe(s) are replaced Ej Y Ej N F] ND (Explain below):
obstruction is removed Y F� N E] ND (Explain below),
distribution box is leveled or replaced [I Y E NEI 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 El' Y Ej N F1 ND (Explain below):
El obstruction is removed Ej Y [I NEI ND (Exp lain 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(l)(b)that the system is not,funct,ioning in a manner which will protect public health,
safety and the environment,:
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o►mmonwealth of Massachusetts
Ti
.. "tie
o a .
5 wyncial Inspection Form
" Subsurface Sewage Disposal System Form Not for Voluntary Assessments
19,7 INGALLS STREET
Property Address
MATTHEW MCMAHON
Owner ' _._
Owners '�arne
information is NORTH AilDOVE MA o1 45
required for every U L '" ��I �+ �
page. City/Town State Zip Cede Date of Inspection
C. Inspection Cont.
0 Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b 01 System will'fail unless the Beard 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:
] 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.
0 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The do has a se tank and SAS and the SAS is within 5o feet of
systemseptic private water
supply well.
Ej 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 EF certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 m provided h i
pp , p ether failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. other:
4 System Failure Criteria Applicable to AllSystems:
You must Indicate "Yes" or"No"to each o►f the following for all inspections:
'es No
El E Backup of sewage into facility or system component due to overloaded or
clogged
d 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
t in p,doc»rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage disposal System W Page 4 of 18
n nwealth of Massachusetts
"tle 5 Q' t't'i"c"ial,
Subsurface ,Sewage Disposal System Form Not for Voluntary Assessments
197 I GAL.L S STREET
Property Address
Owner owner's Name
informat
ion is NORTH AI oVE MA o 1 45 J U L.Y 26 2025
required for every �_.. I
page* City/Town State Zip Cade date of Inspection
C. Inspection Summary (cont.)
4) 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
E] E Liquid depth in p cesspool is less than 6" below invert or available volume is less
than Y day flow
Required pumping more than times in the last year NOT due to,clogged or
re
obstructed pipes . Dumber of times plumped.
Any portion of the SAS, cesspool or privy is below high ground water elevation.
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.
El E Any portion of a cesspool or privy is within 50 feet of a private water supply well..
p pp
Any portion of a cesspool or privy is less than 100 feet bust 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 DE,P certified
laboratory, for fecal coliforrn bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or lees than 5 ppm,
provided that no pother failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this fo►rrn.
The system is a cesspool serving a facility with a design flow of 2,000 qpd-
101000 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 ghat will be
necessary to correct the failure*
5 Large Systems: To be considered a lame system the system must serge a facility with a
design flow of 10,000 d 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 CA.
4.
Yes No
the system is within oo feet of a surface drinking t y q water suppily
the system is within Zoo feet of a tributary to a surface drinking water supply
E] t y w nitrogen sensitive * (Interim Wellhead Protection
e system em �� located �n a nitro en �en�Itive area
Area-� IW A) or a mapped `one Il of a public water supply well
t5ins .doe«rev,7/2 /2018 Title 5 Official Inspection Farm Subsurface Sewage Disposal System.Page 5 of 18
Commonwealth of Massachusetts
fte,cti'on Form
5 utficial Inspm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
197 INGALLS STREET'
P,roperty Address
MATTHEW MCMAHON
Owner Owner's Name
information is NORTH ANON MA 01845 JU'LY 26 20,25 required for every - - I
Page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) ,
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 GA above the large system has fai'led. The
owner or operator of any large system considered a significant threat under Section G.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 El Pumping information was provided by the owner, occupant, or Board of Health
1:1 E Were any of the system components pumped out in the previous two weeks?
E El Has the system received' normal 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 plans of the system obtained and examined' (If they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
E EJ 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?
1Z 1:1 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 determined based on:
Existing information. For example, a plan at the Board of Health.
E El 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)]
t5insp.doc-rev,7/26/2018 Title 5,Official inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachuset,ts
w
i'tie tticiai insp
rA T 50 e c t,io n F o r m
I.
> Subsurface Sewage Disposal System Form Not for voluntary Assessments
197 I NGALLS STREET
Property Address
MATTHEW M C f A H ICI
Owner Owner's Larne
inform NORTH Al lI OVE l A 1 45
L "
information 1s
required'for every �I �"���"
page. City/Town State ;dip Cade Date of Inspection
D. System Information
1. Residential Flow Conditions.:
Number of bedrooms (design 4 Number of bedrooms (actual').-
DESIGN flow based on 31 CM 151.203 (for example: 1 gpd x�of bedrooms)-. 6 GPD
Description:
Number of current residents: 3
Does residence have a garbage grinder" "des No
Ices residence have a water treatment unit'? El Yes E No
I yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) "Yet � I 'e
Laundry system inspected` Yes El No
Seasonal use? El Yes E No
Water meter readin s, if,available last 2 years usage d WELL
Detail:
,dump pump' El Yes E No
Last date of occupancy; CURRENT
Date
t5%nsp.dcc•rev.7/ /2018 Title 5 Official Inspection Form:,Subsurface Sewage Disposal System► "ago 7 of 18
uom,monwealth of Massachusetts
1A "Itle ection Form
!s a iciai insp
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
MAT'TH EW I" C MAHON
Owner � _..... .. ..
Owner's Name
information!is NORTH AND OVER MA 1 45 J L 2 2
required for every _ ____. _ . _ _ I �� __..
page. City/Town State Zip Code Cate of Inspection
D. Syst,em Information (cont.
2s Commercial l'ndus rlal Flow Conditions:
Type of Establishment:
C esign flew based on 310, CMR 15.203 . Gallons per day d
I �'CIS )
Basis of design flow seats personslsq.ft., etc.),
Crease trap present? F-1 Yes E] No
""water treatment unit present's El Yes 0 No
If yes, discharges to:
Industrial waste holding tank present" El Yes Ej No
Non-sanitary waste discharged to the Title 5 system' F Yes ® No
Water meter readings, if available:
Last date of occupancy use:
Date
Other(describe below
3, Pumping Records:
ATESON ENTERPRISES INC J U L 21 2025
Source of information: ..
Was system pumped as part of the inspectiien ' El Yes 0 No
If yes, volume pumped:
Gallons
How was quantity pumped determined" _._... _.
Reason for pumping:
t5insp.de »rev.71 /2018 Title 5 Official Inspection Farr:Subsurface Sewage Disposal'System.Page 8 of 1
t;ommonweal'th of Massachusetts
a
Title Off"icial Inspecti"on Form
r7l
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
197 INGALLS STREET
J11
Property Address
MATTHEW MC MAHON
Owner Owner's Name -
information is NORTH ANDOVER
required for every �MA 01845 -J'U LY 261 2025
page. City/Town;, State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
2 Septic tank, distribution box, soil absorption system
E] Single cesspool
1:1 Overflow cesspool
El Privy
EJ Shared system (yes or,no) (if yes, attach previous inspection records, if any)
Ininovative/Al'ternative 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
Tight tank, Attach a copy of the DEP approval'.
Other(describe):
Approximate age of all components, data installed (if known) and source of information:
37 YEARS, INSTALLED JUNE 1988, AS BUILT PLAN NEW OUTLET TEE 2015 TITLE 5
Were sewage odors detected when arriving at the site? E Yes E No
5. Building Sewer(locate on site plan):
Depth below grade: 2411
feet
Material of construction:
cast iron 4 , PVC 0
0: El other(explain):
Distance from private water supply well or suction line: 30'
feet
Comments (on, condition of joints, venting, evidence of leakage, etc.):
JOINT'S AND VENTING OK
NO EVIDENCE OF LEAKAGE
t5insp.doc-rev.7/26/2 18 Title 5 Official Inspection Form-Subsurface Sewage Disposal System-Page 9 of 18
AML
uommonwealthi of Massachusetts
N ONES
'ciai ins
?A IN t I e To"'to I IN ' E
ion Form
Ject
Subsurface Sewage Disposal System Fora - Not for voluntary Assessments
197 INGALLS STREET
Property Address
MATTH EW MCM�AFI N
Owner Owner's Nerve
infermatien is NORTH AND yE R �A
required for every _..._ 01845 J U LY 261 2025
page. City/Town State Zip Code Date of Inspection
D. Information (coat.
6. Septic Tank (locate can site Galan):
Depth below grade: 12
feet
Material of construction:
concrete El metal Ej fiberglass El polyethylene; other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?nce? (attach a copy of certificate) El Yes Ej No
'IX5X4
Dimensions: __.�.�..n
Sludge depth:
Distance from top of sludge to bottom of outlet tape or baffle NA
`cum thickness c
Distance from top of scum to top of outlet tree or baffle NA
Distance from, bottom cif scum to bottom of cutlet tea cr baffle NA
How were dimensions determined? SLUDGE JUDGE AND TAPE
MEASURE
Comments on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
RECOMMEND PUMPING OLDER, SYSTEMS YEARLY
L..Y
PLASTIC OUTLET TEE O
CONCRETE INLET BAFFLE OK
TANK IS OK
LIQUID LEVELS GOOD
NO EVIDENCE OF LEAFAGE
t8 nsp.doc•rev,71 81 018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
�. � meat N Commonwealth ofWassachusetts
"tie
Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
197 INGALLS STREET
Property Address
MATTHEW MCI AH0N'
Owner owner's Name
information is No RTH AN DOVE R MA o 1 45 �J U L '26 2025
required for every f
page. City/Town ,Mate Zip Code Late of Inspection
D. System Information
?. Grease Trip (locate on site plan):
Depth below grade:
Material of'construction:
El concrete El metal El fiberglass El 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 - ._.....
_�_
Gate 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.
. Tight or Holding Tank (tank must be pumped at time of i'nspectio�n) (locate on site plan):
Depth below grade:
Material of construction:
El concrete E] meta I El fiberglass polyethylene El other(explain):.
Dimensions:
Capacity:
gallons �....
Design Flow:
gallons per day
t insp..d'ee•rev. /26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System«Page 11 of 18
MassachusettsCommonwealth of
tA
tie Official Inspection Form
,
Subsurface sewage Disposal System Form - of for Voluntary Assessments
197 INGALLS STREET
ET
Property Address
Owner wner''s Name
information is NORTH AI"�11 C VE"� MA 1 45
required for every J U LIY 261 2025
page. City/Town State Zip Code Cate of Inspection
D. System Information (cont)
8-1 Tight or Folding Tank (cunt.)
Alarm present:: EJ Yes N 0
Alarm level: Alarm in working order: El Yes El No
Cate cat last pumping
Cate
Comments (condition of alarm and float switches, etc.):
Attach copy of currant pumping contract required). Is copy attached? El Yes El No
. Distribution Box (if present must be opened) (locate on site plan):
Depth 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.):
D-BOIX IS LOCATED UNDER PAVER SIDEWALK
RAN CAMERA ERA FROM TANK TO D-BOX
-I OX IS LEVEL AND DISTRIBUTION IS EQUAL
LIGHT EVIDENCE OF SOLIDS CARRYOVER
NO EVIDENCE OF LEAFAGE
t8in p.do .rev,7/2612018 Title Official Inspection Fora.,Subsurface,Sewage Disposal System.Page 12 of 18
■
Commonwealth of Massachusetts
PA Tutle 5 Offinciai inspection
._
Form
Subsurface Sewage, Disposal System Form Not for Voluntary Assessments
14
19, INGALLS STREET
. _..
Property Address
MATT HEW MCMAHO
Owner Owner's Name
information is NORTH required for every ,,I LY 2,6, 2 ,�
page" City/Town State ,Zip Code Date of Inspection
D. System Information (c n .
10. Pump Chamber(locate can site plan):
Pumps in working order: El Yes 0 No*
Alarms in working order: ] Yes No*
Comments (note condition of'pump chamber, condition of pumps and appurtenances, etc;.),
It 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:
E] leaching pits numbers
El leaching chambers number:
El leaching galleries number:
E] leaching trenches number, length: _
leaching bolds number, dimensions;
El overflow cesspool numbers
El innovative/alternative system
Type/name of technology.- ... ...._......._.....----
t insp.do •rev. 12 1'g18 Title 5 Official Inspection Form Subsurface Sewage Disposal system.Page 13 of 18
Commonwealth of Massachusetts
t 5 UTTIcia tio Form
ie I:nspec n
Subsurface Sewage Disposal System For - Not for Voluntary Assessments
197 INGALLS STREET
Property Address,
MATTHEW MICMAHON
Owner Owner's Name
information is NORTH AN MA 01845 JULY 26 2025
required for every ...... I
page. City/Town State Zip Code Date of Inspection
D. System I nfo rmation (cont.)
11. Soil Absorption System (SAS} (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of pondin , damp soil, condition of
vegetation) etc.):
SOIL AND VEGETATION O K
NO EVIDENCE OF HYDRAULIC FAILURE OR PONDIING
12. 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 0 Yes El No
Comments, (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
.....................
..........
t5insp.doo rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System-Page 14 of 18
Commonwealth of Massachusetts
utficia
tie 5 1 Insopp&ection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
197 INGALLS STREET
Property Address
MATTHEW MCMAHON
Owner Owner's Name
information is NORTH ANDOVER MA 0!1845 JULY 26 2025
required for every I
page. City/Town State Zip Code Data of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solid's
Comments (note condition of soil, signs of h,ydraul'i'c 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 18,
Commonwealth of'Massachu!setts
Y icinal Inspecto
Totle 5 Offm
ion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
197 INGALLS STREET
Property►Address
MATTHEW'MCMAHON
Owner Owner's Name
information is
NORTH ANDOVER I
required for every MIA 0 1 5 JULY 26, 2026
page. dity/Town State Zip Code Date ofinspection
D. Systeml Information (cont.),
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 enters
the building. Check one of the boxes belov
hand-sketch in the area bellow
drawing attached separately
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Mw
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Irk
iommmw
All,
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t5insp.doe-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
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Commonwealth of Massachusetts
orm
"tie 5 ection im
utticiai insp
Subsurface Sewage Disposal ,System Fora Not for voluntary Assessments
Property Address
MATTH W MC MIAHol
Owner owner's Name
It1forf"r`tatlon I'S
required for every NORTH All'�ll oy�� I111A 1 �� � f 2025
page. City/Town! State Zip Cade Cate Of Inspection
D. System Information (cont.
15. SiteExam:
Check Slope
Surface water
Check cellar
F1 Shallow wells
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, date of design p,lan reviewed: AP I L 1987
Cate _.
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of health -explain:
PLANS ON FILE
Checked with local excavators, installers - attach documentation
Accessed USES database -explain:
You must describe how you established the high ground water elevation
DESIGN FLAIL ON FILE
Before filing this Inspection Report, please see Report Completeness Checklist on nest page,
t insp.do .rev,7126/2018 Title 5 official Inspection Farm;Subsurface Sewage Disposal System r'Page 17of 18
W
Commonwealth of Massachusetts
Title 5 O
Subsurface Sewage Disposal posal System Form Not for Voluntary Assessments
Property Address
MATT"H EW MCMAH N
Owner Owner's Name
information is NORTH RT`H AN DOVE R A g 1 45
required for every �_.. � L � , � �
page, ity/Town
State ,dip Code Date of Inspection
E. Report, lChecklist
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 (Failure Criteria) and 6 Checklist completed
D., System Information:
For Tight/Holding 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
t insp. cc.rev,7I /2018 Title 5 Official Inspection Farm;Subsurface Sewage Disposal System•Page 18 of 1