HomeMy WebLinkAboutPass - Title V Inspection Report - 114 STONECLEAVE ROAD 10/8/2025 Commonwealth of Mas,sachusefts
TA Tl"t,le 5 Oiffi"ci*al Inspecti"on, Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
114 STONECLEAVE ROAD
Property Address
Owner RICHARD ADAMS
information is Own r's Name
required for every N-ORTH ANDOVER MA 01845 OCTOBER 8, 2025
page. dity/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 own A
filling out forms A. Inspector Information iown OT NOIM-Anao r,
on the computer,
use only the tab Todd James Bateson
key to move your Name of Inspector OETTC2M25���
cursor-do not Bateson Enterprises Inc.
use the return
key. Company Name,
111 Argilla Road
eBfth- on.n
Company Address
Andover MA 01810
City/Town State Zip Code
978-475-4786 SI-16
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
(31110 CMR 15.000); 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
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. E Passes
2. El Conditionally Passes
3. E:1 Needs Further Evaluation by the Local Approving Authority
4. Fails
ro
OCTOBER 9, 2025
Insp or's Signatur Date
The system 'Inspector shall 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 a design flow of
101000 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
I I
in; the future under the same or different conditions of use.
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:SubUrface Sewage Disposal system-Page 1 of 18
uommonweafth of Massachusetts
a inspection Form
�ntle 5� OT'"T"I"cim 1
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
114 STO,NECLEAVE ROAD
Property Address
RICHARD ADAMS
Owner Owner's Name —
information is NORTH ANDOVER MA 01845 OCTOBER 8 2025
required for every — I
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1 2, 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 CI R 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
El One or mare system components as described in the "Condlitionial 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 It yes", "no$11 or"not determined" (Y, N, ND)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 20 years old is available.
El Y [I N 0 ND (Explain below):
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Commonwealth of Massachusetts
T
-4-le 5 OTTIcial Inspect"ilon Form
FA
>
4W Subsurface Sewage Disposal System Form Not for Voluntary Assessments
114 STONECLEAVE ROAD
Property Address
RICHARD ADAMS,
Owner Owner's Name
information is NORTH AN�DOVER MA 01845 OCTOBER 8 025 required for every — I 2
page., City/T'own State Zip Code Date of Inspection
C. I nspection Su cont.)
2) System Conditionally Passes (cont.,):
Ej Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpis/allarm:s,are repaired.
EJ 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 F1 N 0 ND (Explain below):
EJ obstruction is removed F-I Y El N 0 ND (Explain below):
distribution box is leveled or replaced Y N 0 ND (Explain below):
F-I The system required pumping more than 4 times a year due to broken or obstructed pipes . The
i
system will pass inspection if'(with approval of the Board of Health,):
El broken pipe(s) are replaced EJ Y El NEI ND (Explain below):
EJ obstruction is removed 0 Y El N [I 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 pass unless Board of Health determines in accordance with 310 CMR
15-303(1)(b)that the system is not functioning, in a manner which will protect public health,,
safety and the environment:
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Commonwealth of Massachusetts
tticiai insp
p? �Ntle 5 O&NORN a ection Form
Subsurface Sewage Disposal System Form o Not for Voluntary Assessments
114 STONECLEAVE ROAD_
Property Address
RICHARD ADAMS
Owner Owner's Name
information is NORTH ANDOVER MA 01845 OCTOBER 8 2025
required for every -- - I
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
El Cesspool or privy is within 50 feet of'a surface water
Ej Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board' 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:
El The system has a septic tank and sail absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
El 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'.
[-] 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".
Methodused to determine distance:
"This 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 must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for allillinspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effliuent to the surface of the ground or surface waters
due to an overloaded or clogged SAS, or cesspool
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Commonwealth ofWassachusetts
Titie 5 Otticial Inspection F�orm
Subsurface Sewage Disposal System Form, Not for Voluntary Assessments
114 STONECLEAVE ROAD
Property Address
Owner RICHARD ADAMS .......
Owner's Name
information is NORTH ANDOVER MA 01845 OCTOBER 8 2025
required for every — I
page. City/Town State Zip Code Date of Inspection
C. I nspection 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 cesspool is less than 6" below invert or available volume is less
than % day flow
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipes). Number of times pumped:- --
El E 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 suipply 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. [This,
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.]
El E The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,0010 glpd.
The system fails. I have determined that one or more,of the above failure
criteria exist as described in 310 CM R 15.30,3, 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 Frith a
design flow of 10, O 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 G.4,
Yes No
EJ F� the,system is within 40O feet of a surface drinking water supply
1:1 El the system is within! 200 feet of a tributary to a surface drinki ng water supply
1:1 El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
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Commonwealth of Massachusetts
UT'Pt'Ploc'i"al Inspectimon oi rm
�itle 5 0"'A
X I
?A
>
Subsurface Se�wage Disposal System Form Not for Voluntary Assessments
114 STONECLEAVE ROAD
Property Address
RICHARD AC AMS
Owner Owner's Name
information is NORTH ANDOVER
required for every MA 01845 OCT ER 8, 2025
page. City/T'own State Zip Code Date of Inspection
Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is,considered a signif'icant
threat, or answered it yes" to any question in Section CA 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 CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
shouild, 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 I
2 1:1 Pumping information was provided by the owner, occupant, or Board of Health
El N Were any of the system components pumped out in the previous two weeks.?
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?
N E] 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?
N El Was the site inspected for signs of'break out?
Were all system components, excl'uding 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 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:
El Existing information. For example, a p lan at the Board of Health.
Determlined in the field if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMSR 15.302(5))
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Commonwealth of Massachusetts
T"Itle
Ot't'i':cial
r rr
Subsurface Sewage Disposal System Form Net for voluntary Assessments
Property Address
Owner Owner's Name
informati
on Is NORTH AN VE MA 1 a C A E 5
required for every _.
page. City/Town State Zip Cade Date of Inspection
D. System Information
1. Residential Flow Conditions.
Number of bedrooms (design): 3
Number b�edraenr�� (actual):
DESIGN flew based on 310 CIVIR 15.203 ter example: 1 440 GPI
� p 1� pd � b�edreern�}.
Description:
Number of current residents: 2
Goes residence have e garbage grinder' 0 Yes No
Dees residence have a water treatment unit` Yes 0 No
It yes, discharges to
Is laundry on a separate sewage system' (Include laundry system inspection El information in this report.)
e No
Laundry system inspected? Yes No
Seasonal use? El Yes E No
Water meter readings, if available last 2 years usage WELL
Detail:
Sump pump? Z Yes El No
Last date of occupancy: C R ENT
Gate
t5insp.d'ee*rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system*Page 7 of 18
Commonwealth of Massachusetts
a
FA Title 5 Otticiai inspection Form
> •
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
114 STONECLEAVE ROAD
Property Address
RICHARD ARAMs
Owner Owner's Name ---
information is NORTH ANDOVER MA 01845 OCTOBER 8 202required for everyI
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 CM R 15.203):: Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? El Yes El No
Water treatment unit present? Yes No
If yes, discharges to:
Industrial waste holding tank presenit? El Yes [I No
Non-sani'tary waste discharged to the Title 5 system? El Yes El No
Water meter readings, if available:
Last date of occupancy/use: Date
Other (describe below):
..... .....
3. Pumping Records:
Source of information: BATESON ENTERPRISES INC OCTOBER 2024
Was system pumped as part of the inspection? El Yes 0 No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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Commonwealth of Massachusetts
I itle 5 utficial ins ection Form
Subsurface Sewage Disposal System Form o Not for voluntary Assessments
114 STol" ECLEAVE ROAD
Property,Address
RICHARL ADAI S
Owner � ..
Owner"s Marne
information is
required for every NORTH A OVER MA o1 45 OC TO E , 2025
_.........
page... City/Town Mete Zip Cede date of Inspection
D. System Information (cont.)
4. Type of System.
Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) if'yea, 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 I/A system by system operator under contract
El Tight tank. Attach a copy of the DEP approval.
El Other(describe):
Approximate age of all components, date installed (if known) and source of information:
15"YEARS, INSTALLED JUL"Y 2010, AS BUILT
Were sewage odors detected when arriving at the site? Yes No
5. Building Sewer(locate on site plan):
Depth below grade.
feet
Material of construction:
cast iron [:] 40 PVC other(explain): .. _
Distance from private water supply well or suction line: 25
- ---- --
feet
Comments (on condition of joints, venting, evidence of leakage, etc.).
JOINT'S AND VENTING old
NO EVIDENCE of LEAKAGE
t5insp.doc*rev.7I /018 Title 5 Offici'al Inspection Fora:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of' Massachusetts
mtle 01or"I'ar"i"cimam mnspm"'ecti"on 11""""'orm
Subsurface Sewage, Disposal System Form Not for Voluntary Assessments
(V
114 STONECLEAVE ROAD
Property Address
RICHARD ADAMS
Owner Owner's Name
information is NORTH ANDOVER MA 01845 OCTOBER 8 2025
required for every - - - I
page. City/Town State Zip Code Date of Inspection
D. System Information rat. ........
6. Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
0 concrete El metal El fiberglass El polyethylene El other(explain)
If tank is metal, list age: years
Is,age confirmed by a Certificate of Compliance? (attach a copy of certificate) EI Yes Ej No
Dimensions:
811
Sludge depth:
Distance from top of sludge to bottom of outlet,tee or baffle 3011
Scum thickness,
Distance from top of scum to top of outlet tee or baffle 611 .....
Distance from bottom of'scurn to bottom of outlet tee or baffle 1311
How were dimensions determined? SLUDGE, JUD GE AND TAPE,
MEASURE
Comments can pumpi'ng recommendations, inlet and outlet tee or baffle condition, structurail integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
RECOMMEND PUMPING OLDER SYSTEMS YEARLY
PLASTIC IN K
'LET AND OUTLET TEES O
TANK IS OK
LIQUID LEVELS GOOD,
NO EVIDENCE OF LEAKAGE
t5insp.doc rev,7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
IT xr
it' le 5' Ottlicial Inspectmion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
er
114 STONE,CLEAVE ROAD
Property Address
RICHARD AI AMS
Owner Owner's Name
information is NORTH' ANDOVER MA 01845 OCTOBER 8, 2025
required for every
page., City/Town State Zip Code Date of Inspection
D. s6ystem Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
0 concrete F-1 metal E:1 fiberglass El polyethylene El 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 ...........
Date 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.):
8. Tlight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal El fiberglass E polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp,doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 1 of 18
uommonwealth of Massachusetts
T"tie 5 Off"' I Inspecti"on Form
1 i,cia
Subsurface Sewage Disposal System Form�� � m ot for Voluntary Assessments
Property Address
Owner Owner's Name
information is NORTH AND OVER R
required for every I' IA °� 4� T ��I� , 2025
page. City `own State Zip Cade Date of Inspection
D. System Information
. Tight,or Holding Tank (cont,)
Alarm present. El Yes D N01
Alarm level. Alarm in working order: El Yes El No
Date of last pumping _._. .
[date
Comments ents (condition of alarm and float switches, etc..).
Attach copy of current pumpingcontract(required). Is copy attached* Yes N
.. Distribution Box if present must he opened) (locate on site plan).
Depth
pt of liquid level shove cutlet invert -_--
Comments (note if box is Naval and distribution to cutlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.,):
D-BOX 1S LEVEL AND I'STRI UTION IS EQUAL
NO EVIDENCE OF SOLIDS CARRYOVER
NO EVIDENCE OF LEAKAGE
t5insp.doc.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System»Page 12 of 18
Commonwealth, I
iciai Insp ion Form
tie Off ect
Subsurface Sewage is osal System Form Not for Voluntary Assessments
w 114 STON Esc LEAVE ROAD
Property Address
RICHARD ADAMS
Owner Owner's Name
information is NORTH Al i I OVE F MA 1 5 OCTC E E=F C 5
required for every
purge. City/Town State Zip code Date of Inspection
D. System Information (cont.
10. Pump Chamber(locate on site plan):
Pumps in wring Vardar: Z Yes 0 No*
Alarms in working order: E Yes El No*
Comments (note condition of pump chamber, conlditioln of pumps and appurtenances, etc.):
PUMP IP CYCLED ON THEN OFF
CONTROL PANEL IN CELLAR OK
FLOATS ATS OK
If dumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate can site plan, excavation not required):
If SAS not located, explain whys
Type:
11 leaching pits number: _..
leaching chambers 32; 12,83X' 3 '
number: �- _.
beaching galleries number: .........
El leaching trenches number, length.-
El
leaching fields number, dimensions:
R overflow cesspool number:
El innovative/alternative system
Type/name of technology:
t5in p,d'cc.rev. /26/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System.Page 13 of 1
N,
Commonwealth, of Massachusetts
"tiel Offi'ci"al" 'Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
114 STONE,CL,EAVE ROAD
Property Address
i
RICHARD ADAMS
Owner Owner's Name
information is NORTH ANDOVER MA 01845 OCTOBER 8 2025
required:for every I
page. City/Town State Zip Code Date of Inspection
D. Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of'soil, signs of hydraulic failure, level of pondi'ng, damp soil, condition, of
vegetation, etc.):
SOIL AND VEGETATION OK
NO EVIDENCE OF HYDRAULIC FAILURE OR PO�NDING
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 El Yes 0 No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
...........
....... .....
t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
<4� � w 1of'Massachusetts
H'tl'el 5 Officiai Inspection Form
Subsurface Sewage Dispos ll System Form Not for Voluntary Assessments
Property Address
Owner -
Owner's Name
information is NORTH AND V E
required for every _ MAC 01845 C C TOTER 8, 2025
page, City/Town ,State Zip Coda Cate of Inspection
D. System Information (cont.)
13. _ rlv " (locate on site plan):
Materials, of construction:
Dimensions
Depth th of solidi �.
Comments note condition of soil, signs of hydraul'ic failure, level of pon,din , condition of vegetation,
etc.),: �
t5 nsP„doc.rev,7/26/2018 Title 5 Official'Inspection Form:Subsurface Sewage Disposal system.Page 15 of 18
Commonwealth of Mas,s,achusefts
Tlatle 5 Official Ins Forb
Subsurface Sewage Disposal System Farm Not for Voluntary Assessments
Property Address
RICxHARD ADAMS
OwnerOwner's Name
ir�tc�rinformation is required for eves NORTH lll `" ' CCTC � �, �+
page, City/Town S�tete Zip Code Date of Inspection
D. S to Information (cont.
1 . Sketch Of Sewage Disposal SystemIt
,
Provide a view of the sewage disposal stem, 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 below:
hared-sketch In the area below
drawing attached separately
1, OT Fi
OL
A 311'
fm 5 2
ell
01 6
(�A or-7
K,0 0,(i
�.
9
t8 nsp.de rev,7/26/2018 Time 5 OifficiaN inspection
ion Form,:Subsurface Sewage disposal System•Page 16 4f 18
gV Commonwealth of Massachusetts
itle 5 Official Inspection Form
Subsurface Sewage Disposal Syst
em Form Not for Voluntary Assessments
114 S T N BC Ll AVER ROAD
Property Address
RICHARD Al AMS
Owner Owner's Neale
requrirdfo is NORTH AI' DOVE R CIA '1 45 OCT BE 2025
rerulred far every
page~ City/Town State Zip Cede bete of Inspection
D,. System Information (cont.)
15. SiteExam:
Check Slope
Surface water
Check cellar
El 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, data of design p,lan reviewed: OCTOBER 2009
Cate
Observed site (abutting propertylcbservation hole within 150 teat of SAS)
Checked with local Board of health explain:
PLANS ON FILE
Checked with kcal excavators, installers _ (attach documentation
Accessed EGGS database explain:
You must describe how you established the high ground water elevation:
DESIGN PLAN'
Before filing this Inspection Report, please see Report,Completeness Checklist can next page.
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Commonwealth of Massachusetts
Title 5 official Inspecti"on Form
>
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
114 STONECLEAVE ROAD,
Property Add:ress
RICHARD ADAMS
Owner Owner's Name
information is NORTH ANDOVER MA 01845 OCTOBER 8, 2025
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
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:
11 1 21 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
D. System Information:
For 8,:: 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 hligh roundwater inclluded:
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