HomeMy WebLinkAboutPASS - Title V Inspection Report - 10 WOODCHUCK LANE 12/15/2025 u,ommonwealth of Massachusetts Town of Nod Andover
I Inspect"ion Form
T"Itle 5 Off"
Subsurface Sewage, Disposal System Form o Not for Voluntary Assessments DEC.,15 9025
f. 10 Woodchuck Lane
........ .....
Property Address, Health-bepartment
KellqWa
Owner y,.Glenn- ......... ........... ...................
Owner's Name
information is
No. Andover MA 01845 11/04/2025
required for every —
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, I nspector Information
filling out forms
on the computer, John L. DiVincenzo
use only the tab .....
key to move your Name of Inspector
cursor-do not -J & S DIevelopMent/qtewart's Sep
use the retuirn Service .........
Company Name
key.
58 So. Kimball St.
III tab, I Company Address
Bradford MA 01835
City/To,wn 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 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. Passes
2. El Conditionally Passes
3. Needs Further Evaluation by the Local Approving Authority
4. Ej Fails
1 1/04/2�025
II ect -jDrO QSi,gn Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DAP)with�in 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
in the future under the same or different conditions of use.
t5 insp.doc-rev.7126/2018 Title 5 Official inspection Form,Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
OffiInspecti onForitle �1
' a Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
W
`r
10 Woodchuck Lane
Property Address
lellowa , Glenn
Owner owner's Name
information is No. Andover MA 01845 11/04/2025
required for every
page. City/Town State Zip Code Date of Inspection
Cr 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 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
23 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, 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.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
�wTitle 5 Off Forrr�
~ a
'f i> Subsurface Sewage Disposal System Form Not for Voluntary Assessments
6 10 Woodchuck Lane
Property Address
Kellowa , Glenn
Owner owner's Name
information is No. Andover MA 01845 11/04/2025
required for every
page. City[Town State Zip Code Date of Inspection
C. Inspection Summary
2) System Conditionally Passes (cost,):
El Pump 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):
❑ broken pipe(s) are replaced El Y El N El ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N El ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
Ej The system required pumping more than 4 times a year due to broken or obstructed pipes). The
system will pass inspection if(with approval of the Board of Health):
El broken pipe(s) are replaced El Y El N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y El N EI ND (Explain 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 DMR
15.303(l)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
, Commonwealth of Massachusetts
Title 5 Offici"al Inspection For
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
` g p Y y
7 J�
10 Woodchuck Lane
Property Address
Kellowa , Glenn
Owner Owner's Name
information is required for every No. Andover MA 01845 11/04/2025
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
❑ 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:
❑ 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.
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.
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
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 all inspections:
Yes No
D E Backup of sewage into facility or system component due to overloaded or
clogged 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
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
� Commonwealth of Massachusetts
1pTitle 5 Offici"al Forrr�
' a
I� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
} � � y y
10 Woodchuck Lane
Property Address
Kellowa , Glenn
Owner Owner's Name
information is No. Andover MA 01845 11/04/2025
required for every
page. CitylTown State Zip Code 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
❑ ® Liquid depth in cesspool is less than 5" below invert or available volume is less
than 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(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.
El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El ® 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 forma
❑ E The system is a cesspool serving a facility with a design flow of 2000 gpd-
1 0,000 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 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 105000 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 El the system is within 400 feet of a surface drinking water supply
El ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El 1:1 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 5 of 18
l
Commonwealth of Massachusetts
�GTitle 5 Official For 1
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
jfr g p y y
10 Woodchuck Lane
Property Address
Kellowa , Glenn
Owner owner's Name
information is No. Andover MA 01845 11/04/2025
required for every
page. City/Town State Zip Code 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 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
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
® ❑ 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?
® ❑ 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?
❑ 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;
® ❑ Existing information. For example, a plan at the Board of Health.
® 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 Massachusetts
i
.
„ 1Inspectoion Form
�(* 7 a
a Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
4 �
10 Woodchuck Lane
Property Address
Kellowa , Glenn
Owner owner's Name
information is No. Andover MA 01845 11/04/2025
required for every
page. City/Town State Zip Code Date of inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): N/A Number of bedrooms (actual): 4
� }
DESIGN flow based on 310 CMR 15.203 (for example: 110 d x*of bedrooms)- N/A
gp }
Description:
Number of current residents: 4
Does residence have a garbage grinder? E Yes El No
Does residence have a water treatment unit? El Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection 0 Yes N
information in this re port.) ® °
Laundry system inspected? El Yes ❑ No
Seasonal use? El Yes E No
Water meter readings, if available (last 2 years usage (gpd)}:
Detail:
Sump pump? EJ Yes E No
Last date of occupancy: occupied
Date
t5insp.doc-rev,7/26/201 S Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Form
w
Ile, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Y Y
10 Woodchuck Lane
Property Address
Kellowa , Glenn
Owner owner's Name
information is No. Andover MA 01845 11/04/2025
required for every
page, City[Town State Zip Code Date of Inspection
D. System Information (cost.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seatslpersonslsq.ft., etc.):
Grease trap present? R Yes ❑ No
Water treatment unit present? El Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? E Yes El No
If ,es volume pumped: 1500
y gallons
How was Y uantit pumped determined? Sight gauge on truck
q
Reason for Inspect tank
pumping:
t5in sp.doc•rev.7/26/2018 Title 5 official Inspection Farm:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Ti IslaInspect"ionForm
. a
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
g � v v
s a~ D Woodchuck Lane
Property Address
Kellowa , Glenn
Owner owner's Name
information is No. Andover MA 01845 11104/2025
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
[-1 Privy
1:1 Shared system (yes or no) (if yes, attach previous inspection records, if any)
El 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:
Installed in 1981
Were sewage odors detected when arriving at the site? El Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 36I1feet
Material of construction:
D cast iron H 40 PVC El other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doe•rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
�W 1WTitleci*alForm
u
' Q Subsurface Sewage Disposal System Form Not for Voluntary Assessments
wa
9 ►r r
,4 10 Woodchuck Lane
Property Address
Kellowa , Glenn
Owner Owner's Name
information is No. Andover MA 01845 11/04/2025
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
5. Septic Tank (locate on site plan):
Depth below grade: 24" Built to grade
feet
Material of construction:
E concrete El metal [:1 fiberglass El polyethylene E:1 other(explain)
If tank is metal, list age; years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
5 x 1oX4
Sludge depth:
5"
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness D
,
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle
16
How were dimensions determined? Tape measurelslud e 'ud e
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both baffles are in good shape. No leakage, liquid levels are good.
t5insp.doc-rev.7/25/2018 Title 5 Official inspection Farm:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
cimal Inspect"ion For
Title 5 Offi
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Woodchuck Lane
Property Address
Kellowa , Glenn
Owner owner's Name
information is No. Andover MA 01845 11/04/2025
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
D concrete El metal D fiberglass ❑ polyethylene Ej 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. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
D concrete EJ metal El fiberglass El polyethylene El other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/2612018 Title 5 official Inspection Farm:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
luTitle 5 Off Foral
' Subsurface Sewage Disposal System Form - Not for voluntary Assessments
10 Woodchuck Lane
Property Address
Kelloway, Glenn
Owner owner's Name
information is No. Andover MA 01845 1 1/04/2025
required for every
page. City[Town State Zip Code Date of Inspection
D. System Information (cont,)
8. Tight or Holding Tank (cont.)
Alarm present: El Yes El No
Alarm level: Alarm in working order: El Yes El No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert o
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,..level is good. No solids carryover and the box is 35" dee , but built to rade at 4"
t5insp.doe-rev,7/26/201 S Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
h
i l
,fY°w 10 Woodchuck Lane
Property Address
Kellowa , Glenn
Owner owner's Name
information is No. Andover MA 01845 1 1/04/2025
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: ❑ Yes ❑ No*
Alarms in working order: El Yes ❑ 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 Absorption System (SAS) (locate on site plan, excavation not required);
If SAS not located, explain why:
Type:
E leaching pits number. 3 pits
El leaching chambers number:
El leaching galleries number:
El leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 O Fors
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
g � v y
Y
9 4
10 Woodchuck Lane
Property Address
Kelloway, Glenn
Owner owner's Name
information is No. Andover MA 01845 11/04/2025
required for every
page. City/Town State Zip Code Date of inspection
D. System Information (cant.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No hydraulic failure, no ondin , no dam soils. All 3 its are dr .
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 ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp,doe-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
r (tip Tl"tle Official Inspection Form
d
' � Subsurface Sewage Disposal System Form Not for Voluntary Assessments
10 Woodchuck Lane
Property Address
Kellowa , Glenn
Owner owner's Name
information is No. Andover MA 01845 11/04/2025
required for every
page. City/Town State Zip code Date of Inspection
D. System Information (cunt,)
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 18
Commonwealth of Massachusetts
i Title 5 Official Inspection Form
� subsurface Sewage Disposal System Form Not for Voluntary Assessments
10 Woodchuck Lane
Property Address
Kellowa , Tenn
Owner owner's Name
information is No. Andover MA 01845 11/04/2025
required for every
page. City/Town State Zip code Date of Inspection
D. System Information (cunt.)
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 below:
hand-Sketch in the area below
drawing attached separately
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Commonwealth of Massachusetts
c'ial Inspection For
Title 5 Offi
} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Woodchuck Lane
Property Address
Kellowa , Glenn
Owner Owner's Name
information is No. Andover MA 01845 11/04/2025
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
15. Site Exam:
❑ Check Slope
❑ Surface water
Z Check cellar
❑ Shallow wells
Estimated depth to high ground water: 71+
feet
Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
z Checked with local Board of Health -explain:
Info taken from 252 Raleigh Tavern Lane
❑ Checked with local excavators, installers - (attach documentation)
El Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Seasonal High Water Table = 115.5. Elevation 7' - 9' below rade
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Offici"al Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Woodchuck Lane
Property Address
Kellowa , Glenn
Owner owner's Name
information is No. Andover MA 01845 11/04/2025
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, 2, 3, or 4 checked
® C. Inspection Summary:
11 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 high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 18 of 18