HomeMy WebLinkAboutPASS - Title V Inspection Report - 991 JOHNSON STREET 1/21/2026 Commonwealth of Massachusetts
T"Itle 5 Off"icial Inspect"ion Form fA
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
991 Johnson Street
............
Property Address
Mang1n, M@yrq�-9
Owner Owner's Name ......... ...
information is No. Andover MA 01810 01/21/2026
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 I nformation
filling out forms
on the computer, John L. DiVincen,zo
use only the tab ........
key to move your Name of Inspector
curer-do not i & S Develop en.t/Stewart's Septic Service,
use the return Company Name
key.
58 So. Kimball St.
Company Address
Bradford M A 01835
..........City/Town State Zip Code
9 -37'2-17'4171 78 SIl 13386
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compil'iance with Section 15.340 of Title 5
(310 CMIR 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
21. F-1 Conditionally Passes
3. El Needs Further, Evaluation by the Local Approving Authority
4. El Fail-
01/21/2026
................. ......
'l
I e ol Sig 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.
PIlease note: This report only describes conditions at the time of inspection and under the
corid.itions of use at that time. This inspection does not address how the system will pqrform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/26/2016 Title 5 Official Inspection Forrn�Subsurface Sewage Disposal System,-Page I of 18
Commonwealth of Massachusetts
ci'al Inspection For
Title 5 Offi
Subsurface Sewage Disposal System Form M Not for Voluntary Assessments
9 4'
991 Johnson Street
Property Address
Manning,.............-, Maureen
........... ........
Owner Owner's Name
information is No. Andover MA 01810 01/21/2026
required for every
page. City/Town State Zip Code Date of Inspection
C. inspection Summary
Inspection Summary: Complete 1, 21 3, or 5 and all of 4 and 5.
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:
F] 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 Ej ND (Explain below):
t5insp.cloc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
. Title 5 Official Fors
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 �f
Ln �.; 1e 991 Johnson Street
Property Address
Manning, Maureen
Owner Owner's Name
information is No. Andover MA 01810 01/21/2026
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
2) System Conditionally Passes (cant.):
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 [I Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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 ❑ N El ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ 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 CMR
1 a.3o3(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp,doc rev.7/2612018 Title 5 Official inspection Form:subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
4 r luTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
a 4`° 991 Johnson Street
Property Address
Mannin_, Maureer
Owner owner's Name
information is No. Andover MA 01810 01/21/2025
required for every _
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.
[:1 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".
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
Backup of sewage into facility or system component due to overloaded or
❑ ® clogged SAS or cesspool
gg p
❑ ® 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
�w p-2 5 Official Form
. W
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
° 991 Johnson Street
Property Address
anning, a-uree..n
Owner Owner's Name
information is No. Andover MA 01810 01/21/2026
required for every
page. City/Town State Zip Code Hate 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 r gg SAS S o cesspool
❑ 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.
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 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 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 forma
® The system is a cesspool serving a facility with a design flow of 2000 gpd-
101000 gpd.
El E The system fails. 1 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
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
❑ 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.7I2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
I't2:P Title Form
Subsurface Sewage Disposal System Form - Not far Voluntary Assessments
� � v v
Q11A 991 Johnson Street
Property Address
Manning, Maureen
Owner Owner's Name
information is No. Andover MA 01810 01121/2025
required for every
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 Q.4 above the Iarge 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 of the following for all inspections:
Yes No
E El Pumping information was provided by the owner, occupant, or Board of Health
1:1 ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flaws in the previous two week period?
1:1 ® 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 NIA)
E El Was the facility or dwelling inspected for signs of sewage back up?
E 1:1 Was the site inspected for signs of break out?
E El 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?
E El 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.
E ❑ 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) 31 o 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
Title 5 Official Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ffxrr
by
991 Johnson Street
Property Address
Manning.,... Maureen
Owner owner's Name
information is No. Andover MA 01810 01/21/2025
required for every
page. City/Town State Zip Code Date of inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 for example: 110 d x#of bedrooms)- 440
� P gp }
Description:
Number of current residents: 1
Does residence have a garbage grinder? D Yes E No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No
information in this report.)
p )
Laundry system inspected? El Yes El No
Seasonal use? EJ Yes E No
Water meter readings, if available (last 2 years usage (gpd)}:
Detail:
Sump pump? El Yes ® No
Last date of occupancy:
Occupied
Date
t5insp.doc•rev,7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
.
YOffi i
sIspectionnForm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 �
4�
cs, 991 Johnson Street
Property Address
Mann , Maureen
Owner Owner's Name
information is No. Andover MA 01819 01/21/2026
required for every
page. City/Town State Zip Code Date of Inspection
D. System information (coat.)
2. Commercial/Industrial Flow Conditions;
Type of Establishment:
Design flow(based on 319 CMR 15.203):
Gallons per day(gpd)
Basis of design flow (seatslpersonslsq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? EJ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? El Yes ❑ No
Non-sanitary 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: Last pump: 09/09/2022
Was system pumped as part of the inspection? Yes ❑ No
If yes, volume pumped: 1500
gallons
How was y uantit pumped determined? Sight gauge on the truck
q
Reason for Inspect tank
pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
� wTitle 5 Official ForrY1
P
R t7 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
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f� ;❑$4 991 Johnson Street
Property Address
Mann in--, Maureen
Owner owner's Name
information is No. Andover MA 01810 01/21/2026
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
4. Type of System:
® 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 IIA system by system operator under contract
❑ 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:
2008
Were sewage odors detected when arriving at the site? ❑ Yes E No
5. Building Sewer(locate on site plan):
rr
Depth below grade: 22
feet
Material of construction:
® cast iron ® 40 PVC El other(explain):
Distance from private water supply well or suction line: feet W
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Farm:Subsurface Sewage Disposal system•Page 9 of 18
Commonwealth of Massachusetts
,g i e ICIInspectionForrrl
'` 17 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
991 Johnson Street
Property Address
Mannln-, Maureen
Owner Owner's Name
information is No. Andover MA 01810 01/21/2026
required for every
page, City/Town State Zip Code Date of Inspection
D. System Information (cont,)
6. Septic Tank (locate on site plan):
Depth below grade: Tank is built to grade
feet
Material of construction:
® concrete ❑ metal ❑ 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) El Yes ❑ No
Dimensions:
5X 1oX4
5"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness 0
Distance from top of scum to flop of outlet tee or baffle 611
1911
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Tape measure/sludge judge
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 leaks e, liquid level is good.
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
..........................M ,gTitle 5 Official Form
w
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
KIP
h.
Y
a f.
rJV 991 Johnson Street
Property Address
a r in- _, Tureen
Owner owner's Name
information is No. Andover MA 01810 01/21/2026
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:
El concrete El metal El fiberglass ❑ 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. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete El metal ❑ fiberglass El polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5in sp.doe•rev.7/28/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
�� Commonwealth of Massachusetts
x �r Title 5 I Official Forrr�
w
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
991 Johnson Street
Property Address
Mannin-, Maureen
Owner Owner's Name
information is No. Andover MA 01810 01/21/2026
required for every
page. City/Town State Zip Code Date of inspection
D. System information (coat.)
8. Tight or Holding Tank (cunt.)
Alarm present: El Yes El No
Alarm level: Alarm in working order: El Yes F] No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). is copy attached? D Yes Ej No
9. Distribution Sox (if present must be opened) (locate on site plan):
q
Depth of liquid level above outlet invert 0
P
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.):
Equal distribution. No leakage, no solids care ever.
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
A Commonwealth of Massachusetts
f- _r Title 5 Official ForrY1
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
:. g p Y Y
991 Johnson Street
Property Address
Martin
Owner owner's Name
information is No. Andover MA 01810 01/21/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
10. Pump Chamber(locate on site plan):
Pumps in working order: E Yes D No*
Alarms in working order: E Yes El No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Lifted floats manually at pump chamber. Both um &alarm were workin at the time of ins ection.
* 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:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 4 -40'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovativelalternative 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 Official Forr�
{T � fy
1b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
991 Johnson Street
Property Address
Manning, Maureen
Owner Owner's Name
information is No. Andover MA 01810 01/21/2026
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (font.)
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 ondin , no dam soils, no h draulic failure
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 [:1 No
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 Farm:subsurface sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
pTitle Forb
1
A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
N
w i
�f
� 991 Johnson Street
Property Address
Manning, Maureen
Owner owner's Name
information is No. Andover MA 01810 g 1121/2026
required for every
page. City/Town State Zip Code Date of Inspection
Dr 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 18
Commonwealth of Massachusetts
Title
Official ForP.
r�
'N 10 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M1
7 �
991 Johnson Street
Property Address
Manning,-Maureen
Owner owner's Name
information is No. Andover` MA 01810 01/21/2026
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cant)
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
t5insp.doc•rev.7/26/2018 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 16 of 16
Commonwealth of Massachusetts
Title 5 Offic"ial Inspection Form
'r Subsurface Sewage Disposal System Form Not for Voluntary Assessments
9
l ' 991 Johnson Street
Property Address
M8nnin , I alureen
Owner owner's Name
information is No. Andover MA 01810 0112 112925
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high round water: 50"
g g 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 Daten plan reviewed: Date 8
❑ observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Pulled file
Checked with local excavators, installers - (attach documentation)
El Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Taken from soil assessment on file
Before filing this Inspection Report, please see Report completeness checklist on next page.
t5insp.doe•rev.712612018 Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 17 of 18
Commonwealth of Massachusetts
zTitle 5 Official Form
, 1> Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r q
- 991 Johnson Street
Property Address
Manning, Maureen
Owner Owner's Name
information is No. Andover MA 01810 0 1 l2 1 12626
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 2, 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 1 5: Explanation of estimated depth to high groundwater included
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 18 of 18
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