HomeMy WebLinkAboutConditional Pass - Title V Inspection Report - 626 FOREST STREET 2/26/2026 Commonwealth ofMassachusefts TOWn OfNofth Andover
T"tle 51 Offm' `0 1 Inspection Form
MAR 5 2h
�6 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
626 FOREST STREET
rty,Address
nt
SCOTT SIMPSO:N
Owner nr'
Owes Name
information is NORTH' ANDOVER MA 0:184,5 2026
required foir every FEBRUARY 24,
............. ..................
page. City/Town State Zip Code Date cif 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
filling out forms A. Inspector Information
on the computer,
use oin�ly the to Todd: James Bat,eson
key to move your Name of Inspector
cursor-do not Bate,son Enterprises Inc.
i - ------------- .......... --------
usethe retu!rn Company Name
key.
111 A...rgill:a Road
tab
pany Address,
Andover MA Oil 810
...........
City/T olwn State Zip Code
978-475-4786 -A._...-
.................. ..........
Telephone Number License Number,
B. Ceftificat on
I certify that: I am a DEPI approved system, inspector in, full compliance with Section 15.340 of Title 5
(310 CMR 115.000); 1 have personally inispected 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 ins,pecti'on I have determined
that the system,
1. El Passes
2. Conditionally Passes
3. Needs, Further Evaluation by the Local Approving Authority
4. Ej Fails
FEBRUARY 2,6 20126..........-mm --1--- --- - .-"I,-------- -.---- I-------
Inspe or's Signatur Date
The system i'nspector shall submit a copy of this insplec,t,ion report to the Approving Authority (Board
of Health or DEP)within 30 days of completing thlis ins,pection. If the system has a design flow of
gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regionaloffice of the DEP. The origina,l form should be sent to the system owner and copies sent to
the bu' r, if applicable, and the approving aulthorit .
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
a
in the,future under the same or different conditions of use.
t5insp.doc-rev,7/26/20118 This 5 Official Inspection Fore Subsurface Sewage Disposal,System-Page 1 of 18
Commonwealth of Massachusetts
Title
Otticial III
'ion Form
II
P0 Subsurface Sewage Disposall SystemForm Not for Voluntary Assessments
Y
6,26 FOREST STREET
Property Address
S TT SIMPSON
r7 is
�r�fired for even _ _.. 01845 FEBRUARY 24 2026
r� .._.. - .. _mm _. .. _
pagile, ity/T'olwn State Zip Code Date of Inspection
C. Inspection Summary
Inspection S mar., Compil,ete 1,, 21 3, or 5 and all of 4 and 61.
System Passes;
EJ I have, not found any information which indicates that any of the failure criteria described
in 3110 CMR 15.303r in 3 CMR 15.304 exist, Any failure criteria not a al'uatad are
indicated below.
Comments.,,
2System Conditionally Passes.-
One or more system compoinents, as described in the "Conditional Pass, section need to be
re
placed or ra a,irad. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass
Checkthe box for imyess" "no" or `not determined"' Y, N,, N for the foillowing statements. If"not
determined, please expilain.
The septic tank its metal) and over 20 years olds` or the septic tank (whether metal or not) is structurally
unsound, exhibits sudstantial infiltration or extiltrati n 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 gears old is available.
El Y El N El ND (Explain below):
t5in .do rev.7/26/2018 "title 5 Official Inspection Form:Subsurface Sewage Di l System-Page 2 of 1
uommon,wealth of Mas,sach�u'se tts
wxmrwn
i
Title 51 lutticial nsw%ect" Form
v on
4ji" Sulbsurface Sewage Disposal System Form Not for Voluntary Assessments
6,26, FORESTSTREET
Property Address,
SCOTT SIMPSON,
Owner Owner's Name ......
inform�at,ion is
NORTHANDOVER MIA 011845 FEBRUARY 24 2026 required for every
I page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (co,nt.)
2") System Conditionally Passes (cont.)-,
Pump Chamber pumps/alarms not opera,tion�al. 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) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
broken pipeI(s) are replaced (Explain, below
)-
obstruction is removed E] Y El NEI ND (Explain below):
distribution box is leveled or replaced Y N' ND (Explain below);
D-BOX IS ROTTED AND NI:EEDS REPLACED!
...........
..............
The system required purnping more than 4 times a year due to broken! or obstructed piple(s). The
system will pass inspection if(with approval: of the Board! of Health):
E] broken pipe(s) are repilaced El Y N' [I NID (Explla,in below),:
El obistructioln is rernoved 0 Y El NEI 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
I
the system is failing to protect public health) safety or the environment.
I
a es
. System will pass unless Board of Healit,h de term i!nes in accordance with 310 CMI�R
151.303(1)(b),that the system is not functioning 'in a manner wh,i�ch will protect public heallith,,
safety, and the environmerI
t5insp.doIc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage isposa,l System-Page 3 of 18,
r
Commonwealth f Massachusetts
u ic'ial Inspecti"on__ .. Form
Tatle 5 'ff'
say' Subsurface Sewage Disposal System Form of for Voluntary Assessments.
Property
SCOTT SIMPSON
Owner Owner's Name
information is required NORTH I � 1 F
page. City/Town State Zip,Code Date of Inspection
C. Inspection Summ
El Cesspool or privy is,within 50 feet of a surface water
Cesspooll or priory is within 50 feet of a bordering vegetated wetland or a salt marsh
. Water uglier, if System i fail unless Board + Health, and Public
determinesthat the system I functioning in as manner that protects the, pu licIf
safety and environment.s
The system has a septic teak and spill absorption system (SAS) and the SAS is within.
1 feet of a surface water supply or tributary to a surface wateir supply.
DI The,system has a septic teak and SAS and the SAS, is within a Zone I of a pubilic water
u�i ply
The system has a septic teak and SAS and the SAS is within 50, feet of a private water
supply well.
El The system has a septic tank and SAS a,nd the SAS is less than 1 feet but feet or
more from a pirivate water supply well .
Method used to determine distance:
This system passes it the well grater anal slis, performed at a DEP certified laboratory, for fecal
olrtorm 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
he ,attached to this form,
cM Other:
a System Fai'lu:re Criteria Appilicabll'e to All tems,:
You must indicate "Yes"' or"No"to, each of the foillowi'ng for all, inspections:
Yes No
El Z B ackup of sewage into facility or system component due to overloaded or
cloyed SAS or cesspool
El E: Discharge �r rid a of t"tlur>rt to the surface of the ground, or surface waters
�
due to, an ov rload d or clogged SAS or cess ool1
t5insp.de .rev.7/261/2018 Title 5 Official Inspection Form-,Subsurface Sewage Disposal System•Ple e 4 of 1
'111
CoimmIonlw,ealthofWassachusettstit
T1*t1e 5 Off'ic"ial Inspect*ion For
oww
Subsurface Sewage, Disposal SystemForm Not for Voluntary sass saute
STREET
w ._FOREST__.... . a.. w
Prolparty Address,
SCO T SIMPSON
m..__ ..-... m -- .. ..._ --.... ....._..._�..._.w�.�.w. _,_...... - _ _�._...�...._..��__.__,___.... �.�._. �...._�._ .........
Owner information is N F
026
_�.__. _ _ _. _.._.._ m_..__. __ ____.... __.w.. __.._..
r��u�r� car �r w.. ...�.....__.._..�..w. .w,���.__mm....... _....
page, City/Town State Zip Code Date of Inspection
C. Inspection Summat
y ifs rrr FailluTe Criteria Applicable to,All, t
Yes No
Static liquid level in the d,istribution box above outlet,
clogged oir cesspool
Liquid
than flow
E] Z Required a ping moire tha,n 4 times In the last year NOT dueto clogged or
obstructed . air times pumped,
0 z Any portion of the SAS, c si ooll or privy is belowhigh ground water elevation,
E-1 z Any portion of cesspool it privy is with in 100, feet of a surface ter su i ly or
tributary to a surface water supply,
El Z Any portio,n, of a cesspool, r privy, is wilthin a Zoneis water supply
well.
1:1 z Anil " portion of a cesspool or privy is It i t of a, privateat r supply ll.
Any portion, of a cesspool or privy is less than, 100 feet but greater than 50 feet
from ri t water supply well withi no acceptable wat r quality analysis. [This
system plasses, if the well water analysis, perforrined at a DEP certified
laboratory, fir f c ll colfforrin bract it as In icat s, absent and the pireis,encle
f ammonia n1trogen and nitrate n*ltrogen is equal to or less than 5 ppim,
tired. co of the anal
rove that rrother f r critrr�a r tri p ° i
d chalin of custody meust be attached to this thlis form.]
z The system is cesspool r facility with a design flow of 2
1:1 z The y t Bails. I have, determined that n or or o the o failure
criteria xa t als descry in 1l � th r fair cyst fails, The
systemowner shoul a cost theoar of ��lt to det,eir,myine what will be
necessary to correct the failure.
LargeSystems: To, be considered large yst the system must serve a facility it a
design flow f 10,0010 to 15,000 gpd.
For large y t s, you must,indicate eith r ` s" or"no" to each of the following, in addition to the
questions in Section
Yes No
E] the system iswithin feet of a surface drinking water s,u,pipily
the system a i�thin 2010 feet of a tributary to a surface drinkingt r suipply
the system, as located an a nitrogen sensitive ti area (Interi Wellhead rat ti n
Are, l r a mapped Zone 11 of a public,wa,ter supply well
t5wn r. o -rev, / /2 11 ' T41e 5 Official InspectionForm:Sulbsurfaice Sewage Disposal System Page 5 of 1
Commonwealth of Massachusetts
,. .,,.,.... .LL..".."`...,..,
17
TI"t I e 5 0 t"t'i' ia
�I Subsurface Sewagile Disposal System Form - Not for Voluntary Assessments
2 ORES'1 STREET
Property Add rues,
Owner SCOTT SIMPSON
Owner's Name
ini,foirmatioln is NORTH A Of .—.� M _.. _ F .__R....... 6re ,uired for even ... .__... ...... w..
page City/Town State ,dip Code Date of inspection
C,i Inspection
If you have answered at yes" to any question in Section C,5 the system is considered a significant,
threat, or answered, tIyes," to any question in Section C.4 above,the large system has failed. The
owner or operator of any large system considered a su nif'ica,nt threat under Section . r f i� led
under Section C.4 shill upgrade the system in, accordance with 310 C .3 4. The system owner
should contact the appropriate regional office of the Department.
. Your oust indicant "yes" or"no" for each of the followingi for all inspections;
Yes N
]' Pumping information was provided by the owner, occu anit, or Board of Health
1:1 z Were any of the system components umped out in the previous two weeks?
z 0 Has the system received normal: flows in the roviou�s two weekperiod?
Have large volumes of water been introduced to, the system recently or as part of
this ins otion?
z El Were as built plans of the system obtained and examined? if they were not
available note as, NI/A)
Zi E] s the facility" or dwelling inspected for signs of sewage hack u
EJ: 1:1 Was the site ins act d for signs of break out'
z 1:1 Were all system pompon n,ts„ excluding the SAS„ located on site?
z E] Were, the septic tank manholes uncovered) opened,, and the interior of the tank
inspected folr the condition of the baffles or teas, material of construction,
dimensions, depth of liquid, depth of'sludg�a and depth of sou
z 1:1 s the faci
lity owner Viand occupants of different from owner) provided with
information on the proper maintenance of subsurface sewage disposal cyst
The size and location of the Sell Absorption System (SAS) on the site has
been determined based on:
Z 1:1 Existing information, For example, a pilan at the Board of Health
Determined ined in, the field, if any of the failure criteria refuted to Part C is at issue
Z El:
approiximatioln of distance is unacceptable) [310 C R 15.3 2 5
t rn i. ,o •rev,7/26'12018 Title 5 Official inisplectionForm:Subsurface Sewage Disposal System.Page 6 of 1
of Massa c h uIs,e'tts,
e 51 Off iciall, Inspect"ion For
a � � Subsurface S wa �e Ms Deaf System F+ m Not for V l n� ta� Assessments
--� �
1
Property Address
SCOTT Owne,rI
._ ....m.__Wmm .,.N _
------
information is Owner's,Name
required forevery
RUARY
_..
_ 011845.a . __. .. ._. �_ �. .�.�w.�........... . .._.
page, City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Condiflons.,
Nlum�bler of bedrooms, (d sI . _ ..__ _. .... Number of r of c,tu l
DESIGN flow d oin 3101 (tor example: 110 gpd x#of bedrooms):
Description-
.
31
Number of current residents:
Does residence have a garbage grinder? El Yes No,
Does, residence have a, w�ater treatment It?, Yes �'��� No,
LAWN
It yes, Ilse �
Is laundry one a, separate sewage sl stems (Include laundry system inspection
i�nformation In thisreport.) Yes N
Laundry system inspected? Yes No
Sea,so a l use? El Yes No
at 'r meter eadi s, it available (last
Mall:
sump PUMP? Z Yes 0 No
Last date of occupancy. .._ _ m.._... .___n _...m._.....
.�ate
t i .d - v.7/26/2018 Tille5 Official Inspection Form:Subsurface Sewage Disposal System.Page 7 of 18
* uommonwealth f Massachusetts
a ff a a 0 a w
81
itP Title 5 ul icia,l insv%ection'
101 S surface e a a Disposal System Foi ra a Not for,Voluntary
626 FORESTT E
� ------
P,roplerty Address,
SCO T SIMPSON'
Owner ......---------
Owner's Name
information is NORTH ANDOVER MA 01845 requlired for every � � 24, 20261
page, City/Town State Zip oldie Date of Inspection
D., System Information (cont.)
'. o rciaa Indus ri all FIow Conditions.,
Type, of Establishment:
Gallons per day(gpd)
Basis, of designflow se is rsons/sqft, etc. _mm._._.._. . . ,. ...w _ .., .m__ ---
Grease
G trap present? El Yes E] No,
Water treatment unit present? Yes o
If yes, discharges t s
Industrial waste holding tank present? El Yes El No
o -sanitary waste discharged to the Title 5 systems Yes No
Water titer readings, it available: � ..._m _.._.....w...w � mm_.._��.� __�.�... _.._... �.....
Last date of occupanc usi mm ..... ....__._... ._ _ .. ._ . _.
Date
then(describe Blow
3. Pumping Records,-,
S Source information-,
_�...._....�_ _ _m ........_.... ��
�N''ER 3 YEARS A
Was, system pumped as part of the inspection?, El Yes Z N
It yes, volume pumped-
gallons
w was,, quantity pu termined? ........__. _�_�,��._._._... �� _m_. �.__. �....�...._.._.w. �u..�mm..._... �. ..... .....
�m
elan �n for pu m,ping: .._ ....-
t5iin . w -rev.7/2612�018 Title,5 Official inspection F� irm-Subsurface Sewage Disposal System- f 1
Commonwealth of Massachusetts
ic'i'al Inspect'ion Foirm
T'tle 5 Off*
rA
p -_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments,
w 626 FOREST STREET
Property Address
S C TT SIMPSON
Owner Owner's Name
information is NORTH required fair every _.n
'� 5 R Y 2 20126
page. City/Town state Zip Code Data of Inspection
System
. Information
. Type of System
Septic tank, distribution box, soil absorption system
Ingla cesspool
E] Overflow cesspool
Privy
Shared system (yes or o) (If yes, attach previous inspection records, if any)
Innova ive/Alternative technology, Attach a copy, of the current operation and
ai.ntonanoo 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 ago of all components data installed if known) and source of information-
40,
YEARS, AS BUILT, SI L 19851, BOARD OF HEALTH'
Were sewage odors, detected when arriving at the site? "des No
5. Building in S eMr(locate on site plan):
32111
Depth below grade; _ __.._ _. _._ _ ......m._. ._ ,.m_......._
feet
Material of construction:
oast iron 40 PVC other ax Ia1n ,:
Distance fromprivate water supply well or suction lino: 301
feet
comments on condition of joints, ventin , evidence of leakage, etc.):
JOINTS" AND VENTING
NO EVIDENCECIF LEAKAGE
t5insp. .rev /26/2018 Title Official Inspection Fora:Subsurface Sewage isp ros it System!,-,Page 9 of 18
Commonwealth of Massay s,etts
ul T
FA itle, 5 Official Inspect"ion Form
10 Subsurface Sewage Disposall System Form Not for Voluntary Assessmients
626 FOREST STREET
Property Address
S�COTT --
Owner --......
Owner's Name
information is NORTHANDOVER MA 01845 FEBRUARY 24 2026
required for every — I..-----...,-,,-.�,—.---...------,"---�.,�� --- I
page, City/Town State Zip Code Date of Inspection
D. System Information (co�nt.)
6. Septic, Tank (locate o�n site plan):
Depth below grade: 20
feet
Material of cons,truictionw
Z concrete 0 metal El fiberglass 0 polyethylene other (explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate Yes El No
10' x 5:' x 4'
Dimensions:
6
Sludge dept'h�,
Distance from top of sludge to bottom of outlet tee or baffle, 32
Scum thickness 2
6
Distance from top, of scum to top, of outlet tee or baffle
12
Distance from bottom of scum to bottom of outlet tee or baffle ................
How were dimensioins, determined? SLUDGE JUDGE
TAPE MEASURE
Co,m�ments (on pumpling recommendations, inlet and outlet tee or baffle condition, structural integrity',
liquid levels as related to olutlet invert, evidence of leakage, etc.)::
RECOMMEND PUMPING OLDER SYSTEMS YEARLY
CONCRETE INLET BAFFLE OK
PLASTIC OUTLET TEE OK
TANK IS, OK
LIQUID LEVELS GOOD
NO EVIDENCE OF' LEAKAG,E
.............. —------------ ..................
t5insp.doc-rev.7/26/ 18 Title,5 Off icia:l Inspection Form.Subsurface Sewage Disposal System-Page 10 of 18
uommonwealth oIf Massachusetts
u ilci"al Insa4ftecti'lon Form
q'04'
m
1�7p T10 t I e 5 O%ff
Subsurface a a i silos 1 System or l Not for Voluntary Assessments
62,6 FOR•„
....... ....... _.._ m....__._.. . - __. ..... .. m.m. . ...._..... .. _.._m. m....,_.._.__..... ..... w_..
Pro arty Address
SCOTT l'
Owner Owner's........... ...........
NIamie
information is NORTH ANDOVEi "' MA011845 FEBRUARY 2 2026
required for every, _ .m.........._ ._. µ....m �_...
page, State Zip,Code Date of Inspection
Di., System Information (cont.)
7. Grease Trap locate on site �lan)-
Di e pIt bellow grad&. ......
feet
Material of construction-,
concrete t l 0 fiberglass E] polyethylene El other(explain),-
Dimensiorl
Scum thickness
Distance r 'm top of scum to top o't outllet tee or baffle
Distance from bottom of scum to bottom olt outlet,tee r baffle
Date of last, plumping: D...
ate
Comments ing recommendations, inlet and olutlet tee or baffle condition, structural integrity,
liquid levels s related to, outlet invert, evidence of llea a i , etc,l
8. Tigilll or Holdirl Tank (tank mu!l t be pumped at tim�e of inspection) (locate on site l r)M
Depthl o r ...._. -_.___._.....
Material of construction-
Crete 0 meta,l El fiberglass El po'ly,ethyleneother (expliaill
Dimensions:
�Capacity-
gallons
Design Flow-,
glallons per day
15u .d -rev,7/216/2018l Title,5 Officiall hspection Form Subsurface Swage Disposal System-Page 11 of 1
m, Commonwealth of Massachus,ett,s,
T FE : icia p
n�
l�e 5 OT"T" I Insu'OkIect' Form
i:o,n
Y� Subsurface Sewage Disposall Syste Form - Not for Voluntary Assessments,
M626 FOREST STREET
Property Ad'dress
SCOTT I
Owner
r" .
- �..�.... .....w..�..._�. ..... .... ..._.._._...mm_.�...�. ._�
required for ever
P gew City/Town State Zip Code Cate o inspection
mm
D.
System of r
.. Tight or HI l i Tank (cont.)
Alarm, present- El Yes El N of
Date of last u i a _..W.... ..., ._._._.
Dia
Cornme ts, (condition alarm and floatswitches, et,c., :
Attach copy of current p� mping contract (required), Is, copy a ached Yes No,
9 Distribution Box present must beopened) locate 6n s,ite plan):
0
Depth of liquid I e e I a b� e outlet i e r n '
Comments, note if box is L�elvel and distribu�tion to outlets e ,u�al,, any evidence of solids, carryover,, any
evidence of leakage into, or out of box, etc.):
-BOX IS NOT LEVEL AND DISTRIBUTION IS NOT EQUAL
L.I�GH;T EVIDENCE OF SOLIDS CARRYOVER
EVIDENCE OF LEAKAGE
D-B4OX IS ROTTED AND NEEDS REPLACED
t liu,s i.0 u M rev, /2/2 18 Ti!tle 5 Official Inspection Forn Subsurface Sewage Disposal System Page 12 of 1
p Commonwealth f Massachusetts Titie 15
u icial'u
µ� Insw%ecti"on
Foirm
Subsurface Sewag�e Disposal System F'orml Not for Voluntary Assessments,
62,6 FOREST STREET
Property Addresis,
SCOTT' SIMPSO,N
Owner w6i
me
information is NORTH ANDOVER
age e f i nspection
D. System Information (cont.), ... ....._...__.______
101. PUMP, Chamber(locate on site plan):
P,uimpis, in working r er�� Yes N1 0 �
Alarms, in working r e�r: El Yes D� N
Com�me fs (note condition of plump Chamber, condition of pumps and appurtenances, etc.),
If p� m s or alarms, are molt i�n working, order, system is a conditional pass,,.,
11. Sold Absorption System (SAS) (locate on site plan,, excavation not required)",,
If SAS t 1 icated, ex llai!n whey:
Type:
0 leaching pits, number:
11
leas lng c �a,r tiers number.,der: .m .___.......
leaching galleries number,
24" X !"
leaching fields nu er dimensions,, ��A... ..__.. .e. .,.,.e..
El
overflow cesspool n u!m,de r�� __.... ...mm._. .0.__._.....m.� _._m.....
ili n a ive/alt�ernati e system
Tye a ell of tech n l gy-
t5i nsp. .r / 2018 Tide 5cial Inspection Forma:Subsuirface Sewage r q's al',System.Page 13 of 18
a_mm
lCial Ins&
" Pftlecti"on Form
T"I'tle 5 U'T"T"'
Subsurface Sewage Disposal System Form, Not ter Voluntary Assessments
626, FOREST STREET
Property Address
TT SI PAS
Owner Owner's
information is
required foir every NORTH 1
page. City/Town State Zip Code Date of Inspection
D. System Information cunt.
11, Soill Absorptiion stem (SAS) (cunt.
Comments, (note condition of soil, signs of hey rauilIic failure, level of pon in , damp soil, condition of
vegetation! etc.
SOIL AND VEGETATION GOOD
NO SIGN OF HYDRAULIC FAILURE POI I
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan)*
Number and configuration
Depth top of'liq�uid to inlet inert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Indication of groundwater inflow El Yes N o
Comments (note condition of soil, signs of hydraulic failure, level of pondin , cnitian of vegetation«
etc,):
k
t5insq. a -rev, / /2018 Title 5 Official lnspection Form:Subsurface Sewage Disposal Systern.Page 1 1
.a
tom lth ofMassachusetts,
AoNk Nod*a M
p-ec,tion Form
I.P itie o, utticial InswAft
W
1>
Subsurface Sewage Disposal System For Not for Voluntary Assessments
626 FOREST STREET
Property Add,ress
SC OTT SIMPSON
Owner Owner's Name ..........................
information is, NORTH ANDOVER MA 01845 FEBRUARY 24 2026
required for e�very
page. City/Town State Zip Code Date of Inspection
D. sit Information (cont)
13,. Privy (locate on site plan):
Materials of construction: _ _ w_ __� �..� � __.. _ _mm_..�._.�_. .�___ �__...�_.._...��.__...__
Dimensions
Depth of solids ..............
C mments (note condition of'soil, signs of hydraulic failure, level of ponding, condition of vegetatioln,
etc.):
t5insp.doc-rev,7/26/'2,018, Title 5 Official Inspection Form,S,ubsuirface Sewage Disposal System-Page 15 of 18
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Commonwealth of Massachusetts
-X ■ ■ ■
'cis Inspect"ion
Ttle 5 Off
Form
Subsurface S � ..Sewage Disposal System Form Not for Voluntary Assessments
� 6 626 FOREST STREET
Property Address
SCOTT SIMPSON '
Owner owner's Name
information is NORTH ANDOVER
required for every MA 01845 FEBRUARY 24, 2026
page. City/Town State Zip Cade Date of Inspection
D. System 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 below:
® hand-sketch in the area below
C] drawing attached separately
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t51nsp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth oif Massachusetts
1�'� T'Itle 5 Off*icilal 1ns&P"&,ect1"on Form
Subsurface Sewage Disposall System Form Not for Voluntary Assessments
626 FOREST' ST'REET
Property Address
SCOTT SIM'PS,ON
Owner ............... ...................
Owner's Name
information is NORTH ANDO,VER MA 01�845 FEBRUARY 24,12,0126,
required for every ...........
page. C,ity/Town State Zip Code Date of Inspection
D,. System Information (cont)
15. Site Exam:
E Check Slope
Z Surface wat�r
Z Check cellar
El Shallow wells
Estimated depth to high ground' water: ------......
feet
Please, indicate all methods, used to determine the high g:roue d water el n:
z Olbtalined from sy design plans, on record
OCTOBER 1985
If c,hecked, date ol lan reviewed: -Da..te
Observed site (abutting: property/observation le withins 150 feet of SAS)
Checked with, local Board of Health - explain:
DESIGN PLAN ON FILE) NO,AS BUILT
Checked wi,th local excavators,, ire i,staller's - (attach documentation)
Accessed USGS, database -explain.-
........................
Y u m,u,s,t describe how yolu eta blishe igh ground water elevation,,
DESIGN PLAN ON FIL,E
Before it is Inspection Report, pillease see Report Completeness, Checklist,on next pagie.
t5insp.doc-rev,7/26/2018 Title 51 officia�Inspecflon Form-SUbsurface Sewage Disposal Syst w-Page 17 of 18
Commonwealth of Massachusetts
!nspection Folrm
Title 5 Ot"t'"'iscial
IMM �
m..
Nrj S si rf' c�el Sewage Disposal System Form Not for Voluntary Assessments
6126 FOREST STREET
Axr
_._mm_ ..... „� _ .µ.___....
Property Address
SCOTTSIMPSON
information is NORTH
..mm._ .w.. m..m._ : ...,:. _._...._ _....._w.w .... . _ FEBRUARYreq�uired for every
page, City/Town State Zip,Code Date,ofinsplection
EW Report Compilleteness, Checklist
Complete all applicable sections of this form inclusive
A. Inspector Information: Complete all fields in this section.
B. Certification: w n n w 2q 3, car 4 checked
C. Inspection Summary;
g 3, or 5 colmpileted as appropriate
il'ure Criteria) n (Checklist) completed'
. Slystern Information:
For fight oldie Tank— Plumping contract attached
For 1 : Sketch of Sewage Disposal System drawn on pg or,attached
For 15: Explanation of estimated deptl to high groundwater included
t ini rev. /2612 11 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System.Paige 18 of 18