HomeMy WebLinkAboutPASS - Title V Inspection Report - 43 OXBOW CIRCLE 5/7/2026 �11
Commonwealth of Massachusetts
Tmitle 5� Offm ion
F imcmial Inspecto Form
41
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
' r 43 Oxbow Circle
Property Address
Bacon, Farley
Owner _.. __.__... .
Cwneraa Dame
information is No. Andover ILIA 01845 5/C 12 26
required for every _...
Page, City ""own State Zip Code Cate of Inspection
Inspection results must he submitted on this form. Inspection forms may not he altered in any
way. Please see completeness checklist at the end of the form. Tnwn.of Notl Andover
p°rtant.when A. Inspector Information
filling out forms
on the computer, h L.
use only the tab �� n . L iVi n can�o _...... _.._.. �..__.. AY 9,A 7OZ6-.-
key to move your Dame of Inspector
cursor-do not J � S Develo ment/Stewart's Septic,Service
usethe return �.._..._._W_ - .........._ ........ ._.
key. Company Name
58 So. Kimball fit.
Health
Company Address
Bradford MA 01835,
eE?I -City/Town State ZipCode
978-372-7471 Sl 1
.._
Telephone Num _ _.....� �........ .._.� ..._...._.
ber License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title
(310 Cli 1 . 1 ); 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. Ej Conditionally Fusses
3. El Deeds Further Evaluation by the focal Approving Authority
4. El Fails
051 '22
Insp signatu _.._. Cute
"T e system inspector shall submit a cop this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of co p ting this inspection. If the system has a design flow of
101000 gpd or greater, the inspector an 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.
t ins .doc.rev. /2 12018 `title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
Title
Official Inspection orIry
ti
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
N
Lam- � e 43 Oxbow Circle
Property Address
Bacos, Farle
Owner Owner's Name
information is No. Andover MA 01845 05/07/2026
required for every
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 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Replaced distribution box
2) 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 Ej 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
I?tzr
T'"I'tle 5 Off"icial Inspect"ion Form
Subsurface Sewage Disposal System Form - Not for voluntary Assessments
Ar-z'4V 43 Oxbow Circle
Property Address
Bacas, Farley
Owner wner's Name
information is . Andover MA 0118454/23/2 26
required for every _ �.
page. CIty/T'own State Zip Code late of Inspection
Inspection results must be submitted, on this form. Inspection forma may not be altered In any
moray* Please see completeness, checklist at the and of the form.
Town of Nod Andover
Important:whenA. Inspector Information
filling out forma
on the computer, John L. Divincenzt
use only the tab __..._. . . ....._.
MAY 2 6 '2 26
key to move your Larne of Inspector
cursor-do not J & S Develc ment/Stewart°s Septic Service
use the return Company blame
use p yIth
58 So. Kimball St.
Company Address __......
Bradford MA 01835
City/Town State Zip Code
97'8 ,�I�1
Telephone Number License Nulmber
B. Certification
I certify that I am a P approved system inspector in full compliance with Section 15,.340 of Title
(310 CMIR 15. 0 ) 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. El Passes
2. E Conditionally Passes
3. F-1 feeds Further Evaluation by the Local Approving Authority
4. El F its
e.
04/2 3/2 6
... ........
Ins ctor Sign re Late
The system inspector shall sub it a (py of this inspection report to the Approving Authority (Board
of Health or DE,Pl within 30 days completing th�is inspection. If the system has a design flow of
10)000 g pd or greater, the inspector;and the system owner shal'l 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,
'lease 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 hors the system will perform
in the future under the same or different conditions of use.
t5insp,doo.rev,7/6/2018 Title 5 Official inspection Form:Subsurface,Sewage Disposal System«Page 1 of 18
Commonwealth of !Massachusetts
Title
Official Form
'T o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r �
v v
43 Oxbow Circle
Property Address
Bacos, Farle
Owner owner's Name
information is No. Andover MA 01845 04/23/2026
required for every
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 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) 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 Ej 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
xTitle 5 Official Forrlrl
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
43 Oxbow Circle
Property Address
Bacos, Farle
Owner Owner's Name
information is No. Andover MA 01845 04/23/2626
required for every
page. City/Town State Zip Code Date of inspection
C. Inspection Summary (cont.)
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):
El broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
[� obstruction is removed Ej Y [] N El ND (Explain below):
® distribution box is leveled or replaced N Y ❑ N Ej ND (Explain below):
Box needs re lacin due to corrosion around the outlet inverts.
❑ 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 Ej Y Ej N Ej ND (Explain below):
El obstruction is removed ❑ Y ❑ N ❑ 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(l)tb)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 Official Inspection For
ti p
:.
171 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� N
43 Oxbow Circle
Property Address
Bacos, Farle
Owner Owner's Name
information is No. Andover MA 01845 04/23/2026
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ 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
0 Backup of sewage into facility or system component due to overloaded or
z clogged SAS or cesspool
gg p
1:1 z 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 Farm:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Forr�
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
g Y Y
W
43 oxbow Circle
Property Address
Bacos, Farle
Owner Owner's Name
information is No. Andover MA 01845 04/23/2026
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cost.)
Yes No
1:1 z Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ z Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
1:1 z Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipes). Number of times pumped.
1:1 z Any portion of the SAS, cesspool or privy is below high ground water elevation.
El Z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El z Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
1:1 z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El z 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
El z The system is a cesspool serving a facility with a design flow of 2000 gpd-
101 000 gpd.
El Z The system fails. I 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
❑ ❑ the system is within 400 feet of a surface drinking water supply
1:1 1:1 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 II 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
Commonwealth of Massachusetts
Title
Official
Foral
�> Subsurface Sewage Disposal System Form Not for voluntary Assessments
L
r ,lie
43 Oxbow Circle
Property Address
Bacos, Farley
Owner owner's Name
information is No. Andover MA 01845 04/23/2026
required for every _..
page. City/Town State Zip Code Date of inspection
C. Inspection Summary (cunt.)
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 C.4 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 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
® ❑ 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?
El E 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)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
E El Were all system components, excluding the SAS, located on site?
E El 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) [3 0 CMR 15.302(5))
t5insp.doc rev.7/26/201 S Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
cial Inspection Form
Title 5 Offi
10 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� Y Y
tY
$ 43 Oxbow Circle
Property Address
Bacos, Farle
Owner Owner's Name
information is No. Andover MA 01845 04/23/2026
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: 4
Does residence have a garbage grinder? ® Yes ❑ 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.) El
Laundry system inspected? El Yes El No
Seasonal use? El Yes 0 No
Water meter readings, if available (last 2 years usage (gpd)}:
Detail:
Sump pump? El Yes E No
Last date of occupancy: Occu iedDate
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
pr
Title 5 Official For�1
1>
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
W
43 Oxbow Circle
Property Address
Bacos, Farley
Owner Owner's Name
information is No. Andover MA 01845 04/23/2026
required for every
page. City/Town State Lip Code Date of Inspection
D. System Information (cont.)
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? El Yes ❑ No
Water treatment unit present? El 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:
Stewart's
Was system pumped as part of the inspection? ® Yes ❑ No
if yes, volume pumped: 1 500
gallons
How was ypum uantit pumped determined? St au e on the truck
q p i h
Reason for Inspect the tank
pumping:
t5insp,doc•rev.7/26/2018 Title 5 official Inspection Form:subsurface Sewage Disposal System•Page 8 of 18
, Commonwealth of Massachusetts
rr
Y icial Inspection Form
a
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
� p y y
43 Oxbow Circle
Property Address
Bacos, F�rle
Owner Owner's Name
information is No. Andover MA 01845 04/23/2026
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
❑ 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 I/A 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:
1997
Were sewage odors detected when arriving at the site? El Yes E No
5. Building Sewer(locate on site plan):
18
rr
Depth below grade: feet
Material of construction:
El cast iron E 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.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System■Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Forrn
' a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
w
9
43 oxbow Circle
Property Address
Bacos, Farle
Owner owner's Name
information is No. Andover MA 01845 04/23/2026
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: 6" Built to grade
feet
Material of construction:
® concrete El metal ❑ fiberglass ❑ polyethylene ❑ 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 10x4
Sludge depth: 5
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness 0
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
1411
How were dimensions determined? Tape measure/sludge jud 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 and sha e. No leaks e, liquid is good.
t5in sp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 o€18
Commonwealth of Massachusetts
Title 5 Official Inspection For
' Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�1 43 Oxbow Circle
Property Address
Bacos, Farle
Owner Owner's Name y
information is No. Andover MA 01845 04/23/2026
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:
F] concrete El metal El fiberglass ❑ polyethylene D other(explain):
Dimensions:
Scum thickness
Distance from flop of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle - W
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:
El concrete El metal ❑ fiberglass El polyethylene ❑ other(explain):
Dimensions:
Capacity: W
gallons
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 O Forr�
M1
Subsurface
Sewage Disposal System Form Not for Voluntary
Assessments
01
9 �
43 oxbow Circle
Property Address
BacoS, Farle
Owner owner's Name W
information is No. Andover MA 01845 04/23/2026
required for every
page. City/Town state Zip Code Date of Inspection
D. System Information (cunt.)
8. Tight or Holding Tank(cont.)
Alarm present: Ej Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? El Yes El No
9. Distribution Box (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.):
Box needs to be replaced due leakage around the outlet inverts. No solids carryover.
t5insp.doe•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
;�, Commonwealth of Massachusetts
FA Title- � OfficiaInspectionForm
Subsurface Sewage Disposal System Form - Not for Voluntary a v v Assessments
43 oxbow circle
Property Address
Bacos, Farley
Owner owner's Name
information is No. Andover MA 01845 04/23/2026
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 El No*
Alarms in working order: El Yes El 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:
❑ leaching pits number:
El leaching chambers number:
El leaching galleries number:
® leaching trenches number, length: 2 - 521
❑ leaching fields number, dimensions;
❑ overflow cesspool number:
El innovative/alternative system
Type/name of technology: --
t5insp,doc rev.7/2512018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
. .
_ u 1tle 5 Official I For1'1'1
p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
p Y y
43 Oxbow Circle
Property Address
Bacos, Farle
Owner Owner's Name
information is No. Andover MA 01845 04/23/2026
required for every _
page. City/Town State Zip Code Date of Inspection
D. System information (cont.)
11. Soil Absorption System (SAS) (coat.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No pond.ing, no hydraulic failure, no damp soils
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 El No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/201 S Title 5 official Inspection Farm:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
( Title 5 Official Fors
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
r�
r,r
� rrc; ey 43 Oxbow Circle
Property Address
Bacos, Fade
Owner Owner's Name
information is No. Andover MA 01845 04/23/2026
required for every
page. City/Town State Zip Code Date of Inspection
D. 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.):
t5 insp.doe-rev.7/26/2018 Title 5 official Inspection Form.Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
1"tie 5 Off ion
1 icial Inspect" Form
subsurface sewage Disposal system Form - Not for Voluntary Assessments
43 Oxbow Circle
Property Address
Bacos, Farle
Owner owner's Name
information is No. Andover MA 01845 04/23/2025
required for every
page, City/Town State Zip Code Date of Inspection
D. system Information (coat,)
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
Rol*
l
i
Ir }
f
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t5insp,doc rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18
Commonwealth of Massachusetts
�A r e5 Mc" Inspection ors
IM
Subsurface Sewage Disposal System Form Not for voluntary Assessments
43 oxbow Circle
Property Address
Bacos, Farley
Owner owner's Name
information is No. Andover MA 01845 04/23/2026
required for every
page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
❑ Surface water
E Check cellar
El Shallow wells
Estimated depth to high ground water: 56" to 48"
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 plan reviewed: 06/24/1997
g Date
El observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Pulled files
El 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 design plans on record
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7128/2018 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
1 Commonwealth of Massachusetts
(t�p, Form
a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
43 Oxbow Circle
Property Address
Bacos, Fa rl e
Owner owner's Name
information is No. Andover MA 01 845
required for every _ 04131�06
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 21 3, or 5 completed as appropriate
4 (Failure Criteria) and 5 (Checklist) completed
® D. System information:
For 8: Tight/Holding Tank-- Pumping contract attached
For 1 4: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 1 5: 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