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Home My WebLink AboutPASS - Title V Inspection Report - 373 RALEIGH TAVERN LANE 6/17/2026 %,ommonwealth of Massachusetts OTTIc" ion For ia ftect' T'Itle 5 1 Ins* Subsurface Sewage DIs,posal System Form Not for Voluntary Assessments 373 Ralei h Tavern Leas Property Address Fr n.gule , grist �... .. _.. __ ..... _....�.......__.__.. .............._ ....... w ...... _._....... ........_. __..... __.__.__.. __ .w. Owner Owner's Name information is l` . Andover � 01845 1 " 2 2 required for eve ry _.. _.._.--.._ ...__._.._m..v_... . _.__.... _. .. ........... ._... page. City/Town Mate Zip Code Date of Inspection, Inspection results must be submitted n this form Inspection forms may not be altered in any way. Please see completeness checklist of the end of the form. Important-,WhenA. Inspectorfo a1 o filling out for s Town of Nob Andover on the computer,use only thin tali r� l l�IVir�ce�°"I�" key to move your Name of Inspector, cursor no t Dev�lJUL 13,2026 0 ._ _w._._._.._.._._.�r SwS rvice use the return _..._ _ _ key. Company Name 58 So. Kimball St. Company Address Hea1th--DeW m,ent-l--...----------,------l'. Bradford MA 01835 City/Town State Zip Code 3186- TelephoneNumber License Number B. Certification I certify that- I am a DEP approved system inspector in full compliance ith Section 15.340 of Title 5 (310 CI R 5.000); l have personally inspected the sewage disposal system at the property address listed above; the information reported below elow 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 ofon-site sewage disposal systems. After conducting this inspection l have determined that the system* 1. E Passes . El Conditionally Passes w El Needs Further Evaluation by the L,ocal Approving Authority 4. El Fails 1722 I ctor's S,ig ature Date o The system inspector shall submit a copy of this inspection report to the Approving Authority (Board f Health or E within 30 days of completing this inspection. If the system has a design flaw of 10,000 d or greeter, 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 rote: This report only describes conditlions at the time of inspection and under the conditions of'use at that time. This inspection cues not address how the system ill perform in the future under the same or different conditions of use. k5 nsp.do •rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewerage Disposal System.Page 1 of 18 AO%k t;ommonwealth of Massachusetts ti c"i a T'l t I e 5 0 t""" I Inspect*ion For Not for Voluntary Assessments Subsurface Sewage Disposal System Form 373 Raleigh Tavern Lane Property Address Fran,g,ules, Arist Owner Owner's Name information is No. Andover MA 01845 06/17/2026 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 6. 1) System Passes.* Z 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 Cond"It'll'onally Passes-, El 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. (Explain below)- ........................... ------ ............... .............-.......... ........... t5insp,doc-rev.7/26/2018 Title 5 Offic4 Inspection Form"Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts a 1e Subsurface Sewage Disposal System Form Not for Voluntary Assessments a gh Tavern Lane v� Property Address Frarip'les, Arist Owner Name Information is No. Andover A 01845 09/202 requiredor ever �M..�.M _. �.......... .......... . _..... _.._ ._....m-_-___.._..._..._...__...._.....M._........_. _.... ._._....._...... gage. City/TownState Zip Code Date of Inspection I..................... Inspection results must be su bm'I'tte on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. o[Nofth Andover Important:. WhenA. Inspector Information filling out firs on the computer, John L. i" incenz useonly the tad _..._..___...__..__...__._...._ ..._......ry _.__.._.... ...... �..._.__._. .�._...m �......... ... ..............._... key to move your Navas of Inspector cursor-do not S evel r r use the return �� _.. _ .. ... _... ............... Company Name � _........ ...�...� _. ... .._...a.� 5 So. Kimball St. HealthDepartment _ ...._.w._. .w......... .....___ . .. ___..... ..... ..._ _......... ------- __.. __. .__._w._ Company Address Bradford 1 35 City/'Town _. __ ...._...... Smm._...... .... . ._...._ ._....._.....�.w..�.._w._.._..._. ..�_.....� ..._. _ _ ..._.w..... ..........�...�. ate Zip Code 978-372-74,71 S1133 6 Telephone Number License Number B. Certification l certify that: I am a DEP approved system inspector in fall compliance with Section 15.340 of Title 5 (310 C R 15. ; 1 have personally inspected the sewage disposal system at the property address listed above; the int r ation reported d low is true, accurate and complete as of the time of my inspection; and the inspection was performed based on nay training and experience in the proper function and maintenance ofon-site sewage disposal systems. After conducting this inspection I have determined that the systern- 1. Passes 2. Z Conditionally Passes I Needs Further Evaluation by the . cal Approving Authority . Fails .......... .m. ctor's Sign Date The system inspector shall sub i a copy of this inspection report to the Approving AuthorityCard of Health or DEP)within 30 day of completing this inspection. It 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 he sent to the system owner and copies sent t the buyer, it applicable, and the approving authority. Please note-, This report only +descrirl es con lltions at the time of inspection n nwd under the con loons of use at that time.This ins ecti+ n does not address how the system ill perform in the future under the same or dlfferent conedltlons of use. t5ins ,d -rev,7/26/2018 Title 5 Official inspection Forma Subsurface Sewage Disposai System»Page 1 of 1 Commonwealth of Massachusetts 4 ""nIw,, mm _.. T A. itle 5 Off"Icimal Inspection or ,J Subsurface Sewage Disposal System Form Not for Voluntary Assessments �k q 373........... al i h tavern Lane ---------- Property Address Fran les, rest Owner te r ..... .._...... .. .... ...... H r e inf6rmation is 01845 06/09/2026 re uire for eve _.......__. _....__....... ......... ................ page. C. Inspection Summary Inspection Summary- Complete 1, 21 3, or 5 and all of 4 and 6.. System Passes,# El I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CIVIR 15.304 exist. Any failure criteria not evaluated are indicated below, C meets- 2 System Condi ona Passes-, one or more system components as described in the "Conditional `ass" section reed to be replaced or repaired. The system, upon completion f the replacement or repair, as approved by the Board of health, will pass. Check the box for"yes, 'Ano" or"not determined" , N, for the following statements. If"not determined,1) 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 exfiltrat% n or tank failure is imminent. System ill pals inspection if the existing tank is replaced with a complying septic Mink as approved by the Board of Health. metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is lass than 20 years old is available. El Y [:] N ND (Explain ail t5insp. -rev. /2 /2 1 'Title 5 Official Inspection Form:Subsurface Sewage[deposal Systern.Page 2 of 18 For Utticia -m- ec'" T'Itle 5 1 Insp von Subsurface Sewage Disposal System Form Not for Voluntary Assessments 33 Raleigh Tavern Lane .. .w' _.. ._w... ... .., _..._..._._._ _.. ___..._.___......._..,._._. ..._, _,,.,_. ,,._. . .___.._..._..__._....... Property Address Frapgqles, rs Owner wrier s Name ------------- ................. 06/09/2026 required for eveinformation is page« ate of Inspection C. Inspection Summary (cone.) System Condiltlionally Passes (cont.)-,, E] Pump chamber purr q� alarr s not op era i nal. System ill 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 0 broken pipe(s) are replaced 0 Y N N (Explain below)- obstruction is removed (Explain el distribution box is leveled or replaced E Y El NEI ND (Explain below)- Box __.__.�..._. . ion around the outlet inverts. nee r ..,......_.__..__acin s arou _......�......_�.�,N............. ... �. ._....N.._...... _ ...._.....___.. _._ ..... ... _____..__._ . .w.._..._... ....._......_...... E:1 The system required pumping more than 4 times a year due to broken or obstructed iqe s . The system will pass inspection if(with approval of the Board of Health),- E:1 broken pipe(s) are replaced Y 0 N 0 ND (Explain below).- obstruction is removed N (Explain below): 3 Further Evaluation is Required by the Board Health.- El Conditions exist which require further evaluation by the Beard of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass sunless Board of Health deter lines in accordance with 310 CMR 15.3 3 l that the system s not functioniing In a manner whiich will protect pubfichealth, , safety and the environment., t ins .d a -rev.7/2612018 Title 5 Official InspectionForm:Subsurface Sewage Disposal System.Page 3 of 1 uommonwealth of'Massachusetts icia T*tle 5 Off" I Inspect*ion For c� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 373 Ral!��ih__Tavern Lane Property Address Fran ales, rest ._....�._. _ ._.w ....... Owner O wners game ............................................. ......... ......................... information is No. Andover 5 2 2 requiredr _...._ _._...__ _.....__...M..._..___..__.. -------- _.._.�..�....... _ _.._. ... _..._ _.........._....._ page. City/Town State Zip Code Date of inspection C Inspection Summary (cont.) 0 Cesspool or privy is within 50 feet of a surface water E] Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh bw System will fall sunless the Board of Health (and Public Water Supplier, Iif arty) determines a 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. 0 The system has septic-tank and SAS and the SAS 1s within a Zone 1 of a public water supply. 0 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. E] 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 ed t a DEP certified laboratory, for fecal c liforrn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to r less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this fora. c. Other: �4 System Fa'lur Cr �r i� ►pp i��.b�le All Systems.- You must, indicate es" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to erloaded or clogged SAS or cesspool El Z Discharge r ponding, ace of the ground, r surface waters due to an overloaded or clogged SAS or cesspool t iro . oc•rev.7/26/2018 Title Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 1 Commonwealth assac use s w .. U00"T0*T0*'1*c'i'a1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 373 r-------___ " h rr -La"n,e, ............................. Property 'dress Fran .ul s, rrst .................. ------- OwnerOwner's Name information is 26 required for even _.n. _.�.__ _._............. _............._.....� _..w.._...__...... _... .... _.._.__.._ ... _.... . het n ..__....�...�........�..M......_..M_wM__m_...__._.mm_�..._.�_..._._.� age. .._- a- State Zip Code Date of Inspection C. Inspection Summary (coat.) 4 System Failure Criteria Applicable to All Systems: (cont. Yes No 1:1 z Static liquid level in the distribution box above cutlet invert due to are overloaded or clogged', SAS or cesspool 1:1 z Liquid depth in cesspool is less than " below invert or available volume is less than Y2day flow ED z Required pumping more than 4 tiaras in the last year NOT due to clogged or obstructed ipe s . Number of timespumped- E] 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. 1:1 z Any portion of a cesspool or priory is within a Zone 1 of a public water supply well. [:j Z Any portion of a cesspool or priory is within 50 feet of a primate water supply well. 1:1 z Any portion of a cesspool or privy is loss 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 collif rm bacteria indicates absent and the presence of a mania nitrogen gen and nitrate nitrogen rogen is equal to or less than 5 rd idded that no other failure criteria eria are triggered. A copy o the analysis and chain of custody must be attached to this or The system is a cesspool serving a facility with a design fl,ow of 2000 gpd- 10,000d. The system fails. 1 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. Large Systems.- To be considered a barge system the system must serve aci i y,with a design flow of 10,000 gpdd 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 EJ El the system is within 200 feet of e tributary to e surface drinking water supply the system is located in e nitrogen sensitive area (Interim Wellhead Protection tion Area—IWPA) or a mapped Zone 11 of e public water supply well t5insp,doc.rev.7/26/2018 Mfle 5 Offic4 Inspection Form,Subsurface Sewage Disposal System.Page 5 of 18 Commonwealth of Massachusetts Inspecti'on Form e I> Subsurface Sewage Disposal System Form Not for Voluntary Assessments m ' 373 Raleigh Tavern Lane Property. .w Address Owner ...... F � �� rust .....�.._. �...__..__._._.... ...�._.......n. ._.....�.... .... _.___w...._........ . _......._.-----_____.._. Owner's Name information is o. MA 06/09/2026 required for ev r _......... ....._._. ...._. _....._._.. _....._ __......___.n.._..........................._ _.. .... ..w..... ..... ._... _..........._..... .�........_. 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 (iyes" to any question in Section C.4 above the large system has failed. The arguer or operator of any large system considered a significant threat under Section Cw5 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. . You must Indicate `yes" or"no"for each of the following r aff i rs ec iw rs: 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 twoweeks? Has the system received normal flows, n the previous two week period? El [E Have large volumes of water been introduced to the system recently or as part of this inspection E] Were as built pleas of the system obtained and examined" (If they were not available note as E El Was,the facility or dwelling inspected for signs of sewage back up? [I El Was the site inspected for shoe of brash oust? Were all system components, excluding the SAS, located our situ" 11 El Were the septic tank manholes uncovered, opened, and the interior of the tarok inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,, depth of sludge and depth of scup Was the facility owner (arid occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the S+ ii Absorption System (SAS) on the site has been determined based on: 0 El Existing information. For example, a plea 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 CMR 15.302(5)] t5uns . cc-rear.7/26/2018 "title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 1 tom eat of Massachusetts ................ Form"cial Inspect"ion mm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 373 Rp��g Tavern Lane ............ Property Address Owner Flr?�p g I'es,' i s .......................... ...............Owner's Name information is No. Andover MA 01845 06/09/2026 required for,every --- .......... .......................... ........... page. Cit Town State Zip Code Date of Inspection D. System Information 1. Residenfiall Flow Conditiow, ? 4 Number of bedrooms (design)- Number of bedrooms (actual). DESIGN flow based on 310 CMR, 15.203 (for example- 110 gpd x#of bedrooms).. Description: ............. --------- ........ ............ ......................... 4 Number of current residents: Does residence have a garbage grinder? Yes No Does residence have a water treatment unit? El Yes E No If yes, discharges to. ... ............ -------_1.._1..__1 Is laundry on a separate sewage system? (include laundry system inspection Yes No information in this report.) Laundry system inspected? El Yes, Seasonal use? EJ Yes No Water meter readings, if available (last 2 years usage (gpd))- Detail: .................. ...... ...... .............. ----------------- ...........----------------- .................. SUMP pump? Yes No Last date of occupancy: Date t5insp.doc-rev,7/26/2018 Tfle 5 Offic4 Inspection Form"Subsurface Sewage Disposal System•Page 7 of 18 N, %,ommonwealth of Massachusetts r a M, T"I t I le ff i*��ciai i�n�spe c'u'on Form (S Not for Subsurface Sewage, Voluntary a�ispos,al System Form 373, Ral�e ' r rr _.. _µ...._........_...w..... .. _.................... Proplerty Address 'rar ules�, Arun information is, required ��w_a.._,..�_.. _.._m�.m. _� ._ __. _m�._._��..m__._.�....__�.._..�.... .�_._....._ . ..._......_..__. ...m �........mm...�....__�___. ._�_....m... .................m..._.__. ... page., CiIt Town State Zip Code Date of Inspection D. System Information (cont.) 2. cia ustri Flow GSM : Type of Establishment: De�s,ign Now(based on 3,10 CMR NI - .- ---__ _.....__.. . m.................._ Grease, Gallons per day(gpd) present? El Yes E] No Water,treatment unit present? El Yes No If yes, discharges to-, ............ m.. __m......__.m ......_ .. Indus,tria,l waliste holdingitarp resent? 0! Yes El No Non-sanitar,ydischarged NI y El Water r readings, i i I ..w. �...........�_ Lastd�ate of . a .......- ..... ---------.................... ......... ri N Y 3. u Alin Records: __..' r Sourceinformation: m ....µm._ __ LL ............... _mm.................... ......... systemWas r i� , I Yes, No 1000 If yesp volume gallons ruIlc . How, s quantity mdetermined,?.� � � .�w___ �...Y......_ ................_m _.............._s....� __ ��__.�. .. ��e�.m I'� Iec to rr Reason for �u�rn inn. �__ t5i,ns ..doic-rep 7/26/2018 Title 5 Official Inspection Form-Subsurface'Sewage Disposal System-Page 8,of 1 Commonwealth of Massachusetts ion For TI'tle 5 Offilcial Inspect* ww "ei Subsurface Sewage Dilsposal System Form of for Voluntary Assessments .s 3 Raleigh Tavern Lane Property Address Fran ul s, r st _ Owner Owner's Name ....�. .... information is IVY. Andover !� 5 . 202 required for ever _ _._..._........_..._ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . 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 system by system operator under contract Tight tank. Attach a copy of the DEP approval. Other(describe)- Approximate age of all components, date installed it known) and source of information: Were sewage odors detected when arriving at the situ 0 Yes Z No 5. ullln Sewer(locate on site Ian). 2011 Depth below grade- fee-t Material of construction- cast iron PVC other(explain).- Distance from private grater supply well or,suction line- ee....._...... .__....___....._..... ....... _�. ....w._ .. Comments on condition of joints, venting, evidence of leafage, etc.).* t ire . ' »rev.7/26/2018 Tftle5 c ff dal InspectionForm-,Subsurface Sewage Disposal System.Page 9 of 1 ' _ . For ion 1>1 Subsurface Sewage s sa System Form Not for Voluntary Assessments .373 ......... Tavern Lane ......._._ ...._.._..... .._._..._._..._ Property Address Owner Owner's Name information is N . Andover �1 5 61 12 2 required for r�, _M.... m....._W ..... __....._ _..._........ pad Inspection D. System Information (cone.) 6... Septic Tar (locate on site plan)- Depthbelow � �: Built ..�.��ra e....i a l _....�.... ............._ _. f 11 ee..t Material of construction: concrete El metal El t derglass polyethylene other(explain) If tank is metal, list age- yea rs, Is,age confirmed d a Certificate of Compliance? (attach a copy of certificate) Yes E] No 5X8X4 Dimensions: _ _._..__ . ....._.. ....... ..._ ._........ _.w. _.....w... 711 Sludge depth-, 27 Distance from top of sludge to bottomoutlet tee or duffle 11 Scum thickness 6 Distance from top of scum to top of outlet tee or baffle 11'4._......MM... _... . ... _........_ ._ "' Distance from bottom of scum to bottom of outlet tee or daffy _.... _.__...� .._..._.._ _.._._..._ _.. _.__ _.. _...._..... How �r d% �n,�i�n�d�t�r ln�d Tape.measure/sl.ud��. . .udg ............. _. Comments (can pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of'leakage, etc, Outlet baff'le is PVC in,_good shape t in p. cc-rev,7/26/2018 Titie 5 Offic4 Inspection "arm:Subsurface Sewage Disposal Syst rn.Fags 10 of 1 Commonwealth ofWassac use Title 5 u'fficial Inspect'ion For o .. Subsurface Sewage [deposal System Form Not for Voluntary sass e s 73 Raleigh Tavern Leas ..._... ._...m.._.... ... ......._.._.._ ....__.. w..._...�...... __... ......__... __.._.... ..... Property Address Fran les, Arist Owner ._�..._._�_-�____...._..m.�..�.... _...._�...�..M_ M...__�.... .�..m.....�_....� ..._...._.m.w�__--__�.�.N.........._��__ _...___-___...._n...._._.._..µw. .w....ww...__.._.a..w-.___.w._..,_.�...� ...._ . ...�... ....._.........._....M_._.._.. Owner's Name information is o�. Andover 5 2 2 requiredfor every _... ._.a.w.._�..............._... ._ ........... �_.._ .. .....__. _.._.__........... __. _._...... _...._.. _._ age. City/To w n State Zip Code Date of Inspection D. System Information (cone.) . Grease Trap (locate on siteplan): Depth below grade- feet Material of construction- concrete El metal 0 fiberglass El polyethylune other(explain)* Dimensions- _.........._. ��__.... .........._............ ..... ....._w..._ Scum thickness _.___...... ._ _..._...... _..... ..�......_�.m......... ..... __... Distance from top of scum to top of outlet tee or baffle _._.....__ ..��......_._w_._ _....�.. ._.._.m._....... . ......_..._._......_.... _. Distance from Otto scum to bottom of outlet tee or baffle Date of last pumping: Da.t e Comments, n pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leafage, etc.)- . . Tilght or Holding Teak (tank must be pumped at time of inspection) (locate on site plan)* Depthel grade: _._ .._.....a.�...... _. _.__. ._...._.._. .............__ m ._. . aterial of construction: El concrete El metal tal fiberglass El polyethylene other(explain): Dimensions.- Capacity, gallons _ ......m..__. .... ... ..w._._. .._. _ .. ... ..n__.._.._.. Design Flow, gallons per day t i p. .rev,7/26/2018 Title 5 Official inspectionForm-.Subsurface Sewage Disposal System-page 11 of 1 Commonwealth of Massachusetts T'tle 5 U'T"T'"Icial Inspect' For ion °4 k Subsurface Sewage Disposal Satan Form Not for Voluntary tar ssess eats ., 3 3 ��e Tavern Line �...w.._.-.__.__._....�m......_..... _.. ... ��.....�.. ..M...._...__.._..._. .....__..m.___.-___.w_......_.. ... ......�....._ __.M.... .._._...._.. __.....__. Property Address Fran uls, Arist _._ _.........w.w.. _ ..._. _.__....._.. Owner Owner's Name information is required f'or even _......v ..._MA 01845 26 _......_.....___.. ......w..... ._ __.._.._. page. City/Town State Zip Code Date of Inspection D. System Information (coat.) . Tight or Holdwing Tank (coat.) Alarm present: El Yes l lar level. ._.. .................. __.. mm..._.. ..... Alarm ire wor inn order. Y�� N o Date of last pumping- -Date Comments (condition of alarm and float witches, etc.)- Attach copy of current pumping contract(required). is copy attached? El Yes F] No 9. Distribution Box 1 ' resent rust he opened) (locate on site plane): Depth of liquid level above outlet invert .. .. . .._____w..._...__.._._ ...._ .... _.... ___... . .... __.._ . ...__._._..___._ Comments (note if box is hirel and distribution to outlets equal, any evidence of solids carryover, are evidence of leafage into or out of box, etc.)* _.Box..needs replacina...._w.On. wall has faller inward in ...-to c�.x..........._ . t5in . w rear.7/26/2018 Title5 Official Inspection Form:Subsurface Sewage Disposal l System.Fags 12 of 1 Commonwealth of Massachusetts Title 5 Official Inspect'ion For ro I Subsurface Sewage Disposal System Form Not for,Voluntary Assessments wN 373 Ralei!p Tavern Lane Property Address Frangules, Arest Owner 's Name information is No. Andover MA 01 845 06/09/2026 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.- EJ Yes No Alarms in working order- 0 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): It'SAS not located, explain why- .............. Type* 1:1 leaching pits number- E] leaching chambers number- El leaching galleries number- El leaching trenches number, length- ....... leaching fields number, dimensions'. 1� 20_X..__...3 5____ overflow cesspool number: innovative/alternative system Type/name of technology- t5insp,doc-rev.7/26/2018 Title 6 Official Inspection Form,Subsurface Sewage Disposal System-Page 13 of 18 w %,ommonwealth of Massachusetts ....... Tiotle 5 Offli'cioal Inspectimon For lei Subsurface Sewage DI*sposal System Form of for Voluntary Assessments o hq 373 Ralej h Tavern Lane Property Address rar glee, Arist Owner ...... Owner's Name information is o Andover 5 6 2 2 requiredfor even ... _µ. _._._,__. ,.. .,.. ......_ . .,.._. _. _._,............ ._..,.... ._._.... _.....w.....ry..._ age City/Town State Zip Code Date of Inspection D. System Informationcone. 11. Soil Absorption System (SAS) (coat.) Comments note condition of scaly, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No dig 1 ,,.. . wlr ..w.m�ilr , r r .�..,. no.,darn oul 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plea): Number and configuration ...__. ..__._.------- Depth - top of liquid to inlet invert . ._ Depth of solids layer _._� .. . .............�.w__... .. _. _._ Depth scum layer _ .._..�. ..........._....,..,. .N. ......._....___ _.._.._..._,._.....__..w Dimensions of cesspool �..._w._ww.__ ._.._.._ .......... _ __..._..__..._.......... Materials of construction _....w... _..... _.m__.... _. Indication of groundwater inflow yes N Comments (mote condition of soil, signs of hydraulic failure, legal of ponding, condition f'v°a etatiorn, etcµ t5'in p.doc rear.712612018 Title5 Official Inspection Form,Subsurface Sewage Disposal System.Page 14 of 1 It i i icia ion Title 5 Ago"'ff I In�s,pecto Floir Sluibisurface Sewages seem Form NotVoluntary p .� , . mm.,21 .°W _.. _...._.._N,. w _ _._. .mm_. ._m._..__...............n.............. _.._..m_......._....W. .............. .__... _ .m.... ............... ......m.... ._........_.._...._..M.._.,.__... Property Address Ow�ner wner's Name ..................... -—-------- in�for,m,atioln is required for every . Andover� MIA 8 5 '6 9/2026� �w_- _ __._._ ............page. City/Townstate Zip Code Date of Inspection D. System Information (coint,.) 13. Privy (loca,te on sit construction: _. ..... ._......._....n. ..._....... . .. w.. w._...... m.. i i ------- Depth solids, �w._ _� _ mm____ m.... Comments note co i iio ill, signs of'hydra,ulic failur , Ievei of ploindin,g, condition of vegetatioin, etc.): 5f s . c.rev.7/2612018 TMe5 Offic4 Inspection Form:Subsurface Sewage Disposall System-nags`,5 of 1 Commonwealth of Massachusetts icia 1 T Inspecti'on Form Subsurface sewage disposal System Form Not for voluntary Assessments 373 Ralel h Tavern Lane Property Address F ran ales, Ari st Owner owner's Name Information LsNo.Andover MA 01345 required far every page. City/Town State Zip code Date of inspection D. System InformabiDn (cont.) 14. Sketch of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmafks or benchmarks. Locate all wells within 100 feet. Locate where public water supply eaters Fb •ding. Check one ofthe boxes below. d-sketch in the area below wing attached separately y s[t •� to �/ ./Mq j �on 14�1 -War-) Una 14-- 61" �` •� ■ t8lnsp.dae-rev.712=018 Title 6 O3#1cW]Inspection Form.Substkocs Sewapa disposal System■Pep 18 of I8 �ro � uommonwealtho Massachusetts vTTicia ect" T"Itle 5 1 Ins ion For r Subsurface Sewage Disposal System Form Not for Voluntary Assessments �"M• 373 Ralei h Tavern Lane Property Address F r r u l es, Arist _.. ..__. ............_....__..__.....__. _...... OwnerOwner's Name information is No Andover MA 06/09/2026 required for every . yea Inspection --D seInformation (coat.) 15. Site Exam* Check Slope El Surface water El Check cellar [:] Shallow wells Estimated depth to high ground germ _......_... ._......_..... ......._.�w................_....M. ...... .__.... _... _......_ feet Please indicate all methods used to determine the high ground water,elevation: Obtained from system design plans on record If checked, bate of design plan reviewed* ..�.... _._ _._...w�. � _. ._... . _..____ 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 USES database explain: You must describe how you established' the high ground water elevation- o sump,pumpin the basement. Bottom of bad is approximat h,igher than the basement floor. Before filling this Inspection Report, please see Report Completeness Checklist on next page. 5i sp. .rev,7/26/2018 Tifle 5 Off icW inspection Form:Subsurface Sewage Disposal System•Page 17 of 1 Commonwealth of Massachusetts Tl'tle 5 Off"ici"al Inspect"ion For �s Subsurface Sewage Disposal System Not for Voluntary Assessments, �_ ......_ w.__a._... _... --------- Propertyaddress Frangy,les, Arist ................... _w..._.._...._._.__._.._.__..mmu........... . ___._ __...._. ...._... .. ...... _..._..........._...._..____._._.. .._....._... Owner Owner's Name infor,mation is MA 01845 2026 required for eve N9.!'....._...... . ....N. .� .........ndover w._...._w......�..._.........._....... _._w.....�_._.. ........__...._..._....... . ._._...._. _.....a .... _.�.__..... ....... _...w.._._....._._. --------_- page. .w.._... ......._...w. CityfTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections *1s form incluslive 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 (FailureCriteria) a (Checklist) completed D. System Information: For : 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.d c.rev.7/26/2018 This 5 Offic4 ire tin Form.,Subsurface Sewage Disposal f Systern•Fags 18 of 1