HomeMy WebLinkAboutPASS - Title V Inspection Report - 72 STERLING LANE 7/14/2026 uommonwealt,h of Massachusetts
f Town of fth Andover,
I Inspectsion Form
V4
X
Totle 5 Offincia
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
JUL 2 3 2026
72 Sterlipg Lane
Property Address
Co in Glenn Health Do artment
Owner Owner's Name P-
information is Andover MA 01845 07/14/20126
required for every Ng-1. ....................
page. City/Town State Zip Code Date of Inspection
Inspection results must, be submitted on this form. Inspection forms may not be altered in any
I
way. Please see completeness checklist at the end' of the form.
Important:When A. Inspector Information
filling out forms
on the com�puter, John L. DiVincenzo
use only the tab ...........
key to move your Name of Inspector
cursor-do not J & S Development/Stewaq _���ervice
use the return Company Name
key.
58 So. Kimball St.
Company Address
Bradford MA 01 a 35
City/Town State Zip Code
978-372-7471 S113386
Telephone Number License Number
B. Certif ication
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1: have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. 0 Passes
2. El Conditionally Passes
3. Needs Further Evalulation by the Local Approving Authority
4. Fails
A 07/14/2026
Ins ign Date
he system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
1010010 gpd or greater, the inspector and the system owner shall submit the report to the appropriate,
regional office of the DER The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that,time. This, inspection does not address how the system will perform
in the'future under the same or different conditions of use.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
14 �
Commonwealth of Massachusetts
WTitle 5 Official Form
Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments
v v
72 Sterling Lane
Property Address
Cqppinger, Glenn
Owner Owner's Name
information is No. Andover MA 01845 07/14/2026
required for every _ W
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 and added risers
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 El 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 TOwn of Nod!")Andove
T"Itle 5 Off I Inspect" Form icia ion
Subsurface Sewage Disposal Sy stem Form Not for Voluntary Assessments 2026
72 Sterling Lane
Property Address epcIrtMent
Owner Coppinger, Glenn .... .............
Owner's Name
information is No. Andover M A 01845 06/23/2026
required'for every .............
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A, Inspector Information
filling out forms
on the computer, John L. DiVincenzo
use only the tab ........
key to move your Name of Inspector
cursor-do not J & S Development/Stewart's Sept'ic Service
use the return Company Name
key.
58 So. Kimball St.
..........
6 1 CIA Company Address
Bradford MA 01835
City/Town State Zip Code
978-372-7471 S113386
..............
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compiliance with Section 15.340 of Title 5
(310 CMR 15.0001); 1 have personally inspected the sewage disposal system at the property address,
l'isted 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. 21 Conditionally Passes
3. 0 Needs Further Evaluation by the Local Approving Authority
4. 0 Fai
A 6/23/2026-6/231
/11spector Sign ure Date
The system inspector shall submit a copy this inspection report to the Approving Authority (Board
g
of Health or DEP) within:, 30 days of compl t! , this
inspection, If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DER The original form should be sent to the system owner and copies ies 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 tMe. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
fTitle 5 Offic'ial Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y
w
,� 72 Sterling Lane
Property Address
Coppinger, Glenn
Owner Owner's Name
information is No. Andover MA 01845 06/23/2026
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:
[-1 I have not found any information which indicates that any of the failure criteria described
in 310 CM R 15,303 or in 310 CM R 15.304 exist. Any failure criteria not evaluated are
indicated below,
Comments:
2) System Conditionally Passes:
Z 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.
D Y ❑ N El 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
Title 5 Official Forr�
ICE 0 Subsurface Sewage Disposal System Form - Not for voluntary Assessments
72 Sterling Lane
Property Address
Co in er, Glenn
Owner owner's Name
information is No. Andover MA 01845 06/23/2026
required for every
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. 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):
Ej broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed Ej Y Ej N ❑ ND (Explain below):
E distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
Distribution box needs replacin because all sides are broken.
❑ The system required pumping more than 4 times a year due to broken or obstructed pipes), The
system will pass inspection if(with approval of the Board of Health):
El broken pipe(s) are replaced El Y ❑ N El ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N El 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)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp,doc•rev.7/2612018 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
eOfficyInspection Form
' Subsurface Sewage Disposal System Form Not for Voluntary Assessments
w
9
' a kt~e 72 Sterling Lane
Property Address
Ca in er, Glenn
Owner Owner's Name
information is No. Andover MA 01345 06/23/2026
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
El Cesspool or privy is within 50 feet of a surface water
E:1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fall 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:
El 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.
El 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 DFP 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
El Backup of sewage into facility or system component due to overloaded or
E clogged SAS or cesspool
gg p
El E Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
<1^1, 1
Commonwealth of Massachusetts
� µ ci'al Title 5 Offi
Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary: y Assessments
72 Sterling Lane
Property Address
Coppinger, Glenn
Owner owner's Name
information is No. Andover MA 01845 06/23/2026
required for every
page, City/Town State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
1:1 ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
1:1 ® Liquid depth in cesspool is less than 5" below invert or available volume is less
than 1/2 day flow
1:1 ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipes). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well,
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
101000 gpd.
El 0 The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure,
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section C.4.
Yes No
El ❑ the system is within 400 feet of a surface drinking water supply
Ej 1:1 the system its within 200 feet of a tributary to a surface drinking water supply
El 1:1 the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area-- IWPA) or a mapped Zone 11 of a public water supply well
t5insp,doc-rev,7/26/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Form
Ire �y
a
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
W
72 Sterling Lane
Property Address
Coppinger, Glenn
Owner owner's Name
information is No. Andover MA 01845 06/23/2026
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cant.)
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.
5. You must indicate "yes" or "no"for each of the following for all inspections:
Yes No
E ❑ Pumping information was provided by the owner, occupant, or Board of Health
El E Were any of the system components pumped out in the previous two weeks?
❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ Were as built plans of the system obtained and examined? (If they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
E El Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
E ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) 310 CMR 15.302(5)]
t5insp,doc•rev.7/26/2018 Title 5 official Inspection Farm:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Officimal Inspection Form
Subsurface Sewage Disposal System Form �- Not for Voluntary Assessments
A
72 Sterling Lane
�w
1
Property Address
Coppinger, Glenn
Owner Owner's Name
information is No. Andover MA 01845 0512312025
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
it }
DESIGN flow based on 310 CMR 15.203 (for example: 110 d x#of bedrooms): 440
gP }
Description:
Number of current residents: 2
Does residence have a garbage grinder? El Yes H No
Does residence have a water treatment unit? El Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection Yes No
information in this report.) ❑
Laundry system inspected? El Yes ❑ No
Seasonal use? El Yes ® No
Water meter readings, if available (last 2 years usage (gpd)}:
Detail:
Sump pump? El Yes ® No
Last date of occupancy: Occupied
Date
t5insp.doc•rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
1x _ Official ors
' w
', > Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M1
72 Sterling Lane
Property Address
Co in er, Glenn
Owner Owner's Name
information is No. Andover MA 01845 06/23/2026
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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? ❑ Yes ❑ No
Water treatment unit present? El Yes F] No
If yes, discharges to:
Industrial waste holding tank present? El Yes El 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:
Was system pumped as part of the inspection? ® Yes No
If yes, volume 1500
pumped: gallons
How was v uantit pumped determined? Sight gauge on the truck
q
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
ion
Title 5 Official Inspect" Form
Subsurface Sewage Disposal System Form Not for voluntary Assessments
0
M1
72 Sterling Lane
Property Address
Coppinger, Glenn
Owner Owner's Name
information is No. Andover MA 01846 06/23/2026
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
1:1 Shared system (yes or no) (if yes, attach previous inspection records, if any)
El Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the IIA system by system operator under contract
El Tight tank. Attach a copy of the DEP approval.
El Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Approximately 1997- 1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
6. Building Sewer(locate on site plan):
Depth below grade: 5'feet
Material of construction:
El cast iron N 40 PVC ❑ other(explain):
Distance from private water supply well or suction fine: 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
.
Official Forf'rl
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
8
M1
t - ~ 72 Sterling Lane
Property Address
Coppinger, Glenn
Owner owner's Name
information is No. Andover MA 01845 06/23/2026
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: 48" Built to..grade
Material of construction:
E concrete El metal El fiberglass El polyethylene El other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No
Dimensions;
5X 1oX4
rr
Sludge depth: 8
22
� !r
Distance from top of sludge to bottom of outlet tee or baffle 2
[1 r
Scum thickness r
Distance from top of scum to top of outlet tee or baffle 511
Distance from bottom of scum to bottom of outlet tee or baffle 8" W
How were dimensions determined? Tape measurelsludgeudge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both baffles are in good shape. No leakage, liquid level is good.
t5insp,doc•rev.7/26/2018 Title 5 Official Inspection Form:subsurface sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
.
e 5 Official Forr
'� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
g p Y Y
72 Sterling Lane
Property Address
Co in er, Glenn
Owner owner's Name
information is No. Andover MA 31845 06/23/2626
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
D concrete El metal El fiberglass El polyethylene El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 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 ❑ metal El fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: 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 Form
M
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
72 Sterling Lane
Property Address
Coppinger, Glenn
Owner Owner's Name
information is No. Andover MA 01845 66/23/2026
required for every
page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: El 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? ❑ Yes El No
9. Distribution Box(if present must be opened) (locate on site plan):
q
Depth of liquid level above outlet invert o
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 is corroded and there is leakage around the outlet inverts.
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
cial Inspection For
Title 5 Offi
ire 11
r w
tiQ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v v
04
�a 72 Sterlin Lane
Property Address
Coppinger, Glenn
Owner owner's Name
information is No. Andover MA 01845 06/23/2026
required for every
page. City/Town State Zip Code Date of Inspection
D.......System Information (cont.)
0. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes El No*
Alarms in working order: D Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
2 -66'
® leaching trenches number, length: W
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
. .
wOfficial Form
� a
Subsurface Sewage Disposal System Form Not for voluntary Assessments
M
R. ,yl6titib4 72 Sterlin Lane
Property Address
Coppinger, Glenn
Owner Owner's Name
information is No. Andover MA 01845 06/23/2026
required for every __
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No hydraulic failure, no ondin , no dam soils
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth --top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7126/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
.. wTitle 5 Official Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
ma
v v
M1
r �k.
�fti'1 qy v�+ 72 Sterling Lane
Property Address
Coppinger, Glenn
Owner owner's Name
information is No. Andover MA 01845 06/23/2026
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Officiai inspection Form
� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
72 Sterling Lane
Property Address
Co in er, glen
Owner owner's Name
information is No. Andover MA 01845 06/23/2026
required for every
page. City/Town State Zip Code 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 bu, ding. Check one of the boxes below:
nd-sketch h� c in the area below
drawing attached separately
.:........:.
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t5insp.doc rev.7l2612018 Tit' 5 O��s�ll Inspe�tion Foi�� 5ubst�rfaue Sewage Disposal System•Page1C of 18
Commonwealth of Massachusetts
�x lWTitle 5 Official Form
Subsurface Sewage Disposal System Form - Not for Voluntary� v Assessments
r�►
i ti�y`6 72 Sterling Lane
Property Address
Coppinger, Glenn
Owner Owner's Name
information is No. Andover MA 01845 06/23/2026
required for every
page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
El Surface water
El Check cellar
❑ Shallow wells
32"
Estimated depth to high ground water: 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 Ian reviewed: 10/29/1997 W
g p Date
❑ 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)
[� Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Taken from design plan on record
Before filing this inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 1aInspectionForf1
) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v v
9 J�
72 Sterling Lane
Property Address
Coppinger, Glenn
Owner owner's Name `
information is No. Andover MA 01845 06/23/2026
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. inspector information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 21 3, or 4 checked
® C. Inspection Summary:
13 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank-- Pumping contract attached
For 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