HomeMy WebLinkAboutPass - Title V Inspection Report - 135 APPLETON STREET 7/26/2026 Town
of NWh
Andover
Commonwealth of Massachusetts
Title 5 Official Inspection Form AUG 4,2 2
- Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments
Y -Health DepcIftmentPry ert Address
Owner ;Owner's Name
information is' �required for else _page, 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 I formation
filling out forms
on the computer, I C-.k Q,
use only the tab _- _ �_ _ _ _ _ _ _
key to move your Name of Inspector _
cursor-do not
use the return
key- Comp Name
Co y AddressIL Ar -
it fTo n State Zip Code
Telephone Number License Number
B. Certification Y
l certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CM R 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the in€variation 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 l have determined
that the system:
1. Passes
2. ❑ Conditionally Passes
3. El Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspector's Signature Date -
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection, if the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shalt 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.
M+,x;d6c•t&. 5 1 WDIX T 4#Is of"*al�,&P *n r&n of 18
3 Commonwealth of Massachusetts Ad
Title 5 Official Inspect0ion Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
R
i. 1K
r Property Address l
r
Owner Owners N
information is � r
required for every .- 2 ---- ---`
page. CitylTown State Zip Code Date of inspection
C. inspection Summary
Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 5.
1) System Passes:
kN 1 have not found any information which indicates that any of the failure criteria described
in 310 C M R 15.303 or in 310 CM R 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
L&Q-,
2) System conditionally Passes:
El e or more system components as described in the"Conditional Pass"section need to be
re aced or repaired.The system, upon completion of the replacement or repair, as approved by
the rd of Health, will pass.
Check the box "yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," pleas xplain.
The septic tank is metal an er 20 years old*or the septic tank (whether metal or not)is structurally
unsound, exhibits substantial in i ion or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replac with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is struc Ily sound, not leaking and if a certificate of
Compliance indicating that the tank is less than 20 years is available.
❑ Y El N El ND (Explain below):
tsinsp.doc-rev.6119/2026 Tiffe 5 Official lnspecton Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts '
.r"w,. _ a
� -� - _ TitleectionForm
- Iro Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
jr
Property Address
Owner
owner's N ame
information is r�
required for every _ _ _ _ —2 S `•C
page. city/Town State Zip code Date of inspection
C. Inspection Summary (coat.)
2) System Conditionally Passes (cont.):
El Pump 01j@mber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/a[a s are repaired.
El Observation of sewage ckup or break out or high static water level in the distribution box due
to broken or obstructed pipe or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval oard of Health):
El broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ N ❑ ND (Explain below):
El distribution box is leveled or replaced EJ Y ❑ N ND (Explain below):
D The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
syste will pass inspection if(with approval of the Board of Health):
[] roken pipe(s)are replaced El Y D N ❑ ND (Explain below):
Ej obstru n is removed Ej Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Boar f Hearth in order to determine if
the system is failing to protect public health, safety or the envir meet.
a. System will pass unless Board of Health determines in acc rdance with 310 CMR
1 5.3Q3(1)(b) that the system is not functioning in a manner whi h will protect public health,
safety and the environment:
!_5w-=*Ax•rev S 1 IV202f Offto.A H morn Fomw cumu4a-*eAwage L), ;,rsit m•page 3 of s g
Commonwealth of Massachusetts A
!�
itle
Form
___ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property 175-&�SA-r>
SS
Owner Owner's Na
information is e.
required for every,
.�b-
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Ces 1 or privy is within 50 feet of a bordering vegetated wetiand or a salt marsh
b. System will fail unie the Board of Health(and Public water Supplier, if any)
determines that the system unctioning in a manner that protects the public health,
safety and environment:
[:] The system has a septic tank and soil a rption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to rface water supply. _
❑ The system has a septic tank and SAS and the S is within a Zone 1 of a public water
supply.
El The system has a septic tank and SAS and the SAS is withi o feet of a private water
supply well.
[:] The system has a septic flank and SAS and the SAS is less than 10 eet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
❑ due to an overloaded or clogged SAS or cesspool
t5lnsp.doc-rev.5119/2026 Tile 5 official lnspecdon Form:Subsurface Sewage Disposal System•Page 4 of 18
}
Commonwealth of Massachusetts
AL
Tiotle 5 Official Forrr�
--= r Subsurface Sewage Disposal SystemForm Not for Voluntary Assessments
Property Address
Owner 6wner's Name
information is Irl �--.
required for every _.
page, ity{Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System 'Failure criteria Applicable to All Systems: (coat.)
Yes No
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less
❑ 11Athan /2Y
da flow
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ P Any portion of the SAS, cesspool or privy is below high ground water elevation.
El 5<T Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributaryto a surface water supply.
Ej 0" 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.
❑ 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 DFP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than a ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this forma
ED The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ The system fans. l 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 151000 gpd.
For large stems, you must indicate eithe "= es"or"no" to each of the following, in addition to the
questions in ction CA.
Yes No
❑ ❑ the system I 'thin 400 feet of a surface dri water supply
❑ �] the system is within 2 eet of a tributary to a surface rinking water supply
❑ ❑ the system is located in a nit en sensitive area (interim llhead Protection
Area --- 1wPA)or a mapped ne 11 of a public water supply 11
t5w iP(UX-rev 5 1I Si O.V f do IJ�-9-3.e1 tes'"r orm IiAA; il'JE Sr�' rkuv: +,-j 4i 7'rIftni-Pao*S of L 3
r * A
Commonwealth of Massachusetts
Title 5 Official Form
. . .... Subsurface Sewage Disposal System Farm=Not for voluntary Assessments
r
Property Addres �
P Y
Owner owner's Name
information is _ C .-
required for every A0!Q6t&
page. CitylTown State Zip Code Date of inspection
c. Inspection Summary (cont.)
If you have answered `yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA 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 CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
0. You must indicate"yes"or "no"for each of the fallowing for of inspections:
Yes No
5A ❑ 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?
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 N/A
❑ Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
El were all system components,excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Ei 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:
El D Existing information. For example,a plan at the Board of Health.
Ei Determined in the field(if any of the failure criteria related to Part G is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
t5insp.doe•rev.5/19/2026 Tile 5 Of ia!inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
A
qb
t Commonwealth of Massachusetts
- Title 5 Officia ionForrr�
3 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�' 3 � __tom
77d-
Property Address
-Z CA�vcs'ou
information is 6 &— (3
required for every - -- -- ..�_ .�_ . ___._ _ _ .�. _._
page. �1Town State Zip Code .�Date_ of insp. _ection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CNIR 15.203 for example: 110 d x#of bedrooms):
{ p gP �
Description:
Number of current residents.
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes No
If fires,discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection Ej Yes No
information in this report.)
Laundry system inspected? ❑ Yes No
Seasonal use? El Yes No
Water meter readings, if available Mast 2 years usage (gPd))= /J
Detail:
Sump pump? El Yes 16 No
Last date of occupancy: �..0.1P,(1�e��'
Date
t`ow fkx•wj 5 1W42f; T- 5 C^nal Ir Form IrA satxo S,raae(>%w.M S rtoon•Pao T of 1a
Commonwealth of Massachusetts r
T otle 5 Offm 0 1 Inspect"ion Form
icia
_ - I Subsurface Sewage Disposal System Form r Not for Voluntary Assessments
Property Add �`y
Owner Owner's Na
information is [ `` -•2,] ��
required for every
page. City/Town State Zip code Date of Inspection
D. System Information (cont.)
2. C merciaMndustrial Flow conditions:
Type of Esta ment:
Design flow(based on 3 MR 15.203): Gallons per day(cgpd)
Basis of design flow(seats/persons ft., etc.):
Grease trap present? El Yes ❑ No
Water treatment unit present? El Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? Yes No
Non-sanitary waste discharged to the Title 5 system? El Yes N
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
r
3. Pumping Records:
LU
Source of information:
Was system pumped as part of the inspection? El YesA No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc.rev.519/2026 Tide 5 official lnspecdon Form Subsurface Sewage Disposal System•Page 8 of 18
y �
t
} g Commonwealth of Massachusetts
r
- Title
icial Inspection For�1
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
Owner ner's Na e
information is IJXJ4,required for every __ _
page, CitylTown 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 no) f 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 11A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ other(describe).-
Approximate age of all components, date installed (if known)and source of information:
k
6.__s
Were sewage odors detected when arriving at the site? ❑ Yes No
5. Building Sewer(locate on site plan):
cr
J�
Depth below grade: feet -
Material of construction:
cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
/101
Comments (on condition of joints, venting, evidence of leakage, etc.):
/11 C., , j
� r".0 ri c- ►S t � T4@ 5 0ft�at in{.De tw Fon-:.St".Aace C.4w D-.V-rej Syet�r-p -e 9 of I g
m
y w
u
mm
Commonwealth of Mas,sachusefts
ici*al Inspection Form
... ..........
T*tle 5 Off*
Subsurface Sewage Disposal System Form Notfor Voluntary
Assessments
wf n a
r
000
03
3'00"
Propedy Address,
C-L),4)
Owner Owner's Na
inforn,-tation is
r eq UircA for' ve
pity e Da �of Inspection
D, System Information (cont.)
. Septic Tank, (locate on site pfan)-
Depth below grade.- -feet
Material of construction:
concrete metal iberg spolyethylene then(explain)
If tank is rnetal, list
s age confirnied by a Ce,rtificate of Comipliance? (efface a cop certificate) es, No
Dimensions-
Sludge
Distance from, top of sludge to bottom of outlet tee or baffle
Scum thickness
dimensionsDistance from tOp Of'SCUM to top of outlet tee or,baffle
'0/
Distance from bottom of scum to bottom of outlet tee or baffle
How were
Comments (on pumping recommendations, inlet condition,i , structural �i ,
liquid levells, as related to outlet invert, evidence of leakage, c.'
� ��
t5insp,doc, rev,5 1 W2026 T'Ide 5 Off�c�al finspecton Form.,Subsurface<_;ewage Nspiosal System-Page 10 of'18
Commonwealth of Massachusetts
`y
== Title 5 Official
} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
lr ry
ry
Property Address
Owner owners Na e _
information is '+ �l
required for eve _
page- Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
7. Grease Trap (locate on site plan):
Depth be grade: feet
Material of const Lion:
El concrete El m al ❑fiberglass Ej polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle - _ - - -- -- -- ---- ------ -- -
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date - ---
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, ructural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
S. Tight or Holding Tank (tank must be pumped at time of inspection) (locate an site plan):
Depth below gr e:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass El polyethylene [] other(explain):
Dimensions:
Capacity:
gallons
Design flow:
gallons per day
t5on-M 1.44X.eev 5 r*rA26 �Al Ir.specoo rota Sk&4(AV.0 stwage r> rye: t is
,%.,w I'
.5'ft :" ,
do
�LN Commonwealth of Massachusetts
1tle 5 Official I Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
_ � T
3l
Property Address U0
Owner ei's
information is ,
red far ev required every
equi City/Town State Zip Code Date of inspection
D. System Information (cont.)
S. Tight or aTank(cons.)
Alarm present: EI Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes El No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). is copy attached? EJ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
lj�/ �.
1 ,-)
AJ 6 Q A Ry )t-Ctn�--A�
0eva S'r *M00000W
L!
t5insp.doc•rev.5119=26 Tile 5 Off Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
we 1�
Commonwealth of Massachusetts
�_ = piaInspect"ion F
subsurface sewage Disposal system Form -Not for Voluntary Assessments
13
Property Addr
�vcw
___ 1! �
Owner /�er's
infomia/-tion is c�
required for every
page. ,.,.-
page, CitylTown State Zip Code Date of Inspection
D. system Information (cant.)
10. Pump C mber(locate on site plan):
Pumps in working or D Yes ❑ No*
Alarms in working order: Ej Yes El No*
Comments {note condition of pump chamber, condition o s 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: _
❑ leaching trenches number, length:
leaching fields number, dimensions: t3
overflow cesspool number:
EJ inn ovative/alternative system
Type/name of technology:
'S-nW d0C•rev S 1 W02G fi Ze 5 OMuai lnspecWn Farm S"bwrface Sao[>,% A 5bra3am•Pa"13 of 18
r� ,�
Commonwealth of Massachusetts r
=-w Tmitle 5 Off Forr
y Y
T subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y~
Y
Property Address
Ile?C-
owner Ownees Nam
information is -►r �.-
e uired for eve f
q
page. Ci�[Town State Zip Code Date of Inspection
D. System Information (cant.)
11. Soil Absorption system(SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soli, condition of
vegetation, etc.),,
k�§vg-
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number configuration
Depth—top of liq ' to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow Ej Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of p ding, condition of vegetation,
etc.):
t5insp.doc-rev.5119/2026 Tine 5 dffidal Inspection Form:5ubsurfaoe sewage Disposal System•Page 14 of 18
� -r,
N
Commonwealth of Massachusetts
y \
r.
_ �
TitleOff'ici'al ectsion Fo rm
-� +y Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
f
Property Address too
Owner Owner's X/e�,
informativn is
r 'red for every
eq
page. City/Town State Zip Code Date of Inspection
D. System Information {cant.}
13. Privy(loc on site plan):
Materials of construc
Dimensions
Depth of solids - -- -- --�- - �- -�-
Comments(note condition of soil, signs of hydrau' failure, level of ponding, condition of vegetation,
etc,):
tS4r-,W •rev S 1 W3�Ei IF"5 Muni hspocWn ranyr Sot-Aye
Commonwealth of Massachusetts
Title 5 Off"icial Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
{
Property Addrep&B
Owner Owner's Na^ .
information is
required for eve �
ry City/Town frown State ip Code Date of Inspection
page.
tY
D. System Information (cunt.)
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 bones below:
❑ hand-sketch in the area below
❑ drawing attached separately
w
C.
7B � C.
7
t5insp.doc•rev.6119/2026 Ti#e 5 official Snspecton Farm:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Tl"tle 5 Official Inspection Form
- -
_-- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner owner's NamX:k
formation is ._._. ��
' ?f)--
eq red for every _.�. ____._.
page. city-. own State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
Surface water AS-i� AJ"-
Check cellar
❑ Shallow wells
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 plan reviewed: Data
❑ observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health- explain:
El Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you estab' ed the high ground water el nation:
r-7, (� , J3
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
taursr,riot-•rev 5 1 SM23 I do 5 or-oat hspet*cam Form S"bsurface S&&n*1> ;y%tem•Page 17 of 1 S
r
Commonwealth of Massachusetts 1,6
f icimalForl'�1
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
),e .'7'JA/x
Property Address
Owner e(s Nam `
information is /V
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, 2,3,or 4 checked
C. Inspection Summary:
1, 2, 3,or 5 completed as appropriate
4(Failure Criteria)and 6 (Checklist)completed
D. System Information:
For 6: 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
t5msp.doc.rev.511912026 Tile 5 offidal hspccdon Form:Subsurface Sewage disposal System•Page 18 of 18