HomeMy WebLinkAboutPASS - Title V Inspection Report - 1 BRECKENRIDGE ROAD 10/19/2026 Town of Nofth Andover
Commonwealth of Massachusetts
itlel 5 Official Ins ection, Form OCT 19 2026
P
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1 Breckenridge Road Health Dep_artme...nt
Property Address
M
I!iller, Co,ll;een
Owner
Owner's Name
information,is No Andover M�A 01845 09/11 0/2026
reqluired foir every
page. City/Town State Z,ip Code Date of Inspection
Inspection results must be submitted on this forma. Inspection forms may not be altered 'in any
way. Please see completeness checklist at the end of the form.
Importan't:Whe�n A Inspector Information
filling out forms .
on the computer,, John L,. D�iVincenzo
use only t to he —1-...... .........
I to move your Name of Inspector
cursor-do not J & S Develo ment/Stewart"s Service
..........p_...........
use the return Company Name
Iv ey.
58 So. Kimball Sit.
tab Company Address
Bradford MA 01835,
........... . .......... ........ --------
City/Town State Zip Code
91781-372-7471 S113386
---------------------__.................. ............................................. ..........-----------.........................................................................................................................
'Telephone,Number License N�umber
B. Ceftification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 1:5. 10); I have personally inspected' the sewage disposal system at the prope�rty address
listed above-, the information rep�orted below is true, accurate and complete as of the time of my
inspection; and the ins,pection was performed based on my tr,ai,ning and experie�nce in the proper function
and maintenance of on-site sewage disposal systems. After condu�cting thi's i'ns,plection I have determined
that the system,
1. Passes
2. Conditionally Passes,
3 Need's Further Evaluation by the Local Approving Authority
Fal
09/10/2026,
I pect r's,Sign at e 4_11 Date
I
The system inspector shall submit oply of this inspecti n report to the Approving,Authority (Board
of Health or DEP) within, 30 days, o, 'completing this inspection. If the system; has a design flow of
1010100 gpd or greater, the inspector and the system, owner shall submit the report to the appropriate
regional office of the DEP. The original form!, should be sent to the system owner and c,oplies sent to
the buyer,, if applicable, and the approving authority.
Please note: T'h�i�s report on:l,y 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.
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1Commonwealth of Massachusetts
i
io:n
I Ins&ftect" Floir�m
T"Itle 5 Q'"O" t6*t0**icia
Subsurface ew Disposall System Form Not for Voluntary Assessments
1 c Ili i
-------
Property Address,
iller�, C blear
�_...w.0 _ _ -----_------------- ---Owner ..._............... ... ....,....... _ �.�....-.._�._ ._. _..____....._._. _.....
Owe'r's Nary
information is, Noa r 1 1 2
required `oar --ww- _...,_w__.. V _._ m _._ -_ --- - --- �.._. .._....... ..._...
ogle. City/'To City/'Tolwn, Mate Zip ode Date of A' is lecti oR M
C. Inspection Sumimary
Inspection Summary, Complete 1, 21 3,1 or 5 and all of 4 and 6.
I have not found n iniformation whichindicates that any of the faillure criteriadescribed
in . 1 or in 310 CIVIR 1151.304exist Any failure criter,ia not evaluated are
indicated i l
Comments.-
.
Condtionally Passes:
1,
E] one r moresystem complonen�ts as describedin t1 "Conditional P ass," section need to be
rep
l it , The system, upon completionthe replacement or irl as approved
the Board of Health, 'will pass.
Checkthe box for ", "no" or"not determined" , N, for the following t t rats. I "snot
determined,1'1' lies lain.
The tic t i l't r 20 years old* r t tic t (wheth�er metal t is structurally
unsound, exhibits substantial infiltration r exfiltration or ta,nk i�llur nent., Syst ill pass
inspection it the existingta:nk is replaced it complying septic tank as approved by the Board of
Health.
metal s tic tank ill pass inspection it it is structuralll,ysound, not leaking andif a Certificate
Clompliance indicatingthat the tank is less than 20 years old is availabile.
EI Y N ND I below),
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Commonwealth of Massachusetts
Tultle 5 0 1 Inspection Form
Subsurface, Sewage Disposal System Form Not for Voluntary Assessments
1 Br,eckenr'io .................................. ...... -—----
Property Address
Miller, Colleen
Owner Ow ner' Nam ......................................s e
information is
:over N ol. A n,d' M A 01845 09/10/2026
required for every —------
page. City awn state Zip Code Dia,te of Inspection
C. Inspection Summary (cont)
1
2) System CondI'tionally Passes (cont.).-
Pump Chamber pumps/ala:rms not operational. System will pass,with Board of'Health approval if
plumps/alarms, are relpa,ired.
Observati 'sewage backup or break out or high static water level, in the distriblution 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):
E:1 broken pipe(si) a!lre replaced 0 Y El N El ND (Explain below)-
El obstruction is removed F1 Y N 0 ND (Explain below)-
E] distriblution box is leveled or replaced El Y N!, El N�D (Explain below)-
................ ..................... .................................... .............11..........................................................................11...........
............... ------------------_................... .....................
The system required pumping more than, 4 times a year due to broken or obstructed' piplel(s),. The
systern will pass inspection if(with approval of the Board" of Health)�
0 broken, pipe(s) are replaced, [I Y El NEI ND (Explain, bellow).1
0 obstruction is removed [:1 Y El NEI N�D (Explain below):
........... ..........................
3) Further Evaluation, is, Required by the Board of Health:
El Conditions,exist is require further evalu t,ion by the Board of'Health in order to determine if
the system is fa,iling to protect public, health, safety oir the environment.
a. System will pass unless, Board of Health determines in accordance with 3110 CMR
15.303(11)(b),that the system Is not functioning in a manner whilch,will protect public health,
safety and the environment-*
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Commonwealth of' Massachusetts
4"NXw4rvNx ry
I� 11
' '��c ioln Form
Ir. .w �.-
jo Subsurface, Sews � Di�� ��l SystemForm Not for Vluntar Assessments
1 Breckenridge Road
....w_ ..,..�u....___.—_�_..__.. W.._.w..... ..�......�...�w. ...... ...___.. tin„n__.....ro.._.mm..
(Property Address
Miller, Coll n
Owne,r ------------- ....... .............................------- ------
Owner's, e
information is . Andover 1 1
0/20,26
required r ever �...._. _.w..,..wu w.... ... .. .,m ...m.........._......_. ----- -w_ -- _. �. _.__..... .....W
page, City/Town S,tate Zip,Code Date of Inspection
C. Inspection summary (c,o:nt.,)
0 Cesspool! or privy is within 50 feet of a, surface water
El Cesspool or privy is within 50 feet of a doirdering vegetated wetland or a salt marsh
b. System will fall unless the Board of Heal( and Public Water S pplieri, ii,f any),
determines that,the systems nctiionmg� in a manner that protects the pub ilc h:elallth,,
safety and environmen
Ej, the system has a septic teak and s lil absorption system SAS a d the SAS is within
10101 feet of a surface water supply or trld� tart'to a surface water supply.
The system has a septic tank and SAS and the SAS Is within a Zonie 1 f � llc water
suppily.
The system has a septic tank and SAS and the, SAS is withl!n 510feet of a private water
supply well.
The system has a septic tank,and SAS and�,the SAS is less than 0 feet but 5�O feet or
more from a, private water su�pply well� .
Method used to,determine dista,nce:
lis, system passes If the well water anal �sis, performed at a DEP certified laboratory, for fecal
c l f rm bacteria inddicates absent and the presence of ammon�ia nitrogen and nitrate nitrogen is equal
to or less than 51 m�, provided that no other failure,criteria, are triggered. A copy of the analysis must
be attached to t is form.
c. Other:
Criteria14) System Failure
You must I*c "' or" "to,each n for all e
Yes No
c u f sewage iinto facility r system component due to overloadedr
clogged', r cesspool
Discharger ponding of effluent to the surface of the groundr surface water's
due to an overloaded l r cesspololl
t5iin .rev,7/2612018 Tifle 5 Official Inspecfion I it ;Subsurface Sewage Disposatl Saga-Page f 18
11^N,
Commonwealth of Massachusetts
MAMIii,ANN&
itticia
T18 t I e 5 lectilon For
Slubsu�rf ce Sewage DiI sposal System Form Not for Volluntary Assessments
1 Breckenridge Road
................ ................................. ...............
Property Address
Mill! r, Colleen
Owner
a m�e ............... ..............................................
Owner's Ni
informiatioln is No. Andover, MA 01184 5 09/10/20,26
required for every ------------........................... ........... ---
age. ........................ ..........
City/Town State Zip Code Date of Inspection
C., Inspection Siummary (cont,.)
4) System Failure Crilteria App dice b,le to All Systems*, (conit.)
Yes No
El z Static liquid l veIl in the distribution box above outlet i,nvert due to an overloaded
or clogged S,AS or cesspool
11 z Liquid depth in cesspool, is less,than 61" below invert or available volume! is less,
than 1/2day flow
1:1 zi: Required puimpling moire than 4 times in the last'year NOT due to clogged or
obstru mes cted pipe(s). Number ofti , pumped-,
Ell Z, Any portioln of the SAS, cesspool or privy is below high gir,ound water elevation.
0i z Any portio l or privy is within 100 feet of a, surface wat r supply or
tributary to a surface wateir supply"
El Z Any portion of a cesspool, or privy i It a Zone 1 of a public water supply
weill.
1:1 z Any, portion of a cesspool or privy is wit,h�in 50 feet of a private water s,uppil�y well.
El z Any portion of a cesspool or privy is less than 11 00 feet blut greater than 50 feet
from, a private water ll with no acc ,abIle water quality ana,lys,is., (Thils
system passes if the well water analysis, pert"ormed at a DEP certified
laboratory,, for fecal c ill f'olrim bacteria indicates, absent and the presence
ofammon1a nitrogen and nlitriate riliftrogen is equal to or less,than 5 ppm,
p "ded that no other fai Ilure criterila err e triggered. A copy of the analysis,
rovi
and chial*n of custody must be,attached to,this for .]
1:1 z The system i l serving a facility with a design flow of 2000 gpd-
10,0100 gpd
El Z The system falls. I have determined that one,or more of the above failure
criteria exist as, described in 3101 GIVIR 15.303, therefore the system fails,. The,
system owner should contact the Bloiard of Health to determine what will be
necessary to correct the faiIlur,e.
5) Large Systems,: To be considered a large system the system must serve a facility with a
design flow of 10,0100 gpd to 15,000 gpid.
For large systes, you must indicate eit "yes," or"n o"m her, to,each;, of the following, in addition to the
qlu�estio:ns in Section C.4.
Yes, No
El 11 the system is within 400 feet of a surface drinking water suppil�y
E E the system is within 200 feet of a tributary to a surface drinking water s,upp:ly
the system is located in a nitrogen sensitive area (Interim WellhIead Protection
Area!,— IWP,A) or a mappied Zone 11 of �blic water supply wel;l
t5insp doic-rev,7/26/2018 Title 51 Official Inspection Form:Subsurface Sewage Disposial System-Page 5 of 18,
Commonwealth of Massachusetts
:nspect._ p Gw _ 10 To:tle, 5 Ot4*t'91micoial I' n For
Subsurface Sewage, Disposal System For Not for Voluntary Assessments
T
_Aw 1 B.rec.ke.n.ri.qge-..R.o.a-d-----,-,-,,,--- ............
Property Address
Miller, Colleen
.....................
Ownier Owner's Name
information is No nd MA 01,8451 0 9/10/2 0 2 6
required for every over A .............
paige. City/Town State Zip Code Date of Inspection
C, Inspection Summary (cont,.)
If'yolu have answered "yes' to any question in Section C.5 the system is considered a significant
threat, or answered 11 yes" to any questioln in Section C.4 above the large system has failed. The
owner or operator of large system considered a siginificani,t threat under Section C-5 or failed
under Section CA shall upgrade the system in accordance with 310 CMIIR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must wind icatie "ye s" or"null for each of the following for all inspections-:
Yes No
Z 0 Purnping information was provided by t r, rat, or Board of Health
0 Z Were any of the system components pumped out iin the previous two weeks?
E 1:1 Has,the system received normal flows in the previous two week period?
El Z Have large volumes of water beein introduced to the,system recently oir as part of
this inspection?
Were as built plans of the system obtained and examined? (If they were not
available note
Z El Was the facility or dwelling inspected for,signs of sewage back up?
E El Was the site ins:pleicted for signs,of break out?
Were all system coimponents,, excluding the SAS, located on site?
Were the septint anik manhoiles, u,ncovere�d, opened, anidthe interior of the tank
inspected for the condition of the baffles,or tees, material of construction),
dimenisions, depth of liquid, depth of sludge and depth of scum?
0 Was the facility owner n cc t if different from owner) provi ded with
information on the proper maintenance of subsurface sewage dig,posal tems,?
i
The size and location of the Soil Absorption System (S,AS) on the site has
been determined biased on:
E El Existing information., For example, a plan at the Board of Health.
i I I
Determined in the field (if any of the,failure criteria related to Part C is at issule
Z approximation of distance is unacceptable) (310 CMR 15.302(5)]
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Commonwealth of Massachusetts
I(V"P, 1"t1e 5 UITTIcial Inspo%ection Form
Subsurface, Sewage Dil'sposal System Folr,m Not for Voluntary Assessments
1 Brecken(i4ge Road
............... .....................
Property Address
Miller, Colleen
Owne,r Owner's Name
information is N�o�. Andover MA 01845, 09/10/2026
required for every ............................... ............. .............. ............
page. CitylTown, State Zip Code Cate of Ira spection,
D. System Information
1. Residential Flow Condilbonse,
Number,of bedrooms (design)- Number of bedrooms (actual)*
440
DESIGN flow based on 31'OfC,MR 1'51.,2,013 (for example: 110gpdx#ofbedrooms)"
Description�
............ ............... ...... ...... ........ .......... ...........
.......... ..........-........... .................................................
Number of current residents',
Does residenice have a garbagie grinder? Z Yes 0 No
Does residence have a w,at r treatment unit? E] Yes Z� No
Is, laundry on a separat stem? (Include laundry'system inspection EI Yes, Z No
infor ti,oin in this report.)
Laundry system inspected El Yes, No:
so use? El Yes Z No
Water meter readings, if alv air lable (last 2 years usage (gpd)),
Detail:
..............-........................... ......-- ..............
.....................................
.................................... ------
Sump pump? El Yes Z No
Last at of occupancy.- 'y pj'eld
Date
t5insp.doic-rev.7/2 201I8 Title 5 Official l'inspection Form Subsurface Swage DisposW System-Paigie 7 of 18
Commonwealth of Massachusetts
A.
tticia
T10 t I le 5 n�s w%ection Form
-1 Not,for Volluntary Assessments
Su�bisu�rfa,ce Se�wage Disposal System Form
roc �r'i
_...... . m... ..__... _µRoad
..Pro 's delis
M�iller, Colleen
_............... .......... .......m...... ....m...mm.....
Owner'sOwner
information is Andoverreq:uired for ev�ery2026
............
MA 018451. _.. y..uw._
page. City State Zip C Ie ate._.. l nil ecti n,
D., System Information
2. Commercial/Industrial FloCon ':':
Desi _..._. _.._. ..............�............ ..m._�. ....Wµ_.__.. .... ....
Gallons per day(gpd)
pis of designdo is n .tt., etc. m____. ._................................ ...
Grease tau rat? El Yes No
Water treatment it present? EJ Yes No
If yes, discharges,to:
Industrial'waste holding tankresent
Non-sanitaryate discharged to the itlsystem,? 0 Yes, [:j No,
Wa�ter meter readings, if ii i
Last, t
r (describe it -
., Pumping Recordsol
Source ........
it tir t . ::._ '. .� ww_w
systemthe i ti WYes No
1500
If yes, volurne pumped* gallons
How was ntit t in Slight gauge on
a
true _
nk
Reason forplumping'.
lu ire : spe�t t
.... ... ..... _ _ _ w.m. w._u.,..,. . .. __.__.__ _. _.
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Commonwealth of Massachusetts
I l cmia- Inispr%ection Tot,le 51 0""'000 For
Subsurface Sewage Disposal System Form Not for Voluntary Assessments,
1 Breckenrid e Road
.....................
Property Address
Miller, Colleen
Owner
Olwner's,Name
information is
No. Andover MA 018451 09/10/2026
required'for every
page. City/Town St___ ate Zip Code Date oflnispectioln
D. Systemi Information (core.)
4. Type of System:
Septic tank, distribution box, soil absorption system
Single cesspool
Overflow,cesspool
Privy
Shared system (yes, or nio) (if yes, attach previous inspection records, if
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 olpl rator under contract
Tight tank. Attach a copy of'the DEP approval.,
Other(describe)-
.................-
Approximate age of all components, date inistalled (if known) and source of information-:
1 1
989
............. ------
Were sewage odors detected when arriving at the si!te? El Yes [E No
5. Buildlingl Sewer(locate on site plan),:
2011
Material of construction:
Z cast iron E] 40 PVC 0 other(explain),- ------ ............ .........
Distance from private water supply well or suction line.. -1 fee-t ...........
Comments, (on condition of joints; venting, evidence of leakage, etc.):
t5i,n:sp,doc-r v,7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
vttici"al Insw%ect'
T t le 5 V ion For
:.._
Subsurface Sewage [deposal System Form Not for Voluntary Assessments
Property Address
Miller, Colleen
Owner ...........
Owner's Name
information,is
MA 01845 09/10/2026
required for �every _�_.__�_�._..._�._�...m�..._...................._ _..._�.m_"._�_. .� � �. ------ _w�. ___
page City/gown State Zip Code Cate of Inspection
D. System Information (cost.)
Septic6. drank (locate on site lan
Depthtograde-
Material of construction:
conicrete metal fiberglass polyethylene other(explain)
If tank is till, list
years
Is age confirmed Certificate of olmpilian,ce? (attach a copy of certificate) D Yes El No
1
51
Sludge depth:
__...... _..... _ _... mm_............. ... .......mmm.M........
Distance from top of sludge to bottom of outlet tee or baffle
Scumi, thickness
Distance from top of scum to top of outlet tee r baffle
15,
Distance from bottom of scum to bottomof outlet tee or,baffle
How were dimensionst r ire . Tape measu�re/slud:ge Judge
Comments on pumping recommendations,l inlet rr outlet tee or,baffle condition, structural integrity,
liquid l v is as related to outlet inv rt,1 evidence of'leakagel, etc.
t baffles r n i k li l l is__g.00d,,
..............t5i .d •rev. f' / 1 8 TifleOfficial i Inspection Fora;Subsurface Sewage Disposal System.Page 10 of 18
rCommonwealth of Massachusetts
T TTICI ion
"tie 5 0"" al' Inspect" For
ra .n_ ..
.� SubsurfaceAli �"cr for Voluntary Assessments' '
wa
r n ri d
_........ w.......
Property Address
iller, Colleen
Owner Owner's Name
information is
mmw,..... ......_._�m��...�m�e.mm..�. .... , ._... _................. ._ w... _...._.._...m_..required: r �_
gage. City/Town
State Zip Code Cate of Inspection
D. System: Information (cont.)
. Grease Tr, 1ocat on siteplan)-
grade-
feet
Material of construction-.,
El concrete, D metl fiberglass El polyet ylen other(explain):
Dime�nsi sa
-------
Scum thickness
Distance from top of scam to top of outlet tee or ba,ffle ......
Distance from tt �r w of scum to botto�m of outlet tee or baffle
Date �f last purnping. Date
Commentspumping r c rr mer nd tions, inlet andoutlet,tee or baffle condition, structural integrity,
liquid Bevels as related to outlet,inv rt,I evidence of leakage, etc.):
8. T"Ight or H ld'Ing Tank (teak must be pumped at time of inspection) (locate on s%tplan):
Depth below grade-
eternal of construction:
El concrete El metal fiberglass polyethylene other(explain)*
allo ns
Design Fly: gallons per day
t insp. -rear.712612018 Ttle 5 Official Inspection Forn Subsurface Sewage DisposaN System Page 11 of 1
Commonwealth of Massa ch usetts
-00
mm
UTT 1 Inspection Forill,
Totle 5 0""""iucia
"I Subsurface age Dilsposall System Form Not for Voluntary Assessments
� ,` � 1 B rec n ker Road
�(Oqf�............................. mm� .......
Property Address
Mi�ller, Colleen
...................... ............
Ownier Owner's Name
inform�a,tion is No. Andover MA 0845 09/10/201
r equired for every 1 26 ..............--------
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tilght or Holding Tank (cont,):
Alarm pr t- 0 Yes E] N o
0 Yes N ol
Alarm lev l: Alarm in workiin!g order'.
Date of last pumping-
Date,
Comments (condition, of alarm and float switch s,, etc.)*
.................-.............
..................
Attach copy of current pumping contract(required). Is copy attached? Yes NI ol
9. Mistribution Box(if present,must be opened) (locate on site plani)-
0
Depth olf'liquid level above outlet invert
Comments (note if box is, l l and distribution to outlets equal, any evidence of solids carryo!ver, any
evidence of leakage into or out of box, etc.):
ual distributi�oni, no leakage,, no solids carryover ------
..........--.-...........
.................... --------------- ..........
................ ........
.............
t5insp doc-re'v 7/26/2018 Title 51 Official inspection Formi-Subsurface Sewage Disposal!System-Page 12 of 18
Commonwealth of Massachusetts
�T�icia von or
Tl"tle 5 Q' T""" I Insw%ec'" F
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1 B reqk
Property Address
Miller, Coillee
ner's �n
Owner ......... ...............----------
Ow Name
information is No. Andover MA 01845 09/1,0/202�6
requiredfor every ...... ................. ........... ................................................-.......................... .............................
page. Ci,ty/Town State Zip Code Date of Inspection
D. System Information (coin,t,.)
10. Pum�p a_ bed`(locate on site plan):
Pumips iln working or rl- El Yes No*
Alarms in working order: Z Yes 0 Noi*
Comments (note conlidit,ion of'pum,p chamber, condition of pumps and appurtenances, etc.):
Tested pump by lifting floats, in the pump chamber. Pump,&alarm were working at the time of
inspection.
..........
........... .......-..I...---.........................................................................................................
...............-....................................----......... ................................................. ........... ..........
* If' u:mps or alarms are not in working order, system is a conditional pass.,
11. Soill Absorptilon System (SAS) (locate on site plan, excavation not required):
If SAS, not located, explain why:
................. ....... ....... ......................... ......... .................. ..................................... ...........
................ .......... ------------.......................................
Type,-
ED leachiing fits, number.
E] leaching chambers num:be�r.-
El leaching galleries number-. ............. .................................... ................................................
4 -43f
leaching trenches nuimber, length- ................................................................ .....................
leac,h!ing file�lds number, dimensions:
Eli overflow cesspololl nu�mbe,r-
innovative/alternative system
Type/name of technolo� -
t5insp.doc-rev.7126/2018 Title 5 Official!Inspection Form.Subsurface Sewage Disposall System-Page 13 of 18
Commonwealth of Mas,s,achuse�fts
attnia
__ _._:. . Title 5: Lc 11 Inspection For
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1 Breckenridge�oad
........................................................................
Property Address
Miller, Colleen
Owner
Owner's Name
ini fir mation is, No., Andover MA 01845 09/10/202�6
re quire d fair ever y
page. City/Town to Zip Code Date of Inspection
D. System Information (cont,.)
11. Soil Absorption System ($AS) (cont.)
Comments (note coi ition olf solill signs of hydraulic failure, level of ponding, damp soil, condition, of
vegetation, etc.).,
No pond_ina, no dam P_ lsl no hydraulic failure.so-1-1- ---
......................... ----------------
12. Cesspools, (cesspool use be plumped as part of inspection) (locate on site plan)'�
Number and configuration
Depth �—top, of liquid to ilnlet invert
Depth of'sollids layer
Depthof scum layer ww........... ........... ...............................................................................................................................
Dimensions of cesspool
Materials of construction
Indiaion ofgroundwate,r infl No
Comments (note condition of soil, signs of hydraul'i failure, level of ponding, condition of vegetation,
etc.)�.
............ ........_1.................
............ ---------
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' r
"tie 5 Q'g�'Tr-Trincm I
wCommonwealth of Massachusetts
Insaftecto
1�7� i a ion
u";� Subsurface Sewage Disposal System Form Not for Volunta,ry Assessments
^C
Property Add,ress
iller„ Colleen
Owner .............
Owner's,Name
informat,ion is, l �. Andover
page.required for every
it Town State Zip Code Date of Inspection
D., System Information (cont.)
13. Privy (locaten: site plan):
r
sls, of construction'
Dimensions
Comments (note condition s' it, signs'of hydraulic,failurey level of ponding, condition of vegetation,,
etc:
f rasp. »rev.7/2612018 TAIe 5 Offic4 Inspection Fora:Subsurface Sewage'Disposal System-Page 15 of 1
ch of Maosachusetts
Commonweaft
� Off's
■ :IInspectoion Fors
Subsurface Sewage Dispa al System Farm -Not for Voluntary Assessments
I Brackendd a Road
Property Address
offer, ColleenF - - ..• - - -- _ �._ ..._ ... _....
Oviner Owner's Name
information is � � �.� � 09��������
required for every No.Andover
page. City/Town k State Zip Code Date of Inspection
D. System Informafi n (cont
Sketch of S&m a D os�i System:Provide a view of the a di Ma $ s am n fudin ties to
at least two permanent re renca landmarks or benchmarks Lo to a well In 1 o t. Locate
where public water supply enters the building.Check one of a x belo :
hand-sketch in the arda baler
0 drawing attached separately �
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Commonwealth of Massachusetts
Otle 5
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i o n
ubsu ace Sewn a Dis s 1 FInspect'
Breckeinrid e Roadu__._...,_,.
Property Address
Miller, Colleen
Owner ------..m�___m.___-____�mA A_�___-��_.r....�..�_...._�.._....�._mm�..�._.._.� .�__......e..._.....mm...._.m....._...�._�.�.m..�..��....._�.._.�.....__._........�.m_.. ___-_-
Owner's Name
information is
And
09/10/2026,
r quir d for every .. �..w.._. __..� � �
page. Cit /T'ow n state Zip,Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Check1
SurfaceEl at r
Check cellar
El Shallow ells
Estimated depth to high groundwater: 20" belowrade
feet
Please; indicate all methods used to deter ire the high ground water elevation,
.
Obtained fro � system des,ign planscan record
1
if c ticked ate of e l plan r vi e 1 1
999
r Date
Observed i (abutting r r r tioln hole withinfeet of SAS)
Checked i h local Board of Health - explain".
Pulled fide
Checked with local excavators, installers- (attach documentation)
databaseAccessed UISGS -explain-
.
You mush describe howyou, st lis a the high round) water elevation-
Taken from deli n j�ns n r-cord is r is to mint in a ' titer se �'r tip .�.w�..._..��..,.�.�_.�.__......r�....�.�._..�....w..�....... ....�.� �..........w..w�...�._..._.... .. .�. ...mm��....._...�_. .�mm......._.
-------
Before filing is llnspection eport, please see Report Completeness Checklist on next
t5 i nsp.doc.rep,7/26/2018 Tifle 5 Official InspectionForm:Subsurface Sewage Disposal System-Page 17 of I
Commonwealth of' Massachus,etts
Aftb,, AN AW 0 to
I PA v%ection
..................... Title, 5 aitticial Insp Form
14,11 Subsurface Sewage Disposal System Form Not foir Voluntary Assessments
1 Breckenridqe�oad
........................ ..............-----------
Property Address
Mi�ller, Colleen
............................................................. ............... ....... ------
Owner Owner's Name
information is No Andover MA 0,1 8�45 0191/10/2026
requiredfor every .................................................. ...... ......... ................
Page., City/T'own State Zip Code Date ofInspection
E. Repoirt Completeness Checklist
Complete all applicable secti"ons, of this form 'Inclusive of:
El A. Inspector Information- Complete all fields, iIn, this section,
Z B. Certification- Signed & D,ated and 1, 2� 3, or 4 checked
Z C., inspection Summary-
11 21 3,, or 5 completed as appropriate
4 (FaiIl re Criteria) and 6 (Checklist) compilie,te,di
Z Di. System InIfor ion-
For 8,W Tight/Holding Tank— Pumpingli contract attached
For 14: Sketch of Sewage Disposal System drawn on p:g. 16,or attached
For, 15- Expla�nilat�ion o!f'estimated de�pth to high gro�undwater inicluded
t5 i ns,p bloc-rev 7/26�/201 8 Title 5 Official Inspection Form-,subsurface Sewage Dsposal System•Page 18 of 18