HomeMy WebLinkAboutSeptic - Title V Inspection Report - 255 HAY MEADOW ROAD 10/13/2026 Commonwealth of Massachusetts
19111 Ammon
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.. ..........
Title 5 UItticial 1�nsspftect'ion For
Not for Voluntary Assessments,
S ubsurface Sewage Disposal System Form
255 H ow Road Property Address
Arc,ari�,, Jonathan
Owner Omttriers,Name
information is N�o. Andover MA 01845 1 Ol/13/2 O26
required for every
page. City/Toiwn State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not,be altered i,n 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 nIot J &S Dicar q!qpment/Stewart's Septic Service
use the,return Company Name
key.
58 Sol. KimballSt.
!V Ub any Address
Bradford MA 01835,
C fty/Town State Zip Code
978-372-7471 S 113 386
T'elieph�one Number License Number
B. Certification
I certify that: I am a DEP approved system, inspector in full,compli'ance with Section 1151. of Title 6
(3110 CMR 15-0100); 1 have personally inspected the sewage disposal system at the property,address
listed above; the i nfo�rmation reported! below is true, accur�iate and complete as of the time of my
i,nspecti,oin; 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. N Passes,
Conditionally Plassies
3. 0 Needs, Further Evaluation by the Local Approving Aulthority
4. El Fails
101/13/2026,
pect&s Sighatuh to
The system inspectoir sihall subm It a copy of this, inspection report to,the Approving Authority(Board
of Health or IDEP)within 30 days of complet,ing this inspectioln�. If the system has a design flow of
10I,000 gpid or ire ter, the inspector and the sys,t owner shall submit the report to the appropriate
regional oiff'ice of the DER. T �inal form should be sent to the system owner and copies,sent to
the buyer, if appilic le, and the approving authority.
P'lea,s,e note: This report only describes conditions at the time of inspection, and under the
cond*ltlons,of'use at that time. This, inspection does not address how the system will perform
in the future under the same or different con 'itioins of .
t5ins,p.doc-rev,7/ /2018 Title 5 Offic4 Inspection Form-,S uirface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
M �� T'ItleInspect'ion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
44
..� ,q 255 Ha meadow Road
Property Address
Arcari, Jonathan
Owner Owner's Name
information is No.Andover MA 01845 10/13/2025
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 0.
1) System Passes:
® l have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
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.
❑ Y Ej N El ND(Explain below):
Mnsp.doc■rev.712612018 Title 6 Official Inspection Form:Subsurrace Sewage Disposal System-Page 2 of 18
m Coommonwealth of � tr•
.,,,. pI -&-lect'
P
.4 it, e 5 uTTicia p
Subsurface Sewage Disposal System (Form Not for Voluntary Assessments
N-
255 Ha eadow Road
Property Address,
rc rl, Jonathan
Owner Owner's INiame
in
formation is . Andover 1' 1 2
r quired for eve �_ _. . .,.._wW....._ _ ___._... _.. _ .._� .__-___ . _.....
page,, CitylTown state dip Code Date of Inspection
C. Inspection,, Siummary (cont.)
Systemn lti n ll Passes c log .
Pump,Ej r pIumps/ala,rms not operational. ill pass with Board of Health apip:rolval if.
pumps/allarms arere a I reu ,
El Observation of sewage backupr break out or high statictiter level in the distribution box due
to broken or obstructed fir' it due to a broken, settled or uneven l r tion box. System will
ass inspection iilf'(with approval of Board of Health):
broken I are replaced Y 0 N NID(Ex l ln
below)-
obstruction W
removed Y 0 N ND (Explainbelow)-
EII distribution box is leveled or replaced lN, (Explain to
E] The system required a ling moire h a times, year due to broken or obstructed l . The
system, ill pass inspection if(with approval of the Board ofHealth)-
broken pl re replaced 1 ' N''Di(Explain below):
obstruction is removed l (Explain below):
Furtheralatl the Boardof Health.-
Conditions, Health.-exist lac require further evaluation oar of Health In order to determine it
the system is failing I to protect public health, safety or the environment.
a. to ill pass unless Board of Healthdetermines in cc r nce wilth 3101 CMR.
i that,the st is not functioning in a manner which will, protect public health,
safety and the environment:
t5inspi.doc rev.7/26/2018 Tide 5 Official Inspection Form.Subsurface Sewage DisposaW System-Page 1118
Commonwealth of Massachusetts
........5P ial, Inspectuion Form
I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
255 Haymeadow Road
Property Address
Arcari, Jonathan
Owner Owner"s Name
information is No. Andover MA 01845 10/13/20,26
required for every
page. City/Toiwn State Zip Code Date of Inspection
C. Inspection Slumm�a y coin .)
El Cesspool or privy is,withi,n 50 feet of a,surface water
Cesspool or privy is within 510 feet of a bordering vege�tated wetland oir a salt marsh
b. System will fail unless the Board of Health (and Pu�b,lic Water Supplier,, if'any)
determines that the,syster i nis functioning n a manner that protects the public health,
safety and environment.:
E:1 The system has a septic tank and soil absorption system (SAS),and,the SAS is,within
1010,feet of a surface water supply or tributary to,a surface water supply.
0 'The system has,a septic tank and SAS and,the SAS is within a Zone 1 of a, public water
supply.
[] The system has a,septic tank ands SAS and the SAS, is,within 50 feet of a private water
supply well,.
El,, The system has,a septic tank and SAS and the SAS, is less than 1010 fe�et 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
coll'ifoirm bacteria indicates,absent and the presence of ammonia nitrogen and nitrate nitrogen, is equal
to or less than 5 ppml, provided that no other tail re criteria are triggered. A copy of'the analysis must
be attached to,this form.
c. Other:
41) System Failure Criteria Applic ill tems:
You must indlicate"Yes"' or"No"to each of the,following for,all inspections,-.,
Yes, No
El El 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
t5insp.doic-rev.7/261/2018 Title 5 Offidal Ins ton Form Subsurface S Disposal System-Page,4 of 18
4
Commonwealth of Massachusetts
1Title 5 Official Form
ti
t Subsurface Sewage Disposal System Form-Not for voluntary Assessments
y
°4 255 Ha meadow Road
Property Address
Arcari, Jonathan
OwnerO mees Name
information is No.Andover MA 01845 10/13/2026
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded
El z or clogged SAS or cesspool
g9 P
Liquid depth in cesspool is less than 6" below invert or available volume is less
❑ ® than day flow
Required pumping more than 4 times in the last year NOT due to clogged or
® obstructed i e s . Number of times pumped: 1.❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
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.
❑ ® 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 coiiform 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-
❑ ED 10 000 gpd.
The system fails. I have determined that one or more of the above failure
El ® 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 16,000 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
D El the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(interim Wellhead Protection
D 1:1 Area--IWPA or a mapped Zone 11 of a public water supply well
} pp
t5insp.doc•rev.7/26/2018 Me 5 of ias inspection Form:Subsurface Sewage Qisposal system•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Off Forl"Y1
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
F
255 Ha meadow Road
Property Address
Arcari, Jonathan
Owner Owner's Name
information is No.Andover MA 01845 10/13/2026
required for every
pale, 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"yes"to any question in Section C.4 above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for a!1 Inspections:
Yes No
® D Pumping information was provided by the owner, occupant, or Board of Health
El N Were any of the system components pumped out in the previous two weeks?
Z ❑ 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
Z 1:1 available note as N1A
)
Z ❑ Was the facility or dwelling inspected for signs of sewage back up?
Z El Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
M El Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
Z El information on the maintenance of subsurface sewage disposal systems?
proper 0
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
Z El 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
N El approximation of distance is unacceptable) 310 CMR 15.302 5
pp p � � � )]
t5insp.doc•rev.7/26/2018 4 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
a _ , Toitle 5 Official Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
255 Ha meadow Road
Property Address
Arcari, Jonathan
Owner Owner's Name
information is No.Andover MA 01845 10/13/2026
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 for example: 110 d x#of bedrooms): 498
� P 9p �
Description:
Number of current residents: 0
Does residence have a garbage grinder? ® Yes ❑ 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? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)}:
Detail:
Sump pump? ® Yes ❑ No
Last date of occupancy: 2 years ago
Date
t5insp.doc-rev.7/26/2018 Title 5 Official inspection Form Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title
Official Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°y 255 Ha meadow Road
Property Address
Arcari, Jonathan
Owner Ovmer's Name
information is No. Andover MA 01845 10/13/2026
required for every --
page. City/Town State Zip Code Date of Inspection
D. System information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): �- -- �--- ---- -- '
Grease trap present? EI Yes ❑ No
Water treatment unit present? El Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? El Yes [:1 No
Non-sanitary waste discharged to the Title 5 system? Ej Yes ❑ 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 pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/2612010 Title 5 flty'fcid Inspedon Form:Subsurface Sewage Disposal System•Page a of 18
Commonwealth of Massachusetts
-.
i iciaInspect"
ion
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
rt
.a ,,•''° 255 Ha meadow Road
Property Address
Arcari, Jonathan
Owner owners Name
information is No.Andover MA 01845 10/13/2026
i requred for every e City/Town State Zip Code Date of Inspection
p .
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 I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
El other(describe):
Approximate age of all components, date installed (if known)and source of information:
1992
Were sewage odors detected when arriving at the site? El Yes ® No
5. Building Sewer(locate on site plan):
011
Depth below grade: feet
Material of construction:
E cast iron ❑40 PVC El other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5Ensp.doc•rev.7/26/2018 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
w w w w
�. i e icialionForm
b Subsurface Sewage Disposal System Form Not for Voluntary Assessments
.a a
`~ 255 Ha meadow Road
Property Address
Arcari, Jonathan
Owner owner's Name
information is No.Andover MA 01845 10/13/2026
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
C. Septic Tank(locate on site plan):
6�,
Depth below grade: feet
Material of construction:
M concrete El metal Ej fiberglass El polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes D No
Dimensions: 5 X 10 X 4
Sludge depth:
o
Distance from top of sludge to
bottom of outlet tee or baffle Tank had only 12" in it
Scum thickness
p Distance from top of scum to to of outlet tee or baff le 6"-inlet to top of tee
Distance from bottom of scum to bottom of outlet tee or baffle 16"baffle
How were dimensions determined?
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. Tank was 1/3 full. Has been vacant for 2 years.
t5lnsp.doc•rev.7l25I2018 Title 6 official Inspection Form Subsurface Sewage❑isposal System•Page 10 of 18
Commonwealth of Massachusetts
_
=- Title 5 Official Form
T• a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y
N
255 Haymeadow Road
Property Address
Arcari, Jonathan
Owner Owner's Name
information is No.Andover MA 01845 10/13/2026
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
El concrete El metal El fiberglass ❑ 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, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal ❑fiberglass El polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc■rev.11251201S Tile 5 official Inspecton Form:Subsurface Sewage Disposal System■Page I of 18
Commonwealth of Massachusetts
f Title 5 Officialiono arm
y Subsurface Sewage Disposal System Form Not for Voluntary Assessments
c
. 255 Ha meadow Road
Property Address
Arcari, Jonathan
Owner Owner's Name
information is No.Andover MA 01845 10/13/2026
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
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? El Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
P �
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Equal distribution, no leakage, no solids carryover.
ffilnsp.doc•rev.R2612018 Title 5 00cial inspection Farr:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 O Form
y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w
ti
x
255 Ha meadow Road
Property Address
Arcari, Jonathan
Owner Owner's Name
information is No.Andover MA 01845 10/1312026
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: El Yes ❑ No*
Alarms in working order: El 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:
El leaching chambers number:
❑ leaching galleries number:
® leachingtrenches number, length: 3--45'
9
❑ leaching fields number, dimensions:
El overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/25/2018 Tito 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth ofMassachiusetts,
T"Itle, 5 Q't"fi"ci'al Insimecti'on: Form
�M Subsurface Sewage is,posal System Form Not for Voluntary Assessments
5 oa,d
' Ile 25 Haymeadow R
Property Address
Arcari, Jonlia,t,han:
Owner
Own&s Name
information is No. Andover MA 01845 10/13/2026
req,uired for every
page. City/Town State Zip Code Date of In spection
D. System Information (cont.)
11. Sbill Absorption System(SAS) (coint.)
Commen ts (note condition of soil, signs of hydraulic failure�, level of po�nding, damp s,oil�, condition of'
vegetation, etc.)*
No pondi,ng, no damp s,olils, no,solids carryover. Ran water in d,-boix. Maintained good height at,time
Cif i n
.............
12. Cesspools (cesspool must be pumped as part of inspection) (locate,on pit e plan),.
Number and configu ration!
Depth—top,of liquid to, inlet invert
Depth, of solids layer
Depth: of scum layer
Dimensions of ce,sspio�oll
Materials of construction —
Indication of groundwater inflow 0 Yes, Ej No
Comments,(note condit,ion of soil,, signs,of hydraulic fa,ilure, level of ponding, condition of'vegetation,
etc.).
t5insp.do'c-rev,7/26/2018 TM e 5 Offida1 Ins ton,Form:Subsurface Sewage Displos,al System-Page 14 of 18
Commonwealth of Massachusetts
.. . Title 5 Official Form
8 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
C
O
,yy 255 Ha meadow Road
Property Address
Arcari, Jonathan
Owner Owners Name
information is No.Andover MA 01845 10/13/2026
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Forrrc Subsurface Sewage Disposal System•Page 15 of 18
-nk. Commonwealth of Massachusetts
Off" *icial I For
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. Arcari, Jonathan
Property Address
255 lea meadow Rd
Owner Owner's Name
information is No. Andover MA 01845 10/13/2026
required for every
MS. City/Town State Zip Code Date of Inspection
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 hakes below:
' hand-sketch in the area below
drawing attached separately
Z_�
4
C.
..................
s.
�1
d
J
t
t5insp,doc-rev.7/261201 a Title 6 Official Inspection Form:Subsurface Sewage Disposat System•Page is of 1 e
Commonwealth of Massachusetts
! Title Official Inspect'ion Form
M
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4
f.
° 255 Ha meadow Road
Property Address
Arcari, Jonathan
Owner Owner's Name
information is required for every No.Andover MA 01845 10/13/2026
page City/Town State Zip Code Date of inspection
D. System information (font.)
15. Site Exam:
❑ Check Slope
El Surface water
❑ Check cellar
❑ Shallow wells
9'
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: 03/25/1987
g P Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Pulled file
1:1 Checked with local excavators, installers-(attach documentation)
❑ Accessed USOS database-explain:
You must describe how you established the high ground water elevation:
Taken from plans 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
T"Itle 5 Off'icial Inspectulon Form
Subsurface sewage Disposal System Form -Not for Voluntary Assessments
Y
y r
� 255 Ha meadow Road
Property Address
Arcari, Jonathan
Omer Owner's Name
information is No.Andover MA 01845 10/13/2026
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:
Z A. Inspector Information: Complete all fields in this section.
Z B. Certification: Signed & Dated and 1, 21 3, or 4 checked
® C. Inspection Summary:
11 21 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank---Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 15 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doe■rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 18 of 18