HomeMy WebLinkAboutTitle V Inspection Report - 12 FARNUM STREET 10/29/2015 ✓%� Commonwealth of Massachusetts
Title 5 Official Inspection Form
r !
° subsurface Sewage Disposal system Form a Not for Voluntary Assessments
�M 12 Farnum Street _
Property Address
ILia Yaroslaysky
Owner Owner's Name
information is North Andover MA 01845 10/29/2015
required for
every page. Cityrrown 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: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab keyl
to move your Neil J. Bateson
cursor-do not Name of Inspector °�, y-f
use the return
key. Bateson Enterprises Inc. '..
Company Name
111 Argilla
Company Address
Andover MA 01810
renAn Citylrown State Zip Code
978-475-4786 SI 15
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the,""
information reported below is true, accurate and complete as of the time of the inspection. The ift i,
was performed based on my training and experience in the proper function and maintenance
sewage disposal systems. I am a DEP approved system inspector pursuant to section 15x3
Title 5 (310 CMR 15.000).The system: j
® Passes ❑ Conditionally Passes ❑
Fails
❑ Needs Further Evaluation by the Local Approving Authority % j
1 0/29/2015
Inspector's Signature Date "
The system inspector shall submit a copy of this inspection report to the Approvi171 �
of Health or DEP)within 30 days of completing this inspection. If the system is
has a design flow of 10,000 gpd or greater, the inspector and the system own ,
report to the appropriate regional office of the DEP. The original should be sent
and copies sent to the buyer, if applicable, and the approving authority. ]
****This report only describes conditions at the time of inspection and and
at that time.This inspection does not address how the system will perf
the same or different conditions of use. '
t5ins•3/13 Title 5 official inspection Forrn:Sins ,
Commonwealth of Massachusetts
u
Title Official Inspection
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Farnum Street
Property Address
` ILia Yaroslaysky
Owner Owner's Name
information is North Andover MA 01845 10/29/2015
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) 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:
After permit from B.O.H. , install new d-box& , inspection from B.O.H., septic system now passes
Title 5 Inspection.
i
I
B) 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 ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17