HomeMy WebLinkAboutTitle V Inspection Report - 78 VEST WAY 12/21/2015 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owners Name
information is
required for North Andover MA 01845 12/21/2015
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:filling A. General Information
When ling out
forms on the
computer,use 1 Inspector:
only the tab key
to move your Neil J. Bateson
cursor-(to not Name of Inspector
T
use the return
key. Bateson Enterprises Inc.
00---h Company Name
111 Argilla Road
Company Address
Andover MA 01810
Cityrrown State Zip Code
978-475-4786 S115
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 inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
— JJ141 12/21/2015
Inspqi6.tor'-s Signature V 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 is a shared system or
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 should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
APO Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
78 Vest Way
Property Address
Shaun Milliken
Owner Owner's Name
information is
required for North Andover MA 01845 12/21/2015
every page. Cityrrown 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:
® 1 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 now passes Title 5
Inspection.
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):
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