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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary AssessmentsLTH DEPT.
Property Address
Harry Krikorian
Owner's Name
MA 02673
State Zip Code
08/24/2018
Date of inspection
Certification
I certify that: I am a DEPrapproved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); t have personally Inspected the sewage disposal system at the property.eddress
listed above; the ihformation 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 I have determined
that the system: /
1. ❑ Passes UPC A 6ID (t) /Cat n
2. Ot Conditionally Passes ,?Gwct —
3. ❑ Needs Further Evaluation.by the Local Approving Authority1C(� ��C 119 '(J5_77
4. F-1 Falls �j0'
��esig � pector's sDate
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 shall submit the report to the appropriate
regional office of the DEP'. 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.
Mnsp.aoc • row. 71282018 Title 6 dl nW hapealcn Forn Suas dece sewage: Dleposal Sys"- Page 1 o118
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 Information
filling out fortes
on the computer,
use only the tab
Michael J. DeCosta, Jr.
key to move your
Name of Inspector
cursor - do not
Wind River Environmental
use the return
Company Name
key.
46 Lizotte Drive
1�
Company Address
Marlborough
MA 01752
Cityrrown
State Zip Code
(508)400-8083
S113230
Telephone Number
License Number
Certification
I certify that: I am a DEPrapproved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); t have personally Inspected the sewage disposal system at the property.eddress
listed above; the ihformation 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 I have determined
that the system: /
1. ❑ Passes UPC A 6ID (t) /Cat n
2. Ot Conditionally Passes ,?Gwct —
3. ❑ Needs Further Evaluation.by the Local Approving Authority1C(� ��C 119 '(J5_77
4. F-1 Falls �j0'
��esig � pector's sDate
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 shall submit the report to the appropriate
regional office of the DEP'. 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.
Mnsp.aoc • row. 71282018 Title 6 dl nW hapealcn Forn Suas dece sewage: Dleposal Sys"- Page 1 o118