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HomeMy WebLinkAboutInspection Report 2020 Feb 20 + Z5 RECEIVED Commonwealth of Massachusettefr3(zo2) �toa n P it4 do 13 2020 i - _iP Title 5 Official- Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . r ��. Qom. - 4/ , � oo /4i.A90d Slit „El,ll I ;# Property Address leo, .E ✓lpfi' / cit Ce..4 ✓J i. Owner Owner's Name !V( nr� information is wevi ro /II- Q�b QS �• 010 p10 required for every _ page. City/Town State Zip Code Date of fnsp coon 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 filling out forms A. Inspector Infor tion , on the computer, / ,2/ /l; use only the tab a U�` O S'f'i // key to move your Name of Inspector ;/v. 0 /EC cursor-do not L/�—� -�— ill use the return Company Name key. PQgt2. 17 ivCompany Address /�/ �/ � 7 ,G-�iS�l�l a v''r �7' o 04. fes + L City/Town 651 ) go ^D 490 State 474.0 ed._ Zip Code Telephoneumoer License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); I have personally inspected the sewage disposal system at the property address listed above;the information 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 on-site sewage disposal systems.After conducting this inspection I have determined that the sys . 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority • 4. ❑ Fails � dad0 inspector Signature/)4 l/latat . 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 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. t5insp.doo•rev.7!26/2018 —Ite 5 Of`nai.nspec5on Form.S❑bsurface Sewage Disposal System•Page 1 of+8 Commonwealth of Massachusetts , , __-64 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ACCte Owner ! i' Owners Name informationeis ✓� / /�f� �l! 5 a0 dO required for every 4a141004 // O�{p page. City/Town State Zip Code Date of Iv..../62,0/, 0 spe ' n C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Pas s: 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: 2) 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): ISinsp.0OC•rev.7126/2018 Tale 5 Oifiaa anspecuon Form:Suosurface Sewage Disposes System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _= i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 474 17_, Property Address Ownerf r1 OwnePs Name information is �/f required for every OU a,/ //7,/ o 25 a- a 0/%0 page. City/Town State Zip Cade Date of Ins ction / C. Inspection Summary (cont.) p 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution 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): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N E ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.tloc•rev.7/25/2018 'ate 5 O fiaai;nspecton Form:Subsurface Sewage Disposal System•?age 3 of 18 °�'\ Commonwealth of Massachusetts * - Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ‘‘, ,, 471 w00 vim Property Address . ofCCr ✓7! Owner Owner's Name ,,y � /�j� /�/��' informationis crv'10c4/4 /"O4/ 4I o016U o)'0/7 o required for every page. CitylTown State Zip Code Date of In ectio C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 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 and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet 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 coliform 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 must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No �^ ❑ �,/' B kup of sewage into facility or system component due to overloaded or L� clogged SAS or cesspool i I Discharge or pending of effluent to the surface of the ground or surface waters '--' due to an overloaded or clogged SAS or cesspool Title 5 Officai'nspecton Form:Subsurface Sewage Disposal System•Page 4 of 18 t5insp.tloc•rev.7/26/2018 Commonwealth of Massachusetts - , Title 5 Official Inspection Form • 4#17-, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17' / 0 114,490C/ a— Property Address r IACCI (4l Owner Owners Name GYtMOGf44 /ar ' /�/� 0- -C:•& olo information is required for every �p page. City/Town State Zip Code Date of Ins ction 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 or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: E L+7 Any portion of the SAS, cesspool or privy is below high ground water elevation. E Any portion"of cesspool or privy is within 100 feet of a surface water supply or butary to a surface water supply. v Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. El portion of a cesspool or privy is within 50 feet of a private water supply well. y portion of a cesspool or privyis less than 100 feet but greater than 50 feet AnyR from a private water supply well with no acceptable water quality analysis. [This system passes if the welt water analysis,performed at a DEP certified laboratory,for fecal coliform 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.] T e system is a cesspool serving a facility with a design flow of 2000 gpd- ii== 10ILI ,000 gpd. I—, The system fails. i have determined that one or more of the above failure icriteria 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 15,000 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 O 0 the system is within 400 feet of a surface drinking water supply 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 Area–iWPA)or a mapped Zone II of a public water supply well t5irlsp.tlx•rev.7262018 `ue 5 3ffca;nspecaort Fora.Subsurface Sewage 6sposal System•Page 5 of 18 • Commonwealth of Massachusetts ,,� ,,fie Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 474- kk o1fWO0ol eG./r Property Address Owner Owner's Name information is QeriaAlv/ //f/f 6d- 1 6 J 5 aid 0/0)-o�-o required for every _ page. City/Town State Zip Code Date of inspe •on 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 all inspections: Yes o ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as 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 available note as N/A) Vj2 Was the facility or dwelling inspected for signs of sewage back up? id, Was the site inspected for signs of break out? EV,:24:1 Were all system components, excluding the SAS, located on site? E 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 information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. rDetermined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)1 Title 5 afficiei inspection=urn:Subsurface Sewage Disposal System•Page 6 of 18 t6insp.doc•rev.7/26/2018 Commonwealth of Massachusetts '' ,, _F Title 5 Official Inspection Form _- - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address atcc..., 41 Owner Owner's Name �/A �Jn / h information is ar�oA/v/ /if /14 Da,� / c9/740/0).0 required for every V' //// page. City/Town State Zip Code Date of Insn D. System Information 1. Residential Flow Conditions: ,3 .......? Number of bedrooms (design): Number of bedrooms (actual): 330 DESIGN flow based • 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: el /coo 6- 110,7 ID y 44c d oD- d , e ( 6 )cl P( * ' at`fi s1-0� Number of current residents: Does residence have a garbage grinder? ❑ YesNo Does residence have a water treatment unit? ❑ 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? D YesNo Seasonal use? 0 Yes le< Water meter readings, if available (last 2 years usage (gpd)): Detail: �c 00,E ) 9, 00° Sump pump? ❑ Yes Er‹.-- C("tbra lloC4rf i4 _ Last date of occupancy: Date Title 5:STAciai:nspecoon Fcrm.Sccsc`ace Sewage Disposal System.Page 7 of 18 t5insp.doo•rev.7128!2018 Commonwealth of Massachusetts lk., _ Title 5 Official Inspection Form _ _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments II /1140 At/000/ Propertyla --- Address g.4 C G! el / • Owner Owner's Name 1 informationeiscy9"�„y��� ,�r Al OAS 25 �O p�(� required for every .c e fl pr City/Town State Zip Code Date of Ins ction 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? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancyiuse: Date Other(describe below): 3. Pumping Records: Evir7:, ( .e:e,..,.. _ 0(..44. --- Source of information: 7.G Was system pumped as part of the inspection? ❑ YesEt No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5inep.tl0c•rev.712612018 Title 5 Offiaa inspection FormSuosurface Sewage Disposal System•Page 8 0118 Commonwealth of Massachusetts r - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '-...,-1- V 1144.0//ik9 d a "-. Property Address al cc i ,.., i Owner Owner's Name 1t'i X1 information is -/{U— oa 63'" �o required for every page. City/Town State Zip Code Date of In ection D. System Information (cont.) 4. Type of Sys . Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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. ❑ Other(describe): Approximate age of all co po date instal(' n)and source of information: /� Were sewage odors detected when arriving at the site? ❑ Yes o 5. Building Sewer(locate on site plan): e " Depth below grade: feet Material of construction: 0 cast iron 40 PVC ❑ other(explain): (O r Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Title 5 5aai nspecnon Forte.SuZsuriace Sewage Disposal System•Page 9 of 18 t5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts *_ fg Title 5 Official Inspection Form --:,7-__-±,...,i- t Subsurface Sewage Disposal System Form -Not for/Voluntary Assessments // A/-400//Ct/00 0/ ia--- Property Address .ACC/11/ Owner Owner's Name information is Wel ON l'f �/ fi/4 ())6?�' ac) �O required for every �'I ,v page. City/Town -, State Zip Code Date of!n pectin D. System Information (cont.) 6. Septic Tank(locate on site plan): ? // Depth below grade: V Material onstruction: ❑ metvconcrete al ❑fiberglass ❑ feet polyethylene yi El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: d // Sludge depth: OS r/ Distance from top of sludge to bottom of outlet tee or baffle Scum thickness /,� G r Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle g de ,(,, ,..2 .: icc___ 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.): givry ✓fid `�Z c�C/ / afr. 4, 4$4e/ s I v► pow✓ C ./ he, , /42 v 442,4,,i, t5insp.tloc•rev.7/26/2018 Tide S fIcual Inspecaon Form.Subsurface Sewage Disposai System•Page 10 of 18 Commonwealth of Massachusetts -_= Title 5 Official Inspection Form t= = '! it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 knollm;t2d a Property Address p6C (44/Owner Owner's Name ' /f information is A'4 4/r(P/ /7,4 Od-6 95 C16 v'v required for every • page. City/Town State Zip Code Date of in ectio D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete E metal E fiberglass ❑ polyethylene E 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: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Title 5 OffaaInForm:. specuon Fo :Scosurface Sewage Disposai System•Page 11 of 15 t5insp.doo•rev.71262018 Commonwealth of Massachusetts -0 Title 5 Official Inspection Form k,,t ,y -,-_-„-,..44,4-0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments frr.....-- k✓)0I�woo AProperty Address ` gCCii4 / Owner Owner's Name information is oretiovi P//- /¢ a.)-6' /5 40/4xvrequired for every page. City/Town State Zip Code Date of Ins D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ 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? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): ,_. & Depth of liquid level above outlet invert 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.): e#0eonle /.,�'r,° /Cis iA9 °L-es. �—s Tale 5 On1cai.nspeoilon Form.Suos.lace Sewage Disposal System•Page 12 of 18 t5insp.tloc•rev.7282018 Commonwealth of Massachusetts e Title 5 Official Inspection Form I -=- __ - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - Lj` ✓�o /Woo c' ,Q I v�e� Property Address (4 GC-4 el/ Owner Owner's Name A /1M- ��� Jinformation is ..�ov, required for every ldo page. City/Town State Zip Code Date of Ins ection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ 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: - 0) 12 leaching pits number: 6 >1ft $: r ❑ . leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: O overflow cesspool number: ❑ innovativeialtemative system Typeiname of technology: --- Tue 5 Ot5aa..nspeaion Form.Soos.race Sewage Disposal System•Page 13 of 18 t5insp.tloc•'ev.7/2612018 Commonwealth of Massachusetts Title 5 Official Inspection Form vA Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' " 171 killoi/wood Property AddressgotCC—feli .. Owner Owner's Name / information is Arela4 D✓�-^ �� o0 /1�( a0 required for every /��1� /n L V l� J page. City/Town State Zip Code Date of ins ection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): . al 84 CI,ic73 41)1- .5:f-4 I .1 4 rte_. A v stly4i 0-14' N dla w �1 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): ?age 14 of 18 t5insp.tloc•rev.7262018 Tae 5 Oflical�nspecuon Form.Suosu.ince Sewage Dosposal System• Commonwealth of Massachusetts 'i ' Title. 5 Official Inspection Form --,-z-lrzSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 4140&APO d al fr_e_____ Property Address Owner geCivl / Owners Name information is nA O J 0required for everyaav'9o1� /V pZ page. City/Town State Zip Code Date of In ectio 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•res.7/26/2018 T:ue 5 O`fiae lnspeccon=orm.SLosurface Sewage Disposal System-?age 15 of 18 Commonwealth of Massachusetts - =ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k, ., li ki4 011(4490 Cl/ 4,,, Property Address gf CC /N / Owner Owner's Name //�� informationeis AreVa / /g/ /1/4- Od b,?J5' as a O required for every it , N page. City/ own ir State Zip Code Date of Inspe.'on D. System Information (cont) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks orbnchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buildin heck one of the boxes below: and-sketch in the area below ❑ drawing attached separately eA-C A/ \Ix A-- a - i . IcD ) © � �, (000 ,1- e2,C_ r' (rn llo.f 67(6 .5410/1.. AC)----/o), gc-,zo,,c Qitw �� 11 / - i3 R`" f1-'``Yf0 dy, 02� ,O cow,- 1 t5insp.doc•rev.7/26/2018 Title 5 Baal Irspecaon Form.Subs.Yace Sewage Disposal System•Page 16 of 18 r Commonwealth of Massachusetts 0. __* _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments q .. kl40///4/Vod a..-- Property Address Owner C C i 4 / Owners Name n "1- ezi 6/) �c'information is (/Vl required for every ^ IOLA 4, page. City/Town State Zip Code Date of insp ction D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 4Pye.._ Estimated depth to high ground water: /.6s/3 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: Date ❑ served site (abutting property/observation hole within 150 feet of SAS) Checked with local d of Health - explain: Of -t— 71-71Y- / /ex 77 LI Checked with local excavators; installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe hot,you stablished�ti e high ground wate�eva .on t�i —�--- /2 vo- Ove Ci/.t,,- c2� L, L Q 1d a? to nd4H t/ 1(.1 !o,` '4- n -/aL1 l.6',5 qv,..? (..,01D 44 e)iti,e'44-v /VC-a-4-d- � T r ,.....) eek/r gOVe- VI 6-(1/ y --L—&S' �Gd� /-rt,c2ic f 5 qv� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.00c•rev.7(262018 Ha tie 5 cansae ;arm.o :Subs, Dis ace Sewage 4 System Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • ---,..=,-47 47C ilk*1-116/Ou ol Oly" Property Address . N CGt l/! / Owner Owner's Name information is 1 required for every #4401.4 �'/ , - 0.)6 /� a6 11; page. City/Town State Zip Code Date of Ins coon E. Report Completeness Checklist Complete a plicable sections of this form inclusive of: A. Inctor Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failur -Criteria)and 6 (Checklist)completed . System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included (Smog.tloc•rev.7126@018 Tile 5 OffiocI a:,no eon Form Subsurface Sewage Dzsposai System•one 18 of 18