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HomeMy WebLinkAboutInspection Reports 2020 Feb 28 '',,eF.Ietki`i:r L',:],_-t l.� _- oLP 08 2220 E' cp. b 'It Commonwealth of Massachusetts ViElkaPc ter(404keb3 1 MAR 3 0 2020 - .., ,p, Title 5 Official Inspection Form , ,HEALTH DEPT. ��e 1. _= i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments41 ,� { ___ .; _____,_ ,,z, ,.-i, -s ,...„.. ,r;0 ci oVare, i- .l Property Address /SV 9 Ze20 -.7 /fj ✓ba/ , / " O 0 t hcz 4 Owner Owner's Name /�/ � information is required for every 0(�11l 40,44,/�► /Y4 0)6 6q of as do page. City/Town State Zip Code Date of In ection 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 ation 4 on the computer, a rr� /J �/� use only the tab keyto move your Name of Inspector ���i0 �— / , / cursor-do not I �f use the return Company Name1 Q key. f O te0 /J e hot of a+f 114: Company AddressNo .L as t q eti ,//74- (9..164,1_1 / /� 1 City/Town 0100 ,pa State ` _ �� Zip Code jKO X, Telephon /tuber / 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 of on-site sewage disposal systems.After conducting this inspection I have determined that the s 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority ' 4. ❑ Fails Vciag Inspectignature 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. Title 5 Official inspection Fore.Subsurface Sewage Disposal System•Page 1 of 18 tsinsp.doc•rev.7/26/2018 Commonwealth of Massachusetts p Title 5 Official Inspection Form it-S- a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - -- (? (P Property Address 172. / AOwner Owner s Name information is SowilicAceevitvA M` �C6`_ ch ddv required for every /J' (�page. City(TownState Zip Code Date of specti n C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System P s: 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): t5insp.tloc•rev.712612018 'm ;5am e 5 0a speaor.Form.Sla .srrface Sewage rsposa System-Page 2 of 18 Commonwealth of Massachusetts * _"„=-T1JTitle 5 Official Inspection Form , ,,�t) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lt, 2,4 9 gill ..42.-- Property Address ////!`V�f d!tt;2- Owner Owner's Name i'7`- iequiredifoon is ✓ ` - rN•j /1/1 aa‘/, 01-/A6/40 required for every U / G page. City/Town ` State Zip Code Date of Iio C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): El 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 El ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N El ND (Explain below): El 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 ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N El 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: 'Ise 5 Qt6 ai'.nspecuon Form:Subsurface Sewage Disposal System•Page 3 of t8 t5insp.00c•rev.7/26/2018 Commonwealth of Massachusetts Tr;_-_----4------- , Title 5 Official Inspection Form -"- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ./0 41 affrY____ Property Address 34 2 ,Alsiyia vi Owner Owners Name C information is c.�N A,, y /�� d3,( (4 c� a g �O required for every page. City/Town State Zip Code Date of i specti 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. O 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 ckup of sewage into facility or system component due to overloaded or ❑ I/� clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters Li due to an overloaded or clogged SAS or cesspool Title 5 Official'nspecbon Form.Subsurface Sewage Disposal System•Page 4 of 18 t5insp.doc•rev.7126/2018 • • Commonwealth of Massachusetts r ,4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2Y51-. , Z _7;4 Property Address, n 64/ 4.4 (1111P' Owner Owner's Name ' information is �.1G 4 d 2 64 �- required for every 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 Matic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool LI Liquid depth in cesspool is less than 6" below invert or available volume is less an 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: [i Arty 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 litce, well. !_til' y 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 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.] ITV- The system is a cesspool serving a facility with a design flow of 2000 gpd- /10 000 gpd. i— The system fails. I have determined that one or more of the above failure 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 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 the system is within 400 feet of a surface drinking water supply Q 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 Tine 5 CJffdai inspec5on Porn:Subsurface Sewage Disposal System•Page 5 of 18 insp.tipc•rev.7262018 • Commonwealth of Massachusetts W = , Title 5 Official Inspection Form �`- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,342- 414.7 1,e044 se- Property Address /� / �� "!O .4s h i Owner Owner's Name (504/4 ,A Or' y /� information is Q y 7(4 l " 1 c c '! a'" -$ o required for every page. City/Town 11.- State Zip Code Date of In ection 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 ❑ um ping information was provided by the owner, occupant, or Board of Health EDWere any of the system components pumped out in the previous two weeks? 1./..."(,,„,--16- vas 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 7this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Rri- Was the facility or dwelling inspected for signs of sewage back up? 2 -____,In- Was the site inspected for signs of break out? :/".12Were all system components, excluding the SAS, located on site? ❑ 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 R1 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: l❑ 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 approximation of distance is unacceptable)[310 CMR 15.302(5)] T/e 5 Offiaai inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 t5insp.tloc•rev.7/26/2018 • Commonwealth of Massachusetts —_ Title 5 Official Inspection Form j __ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tc; r!, —,--, , se-fi zoic,__ d.d 4- Property Address ./i/p9_01 Aa 0 Owner Owner's Name /� information is <5��/,� y' /9A c1L'6 i �, a.•$ �� required for every V I page. CitylTown State Zip Code Date of In ection D. System Information .1. Residential Flow Conditions: 3 3 Number of bedrooms (design): Number of bedrooms (actual): 3 30 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x##of bedrooms): Description: / Ask /SOO o / ori S�I c I- it, j9cf-feetc...7404.7 d,,I �. Soo 6cilo0 as✓44,_$ 41/ 74'1-.510,- Number of current residents: Does residence have a garbage grinder? ❑ Yes [ o Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection 0 Yes No information in this report.) Laundry system inspected? ❑ YesNo Seasonal use? ❑ Yes to Water meter readings, if available (last 2 years usage (gpd)): Detail: 5'9, 00/0 (a(): 000 Sump pump? Yes [3"‹ .----- Gs rye Last date of occupancy: Date Title 5 3'fidal mspecaon Form Sucscrtace Sewage Disposal System•Page 7 of 18 t6inap.tloc•rev.7/2672018 Commonwealth of Massachusetts *_ F Title 5 Official Inspection Form _ ,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,..7Y2 . 10,,;2., d„,d a,..... Property Address _ .• — Owner /�`/� s w440 Owners Name information is / /1 /41Da 6 b({ C'" oe required onfor every o page. City/Town State Zip Code Date of Insp ion 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 occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 010 tg j..-- Was system pumped as part of the inspection? ❑ Yes If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: [5insp.tlx•rev.7125/2018 -ale 5 Dffiaa nsoect:on Form.Subsurface Sewage Disposal System•Page 8 of is Commonwealth of Massachusetts t-tv_A4Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3(742 Ze 0 Property Address AID ,l4,01 Owner Owners Name �� �� information is ON i ° 6 el required for every ��N page. City/Town State Zip Code Date of Insp ction D. System Information (cont.) 4. Type of Sys . Septic tank, distribution box, soil absorption system ❑ Single cesspool 0 Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) 0 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 components. date installed (if known)and o rce of information: 0100/ - 16) "eel"r 7L ©l-77 Were sewage odors detected when arriving at the site? ❑ Yes El"..No 5. Building Sewer(locate on site plan): Q r/ Depth below grade: feet Material of traction: t iron 40 PVC • other(explain): gas Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 5;,kcal.ospecnon Fomo.St.Csurface Sewage Jtsposei System•Page 9 of 18 t5insp.doc•rev.7/262018 Commonwealth of Massachusetts t _� Title 5 Official Inspection Form ,_ -__-_7716 ; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k -- ---4 3 co Z,,,,:;2_ 4.4,d A��— Property Address Owner Owner's Name /ecg2:41 information is1/l_ 0,00, �J,i a�(4 �� required for every ,u] ISI /, Cif page. City/Town State Zip Code Date of In ectio D. System Information (cont.) 6. Septic Tank(locate on site plan): Cil/ " Depth below grade: feet Material onstruction: concrete ❑ metal ❑fiberglass polyethylene ❑ other(explain) Adi, , els 14 4...--- If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificateE Yes0 No XDimensions: /// Sludge depth: s '/ Distance from top of sludge to bottom of outlet tee or baffle /// Scum thickness Q� v / Distance from top of scum to top of outlet tee or baffle / // Distance from bottom of scum to bottom of outlet tee or baffle ,� / / v le get C‘L.I, c am 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.): ab4V:2 AS 042449/ a.4 4.,. ars- 4eP-5.- � ci Cos* , 4001"co 41#0,-45 t5insp.doc-rev.7/26/2018 -iue 5 Jffcai inspection Form.SLbsurace Sewage Dispose System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34fR ZO /4140/ 4a— Property Address :,2 f;2.4. / Owner Owner's Name l information is required for every ti�� *WOO //A N60" oZpect'g ja o page. City/Town State Zip Code Date of in ion D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: Cl concrete ❑ metal ❑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: ❑ concrete Li metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 7111e 5 Office: nspecuon Form.Suosurface Sewage Disposal System•Page 11 of 18 t5insp.doc•rev.726/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form 414 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • :: 3cliP ZOc N Property Address A Aka 84 Owner Owner's Name Cot �'"�A � information is 7 i),/ cc ot- �s �0 required for every page. CityITown State Zip Code Date of Ins ection 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.): eaCie ,fr° %COM iVO .Le. T;tie 3 Ol`cal:nspection'arm.Suos.rtace Sewage Disposal System•Page 12 of 18 t5insp.tloc•rev.7/25/2018 • Commonwealth of Massachusetts Title 5 Official Inspection Form - _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3'f/ .G-04I go.1 Air r Property Address 0 rIt iiirjr4 Owner Owner's Name �/ information is required for every 66tiy ///9/T 0,?6 6 02, page. City/Town State Zip Code Date of lnspe on 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: G9 SOO 6 //oi CI). ill AX w ef7 ❑ leaching pits number: ❑ , leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativeiaitemative system Typeiname of technology: --- -- -:tie 5 OtSoai:nspe ton Form:SUD%.rtace Sewage Disposal System-Page 13 of 18 t6insp.tloc•rev.7/262018 • Commonwealth of Massachusetts M= _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SY ZO 14 /44d at Property Address �J �/ "lG rr a h Owner Owner's Name information requiredfor every 0(4 aliO4 ( 61L State Zip Code Date of lnsp ction page. City/Town � 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.): / O�c 4 a T at " / /e 4.57 -ft►v/ s)rt,f c,91 c.4ceira 14 1 c 1w,-` 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.): 'me 3 O:`ca;nspectton Form.Sccsuriace Sewage D.sposai System•Page 14 of 18 t6insp.doo•rev.7/26/2018 • Commonwealth of Massachusetts * _e Title. 5 Official Inspection Form ,_ "' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (1/4, 11_ i StfY 4c,14 , /C2leid Aa" Property Address //i0 .41 404 Owner Owner's Name - information equ ed for ievery s�N/4 _ /7_14 OdC v page. City/Town State Zip Code Date of inspe -on 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.): `tue 5 O'nas,,nsoecoon=orm.ScosuCace Sewage D spo$ai System•Page 15 of 18 t5insp.coe•rev.71262058 • Commonwealth of Massachusetts ,r Title 5 Official Inspection Form -71-111#: ). Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3Y P /04, Add .Or Property Address Owner ��/�`, vl t 4.44 Owners Name information is P ,'l� required for every bN c4A60 % /� (J�6� c.2-(01,$ page. City/Town State Trp Code Date of Iin D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of sewage disposal system, including ties to at least two permanent reference landmarks or nchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buil . . Check one of the boxes below: hand-sketch in the area below 0 drawing attached separately f 1 1A 9 /\s --, u 600 ,‘...x., , a 045-kr;4-- 10 ' � . saw 1 't it g_--- art, I li -, , : 1 NQYf / Lge I /1.0. - Lf''' 4)-- ,), c.v.., eJ aS n! 1 i t6insp.tloc•rev.7l26l2078 H-'- TOe 5 O11dsi Inspe=on Form:Subscrtace Sewage Disposal System•Page 16 of 18 • Commonwealth of Massachusetts Title 5 Official Inspection Form ,_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,,,,,,,...-_-_-__.,-). SY 9 go i A pc...., Property Address /1/0 4l a44 Owner Owners Name information is .14 required for every OH A , 1' /1/—4_ ®,2l7 6 T 0,7-74-6/Le page. City/Town State Zip Code Date of Inspn D. System information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells ,f Estimated depth to high ground water: 01-1 � �� 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 ioBoard of Health -explain: /0 Checked with local excavators, installers - (attach documentation) Li Accessed USGS database-explain: You must describ ow you establhed high ground waTpelevation � u / GNta _ ,,,, lNhcG70,....,,,...c./. fz__Te 0,7‘, 04e 4 4 4‘Or r 60.1 ‘6 lay 7 0-do . Sc,7 "-ito1/1 _ I n / %� 46 ti . (5'• /4• s ts 4„a kiL__:. 54 yo u 0 jJ-Q - . Before filing this inspection Report, please see Report Completeness Checklist on next page. 5insp dot•,rev 7!2620.8 -�Ue 5 Drfaa.rspecaon For.Suosiaace Sewage Disposal System•Page 17 of 1 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • • S 174 j4:7(,1-1-1 fecc 40 Li 41 Property Address Owner Owners Name i information is required for every �Q47' 1oN %i Oj66v page. City/Town State Zip Code Date of fnsle.ligti,z tio E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. certification: Signed & Dated and 1, 2, 3, or 4 checked inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 allure Criteria)and 6 (Checklist)completed D. 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