HomeMy WebLinkAboutInspection Report 2020 Apr 10 Commonwealth of Massachusetts
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Vert- R.eJt u.) APR 10 2020
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*=r = Title 5 Official fns ection Form
--- � HEALTH DEPT.Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
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Property Address ''x \+"►W
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Owner Owner's Name M�
information is ��� eyefie l vl /Y.4 C`vR-43 3/01-/a/O
required for every
Page. City/Town State Zip Code Date of 1ti
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 inf tion
filling out forms +
on the computer, I O tr.e.,
//
use only the tab t
key to move your Name of Inspector E��/ ---. ,r-
cursor-do not (2 i
key the return Company Name n <e� ,
key. //—/V'1 K`/- e /C)qY
'
Company Address . - A el /47.4/47.4 /� 1/'fL1
City/To‘73'0g)
n State Zip Code
, v S g (g0 779v (.`yG0g�
Telephone-[hum ber) ) 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 7am :
ses
2. ❑ Conditionally Passes
3. 0 Needs Further Evaluation by the Local Approving Authority
4. E Fails
,44.1‘' 3//011010
(nspecto s Signature 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.
–,-ie 5 ca,,rspe=or.=or-.Suosurace Sewage Dssposal System.Page 1 of 18
:6insp.doc•rev.i 26x20'18
Commonwealth of Massachusetts
,. _ - _- Title 5 Official Inspection Form
___ _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 glieers z_ ,r/
Property Address -in;
Owner Owners Name 6'45
?
information is CO V'7OH it /4 co.)6'25 ,,+ /�' o?d
required for every
page. City/Town State Zip Code Date of spe • n
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System P 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):
t5insv dOC•rev.7/28/2018 7ore 5 Office,,ospe0on Fora.Suosurface Sewage asposai System•Page 2 of 18
Commonwealth of Massachusetts
}_ _ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44/61
Property Address
Owner Owner's Name
information is es A„s /P4 OCG /� ? /� ' )
required for every 111 -/ v tet/
page. City/Town ` State Zip Code Date of specti n
C. inspection Summary (cont.)
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 ENE 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 wilt protect public health,
safety and the environment:
t5insp.tloc•rev.7125/2018 Tine 5 Offiaal inspection Form:Subsurface Sewage Disposal System•page 3 of t8
•
Commonwealth of Massachusetts
* �; gi Title 5 Official Inspection Form
�'- - Subsurface Sewage Disposal System Form - of for Voluntary Assessments
-7_4 / /
Property Address // //
Owner Owner's Name � / ��•/�
information is CN mss'�- A fi 4L-4 s /ot- 00
required for every
page. City/Town State Zip Code Date of specti n
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
Backup of sewage into facility or system component due to overloaded or
IIIlllllllll• ���QQQ clogged SAS or cesspool
D Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Title 5 Ofhoai,nspectlon For:Subsurface Sewage Disposal System•Page 4 of 15
t5insp.0oc•rev.7282018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•• /14,re5 4-0,V
Property Address tot ri /S 410
Owner Owner's Name `J
requiredifo is �s�. A/ �'' Al odic 93 "fro
required for every
page. City/Town State Zip Code Date of lnsp tion
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' day flow
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Any 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.
V❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
�Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ E 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 forma
The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
r--, The system faits. 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
O ❑ 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
tle 5 fca:Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
t5inspApC•rev.7/76/2018
Commonwealth of Massachusetts
„ _, Title 5 Official Inspection Form
ktL ,._
Subsurface Sewage Disposal System Form - of for Voluntary Assessments
7 o we KS
Property Address
G4v►clsIre el
Owner Owner's Name / �/ n2 ?
information is / / -t— crews,4 ,Y,- 0d 6 fJ �J 41 02Q
required for every V�/ �f
page. City/Town State Zip Code Date of pectin
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 0.4 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 N
❑ P ping information was provided by the owner, occupant, or Board of Health
❑ e any of the system components pumped out in the previous two weeks?
❑ s 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
Vavailable note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
LiWere 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?
2,0".. ❑ 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
l5been determined based on:
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)]
t5insp.00c•rev.7/262018 Title 5 Official,nspe,;ion Form:S.bst.riaace Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Formm&.'erc--Not for Voluntary Assessments
/ L./l,
Property Address // /
LGfNCISITo✓`9
Owner Owner's Name ` /information is (, j.eC�y5fiAtOt4 1f At 93 . /AP-1491C�
required for every
page. City/Town State Zip Code Date of Iti
D. System Information
.1. Residential Flow Conditions:
3 3
Number of bedroomsdesi n): Number of bedrooms(actual):
` g 330
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Description: 0
r.
/✓oo 6---g //ay O4(C.. /w I
1 'oo.1 G. `mm Py elP Gly"40/`
01:AS4I! h vh
9 ... 1111//1 4O(f CA'/s4-°11-c 30 .& /-5.
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? 0 Yes No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes g•-•11.6."
information in this report.)
Laundry system inspected? 0 Yes [rl�o
Seasonal use? es ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail: 7// �� u
Sump pump? /VY No
Last date of occupancy:
Title 5 3eda,rspecoor Form.Sucsur`ace Sewage Disposal System•Page 7 of t8
t5insp.doc•rev.7/25/2018
Commonwealth of Massachusetts
at Title 5 Official Inspection Form
i!- Subsurface Sewage Disposal System Fo -Not for Voluntary Assessments
7 V Z._4/
Property Address
I.u»IS-1,19111
Owner Owners Name f ,tz,, /� n
yd-p
reformation ie CSV-�iS� �� V /�required for every n
page. City/Town State Zip Code Dap
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): (gpd)
Gallons per day
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes 0 No
Water treatment unit present? 0 Yes 0 No
If yes, discharges to:
Industrial waste holding tank present? 0 Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? 0 Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records: v ) - t,..lvi/
4
Source of information: /�f/�/ J ��}, p
Was system pumped as part of the inspection? ❑ Yes E No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t6insp.tloc•rev.72612018 Tinaa
Title 5°tfiinspector.Form.Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
i=7?-=-7,-4F-le, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1417 Ar
•.....,---0' 2 gve r 5 r--4./
Property Address
.1--""1540 el
Owner Owner's Name/ / ,y
information is / /es 7 7�f l! Qp2 6 " pZ t7required for everyw2: /page. City/Town State Zip Code Date ofc/0
i
D. System Information (cont.)
4. Type of Sys .
Septic tank, distribution box, soil absorption system "1--QN,M.n aa"4.„
❑ Single cesspool / /"
O Overflow cesspool
O Privy
O Shared system (yes or no) (if yes, attach previous inspection records, if any)
O 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 source of information:
02 003 abi-
Were sewage odors detected when arriving at the site? ❑ Yes No
5. Building Sewer(locate on site plan): /e i/
Depth below grade: feet
Material of construction:
0 cast iron 0 PVC 0 other(explain): /O
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
-re 5 `ca inspection Form.Suosurface Sewage Disposal System•Page 9 of 18
t5inspAoc•rev.7726/2018
Commonwealth of Massachusetts
*4Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ower, 4-47
Property Address
Owner Owner's Name �� / 1 j� ?
information is W e.S `.- Cfebkot4 K /74 0.)695 J .2 .1t,
required for every
page. City/Town State Zip Code Date of In ection
D. System Information (cont.)
6. Septic Tank(locate on site plan): �If
/
Depth below grade: feet
Material onstruction:
concrete E metal ❑fiberglass E polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) .Jt des❑ No
Dimensions: 6
2 U
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle /
OI
Scum thickness 11
G
Distance from top of scum to top of outlet tee or baffle 2 (/
Distance from bottom of scum to bottom of outlet tee or baffle a i., .
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.):
gsm,z, r`0,1 4ee 4 l✓ 4,4c/ `Qs
00c6oh �i1401 .
- a
f
Title 5 Offaal Inspection Form.St.esurface Sewage Disposal System•Page 10 of 18
t5insp.doc•rev.7/26/2018
Commonwealth of Massachusetts
* l_ Title 5 Official Inspection Form
' _ _ i. Subsurface Sewage Disposal System Form - of for Voluntary Assessments
147F-r
, 7 0,,,,e,„ z._ 4.
Property Address
4-(4,el d J 170 eli
Owner Owner's Name 6/es / , r/ Al i3
information is `r
required for every
page. City/Town State Zip Code Date of//.L/. t)
cti
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal E 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 E metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
'me S Offiaal:nspecuon Form.Suos.face Sewage Disposal System.Page 11 of 18
t5insp.tloc•rev.7!2612018
Commonwealth of Massachusetts
x ,; - Title 5 Official Inspection Form
7t;i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 (Avers 4,fr
Property Address /
—..(444'&Jr ley el
Owner Owners Name A //�� 0-..1c77
information is C/el-� ti ? !d. v
required for every2 ✓
page. City/Town 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.):
€0)1 ,z.4,fri, /
A49 So 4 Lis
7.tie 5 Office,.nspecuon For,.Suosurtace Sewage Disposal System•Page 12 of 18
t5insp.tloc•rev.7/26,2018
Commonwealth of Massachusetts
=P Title 5 Official Inspection Form
r�= , Subsurface Sewage Disposal System Form -Not r Voluntary Assessments
‘4,-,...- 2 0 tt/Pr'S 1---/V
Property Address //
tot V/Cid71,kl
Owner Owner's Name t / :::72
�,/ Ail M
information is / J-ex A'Yvoi Cato 9 Q ? /e -/�
required for every ��//``�� !
page. City/Town State Zip Code Date of Ins ction
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: Yes ❑ No*
Alarms in working order: es ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
6d7cI c.... el, 4,0.7
* 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: (f9 V17// r G✓( S ✓►{ 30)4.QCTYP _L-- 4 S ,...5
❑ leaching pits number:
❑ . leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovativeialtemative system
Typeiname of technology: — - -
.5e 5 Oft...nape-ex.Form.Suos..rrace Sewage Disposal System•Page 13 of 18
t5insp.00c.rev.7/25/2018
Commonwealth of Massachusetts
* _ Title 5 Official Inspection Form
f Subsurface Sewage Disposal System Form - of for Voluntary Assessments
ottm-rx 4/
+ Property Address
Ic4selds "jet
Owner Owner's Name6/ /� ) (�j
information is C,/.es �flo(S( A 1 C/-6 /7 4.?/0-ick 0
required for every ll�N/ "I
page. City/Town State Zip Code Date of I
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.):
"A 9 lei otaet4.eci
O / vel G`r i(1,2 . /
44e_ Q✓i c cC42 / C4-4v1 Gam✓!
/171 S✓✓✓ ✓1 f
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 8°moa,,nspe/ion Forn.Sucsw.face Sewage 0isposai System•Page 14 of 18
t8insp-Uoc•rev.7/25/2018
•
Commonwealth of Massachusetts
--i--,71,,i7=-____74 Title- 5 Official Inspection Form
0' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2 lowers L- ii/
Property Address
J.. 4-11.707
Owner owner's Name 11/
information is 2
required for every es '. o"i 4 /Y4( ��6�.3 ✓/1•Vot
page. City/Town State Zip Code Date of Inspe
D. System Informa ion (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.):
Tme 5 of5o.;nscacnon Form Scosurtace Sewage Dtsposat System-Page 15 of 18
t5inep.tloe•rev.7/28/2018
Commonwealth of Massachusetts
t- ----------4-- -ia Title 5 Official Inspection Form
_ -,..,_.1--=s� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
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Property Address / / /
Owner Owner's Name/ is :7;72_
�� 3 �®�information is N/z� A„ O�/ /i ll /9s �d0
required for every �O`G"/page. City/TownState Zip Code Date of Ins ection
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 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
❑ drawing attached separately
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t5insp.doc•rev.712812018Title 5:,;foal irspecaon Form.SuosuRace Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts
% Title 5 Official Inspection Form
`� !- - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 /Lrs L eV
Property Address l
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Owner
Owners Name
information is
6,4.s4c;10,010.4,4 /� o� 3 6`� 3 �� o�required for every
page. City/Town State Zip Code Date of inspe on O
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar �,c
❑ Shallow wells2 / 4 4' b
Estimated depth :
to high ground water. feet
Please indicate ail methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
(;' Checked with 10 31 Board of Health -explain:
PIG NJ f TEE4 /Ao%S
E Checked with local excavators; installers - (attach documentation)
Accessed USGS database-explain:
You must describ w you estaished the high ground water elevation:
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Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.6oc•rev.7t26r2018 -Ne 5 Office:,rsoecaon Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
_i Title 5 Official Inspection Form
Subsurface Sewage Disposal Syste Form -Not for Voluntary Assessments
1 ! owe,-j._ L
Property Address // +
Owner Owner's Name
information is �_ /-eJ� (oaf 14/4 /1/f L 0-.2-6/‘/.7 �] d-Azo
required for every �/V / J`� ( ✓r J
page. City/Town l^/./ State Zip Code Date of Ins ction
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, oro checked
C. inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Fail re Criteria)and 6 (Checklist)completed
D. 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
t5insp.doc•rev.7/26,2018 7:ue 5 O`aa;,nspecnon Form.Suosurtace Sewage Disposal System-Page 18 of 18