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HomeMy WebLinkAboutInspection Report 2024 Jan 19 RECEIVED ;� Commonwealth of Massachusetts Title 5 Official inspection Form FEB 01 2024 y^ Subsurface Sewa a Disposal S stem Po - Not for Voluntary Assess .TH DEPT. a ay) _ ___4t "/" .-e- Property Address _ 7-'"—.'' el",_5 a____ el///// Ovine- 'Owner's Name • Informatlor is -ecured for every . 0 v! "A 6L1664- �,' p1.. patio. ` ItyTorr State Zip, ode D of ins 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. [mpertanf:when A. Inspector I tion filling the computer, J ;Ise only the tab a! ,D 1 key to move your Name of inspec:c Ci;Sor-do not (© ` , G� se the return. ---- / L Key. Comps y Name U)e AI �U Q m Gcm;,ar:y AddreSS .. -L--=--,.5.44,,t4i /1/4 006(46) i ins ty To�� Q—f/ O State '-�[ ^) Zip Code Telephone Number License Number B. Certification i certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title (310 CMR 15.000); ; 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 o' :-site sewage disposal systems.After conducting this inspection I have determined that the systa, .. 1. 7 Passes 2. 7 Conditionally Passes 3. :_ Needs Further Evaivat on by the ..ocal Approving Authority 4. ` Fails 7?-414. � � inspedcr's — --- -- / — — ;ana.,.,_ mate The system inspector shall sub::�t 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 gpa or greater,:re inspector and the system owner snail submit the report to the appropriate regional office of the DEP. The cnginai fors, should be sent to the system owner and copies sent to the buyer, ff 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. 5irso.doc•rev.712£,201£ 7r1e 5 Or❑al irsoeceen Form:Subsurface Disposal Sewa se 5 - ,.asal System•.age 1 of 18 • Commonwealth of Massachusetts . � = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ./VQ G4*-- f 714 Property ACdress (A/0/ / • Owner wA►/liy Owner's Nameinformation is - - arequired for every c.--e;)(4-449rinOVith_ _ � P page. City~?own _-- State Zip Code Date of Ins ction/I �. C. Inspection Summary Inspection Summary: Complete 1, 2. 3. or 5 and all of 4 and 6. 1) System ses: nave not found any information which indicates that any of the failure criteria described n 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are 'ndicated below. Comments: 2) System Conditionally Passes: One or more system components as described in the '`Conditional ?ass"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 eyes`: "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) a structurally unsound, exhbits substantial infiltration or ex-Filtration 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): 5insp.doc•rev.726,2018 -:de 5 O fyGai lnseecax Form.Suosuriace Sewage�ispcsai System•?age 2 of;8 Commonwealth of Massachusetts Title 5 Official Inspection Form 'i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / o,, ?fit„Ire i -ke. Property Address j, Owner � Oi ll/v Owners Name informatior is eau~ed for every4 4 66_ page. City/Town State Zip Coce Date of ..specti C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumpsialerms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. L Observation of sewage backup or break cut 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's leveled or replaced `! Y ❑ N L 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 ❑ 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: 6insp.:ce•rev-r 262�'.8 -•5e 5 C':::ai:nspewor•Form.suosudace SevsSe asxsal Syssm•?a ge 3oi to • °` Commonwealth of Massachusetts Title 5 Official Inspection Form ^� y Subsurface Sewa e Disposal System orm -Not for Voluntary Assessments aa.-17"aaa, q44, /- At/- Property Address (/1/4 /4* Owner Owners Narne irforrnation is /yf� � ) // / /, 1 e rept&edforeverySONA �_ y / �`w� OL page. City/Town State Zip Code Cate of in pection 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. E 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 n1USt Indicate "Yes' or No to each of the following for all inspections: Yes No acKup of sewage into faciity or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 3inso.5oc•rev.7262018 7:le 5 CfP.dal:nspectior.Fom::Su4sw face Sew Ge Disposal System•?ace 4ot 8 Commonwealth of Massachusetts i— . = Title 5 Official Inspection Form ' 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J %.,="/ 7 �� CA-ke__ Property Address E7onr:verj —Owner'sName �/ / (�! / T Ovl A'v7oN page. CityiTown State Zip Code Date of in ection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ V Static liquid level in the distribution box above outlet invert due to an overloaded - or clogged SAS or cesspool i-- ��G/ Liquid depth in cesspool is less than 6" below invert or available volume is less E V*- than Y 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. ❑ _ 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. 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.] L.--2, V_ i he 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. Y@5 No '' the system is within 400 feet of a surface drinking water supply ❑ u 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 1_1 Li Area—IWPA)or a mapped Zone II of a public water supply well ainsp.doc•rev.7:28.2018 T:Ue 5 Ommaa tnsoecuon.FCT:Sunsurface Ser.ne Disposal Sysiem•.age 5 or 18 • Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewa e Disposal System Form -Not for Voluntary Assessments -,,;;;;.,_ _O /V:%, vrht a 4--e-f- Ake_ Property Address tt/ci //IOwner Owners Name44(Y001.044, f v7 l � f /�information isryQ /�� �d E /_ � �—T'required nor eve page. City/Town State Zip Code Date of nspecti n 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 No ❑ ._ mpirg information was provided by the owner, occupant, or Board of Health re any of the system components pumped out in the previous two weeks? the system received normal flows in the previous two week period? J • 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) iJi Was the facility or dwelling inspected for signs of sewage back up? y Li Was the site inspected for signs of break out? r- 0 0 Were ail system components, excluding the SAS, located on site? 2' ❑ 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? 9 The size and location of the Soil Absorption System(SAS) on the site has been determined based on: Existinc 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)) Sinsp.doe•rev.?1282C58 'iUe 5 Official:nspecocr Form.Sons.race Sewage Disposal System.Page:of 18 Commonweaith of Massachusetts _ . w: Title 5 Official Inspection Form __ Subsurface Sewage isposai System Form -Not for Voluntary Assessments Proper Address (Ajasie Omer 4 Owners tiame �)e c-e or ie �jAQJac' / /� v`4 reaured`or every �(/1___ p�(/rJpn �i page. City!own State Zip:ode Date of In action D. System Information ?. Residential Flow Conditions: J 3 Number of —bedrooms (design): Number of bedrooms(actual): SC DESIGN flow based on 3 0 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: / /*eb GA WO wt ‘r—lie-- 7- is C/ b ,--7---=.1 1-7 c frt-,a4,3/5 Al`-r7 // 6 x 6 Number or current resden s: d Does residence have a garbage grinder? 7 Yes o— Does residence have a water treatment unit? ❑ Yes if yes; discnaraes to: is laundry on a separate sewage system? (Include laundry system inspection __ / information in this report.) ❑ "es L�No Laundry system inspected? J Yes Seasonal use? Yes -�'No Water meter readings, if available(last 2 years ;god)); usage ' )): —o Detail: Si 0 0 / Sump pump? --------- - - - No oast Oate o`Occupancy: • ;e 'Sinsp.coe•rev-',25 8 _ 5_ 3.!Z.i lrs..--n..,-.•=c,n.S;;esu`ace Ser2ye D.spcsal Sys_m•?age 7 Of is Commonwealth of Massachusetts Title 5 Official Inspection Form ,11 Subsurface Sewa a Disposal System Form -Not for Voluntary Assessments //:t lid 44- Property Address �'��/-e Cilor A I Owner Owner's Name information:is every �H --- K //l/ [ 00- 66 7ec.uired for eve �L' /�_ J (` page. City/Town State Zip Code ( Date of Ins ction �"/— D. System information (cont.) 2. Commercial/Industrial Fiow Conditions: Type of Establishment: Design flow (based on 3 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatsipersonsisq.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. :::: fl::rn: Was system pumped as part of the nspection? ❑ Yes If yes, voiume pumped: 3aii c ns How was Quantity pumped determines? Reason for pumping: --_ Sinso.00c•-ev.7262018 nUe 5 Ofnc,ai;rspececn Portr..Sus:..:ace Sewage J:soosai Syse r•Page 8 of 18 \ Commonwealth of Massachusetts Title 5 Official Inspection Form er_` Subsurfacep,. �; Sew e Disposal Sy tern Form Not for Voluntary Assessments ,8/1-1-6-ite-e-i-- Ave_ Property Address Owner C,/,_____,q14ei Owner's Name ecinformation is required for every _es, � - fi/¢ 0�667 I/ �y page. CityiTown State Zip Code Date of Ins ctior: D. System Infor tion (cont.) 4. Type of S m: Septic tank,distribution box, soil absorption system I Single cesspool Li Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) 13, 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. j; Other (describe): Approximate a all components, date instaile ' (if' nown)and so e of informati : p/.4s t— .-... (,� Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): // // Depth below grade: Teel— Materia "construction:cast iron _ 40 PVC V C " other(explain): ( r/ Distance from private water su — --pply wall or suction line: feet Comments (on condition of tints, venting, evicence of leakage, etc.): 5insp.coc•rev.7.25f2C18 `ce 5 Oii:aa!-s;ecuor.rcnr..Subsuaacc Sewace 7sp:sai Syslera•Page 3 of'8 ,� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 /444C1 chc,--/- "lye --..,-2„:3---- Property Address tt/Gt /!!(4 - — Owner Owner's Name /- / [� q information is every 5���/,� d, ui/„ Ai Dp)E7�T // required for eve — _ V, page. City/Town State Zip Code Date of Ins ction D. System Information (cont.) 6. Septic Tank (locate on site plan): 1/ Depth below gra de: a aoe. feet Material ` onstruction: concrete ❑ metal Li fiberglass ❑ polyethylene ❑ other(explain) -- If tank is metal, list age: years is age confirmed by a Certificate of Compliance? (attach a copy of certifi te) ❑ Yes ❑ No Dimensions: _ ` l v Sludge depth: c� // Distance from top of sludge to bottom of outlet tee or baffle -- cc � Scum thickness VD -Se Distance from top of scum to top of outlet tee or baffle --- Distance from bottom of scum to bottom of outlet tee or baffle w izi gS.2_ How were dimensions determined? �_ L`1.w1C� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert; evidence of leakage. etc.): -- 041 i/l'e€C ---e- 7--- u r►-� ,h yl — — 1 04.. aNci/ ...keLr -----— — — (on T/ON L,C0 • C S 5[nsp.doe•rev.Trz6i2C 18 -•„c 5 C f,L,a1;^s:e:::en.ern:Suosdace Sew Qge-J sp-sa;System•Page t0 of 18 Commonwealth of Massachusetts 0 Title 5 Official Inspection Form Subsurface Sew ge Disposal System Form -Not for Voluntary Assessments /V GT✓l-co 71 Property Address E1ri:ve r Oers Name ]ry Q page. City/Town State Zip Code Date of I pection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete metal 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 _l polyethylene ❑ other(explain): Dimensions: — --- _ Capacity: gallons Design Flow: gallons per day :6insp.doc•rev.7:26/2018 -:Us S C fcai inspection Fofrr SuPsur1ace Sewage Disxsai System•?age 11 of 18 ("s. Commonwealth of Massachusetts Title 5 Official Inspection Form `_ — Subsurface Sewa e Disposal System Form Not for Voluntary Assessments Lir M N v`Gh G / J�i" I Y �Property Address C ���`Owner — V/ 111—/r Owners Name information is /, required for every _ /4 St QN fl7N /" /� D�G�� m /� page. City/Town ------ State Zip Code ate ofInsp on, ---�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? i jj 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.): --e6be /(A) cccOA/r t5inso..oc-rev.?126d2C S 7:7e 5 i;-:c.ai it soecuon=orm.Sues,::fece Sev.s6-e D.soasaf System•?age 12 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewa e Disposal System� Form - Not for Voluntary Assessments / �'(/q s444- ,fre Property Address W Q/// Etoorr:ve Ownersame // .�l },ry 1 0�(7 page. City/Town State Zip Code Date o' nspection D. System Information (cont.) 10. Pump Chamber (locate on site plan): Pumps in working order: J 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 no: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: (9 274 /11 e`'4s /JokLL I ' )4.1,e6 leaching pits number: leaching chambers n;.moer: leaching galleries n:;m:Per: leaching trenches number, length: leaching tleics number, dimensions: overflow cesspool number: nnovativealternative system Type name of technology: — — ---- --- r5irsp.00c•rev-?g6/ZC118 7iue 5 Orflz.16 nspecuon Form.Suns,dace SewaGe Disposai Sysierr-Page 13 of 18 Commonwealth of Massachusetts -� ��= Title 5 Official Inspection Form j Subsurface Sewa Disposal System Form -Not for Voluntary Assessments /614414 \ 1 Property Address -- Owner Owner's I1t.� Owrer s Name / 4 information is `(/fa /�j� �1 6(O" / f/ nor required for every C c,4c72 ( �' r y page. City/Town State Zip Code Da:e of spect n / 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 d cc/7 de 12. Cesspools (cesspool must be pumped as par 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.): $fnsp.:oc-rev.7.26/2018 'Min 5 C c i l-specoon=o.—.s1_•6s-r.'ace Sev•asc aspcsa System.Page 14 c7 78 Commonwealth of Massachusetts ^a� Title 5 Official Inspection Form 11 Subsurface Sewa e Disposal System Form -Not for Voluntary Assessments 4*: /VG i'dof ,f1/ Property Address 1_,i owir:ve Owner's Name ,]' fa yry H _42W /!/1 vd b l� page. City'•ovr. State Zip Code Date of Insp lion D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: - Dimensions Depth of solids - Comments (note concition of soil, signs of hydraulic failure, level of ponding, condition of vegetation. etc.): 5insp..ot•re•:.7.262:.:8 -:_e 5�'..c:a.nspa.;�o. =art...Sus..;ace Sevrcz=sacsa Sys;ea•?age°S of'.8 \ Commonwealth of Massachusetts ii Title 5 Official Inspection Form Subsurface Sewa e Disposal System Form -No fo-Voluntary Assessments -j a Milv1 � 2 `��GH 4-kr____________ ooe`y Aecress : -:ve ry _ �49., N 6`'fage. own =� __i ma's a`[n� 0 D. System information ;cart.; t4. Sketch Of Sewage Disposai System: Provide a view of the sewage cisbosal system, nciuc:ng ties to at;east two permanent-eferer:ce landmarks or be^ hrnE-Ks. Locate all wells within: 100 feet. Locate where public water suppiy enters the buildir. - L.reck one of the coxes below: and-sce cb 'n the area oelcw crawf-ic attached separately. A• g Acv ,.._ g Gaiw e'hV pi ,r . -, -; - l .. .�• �� - ram• r' Ci �j_ . / r x cZi✓1//7lo�'S 64.�40v� /14,1/ : 9� /b 1l )1366 la-016.4 "-3-- Yw, 9 IS- �� insp.cc_-z..7: 2;,--.s ":e 3 J�'.c-a insoe:t=n-o.-.Soza.:ace S-ev2oe:-s?o5a-Sslec•..a-e 76 of 18 ., Commonwealth of Massachusetts c Title 5 Official Inspection Form k .. .,.: 4-, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 %WWI.' At-i _ ,, & ,,,I, Property4,4/- Address Owner owners Name 6fAc/f nforrnatior. s 'equired for every V///tc: Qt_ 7166ppage. City;;ovm. — State ZipCode Date o .spectior D. System Informa Y ton (cont.) 15. Site Exam: • Check Slope Surface water _._i Check cellar Shallow wells 75[ Estimated depth to high ground water: v feet Please indicate all methods used to determine the nigh ground water elevation: Obtained from system design plans on record t-checked, date of design plan reviewed: Date 7-7 %n rued site(adu ong property/observation hole within 150 feet of SAS) Checked wit'' ai Board of-ieaitn- explain: _ ems -1- �Esf / necked With :Deal excavators, installers- (attach documentation) Accessed USGS database-explain: You must cescrh. ,ow igh established the h round water i vation: _•j.„--___-e-5i-- -:c.,-___Y,icy p 2 6 ‘e, 6 e 4/ 4 r� .,0(c.. -e . koclay.e/- C.-.0 S __ -�tr C/ tyk.'2141 d..44,._ -_ _ltze4.46/.. sty • Before (7as-•ic./4/•,16-e,- filing this Inspection Report. please see Report Completeness Checklist on next page. Sinso.]oc•m.1.261=18 -,ae 5 Coloa:ate.:o^Form 5wosulace Se eye ZIsoosai System..i,e 17 or 18 . ' ,, Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `��� y 7 `� J Property Address Owner Owners Name — G e 4_en4ia-lf6-�//�/;nforr^atior.ise format for every , , / yfilA—: page. Cityrown _Ce � (Zatate u ao:,e a_e o`In E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: (nspector information: Complete all fields in this section. _` Certification: Signed& Dated and , 2. 3. or 4 checked `- inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (F .ure Criteria)and 5(Checklist)completed D. System information: For 8:Tic t Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn or pg. 18 or attached For 15: Explanation of estimated depth to high groundwater Included Sirso.coc• e.?:26,2O.8 :::!IL-.:ae :::!IL-.:as:a:-:ecao. `,,,-.Sus.:mace Seway_7spcsa 5y5Ee^•pave 18 .18