HomeMy WebLinkAboutInspection Report 2024 April 5RECEIYEO
e\ Commonwealth of Massachusetts
Title 5 Officiat
Subsurface Sewage Disposal S
lnspection Form
ten tForm . No: 'o- Volu/,n.
iii
APR 1120?4
men HEALTH DEPIIysniary Assess
STki.ot4Ol^nei
infgr:lation is:ecuir-ei :oi eveiv
page.
b2 dCrry",Tc.rr
Inspection resurts must be submitted.on this form. inspection forms may not be artered in anyway. Please see completeness checklist at the end of the iorm.
A. lnspector ationlrnponant Wierillirg oul for,is
on +,rie ac-tutet,
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o C #
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Zptue
!;cense lluftber
B. Certification
i oeniry iha:: I am a DEP approved system inspector in full comptiance with Section 15.340 of Ti e 5(310 CMR 15.000);i have personally lnspectecj the sewage dispcsal sysiem at the property addresslislec aoove: ihe i;:icr,'na-Jon :eponeo :eiow is ne. accurate anc cornclete as oi the time of mynspectjon: ani il e Insoscjgr't was peffo,'inei based cn l:y ilaining and expenence in the proper functionano mainteaarre ln-site se\ €ge disposai slE:eri'rs. After ccncucting i.]is inspection I have determined'inat th€ s
Passes
2. J Conciitionaily Passes
3. ll Neecs =uEhei =vaiuat;cn by r.e _oaaiADproving Aijthoruy.*
-ihe sys:er,: inspeclci sirail s.,oiiria ccp,v.ci inis irspecricn iepon.:o iie Approling Authority (Board
?ii:iit!jr:=^?$!r1]!-1a^v^19g ccmirietins tiiis inspection'_ rt m- iystem rras Joesign n'ow of:]i:,"^::|:_": y:"-:t:lj j. .xspeclor ano -,he svstem owner sha submir the repo.r ro tnd approprtato.egronal oil'rce ci -ne DEp. The crEi..'ai.'orni snouic be sent ic t'ne system ouiner and cooiei sent torjre buyer. -ri applicalle. ani tne ao;iovinE aut.roi!.
Please note: This report only describes conditions at the time of inspection and under theconditions of use at.that time. This inspection does not address'i,o* G" =y"t"rn *ill performin the future under the same or different conditions of us€.
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Cofioany Nairerffi
1.
S:. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fo
+.7
rmAct =or Voluntary Assessmenrs/1r,< 5l-
Properrry Add.ess
Owner
infoi'natjon is
leouired for every
page.
Owaeas Name a6r5
CitylTown Zip Cooe oaie of ior-
C. lns tion Summary
lnspection Summary: Complete 1, 2. 3. ar 5 and all of 4 and 6.
1) System CS:
I have not found any iniormatioi] wnich indicates ihat any oi Lne failure criteria described
rn 310 CN4R 15.303 or in 310 CMR i 5.304 exist. Any failure criteria not evaluated are
indicated below.
Comments
2) System Conditionally Passes:
! One or more sysiem components as describeci in the "Conditional Pass" seclion 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 ior "yes", 'no' or "not determined" (Y, N, ND) for the following statements. lf "not
determined, ' please explai..
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 iank will pass inspection if lt is structurally sound, not leaking and if a Certificate of
Compliance indicating that rhe tank is less than 20 years old is available.
nY IN f, ND (Expiain below):
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C1 Commonwealth of Massachusetts
Title 5 Officiat
Subsurface Sewage Oisposal Sys - Not for Volunta ry Assessments
STPropeiry Address
Owner
infofiBation js
'eoujred fo. every
page.
Ow.eds Name
9
ciry/r
C.ln ction Summary (cont.)
2) System Conditionally passes (coni.l
Stale Zip Coce Daie of ln
nru
nN
nN
t5
! Pump chamber pumps/ararms not operationar- system wifi pass wit,, Board ol Hearth approvar ifpumps/alarms are repaired.
n Ooservation of sewage backup or break out or high static water level in the distributjon box dueto broken or obstructed pipe(s) or due to a brokei, setted oi rn"r"n distnbution uox. syiiem wi[pass inspection if (with approval of Board of Health):
I broken pipe(s) are replaced tr V
D obstruction is removed n y
n distribution box is leveled or replaced tr y
D ND (Exptain betow)
X ND (Explain betow)
E ND (Explain betow)
n The syste-m required pumping more than 4 times a year ciue to broken orobstructed otoe(s)- Thesystem will pass inspection if (with approval of the Board of Health):
n broken pipe(s)are replacect Xy IN D ND (ExplaiR below):
I obstrucrion is removed n y fl N n ND (Exptain below):
3) Further Evaluation is Required by the Board of Health:
- Conditions exist which requ;re fu.ther evaluation by the Boar.i cf Heeith in o.de. to.jeterminc ifthe system is failing to protect public health, safety or the environrnent.
a. System tyill pass unless Board of Health determines in accordance with 310 CMR15.303(1Xb) that the system is not functioning in a manner which will protect public health,safety and the environment:
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lnspection Form
e,. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fo of ior Voluntary Assessments
tyl€s
Propeity Address
e
Owneds \ame
City,T
c.l nspection Summary (cont.)
n
Cesspool or prily is within 50 feei of a suriace 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 publlc health,
safety and environment:
! The system has a septic tank and soil absoiption systerr (SAS) and the SAS is within
100 feet cf a surface water supply or tributary to a surface water supply.X The system has a septic tank and SAS and the SAS is within a Zone 1 ol 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 irorn a private water supply well'*.
Method used to determine distance:
* This system passes if the well water analysis, periormed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent ancj the presence oi ammonia nifogen and nitrate nitrogen is equal
to or less than 5 ppm. provided that no other iailure criteria are triggered. A copy of the analysis must
be attached to this iorm.
c. Other:
@4ls
Z;p CoceStaie Daie cf I
4) System Failure Criteria Applicable to AII Systems:
You @gs! indicate 'Yes' or "No' to each of the follolying for gl! inspectiens:
Yes No
n
n
p of sewage Lnto faciiity or system component due to overloaded or
ogged SAS or cesspool
Discharge or ponding of eifiuent to the surface of the ground or suriace waters
due to an ovedoaded or ciogged SAS or cesspool
Tlle 5 Oric J lnsoeclioi rofr. Su5*iae S€ege C6o.sal Svsieh'P.oe 4 ol ia6insp.doc. B. '2612014
Owner
informatron is
equircd for every
page.
Cr Commonwealth of Massachusetts
Title 5 Offi cial lnspec
Subsurface Sewage Disposal System Fo
Propetry Address
tion Form
ot for Voluntary Assessments
4<_Sf
Olvner
information is
.equired ior eve.y
page.
Owneds Name
City/Town
0 oJ6tS
Srate Zip Code nc.t nspection Summary (cont.)
4) System Failure Criteria Applicable to AII Systems; (cont.)
static iiquid level in tne distribution box above ouflet invert due to an overioadedor clogged SAS or cesspool
Liquid cjepth in cesspool is less than 6.. below invert or available volume is lessthan % day flow
Required pumping more than 4 times in the last year /VOf due to ciogged orobstructed pipe(s). Number of dmes pumped:
Any portion of the SAS, cesspool or privy is below high ground water etevation.
l1V 3orti3n of ce.sspoot or privy rs within 1OO feet of e surface water supply ortrrbutary to a surface water supply.
Any portion of a cesspooi or privy is within a Zone 1 of a public water supplywell-
y pcrtion of a cesspool or prjvy 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 feetiiom a private water supply well with no acceptable water quality analysis, Fhissystem passes if the well water analysis, performed at a DEP cErtifiedlaboratory, for fecal coliform bacteria indicates absent and the presenceof 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 analysisd chain of custody must be attached to this form.I
'e system is a cesspool serving a faciljty with a design flow of 2000 gpd-10,000 gpd
s)
YgS No
trtr
trtrtrn
:he sysiem is lvithin 400 feet of a surface driflking.rr'ater supply
the system is within 200 feet oi a tributary to a su.iace drinking water supply
the system is located in a nitrogen sensitive area (lnterim Wellhead prolection
Area - IWPA) or a mapped Zone ll of a public water supply well
i le 5 oi:ila risre.ro. FdE su:&r{@ spEge frsposat sysEm r Page 5 ot 13
Yes
tr
n
n
tr
tr
tr
n
tr
No
The system gils. I have determined that one or more of the above failuracriteria exist as oescribed in 310 CMR .15.303, therefore the system fails. Thesystern owner should contact the Board of Health to determin; what will benecessary to correct the failure.
Large Systems: To be considered a large system the system must serve a facility with adesign 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 thequestions in Section C 4.
n
i-5rns..d.c Gv. 725120: 3
Ar Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Sub surface Sewage Disposal System Fo for Voluntary AssessmentsW
Olvner
infonnation is
reouired for every
page.
P.opealy Address
-o_l|c_Owner's Name
0
Cityj-Io,'!n Siaie Zip Cooe Oaie of
C. ln ection Summary (cont.)
j
tr
umping informarion was provioed by the owner, occupant, or Board of Health
the system received normal flows in the previous two week period?
Were any oi the sysiem comoonents pumped out in the previous two weeks?
Have large volumes of water been introduced to the system recendy or as part of
this inspection?
Were as built plens oI the system obtained and examined? (lf they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected fo. signs of break out?
Were all system components. excluding the SAS, located on site?
n Were the septic tank manholes uncovered, opened, and the interior oi the tank
inspected for the ccndition of the bafffes or tees, material of constructron,
dimensions, depth of liquid. dep'th of sludge and deprh of scum?
Was the facility owner (and occupants if different trom owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location ofthe Soil Absorption System {SAS) on the site has
been determined based on:
=xisting lnformatjon. For example. a plan at the Board oi Health-
Deterrxjned in the ielo (if any of the failure criteria related to Part C is at issue
approximaticn of cjistance is uflacceptable) 1310 CMR 15.302(5)l
lf you have answered "yes'to any question in sect,on c.5 the system is considered a signmc€nrthreat, or answered "yes" to any question in Section C.4 above the large system has fail;d. Theowner or operator of any large system considereci a signiflcant threat under section c.s or failedun€ier.section c,4 shall upgrade the system in accordince with 310 cMR 1s.304. The system orvnershould contact the appropriate regional office of the Department.
You must indicate "yes" or ,,no,, for each of the following for a/, inspections:6
Yes
L-..1
f
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*
b6%
Commonwealth of Massachusetts
Title 5 Officiat lns pection FormSubsurface Sewage Disposal System Fo Not ior Voluntary Assessments
Piopeft-v Address U 5
oOwner
informatiqn is
Equired ior eyery
page.
OYyxels Nafie dttt0uCity/Tow,l
D.System lnformation
1. Residential Flow Conditions:
Number of bedrooms (design):
Siate Zip Coce gate ci I
,5
Number of oedrooms (actual)
DESIGN flow based o 31 0 CiVR 15.2C3 (for example: i 1 O gpd x # oi bedrooms)
-llo-L f a.
".<-
! Yes
! yes
k
ut Or?)Zo
3Number of cu.ren! resicienis:
Does residence have a ganage grinCer?
Does residence have a water treatrnent unit?
]:,ly9g on a,separare sewage system? (tnctude laundry system inspectronrntormatlon in this report.)
Laundry system ;nspected?
Seasonal use?
Waler meter ieadings, if available (last 2 years usage (gpd)):
00-v
No
r0 n0
Sump pump?
Las! qate oi occupancy
ves No(^
Daie
5in.p.coc.r' t25,2ola S!5&r.e sa€Se D,.@sr Sy.r.i . ?.a. I or ia
fr.&
Kd
j
5So
Descriprion:
jf yes, discharges to:
! yes
I yes
! Yes
Detail:
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - N r Voluntary Asses
NL
P.opefi-v Address of/e
smentsSt
Clvner
info.liation is
'equircd for every
page.
Ot\.nels Name
City/Town State Zip Code oaie of
D. Sys m lnformation (cont.)
2. Commercial/lndustrial Flolv Conditions:
Type of Establishment:
Design flow (based on 310 CMR I5,203)r
Basis of design flow (seats/persons/sq .ft., etc.)
Non'sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use:
Othar (describe below):
Galloos per cay {gpc)
Evesnruo
Dvesnruo
I Yes[ No
!Yes!No
Date
3. Pumping Records:
Source of information:
Was system pumped as part of rhe inspection?
lf yes, voiume pumped:
How was quantty pumped determined?
Reason for pumping:
Solt OWYlZ-r/^
r__1 Yes
l56s9.doc . 8. 7268014 1 de 5 OmEd lrsre.rioi aom SlbsuJa@ S.€9. O,spod Slslsm . P.9. 3 .r I a
Grease trap present?
Water treaiment unit present?
lf yes, discharges to:
lnduskial waste holding tank present?
=<'
Olvner
information is
requircd for every
page.
Ti
4. Type of
iS,. Commonwealth of Massachusetts
tle 5 Official lnspection Form
Subsurface Seviage 0isposal System Fo Not iof Voluntary,A3 r)4
Assessmentstf
P.opeary Add.ess ofie
Owller's Name
City/To',fi Staie Zip Coce Daie ci ln T
D. Sys lnformation (cont. )
Septic tank, distribution box, soil absorption system
Single cesspool
Ovedow cesspool
Privy
Shared system (yes or no) (if yes. attach previous inspection records, if any)
innovative/Alternative technology. Afiach a copy of the cunent operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the l/A system by system operator under mntract
Tight tank. Attach a copy of the DEP approval.
Other (describe):
Approximate a of all ccmponents. oate lns
n
tr
tr
tr
tr
n
ot3-Wrrff,
and source of inrormarion
Were sewage odors detected when aniving at the site?
5. Building Sewer (locate cn site plan):
Depth below grace:
rstruclion
No
.1J 7
Material of co
I cast iron 40 PVC E olher (explain)
Distance from private water supply well o[ suction line: r.; -
Commenls (on condllion ofjolnts, venttng, evldence of teaKage, etc.):
/o
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er Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form -t for Voluntary Assearl<
ssments.f+
Owner
infor.naton is
iecuired ior eyery
page.
PrcpetyAddress o fie
Owxeis Nar.e
o
City/Town
D. System Information (cont.)
6. Septic Tank (locate o'r s,te plan j:
Stale Zip Code Date of ln
//lcDeoth below grad ieet
lValerial CO nstruction
concrete I metat I fiberglass ! polyethyiene D other (explaan)
If tank is metal. list age
lr'ears
ls age confirmed by a Certificate of Compliance? (attach a copy oi ce te)v Yes ! NowoDimensions:
Sludge deplh:
Distance from top ot sludge to bottom oi outlet tee or baffle
Scum thickness
Oistance from top of scum to top of ouuet tee or baffle
Distance from Sottom of scum to oottorn of ouflet tee or baffle
How were dimensions derermined?
Ata
0a
^L-
3w
//
Comments (on pumping recommendations, inlet ano ouEet tee or baffle condition, structural integrity,liquici levels as related to oJtlet inverl, evidence of leakage. etc.):
4t ;;J_(14
/1
/-4r
*on,
e.Ls
rsinsp.d@ . cY. i2€,20r 3 i'uc 5 aHiq.t risrec.oi -on. Slr,riae se€Se Jisro$t Srsr€6. p.g. :0or la
oals
x}\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
ile
Subsurface Sewage Disposal System Form ot for Voluntary Assessments
Prcperty Adci.ess I efte
Owner
inforalation is
'equired ior every
page.
A605(,
D.S m lnformation (cont. )
Zip Cooe Da:e I
! fiberglass n polyethylene I other (explain)
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom ofscum to bottom of outlet tee or baffle
Date of last pumping:
Comments (on pumping recommendations. lnlet and ouUet tee or baffle condrtion, structural integrity,
Iiquid levels as related to outlet invert, evidence oi leakage. etc.):
8. Tight or Holding Tank (tank rnust be pumped at tlme of inspection) (locate on site plan)
Depth below grade;
Material of construction:
! concrete I metal
Dimensions:
Capacity:
Design Flow
I fibergiass ! polyethylene I other (explain)
gallons
Sinsp.doc. re%'26120ra
galloos per day
'arue 5 oiIcJ hspeclo. a.ftr suD6lrlac. s.dEe cLspcsi sysrem - Page l1 ol18
OYrnels Name
7. Grease Trap (loeate on site plan):
Depth below grade:
lvlaterial of construction:
! concrete n metal
Date
A Commonwealth of Massachusetts
Title 5 Offi
isposal System Form .
cial lnspecti onF
for VoluntaSubsurface Seryage D
tvl
P.opetyAddress
orm
rv Assessmentsf/-
Owneas Name
Cityft
D. Sys m lnformation (cont.)
8. Tight or Holding Tank (cont.)
I Yes nruo
Alarm in working order ! ves ENo
Daie
Comments (condition of alarm and float switches, etc.)
Siate oate of In
m?
'Attach copy of current pumping contract (required). ls copy attached?
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquio level above outler invert
o
I Yes nruo
Ekekl
comments (note if box is level and distribution to oudets equal, any evidence of solids carryover, anyevidence of leakage into or out of box, etc.):
q!,q
,//0 So/, J i
,O0 Lr
$:I) r-
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Olvner
information is
requiaed for every
page.
Ajarm present:
Alarm level:
Date of last pumping:
Zip Caae
1$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface S Assessments,ft'
posal System Fo ot for Voluntary
Cwner
inforfiatio. is
Eouired ior every
page.
rl
P.opelry Address o e
Owner's Name +
City/Tovfi
D. Sys m lnformation (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: n Yes n No.
Alarms in working orcier: n Ves ! llo'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc. ):
Zip Cooe Daie ofStaie
lQc st c Ye_Type
tr
n
I
n
tr
n
I
leaching oits
leaching chambers
leaching galleries
leaching t.enches
leaching llelos
overflow cesspool
Innovative/alternative system
Typei name of technology:
aumber:
number:
number:
number, length:
number, dimennlona:
number:
rsinsp.doc €r 7/2U2013
* lf pumps cr alarms are not in working orcier, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
lf SAS not located, explain why:
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A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
+.7
Subsurface Sewage Disposal System Fo - Not for Voluntary Assessments
(t(,ffI
P!'opeGy Address ile
O'rvner
infonnatiof is
required for every
page.
Ownels Name
0ur
City/Toun Staie Zip Code Daie of I
D. System lnformation (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic iailure, level of ponding, damp Soil, condition Of
vegetation, etc.):
ar'l O
I tlt a t-
/e'
12. Cesspools icesspool must be pumped as gan ci rnspearion) (locate on site plan)
Number anci configuration
Depth - top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
lndication of groundwater inflow n Yes I lto
Comments (note condition of soil, signs of hydraulic failure, level of ponding, mndition of vegetation,
etc.):
sia*..*. '.-.7agb1E -,de 5 Cne- i.spc@.n :.fr Subn.r.e S46Se a'spL., Srs€n '.i.€. 14oI ia
A. Commonwealth of Massachusetts
Title 5 OfficiaI Inspection Form
Subsurface Sewage Disposal 0t for Voluntary Assessmentsqt""W:frP.cpe.iACdress
Owner
infomation is
:equried ior every
Owreas Name
City/Town
D.S m lnformation (cont.)
13. Privy (locare on slte plan):
Materials of consiruction:
Dimensions
Depth of solicis
trJ6
State Zip Code Daie ci I
Commenrs (note concjition of soil, signs of hydraulic iailure, tevel of ponding, sondition oi vegetaton,
etc- ):
!iB?,loc . ?v' ,,26,4 j a Sq.s-na@ Sey€Ee:s..s.l Srscn. iase :5oi 1a
Commonwealth of Massachusetts
Title 5
Subsurface Se
I lnspection FormOfficia
wage Disomal
+3 Form . Noi ior Voiunrarvsf Assessmenis
Prope.{ Address
Owiers l\arne
D.S
t4g
of(c
SE:e Zp Soce
14. Sketch Of Sewage Disposal System::rovrde a view of '.he sewage disposar sysrem. ;ncruoing ties io at re€st two permanenr referenoeiandmarks or fenchrna:Ks. Locate al *erts *rti--in r oo t"".r-iooi" *ne.e pubiic *ate, sulprv "ri""the rtuilding. Cneck one of :ne boxes below:
! :ancl-s<etc- n lne 3fea lg,cw
- cravr'ing ai.achei sesarately
yst nformation icc:t.)
3rt
(,+ct\l/
/a
/loo(j.tl l,a
5zdl,c
tas
7;L
Avor'
Al- at,5
0t- ts
Be -+a'
14cc- let
C l,-"lrszy't*"t
cJ^ 5,f
(3'ao
6i ^ aa,9
,9,,1,,Lt,^^ &x
/14! R )t r
dt tro.
5;.c?-!.. . b-TtZEEara !rs/."e *@!. ;sa.sd sF4 ' -dg. . 6 or 13
Cwnei
infg.iato. js
aequjaec' bi evelv
'Y
7\
Commonwealth of Massachusetts
Title 5 Officiat
Subsurface Seryage Disposal S
lnspectio
ystem Forgo Noi for
//trr<
n Form
Volunt€n Assessm,f enis
Picper,y Adciress
Oltl1eis Nahe (1,
City/-ior,trl
D. Sys m lnformationlcont.l
15. Site Exam:
n Check Stope
E Surface water
E Check cellar
n Shallow weils
Estimated cjepfi to high ground water //t'r /U0/k--
o tr/eO,vnerjnfoarnatjo. is
quired ior everypage.JS:aie Zp Coce
T
Please indicate ail nethods used to deter.fiine ihe xjgh grouna waier elevation
Ob'€ined irom system design plans on record
lf checked. date of design plan reyiewed:Date
--l erved sire (acurting property/obsen,a;ion xoie wiihin 150 ieer of SAS)
CnecKea with iocalnrrc a.a ieatt t -'T"brt /il-f
Cnecked with iocal excavatcrs, insiaileis - (anach cjocumentation)
Accessed JSGS oaiabase - explatn.
You must oesciioe ssiablisheo :ne nicn <Tcl/u? df ""'fh[f;l*o"" 3*z
lp?at4-t
-,7"
Before filing this lnspection Report. please see Report Completeness Chesklist on next page,
5'ne dd E.72t2!r8 . Selri:€ s*€!e a,sr.si s
Commonwealth of Massachusetts
Title 5 Offi cial Inspection FormSubsurface Sewage Disposal System Form -:or Voluntary Assessments
Propeny Add.ess
t ylL ff
rC //e
Owner
infomatton is
€qutaed for every
page.
O\Yneas Name
o/@e0Caty/Tcw1 Zp Coce
E. Repo rt Completeness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspector iniormaiion: Complete allfields in thjs section
9d?erriircaiion. Signed & Dated ano 1 . Z, 3, or 4 checkeci
C. lnspeciton Summaryl
1. 2,3, oi 5 oomplered as appropriare
lure Criteria) anc 6 (ChecKiist) compietecj
D. System lnformation:
For 8: TighVHolding TanK - pumping contract attached
For 14: Sketcn oi Sewage Disposal System cirawn on pg. 16 or attached
For 15: Explanalion of estimated depth to high groundwater :nclucjeo
slns9-do. . B 7.26201 3 ;,n€ 5 c1.ra :st€.r.-..- suD*Ja@ s.d.g. irstcsaj sys€f,. p.oe 18ot:a
Rurrv €f AssocIATES, INc.
ENcrlte*tNc, Lexo SurvevtNc (f ENunolrtlnrtn- Snnvrces
Site Dcvclopmeat ' Propcrty Unc' Subdivision' sanitry' Land Cosrt' Envtonmcntal Pcrmitting
S.?6mbor 24 2Ol3
Mr. Bruac MuEDkY, Ditlsts
Yrcoue Boad of Hoalth
1146Irrritr St]!d
Yrrnord, MA 0266{
Job # 6756
Ro: 43 Pinc St'cot
Asscssor's MaP 123' Patel I
Ysrmou$ PoG MA
Mry BGG Tbschc.' Ox/sct
Ihar lv{r. MurPhY:
Ar s rho lwuir€o€d of tho MB.chuloos sun soitry cod. 310 cMR l5'O2l(3) JJf
6dt1y t -;]["16..,
Inp. has m5,ahd on*io inspoctiog of tto acwty imtrlbd semego
diryoEd systcm ri lhc rbovc rcftluood Prqc.ty-
At 6o doo of oru inspoctin u 9/lti/13' roil rcmod !* Yg!fid a 9l23lll' lhc E/!ilcd-;$.lhi-
hrd ba ir.pUoa wis rto accptioo of brcffitling od qd'l -lrd!!g O't
Ouovtio- ,** lioitod io lb toP of lte Sod e*orptim syltcd (S'A'S')' 6a "lfqel*rt fo U U"O fu s*dc t.uk dd difihlioo tox ad Uo soil coditbns.bovo 6o S,{.8.
srrod o on obetrvulms, tb seryagp 8F6 wrs instrllod wi6in orbcaatid cqftlaco wilh
thc rpg,ovod plu detod (tVt3, as fiIod h yorn offico.
Thi! Lri.r rarcs.ars ,Jr{. oRcilty & A$sii.t, Iac,',s inrpocdm Fiof to b..ldlt No
wlrrD{ir8 6 atriut .s rc orprtscod c inplied frr tto ffruo opcrtim of mis sjit$!6'
plan cmct uy offioc dinctty wlrh my qrrcions, omncoB ot f.[' ay tdditiood infomrim
yor my nood.
Vcry Tilly Yous,
,Jv{. CfRcilry A Ascociaos, Inc.
fernaodoe, P.E.
CivilEogim
cc:Cli*
Joho M. (}killy, P.8., P.L.S.
XEF/coo
r573 Marx Srneur, P.O. Box 1773, Bnuwsrrn, MA oz63 r . PnoNr: (5o8) 896-65or. Fex (So8) 896-66o2
J.M.O'
PnorBssroNlr"
trOVtrE
siP 2 / ?013
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6ENERAL NOTE5 50rL 1E5T LO65 3\€TEM DESiGN CALCUI-ATIONS
CQNSTRUCTION NOTES:
FIOW PR.OFitE,
tf 9l100
t-
FLAN
:-
LE6END
-r
e
-! _-,-jai.!.l..ar.E!e_
lrletla bfiAnq Conpany
s|'t I SEWAGE O15PO5AL 5\5TEM DE5IGNTh&i.r tuf,affi, 43 Piie 5trd. Y,mo!*i, MA
J.trI. 0 RiILIY & Assocr^rEs, Lvc
FLOOR PLAN---;;;i-
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