HomeMy WebLinkAboutInspection Report 2024 April 03 . RFCE,VEn
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Commonwealth of Massachusetts r ?�24
_> J Title 5 Official Inspection Form HST"�FpT
vN ,} , Subsurface Sewa a Disposal Syste Form ?Not for Voluntary Assessments
1-
?-oper y Address ,
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Comer Owners Nave A� (,4 B) Z?A.. �� o_.
information is
repurec for ever`+
pane. :ity/ToVr-- State ?p"ode Date of ns� Son
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 I o do fin theout toms1 ///�//////'''����� //i
cn the COmD�ef, (//�_use only the tab GZ
key to Trove your Name of inspector
cursor-do no / . -/74
use the return -- L•
key.
Company Name
/1 eCY / g6Q
't Oorr:peny Ac �
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crass V -�---
�s i7� — "4 D�`fd
insc� c ty To s go / � Ste O zip Code
Teiephcr 'Num.be-
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 or-site sewage disposal systems.After conducting this inspection l nave determined
that the system:
1. u Passes
2. Conditonaity Passes
3. - Ne .. Further Evaivation by the _ocai Approving Authority
4. Fails
a...,‘ ' , 47.?1/2)-_%e
Inspector's ,gr,ature ate
The system inspector shaii subRilt a copy of this nspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completinc'this inspection. If the system has a design flow of
10,000 cod or greater,the inspector and are system owner snap subrntt the report to the appropriate
regional office of the DEP.The onginai form should be sent to the system owner and copies sent to
the buyer, if applicable; and the aparovirg 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.
Sirso-doc•rev.72S2C18 •-e 3 rraa:-s^e_e cc- r:Subs:ace Sewage]isoosai S ys:em-?age 1 of 18
Commonwealth of Massachusetts
71. Title 5 Official Inspection Form
LT Subsurface Sewage Disposal System Fo m -Not for Voluntary Assessments
QSl
Property Address
/Oy t7
Owner Owner's Name
information is
required for every
page. City/Town State Zip Code Date of spe tion
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ 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 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):
t5insp.doc•rev.7/26l2018 T:de 5 Offiofai Inspection corm.Suosorface Sewage Disposal System•?age 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
=I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 0Le�s/.� �•�
Property Address
/O•'J CIO
Owner Owners Name
information is ad 7 4 /P� �a6�
required for every /o 4,
page. City/Town State Zip Code Date of I spec on
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 ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
7-1
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:
t5insp.doc•rev.7/26/20118 r.a S 08iva Insvertior Form Suosu.1ace Sewage DIsecsal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s sgt
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s z
Property Address
/ON! Q
! ' or':ve
er Owner's Name l
/ '! Pf /1,4ry ���-llll I � lY 1v_�
page. City/Town State Zip Code Date of nsp ction
C. Ins ection Summary (cant.)
❑ 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:
E 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.
E 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 c C-e s5poo/ 54%14 ✓ Ci N to'""C
BacKup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or bonding of effluent to the surface of the ground or surface waters
�- Fri due to an overloaded or clogged SAS or cesspool
t5insp-tloc-rev.7.2612018 `;Ue 5 Oriica!Inspection For,:Su5surface Sewe a Disposal System•Page 4 of 18
Commonwealth of Massachusetts
=_= _ Title 5 Official Inspection Form
_ — Subsurface Sewage Disposal System Form -Not fo Voluntary Assessments_�,, _-- ,
Z..._ �/
Property Address 11�
/04 C42
Owner Owner's Name _
information is 0) /� y
required for every ��� �/�' �./¢ (/ (7 'S
page. City/Town, State Zip Code Dat f Ins ction
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems; (cont.)
Yes No
E 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
❑ equired 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
nbutary to a surface water supply.
❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ llii -
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
nd chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000 gpd-
1
T
0,000 gpd..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@S No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
Sinsp.tloc•rev.7:26/2078 Title 5 Oflic;a inspection FOrm Subsurface Sevrge Disposal System•Page 5 of 18
Commonwealth of Massachusetts
= F Title 5 Official Inspection Form
= = Subsurface Sewage Disposal System orm - of for Voluntary Assessments
S/te_
Property Address
IO4 J
Owner Owner's Name /] jj /'j/�
information is ,-010, 4 /"/f- /�/ i' 5 i y
required for every �t/( (� O�
page. City/Town State Zip Code Date of 1 spe tion
C. Ins ection 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
❑ Li Pu ping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks?
❑ Rr.-------7— he system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
'this inspection?
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Ev2r-----
❑ re 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,
d" ensions, 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?
T • e and location of the Soil Absorption System (SAS) on the site has
een 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)]
LSinsp. oc•rev.7/262018 71ie 5 G1ci i Irspechon Form:Suosurface Sewage Disposal System•Page 6ot 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
— Subsurface Sewage Disposal System Form -Not for V luntary Assessments
7 s its L/1/
Property Address
OwnerOwners Name p2
information is
N I"�7
required for every
page. City/Town State Zip Code Date of In ton
D. Sys em Information
1. Residential Flow Conditions:•
Number of bedrooms (design): — I Number of bedrooms(actual): L/
�Td
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x f#of bedrooms):
Description: 02- Cag S-(00/S
Number of current residents:
Does residence have a garbage grinder? E Yes No
Does residence have a water treatment unit? ❑ Yes No
if yes, discharges to:
is laundry on a separate sewage system? (Include laundry system inspection
r-: Yes No
information in this report.)
Laundry system inspected? E Yes No
Seasonal use? ❑ Yes No
Water meter readings, if availabie (last 2 years usage (gpd)): —
Detail:
Sump pump? ❑ Yes
Last Date or occupancy: Date
Sinsp.tloc•rev.7252018 7,Je 5 G;.;.ai!soecaor.Fo.m $12surlace Sewage Disposal System•?age 7 of 18
Commonwealth of Massachusetts
-_ _ Title 5 Official Inspection Form
Subsurface Sewage Dis osal System Form -Not for Volun ary Assessments
4 //
Property Address
� oi'il,
Owner Owner's Name
information is asi410t e "74 S L�
-equired for every (� (�•! �/f���/ /
page. City/Town State Zip Code Date of Inspe tion
D. Sys em Information (cont.)
2. Commercialflndustrial 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: -
Was system pumped as part of the inspection? ❑ Yes O
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: —
t5insp.tloc•rev.7262078 Title 5 O!5cia Inspection Form,.Subs:Mace Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
es 4_ 4/
Property Addressg(74 //
-157
Er':ve
Owner's Name j/ / /�j� ` J
(? �ry ��� _ �jF
page. City/Town r' State Zip Code Date o,Ins ction
D. System Information (cant.)
4. Type of System:
❑ Septic ank, distribution box, soil absorption system
❑ Single cesspool
Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes. attach previous nspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
Ap imate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes El No
5. Building Sewer (locate on site plan):
Depth below grade: feet
Materi of construction:
' cast iron ❑ 40 PVC ❑ other(explain): /0
Distance from private water supply well or suction line: reef Comments (on condition of joints, venting, evidence of leakage, etc.):
f5insp.doc•rev.7262018 Tide 5 Off:aai inspwuon Form.Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
R -,, 4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System For -Not f r Voluntary Assessments
Property Address //
Er':ve
Owner's Name
ry __Y____ IDPS / '' i°04-- f/ a51.05 ,� y
page. City/Town C State Zip Code Date of In pec n
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
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.):
t5insp.00c•rev.725/2018 T:c 5 Orfip:ai inspecron Form,Subscrfece Sewage Disposal System•?age 10 of 18
Commonwealth of Massachusetts
_== =L Title 5 Official Inspection Form
Subsurface Sewage isposal System Form -Not for Voluntary Assessments
I be_ /fr
Property Address ,.,�
n /QI/C 0
Owner Owner's Name /,/ ///L // ,,/ J�
nformation is
���u /V,I, /e Ud-6
-squired for every
page. City/Town , State Zip Code Date of Inspe tion
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass E 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 ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
15insp.00c•rev.7 26/2O18 -Ue 5 CfScal:rspectt or.=anr.Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
1, Title 5 Official Inspection Form
- _ Subsurface Sewage 'sposal System Form -N for Voluntary Assessments
Property Address gor)Cie
Owner Owner's Name -�information is
ON n/g!f / v�J ai)-6// 1rc
required for every
page. City/Town State Zip Code Date of Ins ecti n
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.):
5insp.doc•rev.7/26/2018 -'tie 5 O-imal Inspecuon Form_Suos..rface Sewage Dsposai System•Page 12 of 18
4i Commonwealth of Massachusetts
_ i Title 5 Official Inspection Form
-pl= - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.4,,,„....,./
________
7 s �, z/v
Property Address /
g O✓1 d v
Owner Owner's Name ✓/' di (X ode^ Y a--cie-
information isa( N/ / (r required for every
page. City/Town State Zip Code Date of ins ecti n
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ Now
Alarms in working order: ❑ Yes E 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:
❑ leaching pits number: --
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ eaching tields number, dimensions:
overflow cesspool number:
❑ Innovative/alternative system
Typeiname of technology: ------ —
t6insp.doc•rev.7;26i2Oi8 -iUe 5 Off i ;nspecuon Form.Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
-ewe Title 5 Official Inspection Form
'� -_„-�I Subsurface Sewa e Disposal System Form -Not for Voluntary Assessments
,, �j, S f-e_ / 4/
Property Addresse/6 17i; /
Owner Owner's Name
information is � ON A , /// Q �pj�1,�required for every /'
page. City/Town ( State Zip Code Date of Ins ctio
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.):
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): '
.4
Number and configuration —
c2-
Depth—top of liquid to inlet invert �
a, i
Depth of solids layer
Depth of scum layer
Dimensions of cesspool �/
Materials of construction /0, " of w4
Indication of groundwater inflow ❑ Yes IC 'o
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): / / �f/f /
e 4/lam. _1l d.,4s ®'[l ,//111r✓7 ��S'S/lmv L—�
(5
Sinsp.doe•rev.726/20+.8 ntic 5 OT,clal Inspection=orm.Sues,tace Sc ase Disposal System•Page 14 or 18
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�'° ti Commonwealth of Massachusetts
�Q Title 5 Official Inspection Form
Subsurface Sewage D'sposal System Form - of for V untary Assessments
'‘..;___47 .e-,5' i-e-.5 Lzi/
Property Address //
4 _ l0✓INO
Owner Owner's Name �F
information is cvviON O '4- lJ / Jrequired for every � (�
page. City/Town4 State Zip Code Date of spe ion
D. Sys em Information (cont.)
13. Privy (locate on site plan):
Materials of construction: - —
Dimensions —
Depth of solids ---
Comments (note condition of soil, signs cf hydraulic failure, level of pending, condition of vegetation,
etc.):
5insp.tlx 'ev.?2620'8 !e 5 0-5c:a�-spection Fo. Suos. ace Sewe a:tspo ai System-?age 15 of 18
Commonwealth of Massachusetts
- _ Title 5 Official Inspection Form
_ _= Subsurface Sewage Disposal System orrn -, t for Voluntary Assessments
Property Address
Owner Owners Name D 14
nformator,is
required for every 00, [� l (�'
page. City'i own di8=� IIVv Off'f
Zip Code Date of I spe r
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide view of the sewage disposal system, including ties to at least two permanent reference
land rks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the uilding. Check one of the boxes below:
Nand-sketch n the area below
drawinc attached separately
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7rje 6 J`:ca ins;.e.,:co Fe.-.:Suasa.rface Sewage^ispcsa m.Syste •.age 18 of 18
Commonwealth of Massachusetts
"- - = Title 5 Official Inspection Form
0*-,0.0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Ze, /t-e_ ,Z-,r/
Property Address
Er:very
/OHOwnesName 0 f40l // : V/5/62.)4page. Ci y, cvState Zip Code Date o
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
Li Surface water
u Check cellar
Shallow wells 4-fY---
Estimated depth to high ground water:
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
Observed site (abutting property/observation hole within 150 feet of SAS)
// ed with th local 5 itof Health-explain:
,As ---- ,„141/)S
Checked with local excavators, installers- (attach documentation)
LI Accessed USGS database-explain:
You must describe mow you est lisped the high g�d w er elevation:
.t"-"Xi c2._
tit ____
74';'/- qt./ff.
4(1
______Ca'c_p_ ____/...,....r a VL---
' ‘ ,4
-- °l-la� � — — --
Before filing this inspection Report, please see Report Completeness Checklist on next page.
Sins,.5oc re,T,262t8 ''de 5 Cvaao:nspeapn=o.—:SuSs„Jace Sewage aspcsai Sys;en•?ape 17 of IS
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form/Not for Voluntary Assessments
2 i-e5 h.,_ Z_er-/
Property Address --_
eO✓4(1O
Owner e
information.is Owner's Nam ��Gv r 0 /`// ��75
required for every
page. City/Town ` State Zip Code Date of Insp ction
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspector information: Complete all fields in this section.
B. C ,fication: Signed& Dated and 1. 2, 3. or 4 checked
C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 ' ailure 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
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