HomeMy WebLinkAboutInspection Report 2024 Apr 05.FntL-"REceryo,"
APR t Z0Z4*\ Commonwealth of Massachusetts
Title 5 Official lns
Subsurface Sewage Disposai S
pection Form
HE4(IHDEpI
WDn Foftn '
/foare,*-'lt'
Noi ior t/oluniary Assessments
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24
e9
P.cpery Accress
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lnspection results must be submitteci on this form. inspection forms may not be altered in anyway, Please see completeness checklist at the end of the form,
A. lnspector
BL*//,,
Imponant Wien
illjrg oL1 ilti.s
.jse ,niv the =riey :c :iove ',,cJialBcr - Cc 1oi
.se 'fe :etrii'i,o Tec*Z") /oa'rffi Conpe.y Air
Crtynown
ieieohc.e l!!irl
,4/oleuasa
{1 aBe'l7lo Zp Code
-icei:se Nui.-lei
B. Certifieation
i certi!1"ihai: I am a DEP approved syslem inspector in full compliance with *ction 15.3ittl of Tifle 5(310 CMR 15.000); ; have personally inspeciei the sewage oisoceal system at the property addresslisied above; the infcr-.naton :eponeo below is :rue. accrrate ani comfleb as oi the .iime o'f myisspection: anc tire lilsceciicn was pea,o.-ned basec on my iraining and expedence in the proSr functionand ;nairitena.cs of o.-s;te sewage qisposai s!€ierirs. AiJr conduaing iris inspection I have determinecjtr-.at th€ syste.-:
2. r Cc.rcitionaiiy -asses
?
1
N
laspec.oa'
=vaiLaticn by tire -ocai Aporoving Authon!{
-.1
i iepo[ -,o ihe Approving Aufiority (Boaro
Sig.Et;:E
a:'i lnscecrc: snaii sLDiiii a ccc;"
'a iis
-l-ne s ci inis :tspealcor 3EP)witirin 3C oays of ccmpletingtnis inspection. li the system has a design flow of'10,000 gpd of greater, :he nspeciroi and 'iie sysieo. owoea sitall submi't lhe report to t]e approPnatcregionai office ci -he DEp The e royld be sent io Lhe system owner and c€oies sent tot.i]e bu-ver. f aDplicable. and tne aD3i-oviFc autiroitv
Please note: This report only describes conditions at the time of inspection and under theconditions of use at that time. This inspection dees not address how the system will performin the futqre under the same or different conditions of use-
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j3. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal S
a7
untary Assessments
Z*"1- ,€d
Propery ACdress
Own€r's NameOvt|ner
infornatron is
reouired ior every
page.
,fll 4.6
City/To',vr1 Zip Coce Caie ci io,l
C. lnspection Summary
lnspection Summary: Ccmplete 1 ,2, 3, a, 5 and all of 4 and 6
'1) System Passes;
I I nave not found any information which indicates lhat any of the failure criteria described
ln 310 CMR 15.303 or in 310 CIVIR 15.304 exist. Any failure criteria not evaluatsd ara
indicated below.
Comments:
2) System Conditionally Passes:
tr One or more Syslem 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 tne septic tank (whether metalor not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
-
inspection if the existing tark is replacec 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 Ceftmcate of
Compliance indicating that ihe tank is less than 20 years old is available'
nY r=r N I ND (Expla n below)
r,d. 3 Onf,d lc)ec1 oi icrm S!bs!.ia@ Sewage lrsposai Svslem ' ia€t 2 o( 13
sin!9.doc. rev 1,26,2015
:t. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System F
9?
orq4- Not for Voluntary
&o*n
Assessments
4o.1.,ar/
Owner
rnfoamation is.equired for every
2age.
Propedv Address o l,le
Owrels Name
av?|o,..cp(E
City,Tor,i S:ate Zip Coce Date o. I
C. lnspection Summary (cont.)
2) System Conditionally Passes (corr.):
n Pump Chamber pumps/alarms not operat,onal. System will pass with Board of Health approval if
pumpvalarn s are repaired.
D 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):
I broken pipe(s) are replaced n Y n N D ND (Explain betow):
D obsiruction is removed n Y tr N n ND (Explain below):
! distdbution box s leveled or replaced n Y n N I ND (Explain below):
! The system required pumping more than 4 times a year cjue to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
n broken pipe(s) are replaced n Y tr N D ND (Explain below):
. obstruction is removed n Y n N n ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
n Conditions exist which requi.6 furrhGr evaiuaii6F by the Boarc ci l.lealtn in o.der to determ jne if
the system is failing to protect public health, safety or ihe environrnent'
a.SystemtyillpassunlessBoardofHealthdeterminesinaccordance\Yith310CMR
tS.S0S(f)(U) ttrut the system is not functioning in a manner which lYill Protect public health'
safety and the environment:
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Owner
informatron is
iequi.ed for every
page.
i},. Commonwealth of Massachusetts
Title 5 Otficial lnspection Form
Subsurface Sewage Disposal System
P.ope-ry Acdress
J7 Forrn- Nor ior Voluntarv Assessments4o*n 6*t' el
/4 a6Ownea's Narne
City/Towr:Siaie Zip Coce Daie cil
C. Inspection S mmary (cont. )
n Cesspool oi- privy is witnin 50 feet of a sur'race water
n Cesspool or privy is witntn 50 feet of a bordering vegelated 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 ancj SAS and the SAS is within a Zone 1 af a public water
supply.
E The system has a septic tank ano SAS anci 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
rrore from a private water supply well.*.
Method used to determine distance:
* This system passes ii the well water analysjs, periormed at a DEP certifieC laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia njtrogen and nitrate nitrogen is equal
to or less than 5 ppm. Drovided that no other failure criteria are triggered. A copy of the analysis must
be attacheC to this form.
c. other:
4)System Failure Criteria Applicable to All Systems
You !!!!s!''Y or "No to each oi the foltowin
?,G Lo ?-'ff.|Tt"Ysfrfu*
I
x
tr
BacKup sewage jnto facility o. system component due to overloaded or
gged SAS or cessPool
Disciarge or Pording of eiflueni to the sudace of the ground or surface waters
due to an overloaded or ciogged SAS or cessPool
Ir.Je 5 Ollrcd lispedjon =c6. su*{aca s.@getr''p's'l svst'h ' Pac' 1 oI 1a
EinsD.doc' rev 726,2C19
NC
er Commonwealth of Massachusetts
lnspection Form
ystemtorm - Not for Volunrary Assessments&-*^- Z"rln
Subsurface Sewage Disposal Sd?2)_
Propelt,v Address
Owner
infomat,on is
required for every
page.
Ownels Name
arlzt a03cda
City/Toyrn State Zip Coce
C. Inspection Summary (cont.)
4) System Failure Criteria ,Applicable to All Systems; (cont.)
tic iiquid level in rhe distflbution box above outlet inverl due to an overloaded
or clo-cged SAS or cesspool
Liquid iepth in cesspool is less than 6" belcw invert or available volume is less
than % day flow
Requirecj pumping more than 4 times in the last year Mf due to clogged or
obstructed pipe(s). Number of limes pumped: _.
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or priv,v is within 100 feet of a surface watersupply or
tributary to a surface water supply.
y portion of a cesspool or privy is within a Zone 1 of a public water supply
Any podion of a cesspool or privy is within 50 feet of a private water supply well.
Any podion of a cesspool or privy is less ihan 100 feet but greater than 50 feet
from a private water supply well with no acceplable water quality analysis. lThissystem passes if the well waler analysis, performed at a DEP certified
laboratory, for f€cal 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 ar€ triggered. A copy of the analysis
and chain of custody must be attached to this form.l
The sysiem is a cesspool serving a facility with a desigr. flow of 2000 gpd-
10,000 gpd.
The system fails. I have determined that one or more of the above failure
criteria exisr as cescribed in 310 CMR 15-303, thereiore the system fails. The
system owner should contact the Board oi Health to determine whatwill be
necessary to corect 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 musi indicate either "yes or no'to each of the following, in addition to the
questions in Section C 4
Yes No
Yes No
n
I
tr
tr
tr
n
n
n
!I
trtr
n
n l--l rhe sysrem is within 400 feei of a surface d.inking water supply
the system is witirin 200 feei of a iributary to a surFace drinking water supply
the system is locaied in a niirogen sensitive area (lnterim Wellhead Protection
Area - lwPA) or a mapped Zone II of a public water supply well
;1Je 5 C','.Ld irspe.lo. :.tr Su:$rae S€d6e :Lsp.sd SysEn . Page 5 or 1Asi..o.d* , e. 72a2a r 3
Title 5 Official
n
Ar Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System F
?
- Not for Voluntarv Assessmentsye,f &""t, ,4/
Propedy Address
Cwner
infomation is
requrred for every
page.
Owner's Name
City/Town Zip Cooe Date
C. lnspection S ummary (cont. )
lf you have answered *yes'10 any question n Section C.5 the system ls considered a signmc€nt
threat, or answered 'yes'to any question in Section C.4 above the large system has failed. The
owneroroperatorofanylargesysten,consideredasignificantthreatunderSectionC.5orfailed
under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304- The system owner
should contact the appropriate regionai offlce of the Department.
6. You must indicate "yes" or "no" for each of the following for a// inspections:
Jes
) auaS;ltru @rE
Yes No
iJ
mping informarion was provioed by the ov{ner, occupant, or Board of Health
any of the sysiem comPonents Pumpe d out in the previous two weeks?
the system received normal flows in the previous two wee k period?
ave large volumes of water been introduced to the system recenfly or as part of
fiis inspection?
built plans ol the system obtained and examinecj? (lf they were not
note as NiA)
facility or dwelling inspected for signs of sewage back uP?
lable
!
tr
tr
t_-.1
Was the
-
Was the site inspecteo for signs of break oul?
all system components, excluding the SAS. located on site?
Were the septic tank manholes uncovered, oPened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, deptn 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?
size and location of the Soil Absorption System {SAS) on the site has
been delermined based on:
Exisiing information. For example. a glan at the Board of Health.
Determined in the flelci (if any of the failure criteria related to Part C is at issue
app.oximation of distance is unacceptable) [31 0 CMR 15.302(5)]
:-]
x
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I
A Commonwealth of Massachusetts
Title 5 Official lnspecti
Subsurface Sewage Dis al System Form -
Propedy Address
ti:I on Form
for Voluntary Assessmen
avk-
L
Owner
infoiinatio. is
ecuired for every
)age.
Ownels Name
City,Tcw.
D. System lnformation
DESIGN flow oased on 3i0 CMR 15.203
Description
e. 1'10 gpd x# oi bedrooms)
f /
Residential FIow Conditions:
Number of bedrooms (cjesign): -e Number of bedrooms (actual)
,for exairorG'
7)6State ZD Coce
(
/-
Nu,.nber of curreni resioents:
Does residence have a garbage grinder?
Does rgsidence have a water trearment unit?
if yes, discharges to
lslaundry on a separare sewage system? (lnelude laundry system inspectionrnrcrmation tn this report.)
Laundry system inspected?
Seasonal use?
Water meler reaoings, if availabie (last 2 years usage (gpd)):
Detail:
JvesK
avesK
I yes
n yes
I yes
dV<
Sump pump?
LaSi Oate oi ocg!,ipaflcy.
n Yes
f,a:e
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eJ
Aa4
o
A, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal Syste m Form ot for Voluntary
Prope.ry Address
AssessrlU ts
/,1r*L e.J
O\,vaet
infor.nation is
:equired for every
page,
Owner's Name
Ciryno,,m
Z+tt 1
Staie Zip Coce Date
D. System Information (cont.)
2. Commercial/lndustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CIVIR i 5.203)i
Basis of design iow (seats/persons/sq.ft,. etc.)
Grease trap present?
Water treatment unit present?
li yes, discharges to:
Industdal waste holding tank present?
Non-sanit€ry waste discharged to the Title 5 system?
Water meter readings, ii available:
Last date of occupancy/use:
Other (describe below):
Gallons p€r cay (gpc)
n vesE No
E Yes E tito
!Yes!No
n Yes[ No
Date
3. Pumping Records:
Source of information:
Was system pumped as pan of the lnspection?
lf yes, volume pumped:
How was quantity pumped delermrned?
Reason for pumping:
Yes No
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D6?3
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
a
Subsurface Sewage Disposal System Fo Not for Voluntary Assessments
r a"PJ
P.ope/ay Address
Owier's Nanre
City/Towr
D. System lnformation (cont.)
4. Type of System:
D Septic tank,
n gle cesspcol
Zl qulsaule
Owner
infonnation is
required for every
page.State Zip Coce Daie oi ln
tributron box, soil absorption system
n
tr
tr
!
n
n
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
lnnovative/Alternative technology. Attach 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 s)€tem operator under contract
Tight tank. Attach a copy of the DEP approval.
Other (describe):
Approxjmare age 3f ts, d
Were sewage odors detected when aniving at the site?
5. Building Sewer (locate on site plan):
Depth below grace:
Matefla CO nstruction:
I 40 PVC I other (explain)
^792s ate nstalled lrf <nown) anCLreI;-d source o#formariok^L n
a
f ves No
cast iron
Distance from priva:e water supply well or suction line: r""t -
Comments (on condfiion of ]ornts, ventlng, evlclence of leaKage, etc.).
lsinsO.ae , a. 72A2Or 6 s{5!:la6 se@ae i6prid s}.l!6 ' ?a0e 9 ol 16
A, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sew isposal System Fo - Not for Voluntary Assersrrents/**L
Property Address a>az-J
Owner
information is
iequired for eveay
page.
Owner's Name
Cily/Town
D. System lnfo ion (cont.)
6. Septic Tank (locate on site plan)
Depth below grade:
Material of construction:
I concrete n meal
a6+3
Stale Zip Code Da:e
! fiberglass f, polyethylene n other (explain)
ul
ieet
lf lank is metal. list age:
ls age confirmed bya Ceriificale of Compliance? (attach a copyof certificate) [ Yes! No
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or bafile
Scum lhickness
Distance from top of scum to top of outlet tee or baffle
Distance from eottom of scum to bottom of outlet tee or baifle
How were ciimensions deiermined?
Comments (on pur,rping recornmendations, lnlet and outlet lee o!'batfle condition, structural integrity,
liquid levels as related tc ortlet inven, evidence oi leakage. etc.):
6insp.3oc . ;ev. 726,2c14 i.. a a-'i..d ins:.s,ci:cr: subsulse seege Drsp3*LSlsleh' ?3Se :Oor la
5}, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System For]ry- Nor to' Vol.rntary Assesjqlenls{Lno- 6*l-4l39
Properry Address
Owreis Name
CityiTown
D. System lnformation (cont.)
feet
I fiberglass n polyethylene fl other (explain)
J a*-s
Owner
informatioi is
-equired ior every
page.
t-rupw Ljaie oi IStaieZip Coce
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of ouflet tee or bame
Date of last pumping:
Comments (cn pumping recommendations. inlet and outlet tee or bame condition, structu|al integrity,
liquid levels as related to outlet inverl, evidence of leakage, etc'):
8. Tight or Holding Tank (tank must oe purnped at time of inspection) (locate on site plan)
Depth below gr-ade:
Materiai of construction:
I concrete n metai
Dirnensions:
Capacity;
Design Flow gailons Per day
irde 5 oitad lnseec{o. Fofr Subsuri@ seeaee Clsposai srsLh ' Page 1 1 oi 1a',iinsp.doc. ev. !26,2C- 3
7. Grease Trap (locate on site PIan):
Depth below grade:
Material of construction:
I concrete E metal
I fiberglass E polyelhylene I other (explain):
gallons
5$' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsuriace Sewage Disposal S
3e
ysten>torm . Not for Vol(funr-untarylryessments
/5ro"L EL
PirpertyAddress
Owner
information is
required ior every
page.
Arlc
Ownels Neme
City/Towr
D. System lnformation 1cont.)
8. Tight or Holding Tank (cont.)
Alarm present:
Alarm level:
Date of last pumping
e(
E Yes nNo
Alarm in working order ! Yes Notr
Comments (condition of alarm anc float switches, etc.)
* Atiach copy of current pumping contract (requirec). is copy atlacheo? E Yes E ruo
9. Distribution Box (if presenr must be opened) (locate on site plan)
Depth of liquic level abcve outlei invert
Comments (note if box is level and dislribution to ouiJets equal, any evidence of solids canyover, any
evidence of leakage into or out of box. etc-):
fL
Zip Cace Dete cfSiale
6insp..oc. s. rE6r2O'a
Date
14 a)6q3
!. 5 Oaic:i l.sodclio. io.n Suos-.i.e Se@Ee D sssa Syslen Fage12olI8
5$. Commonwealth of Massachusetts
Title 5 Official lnsPection Form
Disposal Syste orm - Not ior Voluntary AssessmentsSubsurface Sewap &u/. '<J
Propetry Address artlj
Owner
infonxation is
lequired for every
page.
/A 0J6Owner's Name {h
Ciry/ToMt Daie of I
D. System lnformation (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: E Yes E no-
Alarms in working orcjer: E Yes E ttlo'
Comments (noIe condition of pump chamber, condition of pumps and appurtenances' etc'):
" lf 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:
Srate Zip Cooe
leacning oits
leaching chambers
leacning galleries
leacni trenches
eaching fields
overflow cesspool
Lnnovativelaltemative sYStem
Typelname cf technoloEY:
flo<
number:
number:
number:
number, Iength:
number, dimenoions
nu m oer:
avvt/r
x
n
n
tr
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TYPe:
I
Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface SewagePit
cl
posal System Form . Noi igt VoiJnrarv Assessmenrs? (4^,.rn^ Z*rl-pJ
P.ope(y Address
OlYnels !',lame
arLJ
//o S
Owner
inlormation is
required for eveay
page.
DTb
CityTTown taie Zip Code Da!e
D. System lnform On (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding. damp soil, condition of
vegetation, etc.):
o
/r/-1. 7€. /rt-.
tn /,
yU?
12. Cesspools (cesspool must be pumped
Number ancj 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
Comments (note condition of soil, signs
etc.):
as par. oF inspection) (locate on site p
2
I yes
of hydrauiic failure, level of ponding, con
nHo
on of vegetation,
Oo L
L OtrtSOan
4l
- J. 5 .tr.ric,i Lns.ecn.n .offi Sub! /:e S.Mee DGA.r.i Sys6d . pt. r 4 or 1a
rt
$' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form . N srnents3?6*L ,e./
PiopertvAddress
Owner
info.Tation is
€ouircd ior every
2age.
arl<5
Siaie ryqaic ucce
OrYreis Narne
City,'To,ur
D. System lnfo ion (cont.)
13. Privy (locate on site plan)
Materials of consiTuction:
Dimensions
Depth of solicjs
laie ci I
Comments (note conciition of soil, signs of hydrauiic iailure, level of pondlng, condition of vegetiation,
etc,):
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A Commonwealth of Massachusetts fB\L-
Title 5 Officia
Subsurface Sewage Disposal
I lnspection Form
Systen>m
ltoa
ntEry Assessments
Z""L ,eJ
- Noi ior Voiu
2I
Prgperr'v Address J2,-Swner
infornator Is
:eauied bi gveit
?age.
OHers l\ame
o%4JCiiy/icwn Zp Core
D. System Info rmation (ccni.)
14. Sketch Of Sewage Disposal System:
Provide a view of ."he sewage drsposal system.ncluoing lies :o aI least Iwo perrnangnt ieferenceiancjmarks gr 3e:'tch.ilaiks l-oc€te all wells within 1C0 fge: Locate where pubiic water supply enteEthe buildin k one oi -,l te boxes oelow:
and-s(eica in ti]e area )eicw
ravr'ing araci:ed se3aratgly
a-
t?sl 0Atv
t/-
6rv
?,t
flo>
Ar!.'t r Cet <1wL<
/e9
C3')t
rt3 a1,"ftt .13
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Commonwealth of Massachusetts
Title 5 Offi cial lnspection FormSubsqrface Sewage Drsposa
Cwner
anfomatjor is
requircd ior every
lage.
I System)rm - Noi.oi Vol
/.bartt^
&
untary Assessmenis4*b ,AJP.opert_v A6drcss
O\/yner'S Narie
Ciql-i own
D. System I nformation,coni.'
'15. Site Eram:
I Check Stooe
! Surface water
n Check celtar
X Shallow we s
Estimated ciepih to nigh ground water:
O ,72.
th 4123Siate Zp Coce Jaie .i
/3{" "/o"v-
ieet
Please indicate all me-J]ods used to determine -:he ijgh ground water elevation
tr Obtained irom slstern design plans on fe@rd
lf checked, date of design plen reyiewed:Daie
erveo sile {acutlilig propefty/observado n nole wiihin 15C ieet oi SAS)(rt
T.tl tlt' \/Z.n-
^dr-e-
ai-c of iaalth - extrrc-o
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a
You must oesciiDe ,'l isr:ed :he it, gn gic.ryj,{!ate
v,,v t*
: ere!e!
L/0 aS..5 ,rh
Before filing this lnspectioo Report. please see Repo.t Campleteness Checklist on next page.
slne-d@ ar. r2&"!:a 'r-,ie a Cr:ca,.srdm io- Slbfur'B@ S€€te !E@.1 Sy.r6. p.a. 17 oi ra
Cneci(eo wiih iocal excavatcrs, ins.rallers - (attach documentatton)
Accessecj JSGS Jatabase - expiaii:
!-..1
/s
s.. Commonwealth of Massachusetts
Title 5 Officia
Subsurface Sewage Disposal
! lnspection Form
System Form - Not ior Volunta ry Assessments
(.ooL E,J
Owner
inionhation is
equi.ed for every
page.
Properry Address
Owners Name attl 5ru u)6 YCity/Tcwr State Zio Coce Da!e
E. Report Compl eteness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspecror infoimarion: Complete all fields in thjs secrion
B. Cedificaiion: Signed & Dated anc 1.2.3. or 4 checked
C- Inspsclion uirmary
1,2,:5 compieied as app.opriaie
(Failure Ciiteiia) anc 6 (ChecKlist) complerecj
E D. System lnformation:
For 8: TighVHolding Tank - pumping contract attachecj
For 14: Sketch of Sewage gisposal System drawn on pg. 16 or attached
For 15: Explanalion of esimateci depth to high groundwater :nctucjeo
5'r6p.d6. B- 7,2&2016 :,ue 5 a::ra r.sr€.r..:.a suolla@ s!'ag. fisp..d sysen. ?.a.lscr 16