HomeMy WebLinkAboutInspection Report 2024 April 1 - Unit 10lu*il-b-
Commonwealth of Massachusetts
Title 5 Officiat tns pection FormSubsudace Sey{age Disposai tem Form - Nci io Voir.iniary Assessinenis
P:oper:_r' Aciress
. REc8ry80
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fieS OaO\anei
iifgiilatiof is:ecuir'gd 'oi evei:.,
,age.
Cw.eis \a.re fl OJ9!L
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Inspection rssults must be sub1itte9.9n this form. Inspection forms may not be altered in anyway. Please see completeness checklist at the end oi the form,
A. lnspector atiolrnportane Wier
Slirg .ut iorir,s
cn 'ule ccnoL*:ei,
.ise cniy ihe =c(ey :o incve ycui
cijiscr - do noi
use tie retlr.l
;.ey.
/,/tn
l/,
oE )80 -mo
/ FC/f
:icense ltumber
a
Narile ci Jns3ec:a:
Coinoeny Nalr1e
Cor:rail, Aca:gss
otv,T
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as oJ6
' eteDn Nii
B. Certification
i :eiriiy.. :irai: I am a DEp approved system inspector in full compliance with Section 15.340 of Tifle 5i310 cMR 1s.0o0); ha ve personaily inspectei lie sewage disDosal syslem at 'rie properh/ addressIisted above; ihe iiiior:rl aton repo-ei celow is irue. accurate anc complete as oithe iime of mvnspection: anc ihe ins cn was perfor.nec basei on my raining and experience in the prop€r functjonafid maintenaice oi on-site ser4?ge iisposai sFterns. Aiei conducting iiis inspection I ilave cieterrn inedlnat th€ syst
2
3
f Conriiticnally Passes
] Neecs =ur!he. =valuaiion cy ihe -ocai Aooioving Ai.jthonry*
hsDeC.oa
sa
?
]:::n:": IlB?!l:__?Iil "---?- : a ;cpy.c; i.lis rnspe.i,ci.r ie.ron io -ne Approvins Authority (BoardlJL r"reiir(fl or r=Hr w rnrn -?U drvs of compieting thls :a€pection- lf the system iras JOeSign now oi10,000 gpd or Qrealer', :ue l:rso;crc. anc l;e s-vsien- ori,aer snatt suomrt the report to ths agpropriatc:egional offce ci $e DEP. The cigi..rai icrir- =noulJ u" i.nt ..c .Jllr"t", o*n"r
"nd copies sent totne bu_ver. 'f acplicable and tr.:e aoi:ovir.g a.:lrciiy.
Please not€: This ieport only describes conditions at the time of inspection and und6r theconditions of use at that time. This inspection does not address'r,"w tn" "[Gm wiii'p".ror*in the future under the same or different condilions of use.
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i(!. Commonwealth of Massachusetts
Title 5 Official lnspection Form
C,/o m
Owner
information is
reouired for every
page.
Properly ACdress
Owner's Name
CilyITc',e1
G. lnspection Summary
lnspecti
1) Syste
Staie Zip Oooe
,2a:speclion
on Summa Compleie 1 , 2, 3, or 5 and all of 4 and 6
ses
I have not found any information which indicates ihat any oi lhe failure criteria described
:n 310 CtvlR'15-303or in 310 CIvIR 15.304 exist. Any iailure criteria not evaluated ars
indicated below,
Comments
2) System Conditionally Passes:
E One or more system components aS oescribecj in the "Conditional PaSS" Secdon need to be
replaced or repaired- The system, upcn completion of the replacement or repair, as approved by
tne Board of Heaith, will Pass.
check the box ior ..yes,,, "no" or .not determined' (Y, N, ND) for the following Statements. lf .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 infiltrati;n or exfiltration or tank failure is imminent. System will pass -
rnspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal sepic tank will pass inspection :f it is structurally sound. not leaking and if a ceftmcate of
Compliance indicating that ihe tank is less than 20 years old is available'
trY i-l N f ND (Explain below)
_ de 5 6,r ad i6iadJo. a..s suc*'rae seEge t'spcsd s)slem ' Ptle 2 or 13
6insg.co. ev.'46'2015
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not foi'Voluntary Assessments
/O Uafi,oortoqc Zrl
a
Owneis Name
",am,
City/ToYn
C. lnspection Summary (cont.)
2) System Conditionally Passes (cont.):
E Pump Chamber pumpsr'alarms not operarional. Slstem will pass with Board of Health approval if
pumps/alarnrs are repaired-
E 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, setded or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
n broken pipe(s) are replaced ,I Y tr N E ND (Explain below):
tr obsiruction is removed tr Y ! N n ND (Explain below):
n distribution box is leveled or replaceci tr Y tr N n ND (Explain below):
I The system required pumping more tnan 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 replaceci tr Y tr N n ND (Explain below):
-l obsrruction is removec f Y - N E ND (Explain below):
3) Further Evaluation is Required by thE Board of Healthr
D Conditions €xist which requi.€ fu.ther evaluation by the Board cf Health in orde. to detarmine if
the system is failing to protect public heaith, safety or the enYironment'
a. System tYill pass unless Board of Health determines in accordance with 310 Ci'R
r s.sos(r xo) that the system is not functioning in a manner which will Protect public health'
safety and the environment:
;Z
Olvner
lnfor.ation is
'eouired.+or every
?age.
Zl Er6q
Zip Coce Da:e o:
sinsp..oc :d.72620:A Su.s!n2@ S€'6!e )ispo..l Svsbn'raee 3oi !a
Prcperry Address
5s' Commonwealth of Massachusetts
Title 5 Official lnspection Form
L/"
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Cwnef
iniormation is
reouired for every
page.
Proper.y Address
Cw.]er's \ame
u
City/Tovvn Slaie Zip Caae Date oi ln
C. lnspection Summary (cont.)
tr Cesspool or privy is within 50 feet of a suriace water
X 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, ifany)
deteimines that the system is functioning in a manner that protects the public health,
safety and environment:
n The system has a septic tank and soil absorption system (SAS) and the SAS is wthin
100 feet of a surface water supply or tributary to a surface water supply.
I The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
E The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
E The system nas a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private waler supply well'*
Method used to determine distance:
* This system passes ii the well water analysis, periormed at a DEP certifled laboratory, for fecal
coliform bacteria indicates absent ancj the presence of ammonia nitrogen and nitrate nitogen is equal
to or leSS than 5 ppm, provided that no other failure criteria are triggered. A copy Of the analysis must
be af.ached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You Es! indicate "Yes" or "No to each of the following for a!! insPections:
\,,ES
I
!
5insp.do.- e! ?2&20i3
Nc
or/ Oac*up of sewage rnto facil:ry or system component due to overloaded or
= -cioooeo SAS or cessPool
-/ o,JJn^rre or pondrng of effiuent to the surface of the ground or surface wateG\Z due to an overioaded or clogged SAS or cesspool
cnid l.soeclio.:cfr: s!:s!{.e &€se ci.p.s, s}slAn ' Paa' 40r 13
0)_6ly
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal S m Form - Not for Voluntary Assessments
a,
Propeary Address a
Ownea's Name a
City/Town Zip Code
C. lnspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
Daie of In n
n Static iiquid level in lhe distribution box above ouilet invert due to an overloaded
or clogged SAS or cesspool
Liquid ciepth in cesspool is less than 6" below invert or available volume is less
than % day flow
Required pumping more ihan 4 times in the last year Mf due to dogged or
obstructed pipe(s). Number of tmes 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
tibutary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
n{
!
y poriron of a cesspool or privy is within 50 feet of a private water supply well
Any podion of a cesspooi cr p;'ivy is less ihan '100 feet but greater than 50 feet
irom a grivate warer supply w-6ll with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP c€rtified
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
The system is a cesspool serving a faciliiy with a desigr' flow of 2000 gpd-
10,000 gpd.
The system Ailg. I have determined thal one or inore of the above failure
criteria exi$ as iescribed in 310 CMR 15.303, therefore the system fails. The
systern owner should contact the Boaro of Health to determine what will be
necessary to conect the failure.
Large Systems: To be considered a large system the system must serye a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For Iarge systems. you must indicate either "yes- or 'no" to each of the following, in addition to the
questions in Section C.4.
YES NO
tr tr ihe system is within 400 feet of a surface drinking water supply
tr tr ihe system is within 2OO feet of a tribLrtary to a surFace drinking water supply
the system is Iocated in a nitrogen sensitive alea (lnterim Wellhead ProtectionU L-l Area - lwPA) o!'a mapped Zone ll of a public water supply well
: ue 5 oiha Lnloecuo' icn: su5&'rae se€ge t.p'sal sFem ' Pag' 5ot la
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n
tr
s)
sin.p.noc. .!v. 72612A 13
Owner
infoirnatron is
lequlred for every
page.
/-/
OM?
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Offrer
infomation is
requiaed for every
page.
Subsurfa ce Sewage Disposal System Fo - Not for Voluntary Assessments
arl t4OaProperty Address
a
Ow:reas Naore
a 4)66/City/Tovvn
C. lnspection Summary (cont.)
Stale Zip Cone
6
lf you_ have answered 'yes' io any question rn section c.5 the system rs considered a significantthreat, or answered "yes" to any question in Section C.4 above ihe large system has fail"d. Theowner or operator of any large system considered a signiflcant threat under section c.s or failedundersection c.4 shall upgrade the system in accordince with 3i0 cMR 15.304. The system ownershould contact the appropriate regional office of the Department.
You must indicate "yes" or ',no,, for each of the following for al, inspections:
Yes
DP ping informarion was provicjed by the owner, occupant, or Board of Health
Were any of the sysiem components pumped out in the prevtous two weeks?
e system received normalflows in the previous two week period?
Were all system cornponents, excluding the SAS, located on site?
Were ihe septic tank nnanholes uncovered, opened, and the inrerior of the tank
inspecred for the condition of the baffles or tees, material of constructron,
dimensions, depth of liquid. cjeprh of sludge and depih of scum?
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System {SAS) on the site has
n determined based on
Exisiing informalion. For example. a plan at the Board of Health.
Deterrnined in the iielci (if any of the failure criteria related to Part C is at issue
app.oxi,'iation of distance is irnacceptable) i31 0 CMR 15.302(5)l
n
n
a
x
n
I
6insp.6o. . e!. 7/2520 r 3 iiJ. 5 O nc6 l.sredr.i i.m Sud! rfae S.Mge :'sPo.al S)€lem . p.ge 5 ol 18
tr
Have large volumes of water been introduced to the system recenly or as part ofthis inspection?
Were as built plans ol the system obtained and examined? (lf they were not
available note as NiA)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspecied for signs of break out?
A, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Owner
info.iatioi is
.equired for every
page.
Subsurface Sewage Disposal System Form - Noi ioi Volunia ry Assessments
a 0
Ownels Name
Cjty/Towi
D. System lnfo tion
Number of oedrooms (aclual)
DESIGN ilow based 31C CMR 15.2C3 (for exampie: 1i0 gpd x # oi bedrooms):
oi'
I
33o
//o,'1,.4.,.u
a{f
Descrjpiion:
(-t;
ANumber of current residenis:
Does residence have a garbage grinder?
Does residence have a water treatment unit?
lf yes, discharges to
ls laundry cn a separare sewage system? (lnclude laundry system inspection
information in this repofi-)
Laundry system inspected?
Seasonal use?
f, Yes
I Yes
I Yes
E-fi;-
E-fi;
No
Water meter i-eadings, ii available (last 2 years usage (gpd)):
Det6ir: /OlOOo
flon
Staie Zic Coce Da€ o.l
egO
Sump pump?
Lasi oate oi occupancy z (-1V/,u'
Yes
Caie
Sinsp.doc . cY. i26l2oi a -,Jc t oarca r.sp4u..'ofl S!6ude Se@S6 'E or3 s'r3@ ' r'pt 7 or 1t
Propeny Address.
1. Residential Flors Conditions:
Number of bedrooms (qesign):3
X v"" E4-
tr v* ffi--
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Volunia ry Assessments
yrOa p
Propery Address
a
Owner's N6meOwner
infomation is
:equircd for every
page.
8Q4q
City/Tov./n
D. System lnformation (cont.)
2. Commercialflndustrial FlowConditions:
Type of Establishment:
Design flow (based on 310 CMR 1 5.203):
Basis of design ffow (seats/persons/sq.ft.. etc.)
Grease trap present?
Water treaiment unit present?
lf yes, discharges to:
lndustsial waste holding tank present?
Non-sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use:
Other (describe below):
State Zip Coce Daie
Gallons per cay (gpdl
n vesE ruo
! vesn No
D Yesn No
I Yes! No
3. Pumping Records:
Source of information:
was syslem pumped as part of the inspection?
lf yes, volume pumped:
How was quantity pumped Setermined?
Reason for pumPing:
&/hf^b/-n
! Yes
- ue : Strird lrsp.clo. Fom slce:lae s.6Ec Orsicd SvEtlm ' page 3 51 16
o
rsinsp.doc. cv. 71262018
Date
A Commonwealth of Massachusetts
Subsurface Sewage Disposa Form - Not for Voluntary Assessments
ieq
Prcpeiry ACdress Oa
O!rr1er's Name
City/Town
D. System lnformation (cont.)
4. Type of Syste
I SvstemU.
Olmer
:nfomation is
:equired for every
lage.
J.
tr
tr
tr
n
!
r-i
LJ
Septic tank, distributaon box, soil absorPtion system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes. attach previous lnspection records, if any)
lnnovativelAltemative technology. Attach a copy of the cunent operation and
maintenance contract (tc be obtained from system owner) and a copy of latest
inspection of the l/A system by system operator under contract
Tight tank. Attach a copy of the DEP approval.
Other (describe):
Approximate age of all , date install
Were sewage odors detected when an'iving at the site?
5. Building Seryer (locate cn srte plan):
Depth below grade:
"Wly r o "ource of in{ormation:
3Y'/
[,4aterial of uction
st iron PVC
Distance from privaie watei supply well or suction line: tu"t -
Comments (on condltlon of lolnts, venring, evidence of leai(age' elc-)'
1o
A)66r
Siate Zip Coce
g,,
- d. , cl'r. d lr€p.iloi '.d su5e le S'@Se !6oosC S'rLm ' Pagt 3 ol 18
r5i.sp.dft ' B- 7261201 6
Title 5 Official lnspection Form
E Yes v€-
I other (explain):
Cr Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form . Not ior Volunta ry Assessments
.A 'atroA
P.opedy Address
Oat
Owneds NameOwner
inforrnation is
..equired for every
page.
& 0)kre
City/Torvn
D. System lnfo rmation (cont. )
6. Septic Tank (locate on site plan)
Depth below grade:
Materlal nstruction:
E metat
Zip Code Date oi
J
d'
ncrete ! floerglass X polyethylene n other (explain)
If tank is melal. lisr age
Is age confirmed by a Cedificate of Co,-npliance? (attach a copy oi cedm
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 oottom of ouflet tee or bame
Yes ! No
-53?/r
<_--
5 c<How were dimensions deiermined?
Comments (on pumping recommendatjons, inlet anci outet tee o
liquid levels as related tc oJtlet inveft, evidence of leakage. etc-):
e/_r baffle cond tion. structural integrity,
r'l
a/,4.,,*<s t4
,sinsp.de. rev. I26l2C14 - !c t a:ia, rrs:e.:ci:otr slf*iree s€€le )sposl st:€m. ?.ge l0or 1a
ieet
z[/0 - -Qu '1
53' Gommonwealth of Massachusetts
Title 5 Official lnsPection Form
Subsurface Sew Dispos al System Form - Not for Voluntary Assessments
a ,?1 av10q
Properry ACdress
Owneds Nafie
Ciry[olvn Zip Cace Dale ol
D. System lnformat on (cont.)
Owner
nformation is_equlred ior every
7age.
7. Grease Trap (locate on site plan)
Depth below grade:
Material of construction:
D concrete n metal
Dimensions:
Scum thickness
Distance from toP of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlel tee or baffle
Daie of last pumping:Dale
comments (on pumptng recommendations, inlet anci outlet tee or baffle condition. structural integrity,
liquid levels'as ielated io outlet inveft, evidence of leakage etc'):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan)I
Depth below gracje:
Material of construction:
f_l concrete L--l metal
Dimensions:
CapacitY:
Design Flow
I flberglass ! polyethylene E other (explain)
gallons
gallons Per day
:'de 5 oitrJ iasredJo. =o,n subs.dae s'€te a'p'sd sFten ' P"e I 1 o' la
sirsp.3oc. 8 726,2c18
! fiberglass n polyethylene n other (explain):
Ar Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Nor for Voluntary Assessments
a l.v?q
P!operty Address
Qa
Cwner
infoarnation rs
lequired ior every
page.*#Ow.e.'s Name
City/Tolrn
D. System lnform On (cont.)
8. Tight or Holding Tank (cont.)
Alarm present:
Alann leyel:
Date of last pumping
n ves Eto
Alarm in working order:
Y
Daie of
! Yes No
Comments (condition of alarm ano float switches, etc.):
* Attach copy of current pumping contract (required). ls copy attacheci? E Yes fl t'lo
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquio ievel above outlet invert Erert
Comments (note if box is level and distribution to outlers equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
&l- /e,-//l/o S"/,J sll/rt -L- Ls
Co* r ^t d6 L /ou-z'
t5i.6p.a@. cv.726101a de: OncLd Lnsoe.lo. aom Suos"dae S€€Se a ipot:l SlsBm'?a9' 12 ol 'a
Stale
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
tll.t4 q
Prcperty ACdress
Owner
nfoEnation is
lequ red for every
?age.
Owner's Name J
City/Town Daie oi I a
D. System lnformation (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: n Yes n No.
Aiarms in working order: ! Yes E t'lo-
Comments (note condition of pump chamber, condition oi pumps and apPurtenances, etc ):
- If pumps or alarms are not in working orcjer, system is a condilional pass'
1 1. Soil Absorption System (SAS) (locate on site plan, excavation not required)
lf SAS not located, explain why:
State Zip Cocje
,*.9 F6,J.r'/,
tr leaching pits
I leaching chambers
X leaching galleries
n leaching trenches
n leacning fields
n overflow cessPool
n rnnovativeralternative system
TyPe/name of technologY:
furt -f ar*S/o^-
number:
number:
numbeT:
number, length:
iumbe.. climenoiono
number:
-,J6 i o"-i.a i.soecJo. Fcd Su.6!,{ac. s.6Se oispos'l sF€d ' PagE 13 ol 10
6in.p.o@'B. rzd2a16
@!!v
5*, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for- Vol untary AsseouossmentsPJ
Properry Address
Owner's NameOwner
informatjon is
Gqui.ed for every
page.
a4rv
orJ {,
City/ToMr Srate Zip Cooe De:e ci I
D. System lnformation (cont.)
'1 1. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic faalure, level of ponding, damp soil, condition of
vegetation, etc.):
O*
a
t u
'12. Cesspools (cesspool musr be pumped as pan 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
[/aterials of construction
lndication of groundwater inflow I Yes n No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
5i.so.:io.. €f, 7,?6/20r 3 -,J. t O,i*i,is*4.. 'om Su6in@ S.€!. )isp.sal Srlbm ' t_tg' 1'or 1a
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal - Not ior Voluntary Assessments
€AOat
PropenyAddress
Orryner
infomaton is
equi,'ed for every
page.
Owneis Name
CitylTowr
D. System lnform on (cont.)
13. PriW (locaie on site plan):
Materials of construction:
Dimensions
Depth of solids
Commenrs (note condition of soil, signs of hyoraulic iailure, level of ponding, condition oi vegetation,
0)6+
Zip Coce Dale of
iinsp-.oc . :ev. r,2a?. a
Ol{4ler'
infomatoa ts
ecuired br every
tage.
Pn?oeriy Address
Owlels liafie
c,ry,:'own
Commonwealth of Massachqsetts
Title 5 Officia
Subsurface Sewage Disposal
I lnspection Form
System Form - Nor ior Vo/uniEry Assessmenls
rlOa ,eJ
Oa
oJ66'
ai':a
D. System I nformation (cont.)
14. Sketch Of Sewage Disposal System;
Providg a vie :he sewage cisposai sysre.n. ,nciuo ing :ies :o ar ieast iwc pennanent iefergnceianolneh.iai'<s. Loc€te ali wells witi:in 100 iee:- t-ocate where rublic water supply enteEng- Check one cf ihe Doxes oeiow:
jand-s(eicii :n tite area ?eicw
cravr'ing a:.aci:ei seraratgly
(3) rtq tri:,\-
/u l-l ,,i;,,
3*+"
{;fottr,'aa
C,
.7L
'v)55
't+7/
l!,t14t,r'v
/tl-trtfu-,t,t,,TJ - JY
/1 -*4t
0v-
LBr'ie se€.. as*si sFq- . ?@ .a ot 1a
A, Commonwealth of Massachusetts
Title 5 Offi cial lnspection FormSubsurfuce Sewa Disposal System Form - Noi fo. Voluntary Assessments
Cwner
inforEation :s
equired for every
.lage.
Prope[y Adriress
4Oltr]eis l,iaane
City/To'vfn
D.System lnformation (conr.)
15. Site Eram:
I Check Slope
f Surface water
E Check celtar
X Shallow weits
Estimated ciepih to nign ground water
q rl Oq ,4J
Q@u_JSiate Zp Ca.e |.
ieet
Ootainec iorit system oeslgn olans on re@ro
lf checkgd, date of design plan reyiewed:
n
!Ocserveo sire laoutf ing property/observado
Cnecxec withftl Soard of .lealth - ex,olai
"'"''"""'1li;';'iH@
7 esf //o/", t*Y*A
Ci:ec(ec with local excavatcrs, ins'ralleis - (attach documentatioo)
Accesseo JSGS calabase - explain:
Yoii must oesa llol yo'.,r eStablisieq }e/t.,Jo )'';:^' *"'7',,u;"'"' f , q *J
c.lo1,NW J4,rff f1 #tr'
t/E
{*"--
S rg
Please incjicaie all neil.lods used to determine:he nigh g.ound water elevatjon:
6,e r'+-
.J
ti
Eefore filing this lnspection Report, please see Report Completeness Checl(list en next page.
Su!tu:ra 5.€:e 1,...., sy.b6. 7.E..;.t .A
\\\Commonwealth of Massachuseft s
Title 5 Officia
Subsurface Sewage Disposal
I lnspection Form
System Form - Not ior Volunta/o 4h
ry Assessmenrs
,aJ
@wt o)
Popefty Address
Otmeis Name
Cityficwn
Owirer
infomation is
equjred :or every
page.
o lr,
E. Report Comple ness Checklist
Complete all applicable sections of this form inclusive of:
A. lnspector iniormation: Complete all fieids in this secrion
Staie Zio Coce nspectio.
DfB.Frtiflcanan: Signed & lared ancj .. 2. 3. or 4 shecked
Lf C. Inspeciion Summarv
1. 2, g, oi5 complered as appropflare
4 Iure Crjte.ia) anc 6 (ChecKlist) compleied
D. System lnformation:
For E: TighVHolding Tan( - pumping contract attacheo
For 14: Sketcn oi Sewage Disposal System cirawn on pg. 16 or attached
For '15: Explanation of estimated depth to high groundwater tncluded
5'16r.!0.. !- 72&20:a -:. i a.:a,:sre.i3. :.n 1.s-ta@ seiae.lsfts5 srs€-.iage.5o,16