HomeMy WebLinkAboutPass - Title V Inspection Report - 15 SULLIVAN STREET 10/6/2022 n
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Commonwealth of Massachusotts
TitleUl !
5 Official Inspection Form
for Voluntary Assessments
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uIp«sr�rrfeuCe�9Nra!�j�h C�IspFossut a�`it!em �a -Not
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required for Ye cI UOvMer mraYh '� Slate ... �
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mn
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Date or R
Inspection results must be submitted an this form.Irnslmecubn forms may not Ire,allterperf in any
way.Please see e nlpleteness pcheckltst at the end of the form.
....._.
Irru ,rr lliaru�out�rarutf �rms A. Irl �e c 4oIr Information
on Rho cx"%.t W, r l..-_�4 El .Wu
use only the,tab �, 4m
koy to,move yolur Name or Ins
Lisa key,ruwa ramu any r amp
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f sails 7Jp Code
RA'G4d WK Te N E9 Rim 1r7 Nu License
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I cortify that:Uam a DEP approved system Inwator In fall compliance with Section 15.34,01 of Tide h
(340 Clillilt 1 .010 1); f have personally i'mmspected the sewage disposal sy tern at the property address
listed above;;the Information reported below is true,a=rate and oommmplete as of the time of my
inspection;and time inspection was performed based on my tmir ing and experience in th o proper function
and maintenance of On-site sewage disposal systems.,after condivating this inspection I have determined
that the system:
1. Passes
2.. 0 Conditlanallyr passes
. 0 Needs Purther Eval atop by the Local,Approving Authority
4. 0 Falls
..... .....
The system inspector spina submR a copy of this inspection report to theApproving Authmpmutyr a ard
of Health or,DEP),within 30 days of completing this inspection. If the systerni has a drbnign flow of
10.000 ugpd or greater,the inspector and flee system owner shall submit the report to the appropriate,
regional officeof the Dom„ The original form should be sent to the system owner and copies sent to,
time,buyer,d applicable, and the approving authority.,
Pleass note:This report only describes conditions at than time,of Inspertion and under the
conditions of use at that tlm er This inspection does not address,how the syswt+ern will perform
in the future under the same or different condilions of use.
'Titleit Inspection Form
Subsurface Sewage Disposall System Fa .foot for Voluntary Assessments
n
_.... ... .` ._.......
Owner 0WFW _...
'
required.for every
Me, Ui ty[TownSIA10 Mp Codef 6rw��
C. Inspection Summary
Inspec iorn Summary-Gamplatib,1,2, 3,der 5 and all of 4 and 6.
1) system Posses:
have not found any Irduform llon wrt Ich Ind l tos that any of the failure criteria described
in 310 CMR 16-303 or in 310 CMR 16.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
.............. .......................... _ _ ........
w.W M
� �'"'� yV'.. �.W4+.:.." ',..�-..,.... �� ?,..d �..ti-- I�r°�M. ..... dl,..,w •k�..!14?�.. � r`k.j� ..,,,. .,.. ,, ..,
2), System Conditionally Passes:
One or rnno , l m comporne nts s described inthe " ondition l Pass" Section need to I
replacedQ r ilo . The swystern,upon completion of(tie replacement or repair.as approved by
the Board of Hesilrhis"Wjl pass.
heck Elie b for"yes'," o" or�khot,dettermin d� ( ,N, ND)for the following statements. If'wrdct.
determined',"IFnlunase explain.
The septic tank is metal and over 20 years gal of e septic tank(ww�h���tl� metal,or not)is structurallyu unsound,exhibits substantial infiltration or e�rfrlitr�tn � ?r tank failure,Is immineint.System will pans
Inspection if the existing tank is,replaced with a compl q 7septic tardy as approved by the Board of
Health.
mats'll septic tank will bass Inspection If it is structurally saurd „4 not leaking and if a Certificate of
Compliance:Indicafing that the tarok is less,than 20 ears otd is,sva ilable.
t6mBp. C•.FW.MZMAM TIN 5- alI rorm'.8Lfturfew ORNMe DUPMA SYMm M Pftoj 2 0f W
Commonwealth of Massalchuseft
Title 51 Official In'spectloon Form
Subsurface Sewage Disposal Systam,Forrn-Nat for, Vbluntary Assessments
67, C11"',
V A A
der 0i Marne
linfiximaiiii is V 6
nNiLdred,fpr evi
C' rr om
Po I te Dip Code Dale of Iirmpscwl
inspection Summary (cont.)
2) S�Meim ConAllonality Passes(coi
10 Mp Chamber pumpslatarms not opus-rational,. System md pass vidli Board of Health approval If
puimpslaIarms are repiMredi.
Observation of sewage Wokpip or break out or high static,water level in the distribution bi due
Ito Woken or obstructed pili Oroue to,a broken,settled ar uneven distribution box. Systeni Will
pass inspection if(with approval of 14bard of Health):
broken pipe(s)are ireplaced Y 0 N 10 ND(Explain below):
Ej obstruction is removed ElIr ND(Explain below).
distribution box is leveW or replaced El Y E) N ND(Explain below)i.-
...........
C1 The system required pumping more thain 4 times a year due to broken or obstructed pipe(s).The
system will pass inspectiori jf(withi approval of the Board of Heallh.;
E] br aduerr pilpe s are replaced [I Y El N [I NDI(Explain balow):
Ll o removed 0 'Y [71 11111 1[] ND(Explain belowi
3) re
Fur,their Evaluatio n Is RequIred by the Bloard' "Of""IM.
""
nditios 'bbaro of H"Ih'iin order to,determine if
Con erxist which i,e further evaluatio n by the I",
the system is falflhg�to protect public heaft,safety air the enwrbnMent.,
a. Systern will pass unless Board of Health determini in a urr ili with 340 CMIR
I&303(1)(b)that the system Is not function Ing In a manner which wlft'p public hi
safety and the anvironiment:
Tile 5 0#111 inspeckn Famr,kbsuffec*Gowsp 014xwd Splem-Pop 3 4.4 10
m
lCottturr on,,t oolth of Massachusetts
Title 5 Offliclial Inspection Form
o Assessments m, �Not for Voluntary rrDents;
s�rbsa.rmmifao�a S�r�xag�s Disposal SystemFor
Property AddremCMn —
mm
ar
�D'"t�rru � 9 ��
01�ta�rea� a i� °
require i fur " "
p 0 , Ityrrowwan Iatay Zip Data ofImpW w)w
C. Inspection Summary (cont.,)
� .
® e^ssprOol QT'PdVy is within 5,0,facet of a surface water
%PID
ol or privy is within, 0 feint of a ordering vegetated retiand or a saYt rnarsh
b. System . H unless the Board,af Health (arad'Public' r Supplier,,if any)
deterrrntass that a systam is functioning in a man nor that protects the public health,
safety and+oraiwrrrah la
nt:
� The system hasptio tank and mail absorptibn yr*temr(SAS),and the SAS is within
100feetofasuffacewa supply or tributary to a surface water supply.
Lj The systern IFras a sept tank and SAS and the SAS is Yvithin,a Zone "t of a public waiter
suI{ppiiy.
II The system has a septic ta and SAS and the SAS is within 50 feat of a privatal water
supply well,
®i The system has a septic bank a Sins and the SAS is less than 100 feet but 50 feet or
more from a pate water supply gall"
Method used to determine distance: 7��\
This system passes if the wail wnratar a:maly^sis."pe ed at a DEP certified laboratory,for fecal
rlifoaTn bacteria indicates uabsraua't sine the presenceof rmora+ia nitrogen and nitrate nitrogen is autrrall
to or,less Haan h pprn,R provided that no other falluure acrite are triggered.A copy of the ainaty5is must
be attached to this farm,
m Other:
i
4) System Failure Criteria Appitcable to All Systems:
You mW lundl ate"tires" or"No"p to each of the following for all,Inspections:
Yes No
Backup of sewage into facility or system oomponent date tooverfoaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
dine to an overloaded or clogged SAS or cesspool
ro de . -n�wa.Ra;tEx�'14drY& > 6 5 -M,lnspooW Fgrmu MrAfface 4 cir 18
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C mmonwea fh of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System FoFm-foot for Volluntary Assessments
" Pmparty Address
. ,.
... — _..
� Ow.mrsi NaT
�r
Pii criya wwn State Zip Coda Date oftinspactlom
Q Inspection S,UalMl"f'lanl"y(cont.)
4), System Falture Criteria Applicable to All Systems, (cont.)
Yes, No
tarn liquid level in the distribution box above outlet invert,due to an overloaded
01, or clogged SAS or cesspool
Liquid depth in cesspool Is le than '"below invert or available volume is lass
than r day floww Required pumping more than 4 times in the lase year NOTdrre to clogged or
w
obstructed pipe(s). Nwrmtrer Of tprar~es pumpuad:
Any portion of the SAS, cesspool or priVy is below hough ground water elevation.
Any portion of ceasp dl;or privy .his wwrithtn IDoi feat of a,surfacewater supply or
11 tributary to a surface water supply.
Any portion of a,cesspool or privy is Within a,Zone 1 of a public water supply
' Well..
gray Portion of a cesspool or privy is within, So feat of a pdvate water supply well,
0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from o private water supply well%dthi no aGooptable,water quality analysis. fTh;i.s
system passes If th,a well water analysis,performed at a DEEP certified
laboratory,,,for fecal coliifonn bacteria Indicates,absent and the presence
of ar imonia nitrogen and nitrate niitwguen is equail to or loss than 6 pprin,
provided)that no other failure cr4terfa are triggered,. copy cf tihue analysis
and chain of custody must,be attached to this form-]
The system is a c sspoot serving a feciiity with a design flew of 2000 gpd-
10,000 gpd,
0 Thes um fails.l tame determined that one car irnore the above failure
crateria exist,as described in 310 CM11 15.303.,therefore the system fails.,The
system owner should contact the Board of Health to determine what will be
necessary to u'acrrect the failure
largj,Syst+traris-, To be considered a large system the Systerni must serve a faculty with a
d'sslg flow of 10,000 g"pid to 15,0G�b gpol.,
For large ",qptemis„ you rust indicate eith,ar Wyee or'n'c"to each of the following,in addition to the
questions IrW e an CA.
i des No ,,...
0 0 the syst4rrro is ar�wittrlratit4 feet of a sirrfdc drinking
water supply
El 0 the system Is within 2i g,fept of a,tributary to a surface drinlwingwater supply
the system Is located in a nitr,ra 'en senOve area(Irnterirn 'el!Uh d lP"rrataclldn
1:1 El Area—I1 PA)or a mapped rre If, public water supply well
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
PtopertyAddress
Omer we s NOTIN
infounabon Is
2,
...... .....
Pago. C4,rrown State ZIP CO& Data Mspodim
C., Inspection Summary (cont)
If you'have answered'yes"'to any question in Section C.,5,the system is considered a significant
threat,or answered"yes'to any question in Section CA above the large systern has faded.The
owner or operator of any large systern considered a signifitant threat under Section C.5 or failed
under Section CA shall upigmde the system,in Accordance with 310 CMR MAN., Nye system win ner
should contact the appropriate regional office of the Department.
6. °oai must Indicate "yes"'or"no!'for each Of`the following fdr aUlinspeictions:
Yes No
Pumping information was provided by the ovmer, o4xupant, or Board of Health
El Were any of the systern complonents puimped out in the previous two weeRs?
Q El Has the systern recetved normal flow-$in the previous two week period?
E] Have large volurnes of water been Introduced to the systern recently or as part of
this inspection?
E] Ware as built plans of the systern obtained and examined?(if they were,not
available note as NIA)
Was the facility or dwelling inspected for signs of sewage back up?
Lj Was the site inspected for signs of break cut'?
El Were all system components,exdbding,the SAS,, located on site?
El Were the septic tank manholes uncovered,opened,and the interior of the jank
inspected inspected for the condlNoni or the baffies or toes., material of construction.
dimensions,depth of Rquid, dopth of sludge and depth of scum?
Was the facifity owner(and occupanIs if different from owner)provided with
Information on the proper maintenance of subsurface sewage disposal,systerns?
The size,and location of this$oil Absorptilon System(SAS) on the site has,
been determined'based=
El Exisfing inforrnation. For example,a plan at the Board of Hbalth.
Determined lin the field(if any of, the,failure criteria,related to,Part,C Is at issue
approximatton of distance is unac,c", 1618)[310 CMR 15.302(5)]
Mft 5 OVOW Rapeckn Favii:SubvAfbm SpAwjq LMqqosM-,"tmn,PrAgg OjUf Tg
Commonwealth of Massacbusetts
Title Official Inspection Form
Subsurface Sewage Dt posat System Forme-loot for Voluntary Assem3mernts
P,mptql,y Address r"
µ
inroma,ton
� 1' o. ..
Cityrrom ststateiZip,Cody Date erf by w,i
D.
1. Residential Flow Conditions.
Number of berdroams(design),,, 3 Number of bedrooms(actual):
DE IGN flow based on 310 MR 15.203(tor example 110,gpd x#of bedrooms),
Description'.
i
Number of curTernt residents.
Does residence have a garbage grinder'? Yes o
Does residence have a wvater treatment n nji L1 "des A No
If yes, discharges to .......
is lanundrry oiru a separate sewage system? (lincluda laundry system, Inspe len EI e's I {i l'o
in�t rmaitioe in this report.) y
Laundry system inspected? CI Yes [ff�,NO
Seasonal use? C1Yes J No
Water r meter reedlings„ V available(least 2 yearly(usage(gld))
Detail:
Sump pump? des e I
Last date of ocrAipanzy" Gates
i
TISOS-raj Nn, �p.mj�S uL^am face's r1kpbaa Syslam,.�.Paago 7 of 18..
Title 5 Officinal Inspection Form
{
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
L
Omar r� mrn _ ...
information is s
Nam .w.
required for 60
.-
paqu State Z
D. °Stem Information (cone.)
. rsrn e li`ndustrial Flog Gnirtitionew
Type of F'stahti i l
Galilans per day(9pd)
Basis of design flow(seats/persons/sgi.ft., etc j",..,,...,
Grease traps presents Yes No
Water treatment unit present? Yes No
If fee„ disc barge to; _ _..... _....._
w�M
Mduastriai waste holding tank.present? Yes El No
w
Non-sanitary waste discharged to the Title 5 system? , No
Water meter read ngs„if avaltatrle. _.... �...._
Last date of occrupanuy)uase: Dale
_...
Other(describe below)-,'
Pumping Records:
Source of information: .......
'as systern purnped as part of the inspection? El Yes No
gallons
How was quantityr pumped,determined?
Reason for purnping;. .
Commonwealth of Massaohuseft
TRW ' Official. Inspection Form
Subsurface Sewasle Disposal Systl Funn Viral,fral,'Volu nta sMses,ssramerats
Al -_.._. v _.....
..........
a A
ronmrmnwataoa r t , u r '..
"KIwImd For s .. . �s° 1 �..
Cdy'tr—n a 210 oaf iras on
D. System Information (Gaut.)
4. Type of System.,
Septic tank,distribution box.soil a4surption system,
iragfe cesspool
Overflow cesspool
n Privy
Shared system Ides 0rfra�, Nl'�rea�,a�ttsir pr^eVieros iiu�speuwtimirm records, if any)
lbnovativeAkernative technology.Affa ch,a copy of time current operation and
maintenance oontract(to be obtained from system u rwner)and a copy of lal
inspect.ion of time i/A system tyy system operator under ol
'fight tank,,attach a copy of the DEP approval.
Other(Ades ri e)
Approximate age,of all components,dam installed(0 known)and serwree of inform at ow
Were sewage riders detected when arriving at the site" El yes -- No
5. Building Sewer(locate an site plan):
Dgpth below grauto Nwnwat
Material ofconstruction:
east irran M 40 PVC [I other(ear;plailn)
CbiS
tarmse from private water svpplh well air saaeti n line.
Comments(an condition of joinbsa veratirag, evidence of leakage, . :.
TISC 6 w, ram:ra w -V 6YOOM,• 9 a 16
Commonwealth of Massachusetts
NrmTitle, 5, Official Inspection Form
Subsurface Sewage Disposal Sys,tom Fonrn-Not for Voluntary Assessments
<
2) v
PmpertyAddmss
Owneir firarph
infWMAOII
mqulmdfors evwy
page- C-Ptytrwn stale Z-M code M40 of tnspa�fiwi
D. System InforMation (cant)
6 Septic Tank Qaia416 Gn site plab):
aM
Depth below grade.,
feet
Material of construrWn,
�aconcrete El metal 01 fiberglass polyethylene M other(explain)
Iftank is:metal,,list age,
years
Is age confirmed by a Carlificate of Compliance? (jittAch a copy of cerfifitato) Yes No
Dimensions:
Sludge depth:
Distance from top of sludga to bottom of OuUet tee oir baffle
Soum thickness
Nstance from top of sQum to top of outlet tee or baffle --- ......
DmIance from bottom of scum to bottom of outlet tee or baffle
How were dimens bns,daterm 1hed?
Comments (on pumpling recommendations, Inlet and outlet tee ar baffle c*ndltlon, Structural Mtegrity,
liquid levels as related to oullot Invert avidence of leakage,etc.)'.
9
kv4xK*MF&n1 SLflAwfM= jeftj•pagfM JOW 1,B
* p y
amirpatortweaM of Massachusetts
Title 5 Official, Inspection, Form
w. Subsurface Sewage Disposal Systfarn F rmi-plot for Vo4unlary Assessments
Pcuap Address
r
P�
II(7 � dAi 'ItM l ,..mquired for every
ma cjl m('to" State Code Date of Inspedoft
Di. Systemlnt�rmation (cont.)
7. Grease T ,
p,,(Iocate on site plan):
Depth below p�1
Material of constwHon.:
xM�
h.
p concrete metal
;fib"lass lss polyethylene ®of ier(expla;n):
.,
Dimensions,
Scum thickness �-......
Distance frorru top of scrum two traps of ou ffet tee or baffle
Distance from you,of scum to bottom of ou.det tee or baffle _ .... �
Date cal last pumping: bates ..m... _..... ww
Comments(on,pumping recommendations,insist and ouM.tee or baf b condition.siruustu i t krutegi
fiquuld teals as,rstatedi to ou et invert„evidence of leakage,age,etc,)
_ .....
8,. "i 't or k•oldirrg'Tank(tanks must b,e pumped at tiaras of iiruspecfion) QocMe on site plan):
y
Depth ekuaw girh _.._.. _._...
fwteterisl of cons
El concrete
...,. fibergfass El,po'l th*n otiher,(eurplWn):
Dimensions: _
Capacity,
a
Design Flow ",.
�ls t � y..
15ilo ..eac.-a w.MAW$ Tile 55�Of all . * n fcm4& a®:.. � I Srtem-Pagn I I of TH
Comnonwealth of Massachusetts,
Title 5 Off"cial 1eForm
Subsurface Sewage 0System F'crrrr-allot for Voluntary Assessments
Property Address
Owner OwrpWs Nau a
4infoAj
rmation Is a
P090- 9 - Zip CodeDate ottnspEokon
D. System Inforr ation � .
8. T'f,ght br�Hi 1,dlag Tank,(cont.,)
Adarm preae"r;: El Yes El N
M
lakrrrrn l'eve _ _. — Alarm inn vmrking order: Yes ND
Date of last pu,urnping-,
Comments edition,of alarm and fttoat s hes:j-e
* Attach copyof current pumping contract(required). Is copy attached? Yes [0 No
. Distribution Box(N prO ent must he opened)(!tote on site pf'an).
Depth of liquid level ages outlbt invert —
Cerruraeaf (note if box is level amid distribution to outlets equal,any evidence of solids carryover„any
evi:denoe ofteakage irate or out of box,etc,);
I
6°QK
•ram, f 1tii,� TWO S 01ma r 1'rdft-.&Lh"rNm SWPAW;n 8fti.IPa'a.12a9'$0
Coinmonwealth of Massachusetts
r.
Title fi ll Inspection Form
ubsu ce ,tea Disposal System Foy-Not for Voluntary Assessments
Omar
ily Address
�e Nam
� ...�
is mor���� W�q�.�, � ��A.._
uanod for re
Vie. Ulyfrown Zdla Code Dare ur lrwpezikii
D. System Information (cont.)
t 2,1 uMP,,lal`mmnrn er la to orn s1te plan)-
Purrnp ill" lx ,order: [I Yea ] l'e
Alarms Inwrrlir�r order:
Yes ]� o*
rnanta(rate condition ofp rra di�n of pumps aind appurtenances,etc ,'
.x.
It pumps or glarmsare not In working ing order, system is ma conditional pass.
11. Soil Absorption System(SAS)(locate one;site plain, excavation not required):,
If SAS not located, explain why,
Type,
leeching fits rtilamber_
® ItaGhing chambers number,
lleaching gallmine number:
leaching trenches number, length,:
leaGhing fields number, dinnens'un
overflow cesspool nurnber
El ki nowatNe/altarnaitinr system
Type/name of lechnology,
5WISP.6W FTW,MZ5rarb TM.5Offi" t"CW Form SMK'Wam�+=D,id arm-Hai-3CA18
arlfnoFlweaI'ith of Massachusetts
Title: 5 Official Inspectibn Form
5ubsurface,Sewaga'Disposal System oTm, -Not fOr Voluntary Assessments,
w
Property Address
may,
nformation is
ulIn24'foe every' J� � Aar-�
page. � state aka Code Dale of Rm n
D. System Information (cont.)
11. Soil Absorpptlon System (SAS)(wnt.,)
rnrinsruts(mote condifion of soil„signs of hydraulic failure,level of panyd ng„ damp Wi,concifflon of
Vegetation,etc.):
a
h_..,.. ...... ..... ._.... _.
12'. Cesspools(cesspool must be pumped as part of inspection)(tocate on site plan)-.
Number and oonfiguTation
Depth-two 6f squid to inlet invert
Depth of s(ii>ds layer
Depth of scum layer
Dimensions of cesspool
Materials,of'consLructiorr _..._.
irndi[catian of,groundwater inflow 11 Yes El Nrn
Comments(note condiflon,of soil,, slgn,s,of hydrau He failure,, haves a'Oqndiing,Gondifion of vegetation,
etc.). "k
\y Nlky
I"r 'a.414au�` ,dTIN, ts"RYi� TOO 6 OWal hepwj5wi Irma F
'' ~l•iP'Sp'rL*14 of 1iH1
r n
m
Commonwealth of Massachusetts,
Title 5 Official Inspect.lon Form
Subsurface Sew,ame Dfsp assi1 System Form-Not for Vduntary Assessrao nt
<,...
Property Ad,dress
OM9YffNer s L.
informafion is 7"� _ .,_. C
re qu bred for every pag& tyrr� " tata Zip Code Date
of q
D. System, Information (Cont
13. Privy(locate on site Plan)
Depth of ..........
a mrants(notecoHNOgn of suit, signs of hydraul[c failure,Revell of podding,,eorrodiff an of vegatatioro,
etej
tro d..Tow.MM018 Tames cff a at hapec"'o Fona.,.subaerrf"smaw O*vem 8y ow—«Page is,44%8
Commonwealth of Massachusetts
Title 5 Offlic"al Inspection Form
" subsurface Sewage Disposal System Folm-Not for%roluntairy Assessments
rflergwr9�
information is
A �
weir rcpr mow+ _
Vie. alyrrown startle: Zip b&iW Date of Nri
D. System Information (cowls.)
14. Sketch Of Sewage Disposal S;y stain
Provide a,vie of the sewage dispersal system. inclulding ties to at least two permanent reference,
leundn7auias or benchmarks,LocWe all wells Ydtlnun 100 filet.Lamle where public welter supply eaters
the building, Check one of the boxes balomr;
El haindsketch In thear8a below
d,ra lrug attached separately
:.,
.. .... ....w �
r.' 'n'�'W"Yr'1W"29 7� IMB 5' �dal Il�r w,fi mmFA'rq: heMjrfMaC'@SWASO,u� Kelm,Pba 41 116 of 10
Commonwealth of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal!System Forms-Not for Voluntary Assessments
Property Mdress
_..
w
Owner Owner's Na
M
�,..M 6.- ., 2 .m
required for every
pago. C"�EY/Twn Stag Code Dala of Inspedion
D. System Information (cont.)
15, SiteExam:
Check Slope
Sttrface water
r
r
Chi cellar :,rv„
a
Shallow wells
Estiimated depth t4 high ground water feet _ _...
Please Indicate all methods used to,determine the high ground water elevation,
Obtained from system,i design:plans on record
If checked,date of design plan reviewed:
Cray
El
Observed site (abutfiing property/observation! hole wwrlthirw 150 feet of SAS')
El Checked wwlth local'IB rd of Health explain:,,.,,,
� h
Checked with local excavators,installers (attach,documentation)
Arxes,sed USGS database-explain.
You must describe haw you established the h,'4'i ground water elevation,
dr
Before ttflrmg this Inspection Report please see ffiport Completeness Cherklist on next,tags.
Commonwoalth of'Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposall'sYstem Fom-Not for Voluntary Assessmenis
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Owner Owrm�r's Namp-
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E. Report Completeness Checklist
Com,plete all applicable sections of this form.inclusive of:
A. Inspector Information.Complete all fields in this section,.
B. Cartificaton: &qned,& Dated and 1,,2, 3,or 4 checked
C. Inspect on Summary-
1,,2,3,or 5 compl6ted as appropriate
4(Failure!Criteria)and 6(Checkfist)completed
D.System I nformalfan,
For$-TighlfHoldfng�Tank-Pumping contract attached
For 14.,Sketch of Sewage Disposal Systern drawn On pg, 16 or attached
FOT 15:Explaination of estimated depth to high graundwater indluded
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HEALTH DEPARTMENT
NAME;
Type off'Permit or,License: (Check bear
Araavaeal'
11 Body Art Pra ctitioner ��...
Daaar pster
ILI Food Service-
D Funeral Directors
Massage Fraa,cttay-
0 Of
fal'(Sq7tic)Hauler
LI Recreational Camp
0 Sun tanning $
0 Swta�rraaaan Pool m
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EI TrasIVSotid aaste Hauler
13 Well construction
SEPT7C Sa Meares;
0 Sapttc Soft Testing ..
IJ Septic-Design Approval
13 Septic Disposal Works caimtruction tDWQ 0 Septic Disposat Works Installers(DWI)
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