Loading...
HomeMy WebLinkAboutPass - Title V Inspection Report - 2177 TURNPIKE STREET 4/1/2024 Yw Commonwealth of Massachusetts � Titl+ 5l Official inspectio Form ' Subsurface Sewage[disposal System F"orrn-Not for Voluntary Assessments Owner Property Address7 c. information is required for every page. city/Town state zip Code __..._..r.__._Date of Inspon....._.�,..,m._,..._,.....w.._._.,.__._, ..__ 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:wl^rerr ���_M.� tilling out forms A. Inspector Information on the corn uteriIt 4 ke mouo our N ......ot lln __ wry _. .w._.._ ......_._ ._._.__ ___ ._.._.... ._..___.,.. ......._...,_.___..._use only the tab y to y Inspector cursor-do not ✓ Fise the return !�. ....� __ �M ._ _ .._..,. ..._.. ._ _...._. . _..w......._. Prey. Com an a i� ' Corn Address Cit own state zip Code Telephone Number License Number �. ��'t"tlf�llc"1tIC1�"1 I certify that: I am a d P approved system inspector in full compliance with Section 15.340 of Title (310 CMR 15.000); 1 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 on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. JX\Passes 2, El Conditionally Passes 3. El Needs Further Evaluation by the Local Approving Authority 4. F] Fails 14 , ate Ins s Signature re I� The system inspector sh u t a copy of this inspection report to the Approving Authority(Board of Health or DP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original form should be sent to the system owner and copies sent to the buyer,if applicable, and the approving 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. 15[nV.duc rev.7726r&1e 1"title 5 Offidei inter Fo m Subsurface SeawVe Dirgacm I System•Pager 1 o118 A. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments PnE3 ...�ddress,_.._,.._.__.......__._" �'. . ._µ`--ww-^`...... ...... .__,.. _.._..._ ..._......... ._.,,. ...... _._.....___.. _.,_.......... .._...,_. ... ......_.......____ Owner _2 information I quired for every �....��_ 4� .....,._ ... _... . �_._ page 64nown State Zip Cade ._._..Date of Inspection C. Inspection Summary Inspection Summary:Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System masses: 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. g 2) System Conditionally masses: [� 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, NUJ)for the following statements. If"not determined,"'pieas explain. The septic tank is metarand over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial'infiltration or extiltration or tank failure is imminent.System will pass inspection if the existing tank is rpic.ed 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 2Q,,years old is available. Y N ND (Explain below): E dr&w.rRcac B' +.'fd ildt}t 'ride 5 Official I w¢, awr t"vin sulwwAyfaw,"" jKqvsal sy%twn-Page 2 of 18 Commonwealth of Massachusetts -a Title 5 Offic to l Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pcraperty Address Owner / information i /�/ {,� ✓` J .. .. aired for ev !�s fJr. .. .. ....,.._...__.._._ required page. CitylTown State Zip Code Date of tnspedion C: Inspection Summary (cont.) 2) ystem Conditionally Passes (cont.): mp Chamber pumps/alarms not operational. System will pass with Berard of Health approval if pu s/alarms are repaired. Observation of se e backup or break out or high static water level in the distribution box due to broken or obstruce ep (s)or due to a broken, settled or uneven distribution box. System will pass inspection if(wit appr I of oard of Health): broken pipe(s)are replaced [ ] Y ❑ N (� ND(Explain below): El obstruction is removed Y [� N [3 ND(Explain below): [ distribution box is leveled or replaced [ Y N ® ND(Explain below): _.. .. _ _.....w__._..... ...__, ..._._.._._....._ .. __. _...... _......._ ...� _..... _.. _... . ........... El he system required ired pumping more than 4 tunes a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health) broken pipe(s)are replaced E] Y ❑ N [,] ND(Explain below): E] o istrt/ tion is removed [j 'y N El ND(Explain below): .....__ __......w.. .....__._.... __.w__...-.____ __ ....... 7- 3) Further Evaluation is Required by the Board of Health:" [] Conditions exist which require further evaluation by the Board Health in order to determine if the system is failing to protect public health, safety or the environ ent. a. System will pass unless Board of Health determines in acco nce with 310 CMR 15.303(1)(b)that the system is not functioning Ina manner which 11 protect public health, safety and the environment: U1 nsp.dac-t ev.712W2018 TOIL 5 Qfipddad InWwbm Faxon,Subsurfaxe Sewage D*xAW YSte n-Page 3 Of IS Commonwealth of Massachusetts T"I'lle 5 Official Inspection Form Subsurface Sewage Disposal System form Not for Voluntary Assessments t F"'roflorty Address �5 -2 Owner C7wner'�Nan1 information is / y[ reglltract for every � '_�✓( ! .State_.._. .. _..4.. ......_ 1 _. page. remit Crown Zipo CDat_.. ...,, . of Inspection __ ..... _.__.M._. ,___.... {_c C. I..nl.. spe_. _ctioln Shimmery (cont.) D Cesspool or privy is within 50 feet of a surface water Elfa Cool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fall uiiles �the Board of Health(and Public Water Supplier,if any) determines that the system cttioning in a manner that protects the public health, safety and environment; I El The system has a septic;tank and soil absorp' system (SAS)and the SAS i within 100 feet of a surface water supply or tributary to a su a water supply. Q The system has a septic tank and SAS and the SAS is in a Zone 1 of a public water supply. 0 The system has a septic tank and SAS and the SAS is within 5 et of a private water supply well. Q The system has a septic tank and SAS and the SAS is less than 100 fee t 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 No Backup of sewage into facility or system component due to overloaded or El clogged SAS or cesspool Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 6'"ix nssp.,dou R rev.7/M2018 Tile 5 Official lnsrmom Foam 5ubsurr'aw SawVe L Sy+stwn•Page 4 of 18 Commonwealth of Massachusetts n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Andress f information Owner CrWrter s N 1n1e _..�nfa�rmatian is _a �.. _ �' ..._.... __.M.... _ v_ w ......_._ ... L_.........._-_.._ required for every w_..w � s d... . , .... Cate of inspection page fret State dap�e C. Inspection Summary (cont.) d) System Failure Criteria Applicable to All Systems: (cant,) Yes No 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 V2 day flow Required pumping rnore than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped._. h ( } 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 tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. [� 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 and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. The system falls. 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. ) Larg�stems: To be considered a large system the system must serve a facility with a design b ref 10,000 gpd to 15,000 gpd. For large systeihs ou must indicate either"yes" or"no"to each of the following,in addition to the questions in Section Yes No [l the system is within feet of a surface drinking water supply [� El the system is within 200 feet o tributary to a surface drinking water supply [l El the system is located in a nitrogen se hive area(Interim Wellhead Protection Area—1WVPA)or a mapped Zone 11 of a p lie water supply well t5ahsa.dcx:•rev.'712,IV2018 "nle 5 Offid-N In spec6on Pam:Subcur im, e Disposal«K+ tem•Puget 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments F'mfaerty{address Owner Ownees Nanae __ _____.._. .. . .__..... information is required for every !._...... ..__a, ��, �� ... �U �J page. Grfydl own toe Zip C.eade Date of Inspection_. ........_.._ ....... ._.. .___..�._..w.__IC�IC11""1 .`r►1.11'f"11"M"Ma....___...._�.. _...�._._.__..__....w..,.__.�._..__.w_.. .�... C. Inspection _.... _.._µry (cant.) 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 system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. . You must indicate "yes" or"no" for each of the following for all inspections: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the 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) El Was the facility or dwelling inspected for signs of sewage back up? I ] Was the site inspected for signs of break out? Were ail system components, excluding the SAS, located on site? fi�. EJ- 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,depth of liquid,depth of sludge and depth of scum? E] 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 been determined based on: El 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)[31 Q CMR 15.302(5)] 4. e .drnc r"v.7076r1A�fd 7 rr 5 Gffixiai kw4vAton Form Sutmuifacs sc �G4ru���Syrrnti*r age 6 nrt 1H Commonwealth of Massachusetts Title 5 Official Inspection Form P Y Subsurface Sewage Disposal System l*ort Not for Voluntary Assessments Owner , p information is t1: / required for every _.__. ,/`f _.. . _.ry _� ......._ ......_....___....�... cl .:...._. � ,ca. ..._.__...... . Crown State Zip Cod Date of In ion D. System Information 1, Residential Flow Conditions: / Number of bedrooms(design): � fore Number of bedrooms(actual): DESIGN flower based on 310 GMR 15.2 example: 110 gpd x of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? El Yes No Does residence have a water treatment unit? El Yes J. No If yes,discharges to: ___. . ...._ _.... _._.....__ Is laundry on a separate sewage sytern"? (Include laundry system inspection Yes No information in this report.) IT Laundry system inspected? (I Yes No Seasonal use? El Y,yyes�r No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? © Yes N Last date of occupancy: Date tEilersp.dcrc*nsv.7QF1a171aa I ide 5 OffidA arv4wxfiw rear rm Subs"ilme sevra"DisFm4 Syswm•Pa"7 Of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ------------ Owner Owne,�,N, information is �5T required for every page. Cityrrown State Zip Code Date of Inspec%on D. System 2. Commercial/Industrial Flow Conditions: e of Establishment: 1 Design low, us ed on 310 CMR 15.203): Gallons per day(gpd) ­iiebts/pe ons/sqft., etc.): Basis of design flo Grease trap present? n Yes D No Water treatment unit present? Yes [I No If yes, discharges to: Industrial waste holding tank present? El Yes El No Non-sanitary waste discharged the Title 5 system? El Yes No Water meter readings, if ailable- ------ ...... Last date of oc�cypa�n' /use: -Date Other below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? X"Yes Ej No If yes, volume pumped: .......... ......... gallons How was quantity pumped determined? Reason for pumping: TIOP 5 Off"al Iftspeflkwi Fmm."'Albsurhxx ScAw�)e L*p)%W Sy-Apm-page a 0.fla Commonwealth of Massachusetts Title 5 Off"I t l Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P _ropert_,y v.A_ddress._"s"s,. ..w.__............ ...... . ^; Owner _vr�Neme infonnation is � State Zia Carle Date .../. _of Inspection ..._ .... required for every page. Cxt!"roman .��._.._.�.__._...W......�..._._____.._.._____..._...w.�_..___�.,._____.._,._....,�.__,.�..m______......�..__...._..,....._ �_W.._.___......______._...._.. D. System Information (coat.) 4. Type of System: Septic tarn,distribution box,soil absorption system [� Single cesspool Overflow cesspool El Privy Shared system(yes na)(if yes, attach previous inspection 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 ICA system by system operator under contract EJ Tight tank.Attach a copy of the ar P approval. El Other(describe): Approximate age of all components,date installed(if known)and source of information Were sewage odors detected when arriving at the site? Yes i� No 5. Building Sewer(locate on site plan): Depth below grade; feet Material of construction: [l cast iron 40 PVC other(explain): Distance from private wat er supply well or suction line: tit e............. Comments(on condition of joints,venting,evidence of leakage,etc.): w. d"rinsp.dcac-w'ev.7r' tY1 8 Pine 5 cffx m Inspecdw Frsny,srutm(fam image Dispaswu'ym"•Page 9 tur'18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _..rp_.erty�a�rtre_.. _..w .��_._.._.._.....w _... ... ..___... _ . ' ". .....__ _.._: ...._..._ ._.... _ _.. .__..._ ..... r�r Owner er`..�_....._ .... ..._. _.... _.. _.... __........ ane inato anon ievery f �...w.. requires9 for every d .. CJ 8 I s Y .......,,, �...F_ `' ... page. ty _._.. State ZipCode bate of tnsped n D. System Information (cont. 6. Septic Tank(locate on site plan): Depth below grade: _... _.. _. _....... __......., feet Material of construction. concrete E3 metal fiberglass polyethylene El other(explain) If tank is metal, list age: year; Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) [] Yes L] No . Dimensions: �� .._ .'`�_........ _....._ Sludge depth: I t � Distance from top of sludge to bottom of outlet tee or baffle - -_........ ._.____..__.,. �r Scum thickness Distance from top of scum to top of outlet tee or baffle r� Distance from bottom of scum to bottom of outlet tee or baffle - - - _..._... ...,_.._. �._ How were dimensions determined? ._...__..__.._.�_.___..._..... _ .w___.._..._ ..______. ....... Comments(on pumping recommendations, inlet and outlet tee or baffle condifion, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface sewage Disposal System Form-Not for Voluntary Assessments I V—s _....... 1._.. ._ .__. �.,. .�` ..w. d roperty Address ° inform C)v�rrer s Name r �.. .` _fin_.. -. rnf¢zrn �.. required forrvery .. . _ ._w ...._.._.__ statr _ ...w __._. latrorl rs v `� page City/Town Zip Coe Cate of Inspection D. System Information (cant,) 7. Grea e,yrap(locate on site plan): Depth belo w ow grade: fret Matedat of c onstructioh!".-I [ ]concrete ( metals ]fiberglass F] polyethylene 1-1 other(explain): Dimensions: Scum thickness Distance from top of scum to tp of outlet tee or baffle ..._...w. Distance from bottom o scum to bottom of outlet tee or baffle - - - - .-_ ...... Date of bast pumps g. ... Date Comments(oh/purnping recommendations, inlet and outlet tee or baffle condition structural integrity, liquid levels"as related to outlet invert,evidence of leakage,etc.): 8. Tight or Molding Tank(tank must be pumped at time of inspect' ),,,(locate on site plan): Depth below grade: . Material of construction: n concrete E metal [I fiberglass n polyethylene other(explain): Dimensions. Caachy � .... .._._._.. ...__....... . .._...._.._ .w........ .... ..._.._.w - ..........____..... p � cgallons sign Flow: gallons per day tSimV.doc rev.703201E "rifle 5 OfffdW Inst +'ton Frx rr Ssrrsuffac»Se wVe DI&POSW sysWfn Page 1't Of 18 Commonwealth of Massachusetts T10JI'le 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. . 2- t. `' _ �...w _-_.._ . ,...' . a .. _..._..... .. ......._ _. r� _ rty A..ddress_.... MN Jwnrfd for eve ! .... - information is requir , page, City/Town State. Zip Cade Ins ion D. System Information (cont.) __._._.._._. ._......._....._._.._._..._.__ B, Tight or Holding Tank(cant) Alarm present: "Yes No AIa level: _ _.....__ .._ _...._..... Alarm in working carrier: El Yes ❑ No Gate of last pumping: ... - ante ....__._.. _....._._.._ . ._..._.__.... _ . Comments (condition of alarm and float su►+itohes,eto); w Attach copy of current pumping contract(required). Is copy attached" [ Yes [ ] No g. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(mate if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): yL If L cj! /G'1'(,Z,<-- C�kl' i t5insp.doc W rev.712612th 8 Title 5 01fid A In 0:4xm:Subsuilau;u #e DmpoeW Syxle ni-Paget 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments � .� _._ ....._. / ..._..._. . _....__ ....... .._ _.,_...... ......... Owner Cn'tr3rtnabon is 6Vr1er S _ required for every _ t L .. lean ' _. Pie. C,� frwsvrn . ..._..__ .ww._...w_._ state Zip e of Inspection _ _ D. System Information (+cont..)_.. .. 10. Pump Chamber(locate on site plan): Pumps in working order: Yes r_1 No" Alarms in working order: / Yes [] 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 ...w__.. .. . ._.. . leaching trenches number, length: _- leaching fields number, dimensions: - _..._...__. ❑ overflow cesspool number: _............._......_ ... ❑ innovative/attemative system Typelname of technology: ____........._. .......__.__ _._._.._ __......._ tainsp.doc•rev.712 td 1"iVle 5 offi lel 1 �n Form:Fubsufface Sewage U}s{xxtW systern•Page 13 of I Commonwealth of Massachusetts I `title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f 7 _ .... Property Addrr-�%s Owner ()wrae Ninformation is ar required rear every .. � �.�' page, City/Tr�wn gate Zip Ccxie gate of Irrsp(xMon D. System Information ._w..w_......_.._ 11. soil Absorption system (SAS)(cant.) Comments (note condition of sail, signs of hydraulic failure, level of ponding, damp sail, condition of vegetation,etc.): 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan). Number and configuration _ _...__._w._______._ ....._ ..........._..._.__ Depth—top of liquid to inlet invert __..._.._ w... _.._...._..e___ _...._.._...__.._. Depth of solids layer _.. ........._.. __. ... Depth of scum layer _...._ ......._... ... Dimensions of cesspool _........ .. .....__w_. . __.. Materials of construction � �_ ..... . .. .... ..,. ... Indication of groundwater inflow Ej Yes [I No Comments(note condition of soil, signs of hydraulic failure, level fprnding,condition of vegetation, etc.): , �•M 61n+sp.c,lars*rev.7Y26rA18 701a 5 C11kkA Wqxtdkm Farm Skilaaurf".FAYooge rarsgxws:ra Sysn-page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner 6wru.r's Nar11 ,,:.__ ` _... ......_m...... _ / ✓ .....t .__ ... per( / infornletiran is required for everyInspection _........ page ityd`rown State p Cade Date of Ins dSon D. System Information (cont.)...__ ..__.M.._ 13. Privy(locate on site plan); Materials of construction: _..._ .. _.._..._. .__.___ Dimensions ` • _...... ......__._.. _. .........._ _._... Depth of solids _... .._ _..._._ _....... ...... ._. Comments(note condition~of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)- .. _........... _ .__ ... tapnsga.cfi>t: prs+✓.71'2~6Y.t O '1"wtl t5 GN6dcia aaw Fa me subs facm SewVO ' SYMAWTO•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ... ....._. .. ........ ._ "_. .._... .... __....__w... .... Property Address ._.. . .. __. ..... _ . _-.......... ....._... ------ Owner CJ'WWl1 r" Name � � .. ... information is / required for every4.�... t', ✓. ✓.... _4.0 �_ _ ( . w page. ate Ziff Cade [date of 9ru�p+ tion D. System Information ( cent.)__.._.._...w_...... ....�._._. ___.a.... .._.:__.�__.-._._. __.__..._._......�__...._�. 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: El hand-sketch in the area below �] drawing attached separately 1 ._____ 'cagxdaar•rev.712612t116 'rMe 5 OffidW Er4.m P°rx-sutmjOarx sman je D9spm-A 6 tn-m-f'ege 16 at 18 Commonwealth of Massachuseft T"Itle 5 Offidal Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 63ioperlyAddr'pss Owner Ownees odei information is k -. --- ___ ____ required for every --1-11--�—A-/)�A- ly.� State Zip Code Date of Inspection page. Ci ty[Town D. System Information (cont.) 15. Site Exam'. F] Check Slope Surface water AJ4:-�> Check cellar E] Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record If checked, date of design plan reviewed: Cte EJ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: El Checked with local excavators, installers-(attach documentation) Accessed USES database-explain: You must describe how you established the high ground water elevation.- 1.(2 Before filing this Inspection Report, please see Report Completeness Checklist on next page. 7joe s oMdgA Inspec6on Fow slibsurface l kwage D*"W SY.Orfn-ruse 17 Of 18 t9nsp.dor rev.7126r2018 Commonwealth of Massachusetts Title 5 Official Inspection tion Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ry / J � .Fi __-roperty'"A'.�d�. ..�__ ___._ . ........_w_ Owner er s information is required for every page. C:ityfrown State Zip Code Crete of inspection E. Report Completeness Checklist Complete all applicable sections of this farm inclusive of: A.Inspector Information: Complete all fields in this section. (� B, Certification: Signed & Gated and 1, 2,3, or 4 checked C. Inspection Summary: 1,2,3,or 5 completed as appropriate 4(Failure 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 tlimVAw,•yrv.7tAMIS 110eS OffidA KRxxtan Rxim Sub%uf ce Sewae DistxnalSysbafn•Page 18 of 16 z, ¢ 4 I