HomeMy WebLinkAboutPASS - Title V Inspection Report - 15 SAW MILL ROAD 7/22/2025 Commonwealth of Massachusetts nar
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T'tle 5 Off'lcl'al Inspecti"on Form
Subsurface Sewage,Disposal System Form Not for Voluntary AssameAYG 112,025
Property Address :2. ) "ealth Departmet
OwAor Owners Name
required for every
Informafion Is ell
page. City/Town State Zip Code Date of Inspection'
Inspection results must be submitted on this form.,Inspection forms may not be altered in any
way.Please see compleiene3S Gheckl*13t at the end of the form.
Important:When A. Ins ' ector Information
filling out forms P
on the computer,
use anly the tab _ -.-- __-.-- 1
key to move YO ur Na Insfector
cursor-do root 4 e
M91
use the return Compaq Name
key.
!T Com n dress
%
City/Town -State Zip Code
(MV
Telephone Number License Number
B. Certification
I co if that:I am a DEP approved eystom'Inspector in full cornplilanco,with Section 15.340 of Title 6
(310 CMR 15.000),, 1 have personally inspected the sewage disposal system at the property address
I
;the information reported below is true, accurate and complete as of the time of my
liste d above
inspection-and the inspection was performed based on my training and experience in the proper function
f
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system.
Pa55U=5
Conditionally Passes
3. Needs Further Evaluation by the Local Approving Authority
4. El Fails
Inspector's Signature Date
The system inspector shall submilt a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this Inspection. If the system has a design flow of
I 0,000 gpd or greater,,the I nspector and the system owner shall submit the report to the appropriate
regional office of the DEP.The original foffn should be sent to,the system owner and copies sent to
the buyer,if applicable,and the approving authority,
P'lease 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,th,a system will perform
K a 0
in the future under the same or dWerent condi tions,of use.
t6insp.doe-rev.,7726/20 18 Title 6 Vidal Inspedon Form:Subsurface Sew ge Disposal System-Page 1 of 18
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Commonwealth of Massachusetts
DisposalOffi I Inspecti"on Form
Tiotle 5 cia
> Subsurface Sewage Not for Voluntary Assessments
Property Address
Owner
Owner's Name ,111A 6&L(J
,, ..
information is
-c;( 21
required for every
page. City/To w►n State Zi Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1,2,3,or 5 and all of 4 and 6.
1) System Passes:
1 have not found any"Information which indicates that any of the failure criteria described
in 310 CMR 15,.303 or in 31 G CMR.1 5.304 exist.Any faflurecriteria not evaluated are
indicated below.
Comments.
ajr
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UFT
2)
System Conditionally Passes.
e r more system,components as described the"Conditional Pass"sectionn d�t+ e
placed r repaired.The system, upon completion n�of the replacement or repair,as approved b
t Dead of Health,will pass.
Check the for yes","no"or not determined" , N,ND�)for the following statements. If"not
not
determined,"d,"p se explain.
The septic tank is,me nd over 20 years old* r the septic tank(whether metal or riot)is structurally
unsound,exhibits substan i infiltration r exfiltrati n or teak tallure is imminent.,system WliIl pass
inspe til on it the existing ink i placed with a complying septic tank as approved the Board of
Healt a
metal septic tank will pass inspection i is structurally sound,not leaking and it a Certificate f
Compliance indicating that,the tank is less the 0 years old is available.
t6inspwdoc rov.7/2612010 We 5 Official inspection For.Subsurface Sewage Disposal System image 2 of 18
Commonwealth of Massachusetts
_.�
T'latle 5 Offi"cimal Inspecti"on Form
Subsurface Sewage Disposal System Form Not forVoluntary Assessments
Property Address
)6 tx
O;wner
lrlorrrMati#rr is �Eco
&t4 k is ---CP 2 z
required for every
page. Grt lTown State Zip C6de Date of Inspection
Inspection Summary (cont.)
: System Conditionally Passes coot. .
Pump Chamber p rnps/alarrns not operational.System Will pass with Board of Health approval It
yrnps/alarrns are repaired.
4
Obser atio sewage backup or break out or high stand water level in the distribution box due
to broke
n or o, ntod pipe(s)or duo to a broken, settled or uneven distribution box. System will
pass inspection ection if 'thr approval of Board of Health):
a
broken 11 s ar laced El Y 0 plain below):
G
obstruction is removed 0 Y ;EJ N 0 ND(Explain below),,
I
El
distribution box is leveled or replace Y El plain below
1
El
a
The syst� required pumping more than 4 fi'mes a year due to broken or obstructed pipes .The
system w11l, ss Inspection I' lth approval of the Board'of Health).
broken I (s are replaced El ! El ND �(Explain below):
t
El EJ
+ab, truon'is removed ' El NEI ND(Explain below
r
m
F luation
Conditions exist which require further evaluation by the Roar "of Health in order to determine if
the system is tailing to protect public health,lthw,safety or thee;environment.
a. System will pass unless Board of Health determines,In accordance r rilitb 310 CIVIR
5.303 ( that the system o is not functioning to a manner which,will protect public health,
safety and the environment
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Commonwealth of Massachusetts
on
Tltle 5 Offi'*ci'al Inspecti" Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
16
Property Address
Owner Owner's Name
information Is 20 CIZ Qv
required for every JA Z)
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
El Cesspool or privy is within 50 feet of a surface water
El Ce ool or privy'is within 50 feet of a bordering vegetated wetland or a It marsh
System MIR , unless the Board of Health(and PublIc Water Suppiller,If any)
determines that the stem is functioning in,a manner that protects the pubilic health,
safety and environme
0 The system has a,septic k and s,o l absorption system(SAS)and the SAS is within
100 feet of a surface water sup r tributary to a surface water s,pp,ply.
El The system has a septic tank an AS,and the SAS isWithin a' Zone I of a public water
supply,
El The system has a septic tank and S, S a the SAS is within 50 feet of a private water
supply well.
[:] The system has,a septic tank and SAS and t"hekls less than 100 feet but 50 feet or
more from a private water supply welr*.
Method used to determine distance:
This system posses if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of amimonia 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 followinig for all Inspections:
'Yes No
E] Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or pondin,g of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5l nsp,doa-rev.7/2012018 Tide 5 Offidal frispecton Form:Subs uftoe,Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
-_0 Tl'otle 5 Offici"al Inspectinon Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Lo
Property Address
Owner
Ownef's Name ,
information is
required for every
2—
page. t1ty0own State Zip Code Date of Inspection
C. Inspectimpin, Summary (cont.)
4): System Fallure Cri.teria Applicable to All Systems: (cont')
Yes 0
atic liquid level in the distribution box above outlet invert due to an overloaded
ElSt
or clogged SAS or cesspool
El Liquid depth in cesspool is less than 6":below invert or available volume is less
than Y2day flow
Required pumping more than 4 times ln�the last year NOT due to clogged or
obstructed pipe(s). Number of times punnped:
El Any portion of the SAS, cesspool or priv
,y i's below high,ground water elevation.
Any portion of cesspool or pnivy is wfthih 100 feet of a surface water supply or
tnibutary to a surface water supply.
Any portion of a cesspool or privy is,Within a,Zone 1 of a public water supply
well.
El Any portion of a cesspool or privy is wltl�in 50 feet of a private water supply well.
Any portion of a cesspool,or privy is less than 100 feet but greater than 50 feet
from a private walter supply well with no acceptable water quality analysis. [Th:is
system passes,if the well water analy,sls,,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,ppmv
p r Ided that no other failure criteria'are triggered.A copy of the analysis ov
and chain of custody must be attacho'cl to this form.]
The system is a cesspool serving a facility with a design flow of 2000 gpd-
El 10v000 gpd.
The system falls. I have determined tha:t one or more of the above failure
criteria Exist as described win 310 CMR 1,5.303,therefore the,system falls.The
ie
system owner should contact the Board of Health to determine what will b
necessary to correct the failure.
ry
To be considered a large system the system must serve a facility with a
6) Large System ft
'o ne,
design flow'of I gpd to 1510l00 gpd,.
For largo eya for na, u at indioato either"yos"or"no"to o4oh of the following, in addition to the
yo in
questionsin�Sectlion C
Yes No
o �j the system is within 400 of a surfaG6 drinking water supply
the system is within 200 feet of a Utary to a surface drinking water supply
41
the system is located 'in a nitrogen serl e area (interim Wellhead Protection
Area—IWPA)or a mapped Zone ll of a pub water supply well
Mimp.ldur,-ray.TIP-01,20 10 Title 0 Offidal Inspauflon romg oubauftw 0o a D13ponal Opt=- ''ago 0 of 10
Commonwealth of Massachusetts
.0f in Form
Ti'tle 5 Official Inspectigon
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
Owner Name
information s
required for every OT 6
I
page. City/Town State Zip Code of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section G. the system is considered a significant
threat, or answered"yes"to any question in Section G.4 above the large system has failed.The
owner or operator of any large system considered a significant threat under Section G.5 or failed
under Section C.4,shall upgrade the system in accordance.with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for aH 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?,
E] 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?.
E] W'ere as built plans of the system obtained and examined? (if they were not
a ilable note as N/A)
val
E] Was the facility or dwelling inspected for signs of sewage back up?
0 Was the site inspected for signs of break out?
Were all system components,excluding the SAS, located on site?,
El 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 scurn?
Was the facility owner(and occupants if Merent from owner)p�rovided 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 ow,
Existing information. For example.,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
t5insp,doo-rev.7/2612018 Till e 5 Official frispedon Fom:Subsurface Sewage Disposal System-Page 6 of I a
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Commonwealth of Massachusetts
«.
Ti'ntle 5 orm
O,ffi"ci'al Inspect"ion
Subsurface Sewage Disposal System F Not for Voluntary Assessments
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Property Address
k
h
Owner Owner's s Name
info,rmption i
requirW for ever
City/page.
own State Zip Code Date o Ins edon
D. System Information
dl
1. i Conditions,-.-
Number of bedrooms(design): Number of bedrooms(actual).,
DESIGN ow based o 3 CMR 15.203(for example: I'� g d x# f bedrooms :
Description.,,
Number of current residents:
Does residence have a garbage grinder? Yes No
Dues residence have a wafer treatment unit.? Yes N o
f yes,discharges to
Is laundry on a separate sewage system (include laundry r system inspection
4 Yes No
of rmatio�ire this report.)
LauIndry system inspected Yes I No
,seasonal use? Yes MS
No
WaferjQX4—
meter readings, available(last 2 years usage(gpd)):
Detail.
Sump pump? Yes No
Last date of occupancy s-1
� �
t In p.dou-Mv.7126/20 10 T104 5 Offid2l,lnsaecMn Form:,Subsurface wa e Isposal SYst m•Page 7 of 18
Commonwealth of Massachusetts
rg
Title 5 Official Inspecti"on Form
> Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
,
Owner Owner's Nam
information Is
required for every
page. City/Town State Zip Coldn Date of Inspectlon
U. System Information (cont.)
2. mercialfindustrial Flow Conditions.
Types lishment:
Design flow(base 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(sea orsons/sq.l etc.).-
Grease trap present? El Yes [:1 No
Water treatment unit present? 0 Yes [:1 No
If yes,discharges to:
Industrial waste holding tank present? Yes No
Non-sanitary waste discharged to the Title 5 system??., [:1 Yes E] N o
Water meter readings, if available,.,;
Last to of occupancy/use: Date
Other(describe below):
C.vgv
IL
3. Pumping Records. Ila
Source of information*.
Was system pumped as part of the inspection? Yes No
If yes, volume pumped: gallons
How was quantity pumped determined? `�.j 0
Reason for pumping-, VCA,it Yq v I
t5insp.doo-rev.V26/2018 We 5 Official tnspedon Form:Subsurface sewage Disposal system-page e of 18
1
Commonwealth of Massachusetts
T'Intle 5 Offolcimal
Inspecti'mon
Form
e
nxnnnT.nnn�n
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
Owner Owner's Name ir
information i1000,
required for eves
1j
page. c�� awn State ,Zip Code Date of Inspection
D. System Information (cont.)
. Type
Septic teak, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system m(yes o no) �f yes,attach previous inspection records, if ray
Innovative/Alternative technology.Attach a copy of the current operation and
ma intenance contract(ter be obtained from system owner)and a copy of latest
inspection of the 11A system by system operator under contract
Tight teak.Attach a copy of the DEP appro at.
El Other(describe):
,approximate age of all components,ts,date installed if known)and source of Informations
Were sewage odors detected when arriving at the sits:"? El Yes No
5. Building Sewer(locate on site plan):
Depth below grade
feet
Material of construction:.-
cast iron 40 PVC El other(explain).-
Distance from private water supply well or suction One: feet
Comments on condition of joints,venting,evidence of leakage,etc.).
t6lnsp.doo rev,7/26120,,18 Tide 5 Official In p to Form,:Subsurface sewage usposat system page 9 of l8
Commonwealth of Massachusetts
Ti'tle 5 Offilt'ial Inspection Form
Subsurface S,ewage Disposal System Form-Not for Voluntary Assessments
Property Address
Ow ner Owner's NUT-6
Information i's 2,2,
required for every
page. kilTOWrl State Zip Cade Date of Inspection
D. System Information (cont.)
6. Septic Ta,n,k(locate on site plan):
j
Depth below grade: feet
Material of construction:
Aconcrete El metal EJ fiberglass El polyethylene other(explain)
If tank is metal,list age: year's
Is age confirmed by a Certificate of Compliance?(aftach a copy of cert'ificate) 0 Yes [:1 N o
Dimensions:
Sludge depth:
Distance from top of sludge to bottom,of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 1 ,42
How were dimensions determined?
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural Integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
7
U.�d
4� j
"0000F N_0
15insp.doc; rev.7/20/20 18 Tide 6 Official fnspedon Form:Subsurface Sewage Disposal System-Page 10 of 18
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Tl"tle �k
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Not for Voluntary Assessments
Propel Address4
x
Owner
I Owners Name
Inrt[31 1s Aj 4A.,I %,-��. Vy�
required for eve
page. City/Town! State Zip Cede Date of Inspection
Do Sy m information (cone)
. Grease Trap mate on site plan):
Depth elo*grade:
feet
Material of donstruction
x
El concrete,
a
El metal fiberglass 0 polyethylene other xpl in),-
P
p
w
t
io
i
Scum thickness
Distancefrom top of scum to top of Nutlet tee or b2ftl
Distance fr6m bottomof scan to m of outlet tee or baffle
Date of last rn inn D
ate
Comments on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels'as related to outlet invert,evidence of leakage,etc.)
r
8.
3
a
Tight HOdIn Tank(tank must be pum,ped,at time of inspection)(locate on site la
Depth below grad'e:
Material of onstruction
A
0 con rete� metal fiberglass polyethylene Li other, ex lain -
Dimension
Capacity: Ycr�
g
s
Design Flow.,, lions per day
a
tSl sp.d c- .7126101 � t 5 omdai nspecoo Form:Subsurface Sewage Disposal System�►'age 11 of 18
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Commonwealth of Massachusetts
Title 5 Off'incioal Inspecti"on Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
q57 Property Address "'�B6 L�j dX
Owner Owney's Name let
information is 2 2
required for every E"
page. City/Town State Zip Code Date of Inspection
U, System Information (cont.)
Tight or Holding Tank(cont.)
A rop present: 0 Yes El No
No
Alarm level. Alaffn In workIng order. es
Date of last pumping: Date
Comments(condition,of alarm and float swi S, W.
;Att00
ach copy of current pumping contract requlred). Is copy attached Yes
9. Distribution Box(if present must be opened),(locate on site plan):
Depth of liquid level,above outlet invert
Comments(note if box is,level and distdibution to outlets equal,any evidence of solids over, any
4
evidence of leakage into,or out of box,1 etc.).
04 C C.-
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t6insp.doc-rev.712612018 Tile' Official frispedon,Fomr.Subsurface Sewage Disp6sal System:-Page 12 of 18
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Commonwealth of Massachusefts
DisposalTi"tle 5 'Official Inspect'ion Form
Subsurface Sewage Not for Voluntary Assessments
w'MAd L /<
Property Address
OwnerOvvne,rs Name
information is <S
2 "
m4ulred for eves
ityna state page. ate Zip Code Date of Inspection
D. SystemiInformation (cont.)
10. mp C «��ber(locate on site plan):
Pumps wrking order. 0es El No*
Alarms in Wbrki �rder. El Yes El No*
Comments note conditio ump tuber,condition of pumps and appurtenances, etc.):
a
P
P
I
i
7
A
P
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i
d
p rnps r alarms are not in working order system i�s a condifiona pass.
11. Soil Absorption System(SAS) to on site purr,excava on not required),
e
If SAS not i 6cated,explain why:
F
i
x
1
i
Type:
YI
leaching pits number
n
leaching chambers number:
leaching galleries number:
leaching trenches number,length.-
leaching fields number,dimensions:
ns:
overflow ow cesspool number:
innova i�ve/aiterna ive system
f
Type/name of tec 1ogy
N
Wnsp.doc-rev.712612018 Tide 5Official Ias,pecoan Fenn:SubsurfbLe Sewage Ddsposal System.Page 13,of 1
Commonwealth of Massachusetts
Tl"tle 5 Official Inspecti"on Form
>I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
r.
OwIner Owner's,Na
information is
required for every
page. iti/Town state Zip Code Date of Inspection
D. System Information (cont.)
11. Soll Absorption System(SAS)(cont.)
Cornments,(note condition of soil,signs of hydraulic failure,level of pand in,g,, damp soil,condition of
vegetation,, etc.):
rloqw-W.-
A.)J-
12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Nu er and configuration
Depoth—lbp,of liquid to inlet'Invert
Depth of solid Yer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater'inflow El Yes E] No
Comments(note condition of soil,signs of hydrI failure,,level of ponding, condition of vegetation,
etc.):
ffifnsp.doc-rev.7/26/2010 Tile 6 Official Inspedon Form:Subsufface Sewage 01sposW System-Page 14 of 18
Commonwealth of Massachusetts
Tiotle, icia fi
5 Off I Inspection Form
Subsurface So W� aqe D'I of for Voluntary Assessments
<
Property Address
Owner Owners Name
information is
4 ..0 net
jvquired for every
page. City/Town State Zip Code Date of Insp on
D. ion (cont.)
134,Ir,IV Y(locate onsite plan)-
Materia construct on'."
Dimensiom
0
Depth of s, lids
Comments 6ote condition of soil, s of hydraulic failure,level of ponding, condition of vegetation,
0
etc.),*
t5insp.doc reV.7/26120 1:8 I We 5 OMNI InspecOon Form Subsurface Sewage D:13pmal Sy3tem-Fargo 15 of 18
Commonwealth of Massachusetts
F Title 5 Officiat Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
Owner Owner's Na
information is
required for every
page. ity/Town ' S'6te Zip Code Data of Inspection
D. System Information (cont.)
14. Sketch Of'Sewage Disposal,System;
Provide a view of the sewage disposal system,, including ties to at least two pennanent reference
landmarks or benchmarks.Locate all wells within 100 feet.Locate where pubfiG water supply enters
the building. Check one of the boxes below.*
E] hand-sketchin the area below
El drawing attached separately
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t5lnsp.doc rev.7/26/2o18 Me 6 Official Inspecton Form:Subsuftoe sewage 01spos'al System-Page 16 of I o
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Commonwo,olth of Massachusetts
Offil'ci"al
j
T'latle 5
w «s
r
Subsurfacep DisposalNot for Voluntary Assessments
Property Address
OwnerOwner's Nam
inforniation Is
required for eves
page. cltyffewn. State Zip trade bete of Inspection
D. System Information (cont.)
. Site
El :heck Slope
Surfac water
Check cellar
r
1
Shallow wells
f
Estimated;depth to high ground water. eet
Please indi6ate all methods used to determine the high ground water elevation,.,
El 'obtain from system design an n record
cif checked,, gate of design planreviewed:
Date
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
4
Checked with local excavators, installers-(attach documentation)
Accessed US�GS database-explain,:
g
You musl dlgerihe hoer you estab#ghead the high ground grater elevation
............./ I
C�V, e (j q, ZAS
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Before filing this Inspec4ion Report,ple 3v 3ve Reportm etcne33 ChCGk1i3t on noxtgo.
t5insp.doo.rev.7/2/2 18 Tick:5 Official Insp din Form:Subsurface Sewage Disposal System-Page 17 of 1S
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Commonwealth, of Massachusefts
ff I Inspection Form
TI"tie 5 0 icia
subsurface Sewage Disposal Syste Not for Voluntary Assessments
e
�ty
� a
Propel Address
6 4k1C
Owner Owney's Name
information is
required for eves A)
page. City/Town State Zip Cade Date of Inspection
EE
Report Completeness Checklist
Complete all apolicable sections of this form inclusive of--
. Inspector Information:Completeall fields'in this section.
B. rtl ation: Signed& Datedn , 2, 3,or 4 checked
C. Inspection Summary:
a
, 2, 3, r;5 completed as appropriate
(Failure;Criteria)and 6(Checklist)
D. System Information:
For :Tight/Holding TankPumping wntract attached
d
For *.sketch of Sewage Disposal System drawn on pg. 16 or attached
For 1 : E X l nation of estimated depth to high groundwater
e
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