HomeMy WebLinkAboutPass - Title V Inspection Report - 51 COLONIAL AVENUE 3/20/2026 s ,
tom monwealth of Massachusetts
T"tle Off"c"al Inspecti"on Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
.4
3
Property Address
Owner owner's Nam )
�..
information is .: .� �- _ - 3
required for every __ _...� _
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 completeness checklist at the end of the form.
Important:When I V VM01
firing out forrns A., Ins ec or Information
on the computer,
use only the tab i.... ... .
key to move your Name of inspector _ &_202b
cursor-do not %
use the return C � any Name
key ';�. .. ,
�X Health
Go m a Address _ _�__ ......._...w. . _ ok
Devart
C ity[Town State ZiphodVL: e
Telephone Number - __.. License Number
B. Certification
I certify that; I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CM 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. Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. El Fails
nspector's 5ignat6Ae. ;. Date
�j
The system inspector shall submit 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
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,
'lease note: This report only describes conditions at the time of inspection and Linder 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.
t5insp.dcc•rev.3 1-2,12026 Tide 5 Official Inspection Ford.Subsurface sw,;va,e DisposJ, system•Page 1 of 18
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Commonwealth of Massachusetts
InspectionForm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
__--- ......... �.
Owner Owner's Name
information is
required for eye �+
every �, -
q
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 0.
1) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 C M R 15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ 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, ND)for the following statements. If"not
determined," please ex lain.
The septic tank is metal an ver 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial in ' ation or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is repi d with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is s cturally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 rs old is available.
El Y El N F1 NCB (Explain below):
t5insp.doc•rev.3r 1212026 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 18
_ = Commonwealth of Massachusetts
Tiatle 5 Offloc'18al Inspectnion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
rs J
}
_ Property Address
Owner Owner's Name �_
information ist-
,. M,
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps alarms are repaired.
-
Observation of sewage back-up or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) 6r-due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board-fAHealth):
❑ broken pipe(s) are replaced ❑ N El ND (Explain below):
El obstruction is removed ❑ Y El N ND (Explain below):
El distribution box is leveled or replaced [:1 Y El N ❑ N Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipes). The
system will pass inspection if(with approval of the Board of Health):
El ---broken pipe(s) are replaced ❑ Y El N F1 ND (Explain below):
_t�
C] obstruction1s=romoved ❑ Y EIN ❑ ND (Explain below):
,
3) Further Evaluation is required by the Board of Health.
❑ Conditions exist which require further evaluation by the Boa of Health in order to determine if
the system is failing to protect public health, safety or the envirb ment,
a. System will pass unless Board of Health determines in acc rdan ce with 310 C M R
15.303(l){b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.3 i 2/2026 Title 5 Official Inspection Fumi:Subsurface 5e,,vage Disposal System-Page 3 of 13
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` Commonwealth of Massachusetts
i
x T-- Title 5 official Form
r �10 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is , `3 _ -- - --
y
regtrtired for eery A JJA
page, CitylTown State Zip Code date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ ..� Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will mess the Board of Health (and Public water Supplier, if any)
determines that the sy m is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank an oil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tribe to a surface water supply.
❑ The system has a septic tank and SAS an e SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SA within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is les han too feet but 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
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
❑ r to SAS or cesspool
due to an overloaded o clogged ed
t5insp.doc.rev.312/2026 Title 5 official Inspection Form:subsurface Sewage Disposal System•Page 4 of 18
FCommonwealth of Massachusetts
T'Itle 5 Official Inspectimon Form
- :�+ Subsurface Sewage Disposal System Form Not for voluntary Assessments
�,. -
01
'h
Property Address
Owner Owner's Name
information is
v
,.� .
required for every � _� _ � - �_ k 2
page. CityrTown state Zip Code date of Inspection
C. Inspection u a ry (cont.)
4) System Failure Criteria Applicable to All Systems: (cant.)
Yes No
❑ r Static liquid level in the distribution box above Outlet invert due to an overloaded
or clogged SAS or cesspool
00 P
Liquid depth in cesspool is less than 6" below invert or available volume is less
❑ than '/2y
da flow
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipes). Number of times pumped:
El 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
tributaryto a surface water supply.
pP Y•
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.
❑ � . 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 CEP 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 forma
The system is a cesspool serving a facility with a design flow of 2060 gpd-
❑ 10 000 gP d.
❑ S 1 The system fails. I have determined that one or more of the above failure
� cr
iteria exist as described in 310 AMR 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.
5) Large systems-:--;To be considered a large system the system must serge a facility with a
design flow of' 1040 gpd to 15,000 gpd,
For large systems, you t indicate either"yes"or"no" to each of the following, in addition to the
questions in Section CA,
Yes No
El ❑ the system is within 400 feet of rskrface drinking water supply
1:1 El the system is within 200 feet of a tributary -b--�a surface drinking water supply
the system is located in a nitrogen sensitive area",flnterim Wellhead Protection
❑ ❑ Area— IWPA ma n}or a peed Zone II of a public water supply well
t5inspAoc rear.3 E2I2026 Tile 5 official Inspection Farm:Subsurface Sewage Disposal System-Page 5 of 13
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Commonwealth of Massachusetts
Title 5 Off For-A
nr�
Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
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Property Address rJ
Owner owner's Name
information is Iq z � �
required for every
• _ t-
page. City/Town State Zip Code Date of Inspection
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 C.4 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 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.
5. 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)
❑ Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
were all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
❑ information on the maintenance of subsurface sewage disposal systems?
proper
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
aExisting information. For example, a plan at the Board of Health. / `� ��:-3"�% �---
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)]
pp }
t5insp.doc•rev.3/12/2026 Title 5 official I'nspecdon Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Z
Title 5 Offl'c'lal lnspect'ion Form
11
Subsurface Sewage Disposal System Fora Not for Voluntary Assessments
.r
s _
Property Address
Owner Owner's Name --- -
information is y
A
e
required for every
page. Cityffown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual): --
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes okNo
Does residence have a water treatment unit? El Yes No
f yes, discharges to: -------_-----
Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes L2 No
p }
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ Yes No
Water meter readings, if available Mast 2 years usage (gpd)}:
Detail:
.--..-.---- r.............._.._................._.......
-- ._.�..._...-¢y@',...
Sump pump? E] Yes No
Last date of occupancy: = -_ --------
❑ate
t5insp.doc•rev.3 1212D26 Tile 5 Official Inspectcn Form:Subsurface S&.vaga Disposal Syster;•pag--7 of 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1, : Subsurface Sewage Disposal System Form Not for Voluntary Assessments
IZ
Property Address
Owner Owner's Narne�,,U 72b,
information is
required for every
page. City/Town' State Zip Code Date of Inspection
D, System Information (cont.)
2. Co mercial/industrial Flow Conditions:
ercia'/ n
Typleo Establishment:
Design flow(b spd on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(se_""_�sLpersons/sq.ft., etc.):
Grease trap present? El Yes [I No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? El Yes E] No
Non-sanitary waste discharged to the Title 5 system? El Yes 0 No
Water meter readings, if available: ...........
Last date of occupancy/use: Date mm
Other(describe below)-
L
3. Pumping Records.
Q_
Source of information: .....
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5in sp.d oc-rev.3.1'12/2 026 Tile 5 Official Inspection Form:Subsurface SeNvage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Tl"tle 5 Off'lcl'al Inspect'ion Form
Jim-
Subsurface Sewage Disposal System Form R Not for Voluntary Assessments
C
1 'r
.f
L
+� Property Address
Owner Owner's Name
Information is
Y '
a JJ
required for every
page. CitylTown state Zip Code Date of Inspection
D. System Information (cent.)
4. Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
�.
4
Shared system dyes oAo}`cif yes, attach previous inspection records, if any)
El 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 IIA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP 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? El Yes No
5. Building Sewer(locate on site plan):
,r
Depth below grade: feet -------
Material of construction:
cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: --- - ----- --_�___-
feet
ee
Comments (on condition of joints, venting, evidence of leakage, etc.):
ti..
t5irsp.dcc•rep.3 1212626 Title 5 aff,c al Inspection Form:Subsurface S&,°rage Disposal System-Page 9 of 18
9
v
Commonwealth of Massachusetts
Title 5 Official Forr�
- In Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1 `
Property Address 1
Owner Owner's Name
information is
required for every r r
Page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass El polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1 e depth:
5 Sludge
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 ❑ scu
m um to bottom of outlet tee or baffle
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.):
77T
V
...............
ti
t5insp.dac•rev.3112/2026 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 10 of 18
r Commonwealth of MassachLlSettS
T O'lle 5 Offl"c'I'al Inspection Form
it
i bsu ac sewage Disposal System Foam Not for Voluntary Assessments
x
Property Address
Owner . ,3.
Owner's Name.
information is �,l � ...n..�� zr
required for even � �,, # � ���M�a A _
page City/Town state Zip Code Date of Inspection
D. Systern Information (cont.)
7, Grease Trap (locate on site plan):
Depth below grade. feet._.
Material of construction: -
El concrete [] metal El fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: -
Scum thickness .. ....._.._�
Distance from top of scum to top of outlet tee or baffle ` •� m -
Distance from bottom of scum to bottom of outlet tee or baffle - -- -- - --- -
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc,):
S. Tight or Holding Tank (tank mUs�be pumped at time of inspection) (locate on site plan):
Depth below grade: `� ., _�..__._.._ _ ..�._...------------- --- — --
Material of construction: '
El concrete El metal `Y El fiberglass ���.�� polyethylene [] other explain}:
Dimensions:
Capacity:
gallons
Design Flow
gallons per day
t5insp.dcc-rev.3 1212026 Tale 5 Official lnspacicn Form:Subsurface Sewage Disposal System•Page 11 of 18
• s
Commonwealth of Massachusetts
7� OfficialForm
� �t
I
subsurface sewage Disposal System Form -Not for Voluntary Assessments
(C��
Property Address
Owner owner's Name
infomiation is re � � 14j,
uired for eve �'
q every
page, City/Town State Zip Cede Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cost.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? El Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan).
Depth of liquid level above outlet invert W'
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
�- -<A
t5insp.doc•rev.3:12J2025 Tide 5 official Inspection Farm:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
W' In
'tie 5 Otaft'c'al Inspect
Ti T1 I ion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
_.__._._._. -;
............ ................................. ......... .............................. ............................
Property Address _._
Owner owner's Nam�T _-
information is �
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
10. Pump Chamber (locate on site plan):
Pumpsln-working order: ❑ Yes ❑ No
Alarms in working order: �kW.m rw ❑ Yes El No*
Comments (note condition of pump chamber, condit um s 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: - -
leaching trenches number, Length: :_a _•_.-_
❑ leaching fields number, dimensions: -----
❑ overflow cesspool number:
❑ inn ovativelalternative system
Type/name of technology: ------____ ----------_m.._.-_-_ ........
t5insp.dcc rev.3 12 2_026 Me 5 Official Inspection Form:Subsurface sewage Cizposal Systern•Page 13 of i8
Commonwealth of Massachusetts
cial T Inspection or itle 5 Offi
In Subsurface Sewage Disposal System Form Not for Voluntary Assessments
V.
Property Address
Owner owner's Na e
information is
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
............ C-
................-
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number nd configuration
Depth—t of liquid to inlet invert
Depth of solids.layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, le I of ponding, condition of vegetation,
etc.):
t 5in s p.doc-rev.3/12/2026 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Ot'"T'F'I'cl"al Inspecti"on Form
Subsurface Sewage Disposal System Form m Not for Voluntary Assessments
~+ R .
. _Y ..
.A
_ _
: .. .
--y
----------- ..................
. �......... ......
Property Address
Owner owner's Name
information is ;
required for every ._. ..
pane. City To► n -- State Zip Code Date of Inspection
D, System r t (cont.)
13. Privy locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, sign�-Qf hydraulic failure, level of ponding, condition of vegetation,
etc.):
ti
l
t5insp.doc:•rev.3 12j'2026 TiJe 5 GffidaI InsMacbrn Forrn:subsurface Seviage❑isposai Systerri s Page 15 of 18
r
Commonwealth of Massachusetts
Title 5 Official Forrn
10 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner owners Name
information is �if2�
required for every _Jk_�_ L
Page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
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
D drawing attached separately
C _�,
1
a
15insp.doc•rev.3i 1212026 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
1
Commonwealth of Massachusetts
T'Itle 5 Offic'lal Inspection Form
ell
Y :? Subsurface Sewage Disposal System Form Not for Voluntary Assessments
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•`.-y " -�:. .. f r9 ...._{_........_...------I..-._ ......-----...._--__......._.._..._..-._._._.„_..__._.._..,....�.-....................__..._...._...._..._..__-......_..-......._.._-.-.-r,._-,-__..__.-...............__._................
___ Property Address
Owner �-�
Owner's Name, bL
Information isy,
re u i red for every
page. City/Town State Zip Code date of Inspection
D. System Information (cant,)
15. Site Exam:
❑ Check Slope
Surface water `
Check cellar
❑ Shallow wells
Estimated depth to high ground water: tt
Please indicate all methods used to determine the high ground water elevation:
❑ obtained from system design plans on record
If checked, date of design plan reviewed: Date --
❑ observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health- explain:
❑ Checked with local excavators, installers M (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
Al,
I-J _.
......... .................................
4
................. ..................................... ................................................................................................... ............................. ................................................
............... ...........................-----------------............. ...... ............. ...................I............ ...... ............. .............. ....... ......
Before filing this inspection Report, please see Report Completeness Checklist on next page.
t5insp.dac•rear.3 1 D202 i TIJe 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 15 Off Forrn
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owne's Name-"'_
information is - _ y �2e
required for every
page. CiWTown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspector Information: Complete all fields in this section.
B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
11 21 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
t5insp.doc•rev.3i1212026 Title 5 Official lnspecfion Form:Subsurface Sewage Disposal System•Page 18 of 18
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