501 Septic Inspection Form 2016 M Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
(571 h%.Finl .oau) izonO
Propedy Address
/ZC /g/v122O t
wner Owners Name�f -i y� r��1// 'I
formation is itio /t/7%�fl �4/
age.ed for every
age. City/Town
ei/Dio 3-A 4.416/G
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.
nportant:Wne0 A. General Information
ling out fors
the computer. /19E- lo/ ti
:e only the tab 1, Inspector
so do o G��//L(.//Sj'q (rV t Ste/ter-7i
SL /0 -5-
mnur
Se the return Name of Inspector
ty_ 6'/tvzeiYrg ar/Ga.r//EerciatiG
Company Name
/8 D/5//or R6A1-4
Company Address
L,c-1//F/Z0 T- 0/65
City/Town v/ a ivy /U/ 7 State /0r5
Telephone Number License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection,
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title�5(310 CMR 15.000).The system:
Jy Passes
❑ Needs Fu
❑ Conditionally Passes
aluati�y the Loc Approving Authority
'r/4LIO/ G
ectors Signature
❑ Fails
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 is a shared system or
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 DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
"°"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.
Sins.II/10 Tine 5O fide Inspec on Fom:Subsurface Sewage nispossl System.Paget of l>
vmer
formation is
veered for every
eve.iv10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
szv Cock's ry M l". 2 iO4) . ./2
Property Addrg niuto/GE/ s
Owners Name
City/To
B. Certification (cont.)
A/// D/UUD ,s//' /da/e
State Zip Code Data of Ins ection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
X 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:
No p2�AG.CJ&5 e� D.
53/4nE114 /5 wa//1e-//c/6 tee//
/ OJL
27ren-rS TD (02fcr
B) 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 explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced 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 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
TIy 5 0I9d bassi:Win Fours SUCSUeb Sewepe DSpwc System•Page 2 of Il
"'Commonwealth of Massachusetts
•
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
c D/ CO cc /1-4 a 070 e 120
Properly Addresso „ , / -Z-' A /J L
3ation is
iVOrcJM'9�1 /641 HA D/OGO 5��411.047
d br every
Gryrtown' • State Zip Code • Date of Insp coon
B. Certification (cont.)
I1110
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced O Y E I N ❑ ND (Explain below):
•
•
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box Is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times 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
❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation Is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines In accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ 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
Tile 5 OIdS Wpdion Fenn subsurface Sewage NapoW System.Papa J S 17
Q Commonwealth of Massachusetts
Title 5 Official Inspection-Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
5 / Cotig Ai S.0 ,&'A4
mor Property Addresse 41C-'1i.eCO$t, 2 /
owaera rvafne /%%/ Oita iJ`� �o9i"
or aeon Is 206•277,71$1/J ee££
.9e for every Cltyrtavm. / Slate Zip Code pate of Imp lion
ye
B. Certification (cont.)
2. System will fall unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning In a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has-a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
15m. 11110
"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.
3. Other:
0) System Failure Criteria Applicable to All Systems:
You must Indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ yy
❑ X
❑PALA
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
due to an overloaded or clogged SAS or cesspool
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'/,day flow
Tile 5 Maki inspection Forms Subsurface Sewage Disposal mum.Pegs 4 of 17
"'- Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Cots r /Wapiti ,PD
PropeM Address
eat ,F.UD.GII.s'
n Sur,Hama m'i G/DUa �r o/de//
umallon is � ��/ �/�,�r
'ed far every �D �� - -
stale Zip Code Date of Inspection
ins.111c
City/Town .
B. Certification (cont.)
Yes No
❑ ❑
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:_
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy Is within 100 feet of a surface water supply or
tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
My 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 DEP certified
laboratory,for fecal conform 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 2000gpd-
10,000gpd.
❑ ❑ 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.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,00000 gpd to 15,000 gpd.
For large systems,o must indicate either yes or no to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply.
❑ ❑
❑ ❑
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—I W PA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" In Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgGade.the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
nY s OilIcki u1 W trim FOUR:Subsurface Savage Dispoul strum•Pegs 5 of 11
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`^Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ation e
td for every
II/1Q
L5 / Cot/E S /fi-/E/140k) ,CL)
Propertyy Address
C•412-4. AA .01W J
oW ae1.40/277W#n-1 /r' u MM a/0 GO t5Ain/jG/S
State Zip Code Date of Inspection
ciryRovm
C. Checklist
Check if the following have been done.You must indicate"yes'or"no"as to each of the following:
Yes No
)lX XXX o a o 14
❑ 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?
Ip Have large volumes of water been Introduced to the system recently or as part of
1°l 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?
gWas the facility owner(and occupants if different from owner)provided with
A' ❑ 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:
❑ Existing information. For example,a plan at the Board of Health.
r/ ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
isl approximation of distance Is unacceptable)[310 CMR 15.302(5)]
D. System Information
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):
fre
�96
1114 5 Official he Fun[SuGWp Swago Disposal Syst.m•Page s of 11
pion is
d for every
11110
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
Orel! CI)Idet,S ,144 y,964.1 ,0
Property Address
Owneis Name
140il— wrnz1,t9
City/Town
D. System Information
Description:
,-a 0,066 ,61/0 /#0/4
State Zip Code Date of Ifispection
Number of current residents:
•
Does residence have a garbage grinder? ❑ Yes No
t
Is laundry on a separate sewage system?[if yes separate inspection required) ❑ Yes w, No
Laundry system inspected? , Yes r❑y No
y�
Seasonal use? ❑ Yes No
Water meter readings, if available(last 2 years usage(gpd)):
Detail: ,'I p ) AA <14.01/191-"C ui 4L)
GLLrGLiL� r//���
Sump pump?
Last date of occupancy: y}
Commercial/Industrial Flow Conditions: 0 N/7
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/Wt.,etc.):
Grease trap present?
Industrial waste holding tank present?
Non-sanitary waste discharged to the Tide 5 system?
Water meter readings;if available:
❑ Yes ❑ No
Date
Gallons per day(gpd)
nn.
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes El No
5 on Pepxtlon Form:Subwlvra$eWego Disposal system.Pave 7 or n
umation is
uired for every
vas•11)10
Commonwealth of Massachusbtts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
vim/ 0266-5 / l4ti4Prnx) .tO
Property Address
eivu 4t'aQ05
Owners Name
�(b -T-P1t' a ita o/OGD S /e%ai
State Zip Code Date of In pection
City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below):
Date
General Information
Pumping Records: UuJIJ 4225
Source of information:
Was system pumped as part of the inspection? f it es ❑ No
jCP 0
gallons
/S7 0 /Lf/C-f£Pico/J
,'t'S7€1-4? 0 F Cefl'/ C-
If yes,volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank,distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)Of 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 I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
The S Orndel inspection
brurtaw Swage wsWSal Syelem•Pape 11 el t]
-� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
S01 CO < MaflDo c) 20
Property Address
Cri ru thuo/L D-S"
Owner Owner's Name y. /y y�o , / ,/�J /�)/,{//, V4/0,440/
required for every
page. City/Town Stale Zip Code Date of n
D. System Information (cont.)
Approximate age of all components,date installed (if known)and source of information:
151ns'tub
Were sewage odors detected when arriving at the site?
Building Sewer(locate on site plan):
Depth below grade:
Material of construction:
❑cast iron a0 PVC ❑other(explain).
Distance from private water supply well or suction line:
❑ Yes IS No
1/4.76 '/ •
feet
//O •
feet
Comments (on condition of joints,venting,evidence of leakage, etc.):
ti o/7/-46 le/ad s• //On_/9
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
I,
zy-
feet
gi concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain)
A/at/ /saci GAL, 0.92,4c 1-77,u/C
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) , Yes ❑
Dimensions: 4105 F/OW Dice /6 '4. V 6-'
Sludge depth:
it"
N
4o/4
TN.5 mid Inapecolon Form:subsurface sewage aepwed system.Pepe 9 of n
Commonwealth of Massachosbtts , y
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,f& /,ohs MeenaaAJ- xa44
Property Address
r -.4t /4-,v0/z!S
Mar pwn rs Name
Drmatifore 11Q n/� AI r1,4 ni060 /d 0/ '
Dwred for every n . /"r
ga City/Town State Zip Code Date of nspectlon
D. System Information (cont.)
nm•11110
Septic Tank(cont.) re
Distance from top of sludge to bottom of outlet tee or baffle
22-
3‘
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
y �S
How were dimensions determined? /� U��
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
m79-,UL /d/ ( 'oz' C0440/ /70.0
— /evAl6Unt O!= Qpce — yrosci4J 5WU/245
CO A-Inc-ne-W.C4
Grease Trap(locate on site plan): .l%iv /9
Depth below grade:
Material of construction:
feet
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
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
Date of last pumping:
Date
me s omds lrsp.Clen roan su[Wmro sewage Disposal system.F.ge 10 at 17
"Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
(SD/ LOGS S /lank c)
Property Address
CM,/ ' /y,l>a°S
r Owners Name
adonis Po/2776 I/9 /0 K/ /VA o/o4O ,c/i4/ a/ 0
ed for every
City/Town i State Zip Code Date oft pedion
D. System Information (cont.)
•
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
QAl/
Depth below grade:
Material of construction:
❑concrete
❑ metal ❑fiberglass ❑polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
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? ❑ Yes ❑ No
11155 piptltl impeder Form:Sup5udam S.w•G•DLsposal Strum'P .I1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
ai 6'06•C M"En"ak) ,eA
Property Address
r�4/z-Cu ' 4W, -0S
A/
vner Owner's Name /
ormauonis / Ja it r7/A n�A ALA o/d46 s�/(� 2o/
auired fer every 'I �Z-J /T /" ��/ !!!
go. ClryRown. State Zip Code Date of l section
D. System Information (cont.)
Distribution Box Of present must be opened)(locate on site plan):•
e
Depth of liquid level above outlet invert
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.):
en.IIIIU
Ar a A Zek t is ,va 4,41
eo,r /4/ 14oa CC-On/77d 4/
Pump Chamber(locate on site plan):
Pumps in working order: p. Yes 0 No
Alarms In working order: X Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
No Meo2MT01r a,fl7
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
N.5 Official Inspoclion Fomr subWnace sa'np.Dklw=V Sys Pepe 12 of 17
Commonwealth of Massaclivaetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t✓Z� r6lIrES M tad e4.2 z
Property Address
rA - /rvo/io r
+ner Owners Name ,,C _ / �/ ,} �{ /r
ennation is 1`e a4 t-iA a44t (/ �4/do,3-
Ivired for every
ge.
City/Town • State Zip Code . Date of Ins allon
D. System Information (cont.)
Type:
❑ leaching pits
number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
leaching fields
S fllto_ev/ t Q number,dimensions.
❑ overflow cesspool number:
❑ innovative/altemative system
20 xVS'
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of pending, damp soil, condition of
vegetation, etc.):
/fro Pk g tt/v2 .(io7,O
E6 /t l757-noxJ rd.UT/2 OG /3 lU€.cc otO
/14ow/.fit n, /9iu_/l ,S//DUtD J3�
/+ �/s-/Nib/4_
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
ms.11110
p /v4
❑ Yes ❑ No
Ills S°RdS wp.don ram:euNwaoe Sewage Disposal System'Papa u of 17
Commonwealth of Massachueettsl
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
1W C cot4 /11/ff//6a .) Q0
Property Address n 4 �C n r
CA/ Lt- /T �J
xner Owners Name
formation is /J 771/, 1, .v wig of/06e
quired for every ;tin
"
Cltyrtown, State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
0
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.):
d9 uuoWOO Pant swsunau srwWe DLaPOSa System.Page 14 of n
Owner Owners Name
formation IS
� v —������ /
squired tor every /(� /'fin Zip r//� �G/4
gaga. City own State Zip Cade Date of Ins action
D System Information (cont.)
Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system, including ties to
at least two perrnanentreference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
c.50 Cods /1-1 -41,00 ,tO
Property Address
C✓t# f i1-AJ.o, 2S
3B
An ak.
/000 4-91()Ai
stsevic ink
4-C ZS•o
3c 21. 6
/9/) n
60 56-
tyro/./-/ <rizzi the f
20' t Sib
apes 011dM ispedj Yam:OUGUdaz seaway Moose System..Page.15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
3-0/ rcoe6s / 0 E g vocJ >2-64O
Property Address � �� s"
Owner's Name ti /44 Dmeo �//b/ao/G
nania A/O/2fl//Q' ,O/O
1te,een
City/Town 4 State Zip coos Date of peceon
D. System Information (cont.)
u10
Site Exam:
Check Slope
XSurface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water:
/t/e c 2/,/s,",a ty/s7k-,
c,t/yi.iv/d-L Arc
t�"cpila ✓n/;-r/ Au
feet
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/observationhole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators,Installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation: /
�n,2Z.. OV 1/J/2 /5E4 rys/E#c1
404-124 Oi= /f!;//k../1 /L LO2.D.5
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
MI6 s Meal Inspection Fume Subsurf ace Sewage Disposal System•Pape 16 of n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
so/ cal•c 5 14,471&00 20
Property Address
(',. tt ,9-7&6, 6S
rnlGra Owner's Name
110ns �i/6/277719h9k1AJ ti/4 O/O60 5//b40 /o
;aired for every
3e. Cirylrwm , slate Zip Code Date of Inspection
E. Report Completeness Checklist
nspection Summary:A, B, C, D, or E checked
nspection Summary D(System Failure Criteria Applicable to All Systems)completed
°System formation—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or-attached in separate the
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