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349 Septic Inspection 2015 CITY of NORTHAMPTON PUBLIC HEALTH DEPARTMENT BOARD OF HEALTH MEMBERS: Donna Sa[Ioom, Chair_Joanne Levin, MD—Suzanne Smith, MD STAFF. Merridith O'Leary,RS,Director Daniel Nos/uk Inspector Edmund Smith,Inspector—Lisa Steinhock, RN,Nurse anuary 25, 2016 f. Pasculli M9 Coles Meadow Road Vorthampton, MA 01060 Dear Homeowner: FILE COPY RE: Sewage Disposal System Inspection 349 Coles Meadow Road The Northampton Board of Health is in receipt of a report on the Subsurface Sewage Disposal System inspection conducted by Bill Sieruta at your property, 349 Coles Meadow Road, on December 24, 2015. That inspection report indicates that your subsurface sewage disposal system fails to protect the public health and the environment as defined in Section 15.303 of CMR 15.000,State Environmental Code, Title 5. Therefore,in accordance with the provisions of 310 CMR 15.000 of the State Environmental Code,Title 5, and under authority of Massachusetts General Laws,Chapter 21A,Section 13,you (or the subsequent owner of the property) are hereby ordered to repair the subsurface sewage disposal system at 349 Coles Meadow Road,within two years of the date of the original inspection,(December 24,2017). If further degradation of the sewage disposal system occurs (e.g.increased sewage flowing to the surface of the ground),you may be required to complete the repairs sooner. All work to repair/upgrade your subsurface sewage disposal system must be performed by a licensed sewage disposal system installer,in accordance with the requirements of 310 CMR 15.000,and with plans approved by the Northampton Board of Health. Please be advised that you are entitled to a hearing on this order to upgrade your subsurface sewage disposal system,provided that you file a written petition requesting such a hearing in the Board of health office within seven(7) days of the receipt of this notice. Please feel free to contact the Board of Health office,at 587-1214 if you have any questions concerning this matter. Thank you for your anticipated cooperation in this matter. Sincerely, Daniel Wasiuk Health Inspector FILE COPY 212 Main Street,Northampton,MA 01060 Ph(413)587-1214 Fax(413)587-1221 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Siwage Disposal System Form-Not for Voluntary Assessments r3 S/9 Cocks mitcs-/oo iJ ,ca4 Property Address 7; /ncs'aP c-C rner Owners Name Diadem is wired for every V a,L/wirmlo ieR., eth go. Cityyravn State portent wnen mg out forms the computer, a only the tab y to move your nor-do not e the return Y, (t iino.11/10 a/060 /ZJLv/da/r Zip Code Da 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. A. Gpnerat Information 1 Inspector: PE Zj/cc_/fn'/ cr tS,£/aer joi V6 Company Name is 4etior Ao/tf Company Address vaCrr awl-own 503 .5-Y? /B/ 7 Telephone Number /State o ss to su State Zip Code Sr la SS License Number B. Certification I certify that I have personally inspected the sewage disposal system atthis address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspectOrv, was performed based on my training and experience in the proper function and maintenanc$ofpn Site sewage disposal systems. I am a DEP approved system inspector pursuant to Section T5.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes [Fails —C Needs Further Evaluation by the Local Approving Authority Inspectors Signature t " ` Date 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. NORTHAMPTON BOARD OF HEALTH 212 MAIN STREET NORTHAMPTON, MA 01060 le 5 Oeda myMM Form euba dace smNp•elgasc'sywm•P.O.r of n Ch --*Commonwealth of Massachusetfs FeirTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments d r ? tours ti, bdaJ .0on/2 ais x every oweninTress A/�SCoCC C. Owners Name Naarw/rm AO.v H/5 Di060 ,z-/LSD/.to'r Ciy/rown. State Zip Code . . Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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: 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 O N ❑ ND(Explain below): 110.5akld Inspection Form SAp tface Sewage Disposal System.Page 2of 17 ortfltlDnwealth of Massachusetts 'title 5 Official Inspection Form ubsurface Sewage Disposal System Form•Not for Voluntary Assessments tarn Criers 'lit/sweet; /2" .(9D 'Add /49:szsCvcc v yners Name by/Town . . Stale , Zip Code Daterofl nsp on Certification (cont.) 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 ❑ Y ❑ 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: .t ❑ 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 TIM5 pedal swoon Fn Subsurface Faye Disposal system•Pig.3 a 17 \ ---Commonwealth of Massachusetts's yrTitle 5 Official Inspection-Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments >n Is !or every 10 Jdr9aZs ,ngavowa PmpeM1y Address G / ,0/7l CUcC�/ °cane t%oi4flW / Iaickt d/a60 /* t Wedogs City/Town State Zip Code , Date Inspection B. Certification (cont.) 2. System will fall unless the Board of Health(and Public Water Supplier,if any) determines that theisystem 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 weir. 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. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all Inspectionsr Yes No ❑ M ❑ ❑ ❑nog, Backup of sewage Into facility or system component due to overloaded or clogged SAS or cesspool Discharge or pdnding 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 Of WC Inpion rent Subsurface Sewage Disposal Stun Page 4 a n s N 'Cln amohwealth of Massachusett§ F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments ,gyp Co��s n��.000w Is v every 10 Property Address r/ Pee)cc L O+me?S Name �vorerr/rtrn o 44tJ Cityrrovm State B. Certification (cont.) 0/016 Sehe F ]'p Code - pate of I pection Yes No ❑ (p Required pumping more than 4 times in the last year NOT due to clogged or P 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. ❑,r2g(r1 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑/f A2 1 My portion of a cesspool or privy is within 50 feet of a private water supply well. ❑1A229 My 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 fails.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 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes'or"no"to each of the following, in addition to the questions in Section D. an 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 I I 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 upgtadathe system in accordance with 310 CMR 15.304.The system owner should contact the appropriaje regional office of the Department. Ilk 5 OCdd tuptldM Feint subsurface Sewage Disponi Splem•Page 5 al? SBRetronwealth of Massachusetts ' 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments O S Al, ',Oo.J ' /AD Property Address Owner's Name very 1Va#VW/9,Mf9/A./ o/odl� Ciryrown state Zip Code Dat nspectiort C. Checklist Check if the following have been done.You must indicate 1)es"or'no'as to each of the following: Yes No ❑ ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ X 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 104/ this inspection? % Oa Wore as built plans of the system obtained and examined? (If they were not available note as N/A) P/9/24.1#(... ,41/if q 771i-chi.i 0 }� ❑ Was the facility or dwelling inspected for signs of Sewage back up? Sr' ❑ Was the site inspected for signs of break out? ❑ ❑ Were all system components,excluding the SAS, located on site? X ❑ 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? og 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: A rr 9.ch eed ❑ Xr Existing information. For example,a plan at the Board of Health. /t..1'T441C/LIi6Ae {� Determined in the field(if any of the failure criteria related to Part C is at issue /fJr/v/OTTa- ^^' ❑ approximation of distance is unacceptable)[310 CMR 15.302(5)1 P/N✓ d/i7hR/,.VC(� 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): flea a,flan K.s..wp.Dgaal s`d.n•P g.6 a 17 fro CdittmonWealth of Massachusetts iTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 57? Coz- 5 MalDasc) jW$ Z7 Property Address ery Owner's Name �tl0/Uhfin,o /ON $14 >zzf/ �BrS ciryrtown State Zip Code Date D Inspe on D. System Information Description: Z Number of current residents: • Does residence have a garbage grinder? ❑ Yes ljr No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes No Laundry system inspected? g'Yes ,❑y No yr Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes CY No Last date of occupancy: Date Commercialllndustrial Flow Conditions: A AI n Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes [] No Non-sanitary waste discharged to the Title 5 system? ❑ Yes fl No Water meter readings;if available: TII 5 QIdI ace 6WMe 015WW Systwi,Pep 7 Mn \ tammonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments in is or every ID Property Addres_, Owners Name VoflfAvm-r on/ M.v /2-211 8a.s- City/Town State Zip Code , pate of Inspection D. System Information (cont.) Last date of occupancy/use: Other(describe below): Date General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes,volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: /C/ZG/✓/ O 4_1 .%Z . ,ry Yes ❑. No ✓ao gallons M.EI3SVnit%J /uapgcn6 4i E /794v/t..w_ta/s /.va Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(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 I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. Other(describe): TIM S omaa :S •DIP] ynvn.Pag,e or n ,.Commonwealth of Massachusetts el= II mation Is 'red for every Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �y9 eot.E$ M29pozr) A 0 Property Address f' PA-sco CC... L Owner's Name A earninii- ObU /Yi9 <xisf/ ,O/6 City/rown State Zip Code Date of pealon D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: Were sewage odors detected when arriving at the site? Building Sewer(locate on site plan): Depth below grade: Material of construction: ❑cast Iron ARO PVC ❑other(explain) Distance from private water supply well or suction line: ❑ Yes No s feet pv,6ac Neel feet MOUT £oflZY Comments(on condition of joints,venting,evidence of leakage,etc.): A/0 II co 4A4.1 ,voZoo' Septic Tank(locate on site plan): Depth below grade: Material of construction: 'concrete ❑ metal / " feet ❑fiberglass ❑ polyethylene ❑other(explain) ArA9 at 2 oon,/p*tr/ogicvr /nmv/e. /p', orC ' t4a re9 Piaui G..r. Jut r7-1 F,Lrrcl2 u'vi r If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) g Yes ❑ No Dimensions: '96"`/eui LJM Jtd $ X4-e .v Sludge depth: •11110 nbs Official Fw.tlon fwm eubsarfaes sewage Disposal system•Pape 9 of 17 I --Commonwealth of Massachusetts Title 5S Official Inspection Form Subsurface SewageDisposal System Form Not for Voluntary Assessments (3 99 & s M 40-na&/ n-O Property Address r fin CU L. n Owner's Name Ls - _ / .. . .• . L �. t I n • [� v every 10 City/Town - State Zip Code , Rate of Inspection D. System Information (cont.) Septic Tank(cant) /• 2 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 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.): '• 9,• Z C`O/a-//- u �t1ina•Ac KttOLIO aclio4/ /ti'n 3&A-o.o 5' gLUwr /V L7/hop con-' 7- W.S' /4 0A-PVC- /7v714 T 77r • /JtS )-Z r"C// o» Rya c" �s Et-r€4l2i--rife 7z, ,'// ( N nie sTr'3€ /2E76 /.0 TZ /5 /5 070,5'/'C/. /A/er,,7- 70,5'/'C/. /21er,r G/,(1 70 /3.c /vorizey ,cr✓ Grease Trap(locate on site plan): piing Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): feet Dimensions: Scum thickness Distance from top of scum to top of outlet tee or bathe Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date TNS Official Irlp.dO Fam%subwrtxa Sewage Disposal System.Page 10 N n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,7V? &'L S /-T,e aeci ,p&,Q/J Property Address ,7: /PAL C ,LC. very Ownels Name 02TN ? 4//V A# o/Oed /z/ /4045— City/Town State Zip Code Qatg of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outletinvert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: p.0.4 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 0 No nos 6 otrwiai 4a0araM FmnagMgdace SCwege oLpo. System•P49x11 pit1 `•etommonwealth of Massachusetts F Titl3) e 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address /�/ �"7/7_6-/ CU ! / .�/ / /� OwnerBNameNoee,/ // , /C�.of NA 0/CMO / /t.3/i20/3 in 16 or every City/Town State Zip Code , bete of Inspection D. System Information (cont.) 10 Distribution Box(if present must be opened)(locate on site plan): ,SOX / /y �' g Depth of liquid level above outlet invert 5 COni� 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.): ,g 0X /S ///F/Z y , 1c.Z° — O?Ca C COa_e Lv/9S /2.:/floc/ r10 u0040 L ,g1// Z_ 205 Ov/2 TOP Ox- coateZ • Pump Chamber(locate on site plan):Aen, / Pumps in working order: Alarms in working order. ❑ Yes ❑ Yes ❑ No ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Solt Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: All ,0'Q7 C J9 c/ D /_ / ./-7 Ne B PIJS In.ecSn Fmn sWU„Haa swap.Dsoc S SyWn•Pape 12 d 17 �--��- Commonwealth of Massachusetts j Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 5/9 rOOE s 44 E4,00 cdJ ,e-.0 Title 5 Official Inspection Form Property Address T Pfd cvcGc ner Owners Name ,{ yy y y /V02rn/9A-!,l/6•L/ ,a/ • 0/,deb it/°G `V %427,5—Arad for every relation is e. Ciry/rowu State Zip Code. _ Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): /200 is z Gg 6,0 /t; 173L ,r-/➢-/L 4,44 A 'O egt/OC C/F/L D/2-4r., 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 ❑ Yes ❑ No m.5 ord9 Inspection Form:Subsurface Sewage moose System.Page v oily ier matron Is fired for every 4•unp Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments an cots A-irefecayAW Property Address owners Name 4.102.77 n-ni Q 46•c/ /414 p/Oo 6 /T'2 City/Town State Zip Code, - Date of Insp on D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on stte plan) Materials of construction: Dimensions p fug Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): m s apes rtsa 5,w .q.po Sysbm•P1,9814 alf1 Owner Owners Name information is Page. required every City/Town /V/Ol n , �� V l'/ 'iV O /e/ y/i"0/J- State Zip Code Date of Inspection Commonwealth of Massachusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �":/ 7 cots it -.004t) Property Address SGticcc D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a New 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: Ohand-sketch in the area below COi'£ 5 r/.f�'E0 IL/drawing attached separately /600 Lc/ rH F l/ / # 3 y9 v.,econ_oody 4../0 ./J/s/0 / R D 2cM z5/ /' A5 sr,/ cr r>cs 70 65-4/+J7 C (S%/r'qq/7( 7794/k AC 244 7 5a /S+ / D/$r e6X /9-O AD 35; o SD z/, O ' TM.s Cadet dace SwsW G.WW SW1ani Pa;.15 d 17 ommBnweaith of Massachusetts jTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 3449 Coet.ss /J,�i><47ou) 4/2 Property Address P/Jj CO CC c- Owner's Name y— ,¢ ition for is /l,Q/2/h///j19,2%'Cl M.n a/066 /z/ct v�o�r4 - Cltylrown State Zip Code - Oats of Inspection 11110 D. System Information (cont.) Site Exam: 18' Check Slope 18C Surface water Check cellar ❑ Shallow wells Estimated depth to high ground water. 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/observation hole 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: 695A4-> /S "C./ /t/a/LU2E leE,cfgCE-644.494..// 4P- 1-6f9-04 .c/ac .0 1/E_E_WE/J p/flu M, t4W€c'tJ6 (92004/) Before filing this Inspection Report, please see Report Completeness Checklist on next page. nr.s Official wWNm Fom[subsurface swage Disposal system•Pape 1e an wner formation Is quired for every u•mio Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 9 Cocos .q.eAtootu ,�z.a Property Address . � ,o/9SC !/ CCO iVa6217/441/"/w H4 0fo60 /z/zy�eo IC Cityffown State Zip Code - Date of Inspection E. Report Completeness Checklist Inspection Summary:A, 8, C, D,or E checked 4j Inspection Summary D(System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater y Sketch of Sewage Disposal System either drawn on page 15 orattached in separate file TM 5 OI'dd YU ,Fwm 6dunw Sswge MPG'S System.Page 17 a 1 -5 x3vitr ar7ES 5.61P)67C MN/C- . nc Sc /5-,6 ' Disr- aLs-,0 Nous eepuc 13.131S (See Notes) Existing 4 BR lice= #349 B i'1001)! w 1500 Gallon Septic Tank (See Notes) Conc. Slab 98 Diii )GPD/BR x 4 BR=440.GPD inch(Tested @ 24 min/inch) x24'= 1200 Sq. Ft 10 Sq.Ft. x 0.4 GPD/Sq. Ft=480 GPD 96 — 94 92