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508 Title 5 10-18-17 • ETR Report1025171155 Datee : 10/25/2017 Laboratories P.O.Number: 10/25/17 Visa Enviranment lT..thlaand Research LabonwN.inc. Mettle: Drinking Water Homestead, Inc 1664 Cape Street o c Paul Zawdlick Williamsburg, MA 01096- lintels_ 508 Sylvester Road Location(Florence MA 01062 Phone (413)628-4533 This sample taken by TSL at 11:00:00 AM on 14fe4f[u I f. . rulm ul CUM:Uuuu. isiumen Analytes Results Description Mass DEP Limits Bacteria Total Coliform Absent Indicates Presence of Harmful Bacteria 0 Mineral Chemistry Nitrate as Nitrogen 0.66 mg/L Indicator of Biological Waste 6.0 mg/L Ammonia as Nitrogen Not Detected Indicator of Waste No Limit I Thcimnt ey of the and uftThe Scott cm quakyofs.'WIIng. mum WN arnOXLIPSonly to MeOXLIPSlmeem . Eead annuual TcMue aa.uedl LLuurvdsYun be hdA I morass fon any Ii.GEly anei,g out of of the use of suoh , ill Analyses weremWuapl In accordance with hLaden eusens Dcpvery mm of Protection wmw ion liflesMVL,. 60 Elm Hill Ave. Leominster MA 01453-4864 (978)840-2941 (800)344-9977 Infoggetrlabs.com www.etrlabs.cam Page 1 of 1 COMMENTS: Recommend pumping on a 3 to 5 year schedule. Also, a copy of this plan posted in the basement/utility area would keep this information accessible in future years for maintenance. Partial House Outline Well, reported location I1 1p0tdi 11111 NORTH Septic Tank h NN N bet \\ Leach Tank o � o � �� ---� - Date: Owner: As-Built Drawing HOMESTEAD INC. Existing Septic System 10/18/2017 Paul Zawalick Thomas S. Leue R.S. Scale: 1 : 20' Revision Date: 508 Sylvester Road / - 1664 Cape St. Williamsburg,MA 01096 ` Except as Noted Florence MA 01062 iStao �► / 1413]628-4533 Commonwealth of Massachusetts � Gl Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -F7-142 .? 508 Sylvester Road Property Address -- - - - - - Owner Paul Zawalick Owne information is Owner's Name required for Florence MA 01062 10/18/2017 every page. aty/Town State Zip Code Date of Inspection Before filing this Inspection Report,please see Report Completeness Checklist on next page. E. Report Completeness Checklist Z Inspection Summary: A, B, C, D, or E checked Z1 Inspection Summary D(System Failure Criteria Applicable to All Systems)completed System Information-Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file iems•a•a-a leipsenmdw,ypmi.airnnsws„ s..®y.aeimini'srierk-neemmn Commonwealth of Massachusetts 1� ` � 'yr Title 5 Official Inspection Form -`�- tl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I�— '?:,. —if/ 508 Sylvester Road Property Address --_ _— ---_ --__ owner Paul Zawalick information is Owner's Name required for every pace. Florence _ MA 01062 10/18/2017 Clty/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope L'r Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water 10w— — - -- -— feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record W d edced,date of design pQan 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: Pere test to 10 feet below grade found no groundwater. Ltis•ravage TM S Official auption Form:SubsuMro Sewage Disposal System Page 16 of 17 Commonwealth of Massachusetts • 5 ` ,f Title 5 Official Inspection Form 111_ ; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •�''� , <` 508 Sylvester Road Property Address owner Paul Zawalick mformelion is Owners Name required for Florence MA _ 01062 10/18/2017 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: hand-sketch in the area below ® drawing attached separately Sia.rev&/16 Th.5 Official Inspection Form'.Subsurface s.wage Disposal system.Page 15 o1 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -tl= 7-04. 508 Sylvester Road Property Address owner Paul Zawalick information is Owner's Name required for Florence MA 01062 10/18/2017 every page City/Town 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.): Privy Ware on site pern): Materials of construction: — Dimensions Depot ad scads Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ms•rev&l6 Tib 5groal Impaction Form:Subsurface Sewage Disposal System.Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ki --r'- a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7,o41 508 Sylvester Road Property Address - _—.-- -. owner Paul Zawalick _ Owner's Name - - –requiredfor every page. Florence _ MA 01062 10/18/2017 City/Town State / ... _. Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: - . leaching chambers number: owe ❑ leaching galleries number: - - ❑ leaching trenches number, length: -- ❑Y' Lcidrnny flee% number, dimensions: ❑ overflow cesspool number: --- --- ❑ innovative/altemative system Vypeets:se o6 y. Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No smatalcs (rrotraexs seem_ craaarMea is 24" below scads- 27" dela inside dimension. Dry to the base. Nominal 10' x 15' size with associated gravel. Cesspool's QcesspoM'ohsst be pamper(as part of inspetterb Vacate on see plan): Number and configuration Depth—top of liquid to inlet invert Depth of solicit layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 6M.rev alb Tnk 5 Official Inpcbon Form.subsurface Sewage Dural system.Peg.13 N 17 Commonwealth of Massachusetts yt Title 5 Official Inspection Form ri Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 508 Sylvester Road Property Address Paul Zawalick Owner information is Owner's Name -- _- required for Florence MA 01062 10/18/2017 every page. ___._.. CityRovm State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert None in system Cohered is(nape W@tox vs Pewee and dedltxXion Vo datleas eque4, any evidence of solids carryover, any evidence of leakage into or out of box, et): Ptmtp Chamber(hbcae on die sang Pumps in working order: ❑Yes❑ No* Alarms in working order: ❑Yes❑ No' Conmveras Quare conaco of pump Chamber, coc d idonv of pumps and appulenavices, etc.): • W p&wvtps or aams are col le wonting wdler, system is a sordid a,W,'pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Lna rev.6/16 Title 5 Official Inspection Form.Subsurface Sewage Disposal Syalem•Page 12 of 17 Commonwealth of Massachusetts ft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -,1 f 4 508 Sylvester Road Property Address owner Paul Zawalick information is Owner's Name - -- - -- - required for every page. Florence MA 01062 _ 10/18/2017 _ City/Town State Zip Code Date of Inspection 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.): Toogkeev86a6togTask be pawed at lees : Depth below grade: Material of construction: ❑.b O,� (e other (explain): Dimensions: Capeakt. gallons Design Flow: gallons per day - Alarm present: ❑ Yes ❑ No AlaVeve't _ — -. _ Alarm iii working ordler- n. Yes Alarm ❑ No Date of last pumping: para Comments(condition of alarm and float switches, etc): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Dina rev G16 Til sOfficial Inspection Form:subsumes sewage Disposal system.Page 11o 17 Commonwealth of Massachusetts 15 `t Title 5 Official Inspection Form E _'- ■ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,. 508 Sylvester Road Property Address --- -..- _ owner Paul Zawalick information is Owner's Namerequired for every pace. Florence MA 01062 10/18/2017 Ci /Town - - -' H State Zip zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30^ Scum thickness62m _ Distance from top of scum to top of outlet tee or baffle - - — Distance from bottom of scum to bottom of outlet tee or baffle 18^ - - _ -- How were dimensions determined? ca3lParteC - - Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Cement tank, anent 2524 eyafows. P6^ tafl riser over center access. Grease Trap(locate on site plan): Depth below grade: fee1.._ Material of construction: Elconcrete ❑metal El fiberglass ❑polyethylene other Qen): 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 -- - Aare of lasd2mrmpirg,"- e:mmvdre nM sOfficial Inspection Form:Subsists°.Sewage Disposal swam.Page 10 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form ='1 @ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •">. 508 Sylvester Road Properly Address Winer Paul Zawalick information is Owner's Name required for Florence MA 01062 10/18/2017 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 7/27/1993 system design. _ Were sewage odors detected when arriving at the site? [Yes No Building Sewer(locate on site plan): 3 average Depth below grade: feet -- - _- -- Makev ec cew.s5°tsdtvr:: ®cast iron ®40 PVC ®other(explain): ABS plastic Distance from private water supply well or suction line: 28 feet Comments cal cm:5A ac en:evroeclLeakage,est.?. No problems seen. Measurement is between sewer outlet and water inlet in the basement. Septic Van*pore*o:eee*eV: 2.8 average Depth below grade: feet -- Material of construction: 'may'concrete ❑ ❑tyb mete/ erg4ass `u ponraptNfer>e rl (explain) Concrete about 1500 gallons. if tank is metaV, tst age: - - - -- years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 58" wide, 122" long, 58" tall Sludge depth: 4" • 6/s6 TNe 5Cffcil Inspection Fam'.Subsurface Sewage.Disposal rwm•Peaea of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -r1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ff. --Orr 508 Sylvester Road Property Address -..-. owner Paul Zawalick information is Owner's Name required tor Florence MA 01062 10/18/2017_ _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: -- - ---- Date Other(describe below): General Information Pumping wecantt: Source of information: El Last pumped 7/26/2011 Was system pumped as part of the inspection? ❑Yes No T yes,vdkaae pumped: gallons _--- How was quantity pumped determined? _ Reason for pumping: Type of System: • Septic tank, distributientbox, soil absorption system ❑ Single cesspool • Overftw cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Ynnovative/Attemative 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. Ll Other(describe): Mins revG16 The 5 Oficial Inspection Form:subsurface sewage Papoal system.Pape a of 17 Commonwealth of Massachusetts .9 et Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • '''':-Core 508 Sylvester Road Property Address --_ owner Paul Zawalick thformafon is owners Name required for every pace. Florence MA 01062 10/18/2017 City/Town State Zip Code Dale of Inspection D. System Information Description: 1500-gallon septic tank and a leaching tank. Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes LSI information in this report.) No Laundry system inspected? L�- Yes No Seasonal use? I] Yes No Water meter readings, if available(last 2 years usage(gpd)): -- -- @Zell". Unmetered private well Sump pump? ❑ Yes No Last date of occupancy: �' aze `Lens yeas siame u'Tetact Date — Commercial/Industrial Flow Conditions: Type of Establishment: DeslignElbe:e ased'as 3VDCWOR?5' y' Ga0ons per OaY(gpd) - - - Basis of design flow(seats/persons/sq.ft., etc.): - - --- - Grease trap present? Ili Yes ❑ No indjstnai waste'ivcadi tg tan*presenT? n. Yes ❑. No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings, if available: --- -- --.. tains.r..8•16 .me 5 Official Inspection conn:Subsurface s...ye ammai System•Page 7a 17 Commonwealth of Massachusetts ;1/4._ j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 508 Sylvester Road Property Address Owner Paul 2awalick Owner's Name - -- information is - required for Florence MA 01062 10/18/2017 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No N ❑ t‘a' u corzt;or•was wonted by cower,oxupat, Cr Board?of Health ❑ N Were any of the system components pumped out in the previous two weeks? ❑ 4 Has the system received normal flows in the previous two-week period? Ante large Skews°V water Crewe"KSC9tuaat to Ike 3p/el,rc-txxA}ty'GP as E ® part of this inspection? ❑ ❑ Were as-built plans of the system obtained and examined?(If they were not available note as N/A) N/A N ❑ Was the facility or dwelling inspected for signs of sewage back up? Li i Wwas die site inspected for signs'7/Credit out? N ❑ Were all system components, excluding the SAS, located on site? M ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of emrstauctiork.tea,iffiegitragritruid,depffs5ait sr/Adige alktsieept scum? N ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage The size and location of the Soil Absorption System (SAS)on the site has been determined based on: M Li EXnfn g information. For example, a pian at the Board of Health. N ❑ 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)] D. System htfotmatiott Residential Flow Conditions: Number of bedrooms 3 Number of bedrooms(actual): 3 (design): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x It of bedrooms): 525 Efts•reek/16 See 501fcial lnspacton Ferns Submrac.Sewage LYfyulSystem•Page 60117 Commonwealth of Massachusetts rn -;� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •�': .e. 508. Sylvester Road Property Address owner Paul Zawalick information is Owner's Name required for Florence MA 01062 10/18/2017 every page. _..._._ — City/Town State Zip Code Date of Inspection 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 SAS, cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form]. ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-10,000 gpd. ❑ ® The system fails.l 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 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. 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—IWPA)or a mm{Ipcd Zone II of a 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 upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Ens•rev6.16 Title 5 OM®l Inspection Fon,:Subsurface Sewage Disposal System•Page 5 of 17 1 Commonwealth of Massachusetts G =� Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16e.-ery 508 Sylvester Road Properly Address — _-- — - Owner Paul Zawalick information h Owners Namerequired for every page. Florence 010 _ 10/18/2017 State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail 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: 0 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. El The system Vias a septic tank and SAS and the SAS S Voss Yvan 500 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. tyd'ter. 0) System Farm LYtievra AppiScabile to AW Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No 0 __ 8.eck&of sewage into tacky or system owygorrend due to owasioaded 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 ® is� t�epthY dayf lsf bang'fiebee O anetiante e I 5n:.rev G1e Title 5015da1 Inapecton Fawn Subsume Sewage Disposal System-Page 4 M,1 Commonwealth of Massachusetts el Title 5 Official Inspection Form _ —`r= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ., . �^ — 508 Sylvester Road Property Address _ —--- owner Paul Zawalick _ information is Owner's Name required for every page. Florence _ MA 01062 10/18/2017 City/Town Slate Zip Code Date of Inspection B. 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 Waikato,ohistracitat pcifperist grape em akoken,sedataracoteeetodis :bad dome. SysN.uowith 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 [3Y ®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 ON ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further EvaQuatott is RegrnredRy tete Board ot Vilm09t: ❑ 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, safely 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 him•nv6/18 The 5 ofichl Inspection Form Subsurface Sewage Disposal System•Page 3 S 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form -r'_ l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u- a 4 508 Sylvester Road -_ - Property Address Dimer Paul Zawalick _ information is Owner's Name '- -- - -- required for Florence MA 01062 10/18/2017 every page. _ City/Town 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: ?'have not found any information that indicates that any of the faWWrre arteria desu bS in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Commec*s: Wen water test resePts attached. B) System Condi6vnajy Passes: 0 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., "aro"or"mot dertertmared"Rx,N1.N1DD ref the Woking sem.-erns root 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 •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): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 15im.m6/1e The 50Mcial Impaction Form:Subsurface Sewage Dispteal System•Papa]of 17 14 Commonwealth of Massachusetts Title 5 Official Inspection Form --�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P. 508 Sylves ter Road Properly Address --- owner Paul Zawalick infommfion is Owner's Name required for every page. Florence MA 01062 10/18/2017 _ City/Town State Zip Code Date of Inspection *specificity cestits must be subThlied on Oris form.inspection Terms may not be aatered in any way. Please see completeness checklist at the end of the form. Important: A. General Information Wien filling out forms on the computer,use 1 Ay tor only the nab key to move your Thomas S. Leue cursor-do not use the returnName of Inspector -- '- -- - — key. Homestead Engineering Inc. Company Name (�I 1664 Cape. St. Company Addles - -_ Dm" YO Williamsburg _ MA State 01096 '• Ciy/TownZip Code 413-628-4533 SI-130 Telephone Number Nu P License Number B. Certification I 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 deposal systems.p an a DEP approved systema daspecsor pwsmarA to Section f5.340 ad Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority y.� October 27, 2017 Inspeacr s a nmur 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 onginail should be sem 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•rw&'16 Title 5 Official Inspection Form:Subsurface Sevapa Disposal System•Peg I of 17