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255 Title 5 2018 Commonwealth of Massachusetts g Title 5 Official Inspection Form iv Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t1/4,...„) mss Cly G.E5 //e/ll3o cti lJ) Property Address L e Owner /-3/1P PniF A Owners Name information is -- requvedforevery NO 2rH/Ytl n MA 0/060 p /., y page. City/Town - V/fection p 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 p A. Inspector Information filling out forms on the computer, use only the tab � /[. /O/yy ,J 5,, w/ n key to move your Name of Inspector /' usethsor-donot SP&av7ya /- cur the return /' Ed('6/�t/k.,. iV 6 key. Company Name N 14j� nII /a /a Eger- /2GRQ , V Company Address _ Lel/sk'ETT rums S 0/05-5, City/Town ry State m.. WIfie, r�L /Os3 y /B/ 7 _ Zip Code Telephone Number License Number ii i B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); I 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. l Passes °snob or,ly� a Wiliam z`s 2. ❑ Conditionally Passesffe Jdn slenla G 3. D Needs Further Evaluation b Y the Local A pprovin..c orMq 30142 M 4. 1:1 Fails i°nal En' I, at* ...- 7 6/4/./.7 eV e Inspe:rs Signature - 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. tsmeo xo re..monose tme s omuzl hwegmn Fo[m suoswtara sewage oispowl synem.page i m le Commonwealth of Massachusetts • ti=__ =, Title 5 Official Inspection Form trSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 0s3— Coin/&s it&/WO GO IC) Property Address ,.roc /3 roa.e E..e Owner Owner's Name information isrequi4/d�r///1 /a A-1 _ ,�a./r /04 U 6/00//10/61 page. for every / Mry d page. City/Town State Zip Code Dale of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: NO /D04 4-414,/5- -. /Yt.s Lc/7i.° At -F# vvir Jr .et /x,57-ct ,l t jinx .e pyIZ c 4/1r2 vr/� TG at /. cUFO 0412r/ G0 /.vc-. ,r -. _- . .. - - —• 2) System Conditionally Passes: ❑ One or mare 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)'. 5iny aoc•rev.712S2010 Tole 50r8oal lnspedion Form Suosurfaw Savage Disposal tem pos n Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form s% iso Subsurface Sewage Disposal System Form -Not for Voluntary Assessments <7.7-407 d3S Co jc.cS "if Ago al €4 Property Address nE 113412-2k leo•C Owner Owners Name information is NO t'-l/n-�q,o / .t tit /j inforr anon every I% a �/� U��� � 7/ io/G 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 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 S Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: Melee dac•rev 726/2018 Title 5 Offload Inspection Form Suosurfa`e Sewage Disposal System.Page 3 of 1S Commonwealth of Massachusetts Pi IL.tr-..r.Sr Title 5 Official Inspection Form ij. _ Subsurface Sewage Disposal System Form •Not for Voluntary Assessments pt r,SS GUu-15' /l1ir=--/✓ l7aw Property Address Owner 'DE. 'J '�" - /` Owners Name information is /r n/L/pwnivp % .N/ �/7 A 0/D ^(o G G/a/An iE required for every /V page. City/Town 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 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: 5 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: of 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 ❑ t. Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Slnsp Doc•rev.7/2612018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form x r _ f-ssti6 RSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 0'i Cau-)'es /1(E.400c-u AL) Property Address Andett Owner Owners Name information is ivQ A n ut k page. for every .C!/, i/1 0 67.1/17a/co ab/P page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 2,1 Static liquid level in the distribution box above outlet invert due to an overloaded �V or clogged SAS or cesspool ❑VAn9 Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ K Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . ❑ g Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑aa Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑n Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑darn Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑g1} 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 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.] ❑ X The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ST 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. 5) 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 C.4. QNA 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 mapped Zone II of a public water supply well timp.aw.rev 7/26/218 Title 5 onioal Inspection Farm subsurface Sewage Disposal system.Pogo 5 of 18 Commonwealth of Massachusetts ,N Title 5 Official Inspection Form mitSubsurface Sewage Disposal System Form -Not for Voluntary Assessments aSS CoaJ/es Alen" , j) Properly Address JOE_ dnQ- Owner Owner's Name information is fO�/MVO At/Ole '� e Milt / &/a/A p required for every �//� '! / ' 7 ��dh0 �G page. Cly/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 6. 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? E 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? y-r ❑ 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: W ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 'Seep Sac•rev.7/2612018 Ti11=S OMual Inspection Form Subsurface Sewage Disposal System•Page 6 or 18 Commonwealth of Massachusetts 7==° Title 5 Official Inspection Form ,F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '? c73-3— _ouiLtJ" -Doo LI) Property Address ✓Z. .3n4.--/c.£R Owner Owners Name information is required For every ,JO2n1 N/ / /OA] ✓ i- o,00D elov 0/2 page. City/Town State Zip code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 336 Description: /'/ZUd/.DSD l-/2 Put icU /4/c/99 3ssG•11.s/thSty Number of current residents: / Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes gi No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes g No information in this report.) Laundry system inspected? V Yes ❑ No Seasonal use? E Yes V No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? (Yes ❑ No 1 Last date of occupancy: Date r5ivso dot•rev.726/2018 Title 5 Official Inspection Form'.Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ti ,F- Title 5 Official Inspection Form tlp.wr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments % ' a3 s Cacc�c €s / JEamoccd PO Property Address Owner Owners Name information is A421_1714 nf1/D / �n 0i o4 0 SA;/Aloe tj page.ed for every "V _ C/ O G page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: d tin Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.R, etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: -- . — Was system pumped as part of the inspection? Yes ❑ No /Sao 64-c If yes, volume pumped: gallons How was quantity pumped determined? — �C¢/7=Sv � Reason for pumping: /4)1,o1 hill et/ 151nsp.doe•rev.7/20/2010 Ti1165 Olfival Inspedicn Form:Subsurface Sewage Disposal System•Page a of 18 . Commonwealth of Massachusetts k_ Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments et GCS- rowt.F,r t e..cvoto ,P,O Property Address t7Doe 4144-4-4E-g— Owner Owners Name informaequine for ,W/2JWA�, /04-J MA- 6/660 ey/a//o70/B is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: X 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): Approximate age of all components, date installed (if known)and source of information: assrni'L,0 /999 /?yrs ocio ter /an Were sewage odors detected when arriving at the site? ❑ Yes 5 No 5. Building Sewer(locate on site plan): 24' Depth below grade: feet Material of construction: ❑ cast iron Z40 PVC 5 other(explain): � Distance from private water supply well Cr suction line: 1.)0/6/it /f LU feet Comments (on condition of joints, venting, evidence of leakage, etc.): ,t/G ProAkinr S ,uorE0 tS'nsp Poc.rev.112e12016 rubs OMoai irececlon Form Subsurface Sewage Disposal System•Pages of 19 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a�J3— Coin/pf Mcn/Jacu , /) Property Address 0-02 Sn2zt.€.e Owner Owners Name informationfor every is required for 1(/O/2-J71A plod / /V/} 0/060 fJ/02/40/G page. City/TownState Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): r Depth below grade: feed Material of construction: 'concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) /6VOG-nc s7Ada t6 do Asa Ant-hi Ai mei- c .vir) No ccs If tank is metal, list age- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Ries ❑ No Dimensions: /0 'r S de le '6 reds /Z ., Sludge depth: 25' s, Distance from top of sludge to bottom of outlet tee or baffle 7 - / .. 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 /7 'r Cd How were dimensions determined? /f-A04-5.0 0 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N0 />r014 ." i .Cra rf- .butcrArc ' ,iic/ t iED t51nsp doc•rev.712612018 Tice 5 Official insoMbn Form.Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form 1.4 _ N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments thy a53 2u./c /''L'gvoo AA Property Address ✓z'e 4/272-1C/-L Owner Owners Name information is ,UOZJ7tA A0/0 /VA- OJC46 e9a/40/e required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Dit/ Depth below grade: feet Material of construction: ❑ 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: dniA Material of construction: ❑ concrete ❑ metal E fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ---- Capacity: gallons Design Flow: gallons per day 151nspdoc•rev.71262018 Tulle 5 Official Inspection Farm:Subsurface Sewage Disposal System.Page 11 of 18 Commonwealth of Massachusetts r 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' �tjci GUcc./(&'S fric_esnew 2,0 Property Address Toe eyyJrw se- Owner Owner's Name informequine for ie lla ^ �-y��0/O . / Ain x/06 D 64/40/8 page. for every ,1/ K/ „ 4/ y,r City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) dA ,g Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Dale Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan). Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.). /Vo/to 4 t& .4-/J et/`d Gco 2 CO/(at T/o Ac./ IAnsp.coc•rev 7126/$018 Titles Official Inseecton germ Subsurface Sewage Disposal System•Page 12 of re Commonwealth of Massachusetts lH Title 5 Official Inspection Form _ =hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 401 Property Address � � r ✓2ZZ n/G.E_/T./L Owner Owners Name information isrequir / /Or 7'n�,,o/O� nv� 0/0/O 9/a/4 a/8 information every N /�-/ " V Csp page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: 1g Yes ❑ No* Alarms in working order: Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): .Uo,roI4n-rt .(/orc/J * 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: leaching fields number, dimensions: /Z. X 410 ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: -- 15insp doe•rev.7/3612018 Title 5 Omcal Inspection Fxrn Subsurface Sewage Disposal System•Page 13 of 10 Commonwealth of Massachusetts P Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ao3 0ce-lie s- /9 aaeu AZ Property Address Jot- 4'4n4rE E Owner Owners Name information is iO0 ,f/1 SAA% I / M/4 0/0 6 O o%1/ / required for every ,_/ /ll !/ �0 6 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of sod, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): AA,Ai-046,14s Nart/J IA/54.0 Bt1Ih Ki Ad/7W /AiLy Vat ar /2/c /.vSTO-t -/E/> 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): 4 du A 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): tsinsp.doc•rev.7/26/2019 rue 5 Official mspetllm Form Subsurface Sewage Disposal System•Page 14 of 18 . cP'� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �P c'i5 COw1Ps A / 'sled /Z.D Property Address a Ag ,v',,r` Owner Owner's Name information is � r f0��� AM- OHO 8�1�/�rJ/, requiredonfor every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): P Al i t Materials of construction: - Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 3msp.ax•rev.7/26(2018 Tits Waal nspecion Form Subsurface Sewage Disposal System.Page 15 of IB Commonwealth of Massachusetts rdieaFp Title 5 Official Inspection Form ,3. _ - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , eaUlee , .r. u../ Aj Property Address fn.t $4- ,c Owner Owner's Name reformatifn is AM 2 y 79:Mlif /o ' / "in 0/0 G�/ 4 6 'required nfomaton every i�-f i, % /l/ t/ �/ G/ page. City/Town State Zip Code a Date of Inspection D. System Information ( nt.) f 14. Sketch Of Sewage Dispo al Sys m: 444,0 _% Provide a view of the sewa a dispo al sys , includin• of s to a least two perma -nt reference landmarks or benchmarks. ocate a wells ithi • 100 fe, t Locate • ere public wat= supply enters the building. Check one o he boxes elow: 1 ' I / su $ g hand-sketch in the a below 1 • 1:1 drawing attached se r . 011 NW e i i Nr is 9 it t' 4A10 0 D f�t�O cot4nP G )v 0 15 S n5 b u/tr r7 c S � r��� y i B� / ./ L 377,2 OP TCF_ r 4l/T/t om;Ln/2 A oi _ ASta V�� a �FiOrW f� Ace 8Co 11°.r/ puxtp !L 40 i4.S' . . so 07.6) h . Di sI4ok �' 8c_ //e, o one_ nue 29, L'E,.vr-ft 1 a-P yCie) I 15insp doc•wv 7/2612010 Title 5 Officio Inspection Form Subsurface Sewage Disoosai System•Page 16 a110 Commonwealth of Massachusetts 'L °: a Title 5 Official Inspection Form 't i Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Joi Cowcs.r A- E/tOu(AJ AO Property Address m.E 4•424_,E4 _ Owner Owners Name information is L'027Wn-st-(,o /d4./ 'VA- o/bOo e'/d//ao/d prequired for every /' page. DRy/TOWn State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: III-Cereck Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells v8 Y/ZZ,dn./f/764J /k/ Estimated depth to high ground water: feet ///O,) /O/,r/Y9 Please indicate all methods used to determine the high ground water elevation: r P� /dent Obtained from system design plans on record /%s/77 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: .)24/St €n ,onc L.E40/ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doe•rev.772fii$018 Tule 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts 1F Title 5 Official Inspection Form Vr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments SCocLa J t7�Arno e ,LL) Property Address Owner ✓Z/E ijftnl�� Owner's Information is Name oilrhi/tAY'A/a4J tyA oto‘ 0 et4via o/ S required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist CompleteteIall applicable sections of this form inclusive of: P<.-Inspector nspector Information: Complete all fields in this section. Z B. Certification: Signed & Dated and 1, 2, 3, or 4 checked R-CtsPection Summary: 1, 2, 3, or 5 completed as appropriate ,, 4 (Failure Criteria) and 6 (Checklist)completed Ir�u.`System Information: For 8: Tight/Holding Tank—Pumping contract attached ✓Por 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached vror 15: Explanation of estimated depth to high groundwater included ismsp ox.rev.9126/3010 Title 5 Official Insp tion corm.Subsurface Sewage Disposai System•Page 18 0118