428 title 5 2018 --.-"..a
- -".. Commonwealth of Mass$chusetts
-- Title 5 Official Inspection Form
'( Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
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properly Address
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Owner Owners Name /f/�/ //z y�/�j
Informations /(/D/L/`%/f/12O k.(/ &A D/Oe0 fo �G-"
required for every, earns* State Zip Code Dale of rrnspedi n
pas,
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.
Impaaane wnen A. General Information
NMN out forms
on the computer.
useonIY Me ab 1. Inspector:
key to move your F/�
•
cursor-do not m `(//LL/ill 41 (51%; h.L!771
use the return Name ofInspector ,
key.
<// //&n ocdci O/�•iif�9,-i006
./I„ Company Name
'al- J /a gi r oar AD)1 ,.�/
'1"XCumpeny Address D/O e
L ilia,rT /N/f S S Zip Code
r�
City/Town/. ,c/9 /!i /7 State License rer/OS--
Telephone Number
B. Certification FIL C Copy
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 inspecEdm
was performed based on my training and experience in the proper function and maintenance of on SIM
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
pse Passes ❑ Conditionally Passes ❑ Fails
❑ NeedsFu Evaluation by the Local Approving Authority /
r,,o a'- /P//e_/zev
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.
cop tma Ila 5Ofld Y,.pMan Fore Subsurface soma.ayoW Sya.m•Pop 1 an
-.e . Commonwealth of Massielibtetts, \
'ijen Title 5 Official Inspection Form
m - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
%ZS C-he. 5rXo44
Property Address /
P/2-12/2.-if
Owner Owner's Name
Information Lsrequired for every 1,11144 it/ a /6 c-
page. . ClrRavn State Zip Code Dale of I pecaon
,B. Certification (cont.) (%Z/26/8
Inspection Summary:Check A,B,C,D or E[always complete all of Section D
A) System Passes:
•
gI 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 My failure criteria not evaluated are
indicated below.
" •
Comments: •
steric int'L £ oisr /TG
eliz/zuie
Aro dnn-.n2 W/ -03 c.a z-t s ive r D
.te,drairL p /4n /Anne-AIt4
B) System Conditionally 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","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 exfdtration 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.
•Ametal 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.
0 Y O N 0 ND(Explain below): .f .i
•
*Ina.IVIG 1W 5 Midi W Wrn Font&buten avne•q,CUY Min.Page 2 W 17'
r- Commonwealth of Massach biyetts` '
Title'S Official Inspection Form
to - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
size csiice. Z0 44
Properly Address
LW//Cif Ar FA /
Osier Owners Name
InVWmtionbrd for Y Na2tir<i141,440 Adel oie4a .r/'o /004,4 ,.vc
page. • .City/Tam. Stals Zip Code Date of inspection
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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 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 0 Y 0 N ❑ ND(Explain below):
O obstruction Is removed ❑ YDNO ND(Explain below):
❑ distribution box Is leveled or replaced ❑ Y 0 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 plpe(s)are'replaced ❑ Y ❑ N. ❑ ND(Explain below):
❑ obstruction is removed • ❑ Y 0 N 0 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 falling to protect public health,safety or the environment.
I. 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 pdvyIs within 50 feet of a surface water
❑ Cesspool or prig is within 50 feet of a bordering vegetated wetland or a salt marsh
t5wa.11/10 imams rwea,rale Subsurface Sawa Haloid$HS.m•Papa 3417
-41t.\--c—w Commonwealth of Massachtattts
r Title Official. Inspection Form
i !t Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
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Properly Address
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ovmar Niles.Maine
s
information LiO6tnf /1f� t//D. 4,4 0/04 o-/l4 PG/Irequ .
.ed br every C'brawn Stale zip Code Date or Inspection
C. Checklist G /
page. 212Pit's
Check if the following have been done.You must Indicate"yes'or-no"as to each of the following:
Yes No'
$f 0 Pumping Information was'provided by the owner,occupant, or Board of Health
❑ Al Were any of the system components pumped out In the previous two weeks?
,$] 0 Has the system received normal lows In the previous two week period?
❑ x Have large volumes of water been introduced to the system recently or as part of
this inspection?
o
Were as built plans of[he system obtained and examined?(If they were not
Xavailable note as WA), / e1'o p/an '
0 Was the facility or dwelling Inspected for signs of sewage back up?
Xf" ❑ Was the site Inspected for signs of break out? • •
N ,� 0 Were all systemcomponents,excluding the SA$, located on site?
X ❑ Were the sepUctank manholes uncovered,opened,and the Interior of the tank
Inspected for the condition of the baffles or toes, material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
r f - ❑ Wes the facility owner(and occupants H different from owner)provided with
Rt 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 Infomtatlon:For example,a plan at the Board of Health.
X . ❑ Determined In the field(If any of the failure criteria related to Part C Is at Issue
A+ approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information 1
Residential Flow Conditions:
Number of bedrooms(design): T Number of bedrooms(actual): 'l
DESIGN flow baked on 310 CMR 15.203(for example:110 gpd x#of bedrooms): r V0
Non Wgili,o/o.0 Bob/ /2-c€6
/kDy x yyo • = Aa0Gets. .0-y
ft-cry ffc ra-e.5/ G 4./
eM•1VIO TWO Ofildal Spider,Fes FLMNW snug.DONS Snkom•Popo Solt?
V- Commonwealth of Massabliusetts
10 =-r Title 5 Official Inspection-Form
E laL_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
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Properly Address
• Fx%C// /7—/SC F/f/LIL/S
Owner �/ O/ /�.
Diners Name jo/u Ai/it/¢ Q/oo U ' Z
information a / Gd
pace. for every c/T0 Slate Zip Code Date of Irks ectlon //12/ene
page, - CO G
B. Certification (cant.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines Martha 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 fias 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:
"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. •
i
3. Other.
•
D) System Failure Criteria Applicable to All Systems:
You m=indicate Wes"or"No"to each of the following for a inspections.
Yes No
❑ lir Backup of sewage into facility or system component due to overloaded or
X�
dogged SAS or cesspool
❑ •.Ai Discharge or pending of effluent to the surface of the ground or surface waters
Jam' due to an overloaded or dogged SAS or cesspool
❑ g Static liquid level In the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑° Uquid depth In cesspool Is less than 6"below Invert or available volume Is less
than'%day flow
64..1100 lila solid.'FWbm rem SW"vew Sewage Disposal System:P.S.4 al 11
Commonwealth of Massathbs tts
7�= Title 5 Official Inspection Form
ei_' Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
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Property Address
Owner Jnot,2J,,ceR r� J /K/Lr
ownorr eras. /4W d D ��`�6�0/E •
information le
revuireC for every Stet* ZIP Date of r pection
,B, Certification at/Z/AU/ii
B., (cont.) at•
•
/Z-AP/i
No
• ❑ Requited 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 pottion of cesspool or privy is within 100 feet of a surface water supply or
❑0 tributary to a surface water supply.
❑ 0 Any portion of a cesspool or pdhy is within a Zone 1 of a public well.
❑ Pit}'/J Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑A/tom • Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water system passes If the wel l water analysis,eP rformed at a DEP ptable water quality acertifed�hls
y well with no
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.]
❑pitoq The system/s a cesspool serving a facility with a design flow of 2000gpd-
•
10,000gpd.
❑ •The system bk.I have determined that one or more of the above failure
criteria eidst as described in 310 CMR 15.303,therefore the systemtaiis.The
systenf outer 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 10,009gpd to 15,000 gpd.
OVA-
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)ora 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 upgjt d.@101s
• system in accordance with 310 CMR 15.304.The system owner should contact the appropri0(p
regional office of the Department.
Wa•fib TM 5 Mild m. .tem fore B4e/rac•ammo.Disposal System•P.Ysoln ..
. , e 4
4. •
'�"tammonwealth of Massachusetts* .'
U�, Title 5 Official Inspection Form
-.= i1 - Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
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Pmp.M Address
T ,v,U/fF_,e ,t//-41t1 . .
0wner Owner.None ,S//4 led/6i ,.0 r
Info/nation for
d//z-/Levo'
required fwevery .�/6/ZT/f�i'/'Y//7 Ge(J �LState Lp C�e� Date w Inspection
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D.System Information
Description: '
•
. . . .
Number of current residents: . •
Does residence have a garbage grinder? XJ Yes 0 No
Is laundry on a separate sewage system?[if yes separate inspection required] 0 Yes, ' No
Laundry system inspected? g Yes ❑ No
Seasonal use? D Yes 0 No
Water meter readings, if available(last 3 years usage(gpd)):
Detail: PA/V/1-n. G✓!.GL
cee ?tee /z E
Sump pump? 0 Yes J' No
Last date of occupancy: Date
Commercialflndustrial Flow Conditions: 041/9
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per a.y(gvd) 7
Basis of design low(seats/persons/sq.11,etc.):
Grease trap present? 0 Yes 0 No
Industrial waste holding tank present? ❑ Yes n No
Non-sanitary waste discharged to the Title 5 system? 0 Yes r No
Water meter readings;If avallgble:
on.Iv15 mw500a' mot:arca,swwneo.enm(Mewl Synwn•Paq 7 017
•
`'•t-- Commonwealth of Massath'Dfetts a .
�- Title 5 Official Inspection Form
_et '; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
LL' 928 cal&STf///:[—a AtflProperty Address
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/a./Zo/t /Ale
Owner Owner's Name
c �r/�/ L�
Information la ",9M//p O L/ tin c1//l40 to /2. 7!i/V
required to every .CIWTown. Stat.) Zip Coda Date otluP on
pogo. • .
D. System Information (cont.)
Last date.of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:'
Source of information:
• f72.(l/L ke,/4`aim Yes 0 No
Was system pumped as part of the Inspection?
/craa 4-04-r
If yes,volume pumped: , eayena
How was quantity pumped determined? /144 /7—f
nth)it d o //Lttnc-o a-41
Aa
•
Reason for pumping: �G 42 A4 4 d Ie//l/te /t
Type of System: . Q/s/T' 80x £.4/914 coc/
fir Septic tank,distribution box,soil absorption system
❑ Single cesspool
Q 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 UA system by system operator under contract
O Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
W ..rvlo ier Somas W.pdm mar s'dualc.s.w.c4.eara'sy.t.m•Peg. Of 17
Commonwealth of Massjcliuseitsk
Title 5 Official Inspection Form
- ' Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
l0 s{/L�i C/'/tSJ71t.,7,.t.d .Q-Q
Properly
Address _
V .-�.Lr f//,4€/L FA/1-11_1 5-
Owner
Owner Owner's Name
r
required ab everyA/o/L-T1/nniff /0 41 MLS Gro. o 5//G4 ale' POT
c y
page.. Stale Zip Code Date of pecflen
D. System Information (cont.) 41/e- %/e
Approximate age of all components,date Installed(if known)and source of information:
d(A. "X77nu/c. e/J/sr-Brty 6A; /ao'a
Were sewage odors detected when arriving at the site? ❑ Yes 4No
Building Sower(locate on site plan): • 3b ,
Depth below grade: • pet
Material of construction: •
AJC'-Gr'/ 4/"SC/rx Vo
❑cast Iron Air40 PVC ❑other(explain): ewe._
Distance from private water supply well or suction line: feat / �,S /-
Comments
Comments(on condition of joints,venting,evidence of leakage, etc.):
�� P`u�
,f/Cw /f" sur'go p vL /lop s o fa
,. NPv ' 9"/$cif4/o/l✓G .7-raj/(_ p0 ,C.rQ ic '
,aisr
/vvt._. /yrs
Septic Tank(locate on site'plan): FrOCO'C 47
21`.' ad
Depth below grade: feet
Material of construction •
:
concrete. 0 metal ❑fiberglass C polyethylene ❑other(explain)
/saa 6//`e- 2COniviJy arnct,vt /n.v/
. . Y"ais' 4% fvc fees
kJ, r7a' /=/Lr/2-2 v,cn r I
If tank Is metal,Ilst age: yearn
Is age confirmed by a Certificate of Compliance?(attach a copyof certificate) Yes 0 No
/{e ," ioal1/n.d /---
• Dimensions: /0 Jr'X l0 2. Cc ni,/f/Lr Ace sc�
Sludge depth: a
scop MO - nes Oeae inseam rem Subsurface sewn.ou.po. aM.m'r.n.v ore
--` Commonwealth of Massac'hilsetfs
Title 5 Official Inspection Form
aSubsurface Sewage Disposal System Form-Not for Voluntary Assessments
LI 926, ch/E-57 eF/. A -/Pae)
Property Address
c rr ltW//=E/L ,c4-4„/Zi s p
Owner Ovinefs Nameinform - I / c0 Q/ V SNC
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page.eO kr every .CIS O/L77d�/7/t?,CJ state Zip code Date o Imp° on tw
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page. • '
.D..System Information (cont.) ����/8
Septic Tank(cr;nt.) A/e� -9 Si-
Distancefrom top of sludge to bottom of outlet tee or baffle
U
Scum thickness .a
Distance from top of scum-to top of outlet tee or baffle / tr
Distance from bottom of scum to bottom of outlet tee br baffle
hcen SPA-I,
How were dimensions determined?
Comments(on pumping recommendations,Inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet Invert,eyldence of leakage,etc):
,u.esei nwL 16/,at/zo/8
N 0115thi- Vg ,vvc iCtGl� /l' r AGA' Lti< /Yocehf 5
Grease Trap(locate on site plan): 0 A./4
Depth below grade: feel
Material of construction:
❑concrete ❑metal ❑fiberglass 0 polyethylene ❑other(explain):
t ..
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
M116.11110 11Ysa'a hW.don Fart Subsurface Swept Disponi System.Page IO M1]
Ar-s--"Commonwealth of MassachusbtYs
Title 5 Official Inspection Form
• = Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
4/28
Property Address
FFr 2
Owner pure/s Name
Information Is yt/DfM
g_r7A f IO/kJ4L.3—//4!
. r'4 /0 a040/7 elle //VT
requiredfor even
page.
page. . Cinfrdwn. State Lp"pO e Date of Inspection
D. System Information (cont.) La //t/zo't
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):
Ai rig
Depth below grade: .'
Material of construction:
❑concrete ❑metal 0 fiberglass 0 polyethylene ❑other(explain):
Dimensions:
•
Capacity: pylons ..
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm In woridng order. 0 Yes 0 No
Date of last pumping:
Date
Comments(condition of alarm and float switches,etc.): - -
•Attach copy of current pumping contract(required). Ig copy attached? 0 yes ❑ No
an.•1V1a 111411 MA YapxLal ram WpwMY Sano awes Swan*ons 1101
-"r-"t- Commonwealth of MassSchus'etts
krfTitle 5 Official Inspection Form
r_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
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Property Arldrees
L7n1J.0I G,c2 ,c/t'!Z/L/$
Omar OMW's Name
Information is .Uotr7Innto/oW M4 a/GCD ti
1/4G 20't • .
required for every - Stale Zip Coda Dale of Inspection
page. . . ' GNRoen.
D. System Information (cont.) Le //tlLatt
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.)yo 40 9G X ,(.Eel/Ott e/)
Mete-) .0/Sr sot aU/ rid /L G.Tt p-. e/tr1
ata .a ' ,512A armluaa0_2) 'ken/ sn16te_
/,ew /.fire ovrtist Q Snit ,tev•
,Boon_ CD.vO/rlOq/ r/9/v/ 14) :sG k
A-''01-• 1 ri Stet- r ' U L
\ \ \ Pump Chamber(locale on site plan):
Pumps in working Order: ❑ Yes 0 No
Alarms in working order. ^ 9 Yes 0 No
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan,excavation not required): r
If MS not located,explain why:
IWu•fvfo 1165 ped/e.Ytllan Fane&Wealc.Snap Oepatl SYaaa•Peis 12 el 17
re't— Commonwealth of Massachusetts
c,0 Title 5 Official Inspection Form
'I ` Subsuurrfface Sewage Disposal SSy�sstemm u
Form-Not fVoluntaryy� Assessments
12-6
PropertyAddress
Owner Owner's Name
Informdon Is awry leiat riltAn4/)/04/ eio4o uu�//P oze /tit
requiretor
page: . . - Gly/town, State Zip Code , Date of l pectlon
D. System Information (cont.) 47/t/Z-6/65
Type: •
❑ leaching pits number,
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
leaching fields 0 u("/'+S number,dimensions: 20 X Vo 406/'
•
O overflow cesspool number.
❑ - Innovativelaltemafive system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding, damp soil;conditionof
vegetation,etc.):
• .a pcFIC-C '.c/ d—t4 L- /-icy
•
Cesspools(cesspool must be pumped as part of (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 0 Yes ❑ No
a v.IVIG The IOlele sap.dnm Fp,rc Sueaelpe Sawa.Dispose SwWn•Pepe 13 M17
. _ ,
`tet Commonwealth of Massachusetts
)i- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
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PropertyAddress /
Owner Owne?;Nana^/✓� /N.
Intonation Is •J7`/f/'7i'//G u - /t147 t7JC/O 1/44/2Fi/s
required . I/OI/O/1 fovary City/Tam,m State Zip Code Data of l peoeon
pega. / �G
D. System Information (cont.) . hf/t/z
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
•
Privy(locate on site plan): N -ati4
Materials of construction:
Dimensions
Depth of solids
`. \ \ Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
•
•
•
TN 5 esav MeeNae Pum staeanw• 6M`e•Nowa!Spawn•Pep 14 M 11'1:41411110
. . ' '
Commonwealth of Massachusetts
5= Title 5 Official Inspection Form
al- Subsurface Sewage Disposal System Form-Nofor Voluntary Assessments
y2 C/v.c T7T9L .0//ajj 12 a
Property Address q
ds
Owner
Owners Name� y-� /��y y� Ysr y/ 6
reyu =ery Lit1.C/ /14 /O/v� State 4 Zip0/04d Date oflr/ieaJzo /Jl
page. • • •Cltyrroan •
D. System Information (cont.) WI r/uie
Sketch pf 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:
• Errirci etch in the area below
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dl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
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❑ Obtained from system design plans on record
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\ 0 Observed site(abutting{property/observationihole within 150 feet of SAS)
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You must describe how you established the high ground Water elevation:
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• Beforefling this Inspeetlon Report,please see Report Completeness Checklist on next page.
•
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Commonwealth of Massachusbtts,
Title 5 Official Inspection Form
!I Subsurface Sewage Disposal System Font-Not for Voluntary Assessments
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S-Ifspection Summary A,S, C,D,or E checked
Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
System Information—Estimated depth to high groundwater
fa'Srketch of Sewage Disposal System either drawn on page 15 orattached In separate file
•
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William J. Sieruta, P.E.
413-549-1817 413-627-7244
William J. Sieruta,P.E
18 Depot Road
Leverett, MA. 01054
To: Board of Health/City Hall .
Main Street
Northampton, MA. 01060
June 12,2018
Subject: Jennifer Farris
428 Chesterfield Rd.
Northampton, MA.
An"as built" inspection was completed for the subject septic system. The system is in compliance with 310
CMR 15.0 and all local board of health regulations. If you have any questions or need any further information,
please do not hesitate to contact me.
Very truly ours,
William J. Sieruta,P.E. No "
:1 EY"
Cc: J. Farris
WJS:mbs