428 Title 5 2018 (2) t Commonwealth of Massdchusetts I/
Subsurface Sewage Disposal System Form
Title-5 Official Inspection Form it
-Not for Voluntary Assessments
918 asi .CF/. iz:on d ?
Properly Address
\.7 -ti J/F/f 4 /='/t 412_i S
owner Owners Name rp /z-72.4 Information is fpj/1 fro•a "IA 21101•U ,44 a!O/iU
required for every State zip Code Date of pedi n
Gage. • • City/Town -
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.
Importantwnen A. General Information
gllldg out forms
on the rsrnpuler,
use only the tab 1. Inspector. . •
key to cursor-doeot /' ' .p t$/� h�fa./ p/Z
entreretum m �(/!C-tor /�') !/r
use iM mWm Name of
Inspedar�.r
key. t5',c /Z/JYJ9 .G/t_G/.rJ,C4/t )C
•
-/I„ Company Name
F°m"nyAddmss r h p P-1/1-5. S a/a6`
irt
4,-(/at�"�� Zip Code
CiyRown State3-1/9yi.l iB i l cx ia.rr
Telephone Number 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.Theinspettibm
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems.lam a DEP approved system Inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
pli Passes ❑ Conditionally Passes ❑ Fails
❑ NeedsFu n,L: Evaluation by the Local Approving Authority
/ /.t / i !ate 6—//6 /tee/e
/_lre.i4-y- trill L/ze e'
jre%,•re-.Cna re " - 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.
l& IMO The 5 oed4lnrpdLm Fmrt sWun.w seep tlgom byMWn•P.Q.1 an
Commonwealth of Massatlr9t3etts, \
Title 5 Official Inspection Form
)I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
fXz8 c/I riz// gip 77_044
Property Address •
TJrA/U/,/:..e nilfi/f
Owner Owner's Name
Nromwtbn 4
po,":dfprevery .wMkV/�-//Tile%fi�'Li- �[Y ,GL 0`e"V ,�/ ho/8
pager Oej,?own _ State Zip Code Date or Irkpection
B. Certification (cont.) b//2./26/8
Irl pection 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 My failure criteria not evaluated are
indicated below.
.
Comments: •
Sync rout E Inst 40 le ..t2/EAi/"i-r-6£-4
to//z/za,8
IVC9
01-77-44. ion-04c c-.na s /vor0
Sem .t"e"n i2 p /4n ,1rr/a-c///E4
•
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 ayes','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.
❑ Y ❑ M - ❑ ND(Explain below): •
•
—.1elO N.s maw IWWmfam[Subaudsos Swoop Disponi anlxn.PN.2 oil? _
•
'e' Commonwealth of Massacht Letts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44.2E i7±:/_.-0' /2o ,V4
pmpa,tr 7 ,AN/AL,Q dtAl4/, /5 •
thaw Owners Name
irneret=Ise we ry ND/L77r`r//att//io•U 1t-14 0/640 J/Jo bo/c,..,4 /4c-'r
me. ' . . cily/Tawn. stab, ap Code Date of Inspeethel 2/20/ri
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 ❑ V ONO ND(Explain below):
❑ obstruction Is removed 0`Y ❑ N 0 ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y 0 N 0 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 ❑ V ❑ N. 0 ND(Explain below):
0 obstruction Is removed 0 Y ❑ N 0 ND(Explain below):
•
• C) Further Evaluation Is Required by the Board of Health:
0 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 feel of a surface water
❑ Cesspool or pdvy Is within 50 feet of a bordering vegetated wetland or a salt marsh
51,111110 1114s PIS especeon Fn Ba..s.aw*wg.Disposal System•Pape 50117
Commonwealth of Massaclibsbtts
Title 5.Official. Inspection Form
I = I` ;� Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
nc
`' 1 SL2eY CIfcc//T.c "'P O 4/2
ar .e Property Address
J,(1,t//w45-/L ,1.4-2 c/$ u/�
Omer Omels Name
lecrread/aavery NO.n/irn1/11641 Ai O/oz o ,r�/e
page. . atyrze.. state 71p Coda Date ofIas //�/211fi
C. Checklist
Check if the following have been done.You must indicate-yes"or no as to each of the following:
Yes No• . .._• .
21 0 Pumping information was'provided by the owner,occupant,or Board of Health
❑ ,i Were any of the system components pumped out In the previous two weeks?
• 0 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
eg
this Inspection?
Were as built plans of the system obtained and examined? (If they were not
• ❑ available miteasN/A), µeSCJ p Ion '
• 0 Was the facility or dwelling inspected for signs of sewage back up?
W0 Was the site inspected for signs of break out?
0 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 toes, material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
"( ❑ 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; .
Er 0 Existing Information:For example,a plan at the Board of Health.
• ❑ fieldDetermined In Ihe of the failure
approximation of distance Is unacceptabl)(3 10 criteriaC is at issue
CMR 15.302(5)]
D. System Information 1
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): 996
/o cI ',got/ /2-FG •
. /J7>70. x yyo ' _ eao ones. 1/47y
/.rcptl4G 125/ 6' 4/
aim•11/10 TIY0Ch1,IIW.d EOM e,Yu,IV 6^ae.woos 6yeun'Paw 6 all
Commonwealth of MassebI USetts
Title 5 Official Inspection-Form
` Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
Pm Address
Owner P l ,-eu"v/ .17-15,4 ,t/2/z/S
Owners Name /
Normalbna fo/C/ NAD/d/U J�///i >a/L•' is
required for every_ A10/2-thinw. Zip cod. Data.of Ina action pen . . Cityfrwn s6//z/60/65
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,If any)
determihe3 thatthe 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 hate septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank-and MS and the SAS Is within 50 feet of a private water
supply well
0 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.
•
3. Other.
•
D) System Failure Criteria Applicable to All Systems:
Youima Indicate"Yes"or"No"to each of the following for till inspections' ,.
Yes No
❑ Backup of sewage Into facility or system component due to overloaded or
0 dogged SAS or cesspool
❑ • h r Discharge or ponding of effluent to the surface of the ground or surface waters
Jam' due to an overloaded or dogged SAS or cesspool
❑ jg Static liquid level In the distribution box above outlet Invert due to an overloaded
��aq, or dogged SAS or cesspool
•
❑D • Liquid depth In cesspool Is less than 6'below Invert or available volume Is less
than'%day flow
Ws.11110 TN 5 0114141 Iwo*.Form su*gNb eemym Disposal T'rl"m•Page 4 s IT
' --` Commonwealth of Massadhbebtts a `
Title 5 Official Inspection Form
sic= Subsurface Sewage Disposal System Form•Not for VoluntaryAssessments
LI <fa�' 01,4 7f/z�i PT
P <'/C/li/_ r—/Z2z.<s
Owner Owners Nems y-/� _ ��/ d 0 e` Z0/moi
Income fore Io /'rani /G� /r
pa9s. every ym. s� Oats of l pedis, A
Page. ,B. . 4,AZ/tU/G
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:
o G1 Any portion of the SAS,cesspool or privy is below high ground water elevation.
/''C Any pO tJon of cesspool or privy Is within 100 feet of a surface water supply or
❑B R tributary to a surface water supply.
❑ D(PA My portion of a cesspool or privy is within a Zone 1 of a public well.
❑ d]tril My portion of a cesspool or privy is within 50 feet of a private water supply well.
0 A/tZW . 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 codified
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 yf custody must be attached to this form.]
❑d. ..M•L'J7 Ji The systemis a cesspool serving a facility with a design flow of 20009 pd-
•• 10,000gpd.
❑ The system]a]ig.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
systenf 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 10,00 gpd to 15,000 gpd.
0tiA
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,
❑
0 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
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 arty large
system considered a significant threat under Section E or felled under Section D shall upg[gd
system In accordance with 310 CMR 15.304.The system owner should contact the appropgfl(p
regional office of the Department
In•Ie10 N.5 grdd Mamm fame SWauew stage ovoid stmen•Pp,5417.
C Cpmmonwealth of Massaehusstt's
Title 5 Official Inspection Form
- eI Subsurface Sewage Disposal System Form Not for Voluntary Assessments
'z6 Cllr5nc/Z /Cite-00 ?2O
Propyly pd
Owner Oyafa Name 57/6. leo is ,,t.,r
Information is AQ6/21/1-0-nip44.1 iw 410/0 ePz/2-40/65
repulrotl fu everyant .gb/ror State Zip Coda Date of Inspection
D.System Information
Description:
I,
. . .
Number of current residents:
Does residence have a garbage grinder? jjj Yes '❑ No
is laundry on a separate sewage system?[if yes separate Inspection required] ❑ Yes No
Laundry system inspected? El Yes 0 No
Seasonal use? ❑ Yes R. No
Water meter readings,If available(last 3 years usage(gpd)):
Deta9: p/�/V/Pit. w
5.0 g /2- E
Sump pump? 0 Yes J$' No
Lest date of occupancy: Data
Commercial/Industrial Flow Conditions: /7 AiO
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd) 1 .l
Basis of design flow(seats/persons/sq.ft.,etc):
Grease trap present? ❑ Yes 0 No
industrial waste holding tank present? ❑ Yes (a No
Non-sanitary waste discharged to the The 5 system? 0 Yes [l No
Water meter readings;If avallsble:
wag.11110 N'Iwo Spiralrmit aue.unw q.a.Q Owes sywmpaps of
a a .
-t-.P Commonwealth of MassattioSetts •
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
5Q-el efrii.5J-F/rc-47 AbfrO
Property Address
V//=r.L P#h,Lif 5�� /�O/�D /.vr
Owner Owner's Name � NG k /z 76.8
Information b .Uri/.null info /6 aV itlg / C-
page,requirMev. Cip,/iavn State Zip Code Dete or Inspection
pegs. .
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Ai I. CLS
Source of information: /
U/e—/Ct /4411
Was system pumped as part of the inspection? r Yes ❑. No
Ar-ea 4-/14-$
If yes,volume pumped: / , asp
How was quantity pumped determined? t! /tut Aa
Reason for pumping: r�'U/ 1 O/ /nU R /ioy ,
CO�,r44 c/ ta//k-/ea/�
Type of System: p/ST- BOX /c.¢/1/4GP&
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/Alterative technology.Mach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the VA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑
Other(describe):
In.-,vta fib Saida elapse Fmrt subsurface soma Disposal system.Peo.e N r1. ..
.• Commonwealth of Massachusetts'
- Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
vie C/1e$/774_P/t t..G LI
propedy Address
L7-A24.14.17,4412 ft/A/Pt,/ S
Owner OvnwM1 Name
rept:torn revery A/04_17,4fszf// 442 Mt? 0/OGD ,5-i12 4r✓,8 /•ter
pep.. Ciryrtovm state by Code Dab of pedon
D. System Information (cont.) /p//z. /ze/8
Approximate age of all components,date Installed(if known)and source of Information:
,u1-4,-/ x'/c e/Jesre v G/ice /1aie
Were sewage odors detected when arriving at the site? - 0 Yes 4No
Building Sewer(locate on site plan): b „
Depth below grade: feet
Material of constniction:
0 cast Iron ,!'SI 4o PVC 0 other(explain): PVL
Distance from private water supply well or suction line: feet / ZS "-
Comments(on condition of joints,venting,evidence of leakage, etc.):J /
AJel e/ 4111 SG!, 0e) p YL iiia, f-ea /'U /,1- c/t r ew)
/) 9 SufUOf I'C jf<vt 1G ILAAIC)
/�<sr Ie5jax
ve_ Aix Airs
Septic Tank(locate on aite'ptan): Solo A1:,d
,CAewYJ1Ac/
Depth below grade: feet
Material of construction:
?concrete ❑metal 0 fiberglass ❑polyethylene 0 other(explain)
/,sea c ' - pcio 'nue iv/ /n//
`f"6L« SlU Pvct4Lc
M '# fl" r/LA7z2 (/if✓A s'— ' +
If tank Is metal,list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) Yes 0 No
Dimensions: /b?4' / 3 /ie 4 ' ve `r1c/oa r L/s 1
fLCaAVA,lAarALL.2st —
Sludge depth: • O
eW.WIG Tile 5Oadd Inspection foam Y,Wa6u Savage tl,pu,l aywm•P.o.9s tl
Commonwealth of Massaahtbsetts •
Title 5 Official Inspection Form
•
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9928 citt5 tF/. -G4 "&finO
Property Mdreu
,T IV. )/r—/S2 .cg- 15infere/060 r y R
D+mer ellen Is °Wm"Name �] y�,yr" ,' S�ll��o/ " SNS
page.
required /r/Dm--771/Y r./ _ ' " dddlll
pegs, .GlpRarm . Stele Zip Code Date Hope on hp24 Lt,/�
D..System Information (cont.) Nl— G�V�/R
Septic Tanic(cnt.) �� 354w.
+ , Distance from top of sludge to bottom of outlet tee or baffle
O
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
lu2h SU/ttcI
How were dimensions determined?
Comments(on pumping recommendations,Inlet and outlet tee or baffle condition, structural Integrity,
liquid levels as related to outlet ink/ern:evidence of leakage,etc.):
1 nut6//Z/t o/F
f<115UyL Ve? .avt- •
.0<L/7c.t GrICJ//— / let
Grease Trap(locate on site plan): 0 AiA
Depth below grade: feet
Material of construction:
❑concrete • 0 metal 0 fiberglass 0 polyethylene ❑other(explain):
7
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
tam•11110 1W0010th k S_a,Foam SuScudws Swage Disponi Solon•Pan 10 nr11
."" 'Commonwealth of Massachusbtts
Z5;;;eiili Title. 5 Official Inspection Form
f -? Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
••:,;=:.r SV28 Cr1c$rJiIt.citp .
Properly address
1/4.7-4-4'u/FF& ,tAZ/2.-/ �r
Owner Owner's Name �f- /�/`/ /0 6 0 < /� / p
aWna �(Jd/�T�r�'/�/NrJ�O�L/. r ns etzd�t� //�T
rafor ovary
page. . ClyrtNm. Slate Lp • Dale of Inspection
D. System Information (cont.) La //L/eo'#
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):
hi
Depth below grade: p W
Material of construction:
❑concrete 0 metal ❑fiberglass 0 polyethylene ❑other(explain):
Dimensions:
Capacity: gyms
Design Flow: gallons per day
Narm present: ❑ Yes 0 No
Narm level: - Narm in working order. 0 Yes 0 No
Date of last pumping: Data
Comments(condition of alarm and float switches,etc):
•
•
Attach copy of current.pumping contract(required).Ig copy attached? [] Yes I] No
aw•nno Tina MO Swam rams aaaalw;Valle Offen'ayrW,•vepn ll pl7
- e
Commonwealth of Massachusbtts
Y,- Title 5 Official Inspection Form
)( Subsurface SewageDisposal System Form-Not for Voluntary Assessments
U9.LS/`X/2- P/,C14 r—ve,•
Property Address
Litt /,U//c
Omer Omen Name
e
for atio;Is .Ua2-77/-/1re/,o/alt/ AM- .0144i .r//G/zott
page: . . ' giKo m, Stale Zip Code . Date or Inspection
D. System Information (cont.) !e (/th'c
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.)to al 6,6 X ,t..¢/9/OGt el)
AV-al b/S/- SOY /.v/ //j,%-e/ed^S
CL-a . ore s'i)/3 "T7> 4/04x-.4 k€I-q ni-fn Z
/it) Yx_rt . ourt. TSsir-.e htCPt/•
ooJ2 Co vO/nok/ ..- .
N Pump Chamber(locate on siteplan):
Pumps In working order: 0 Yes ❑ No
Alarms in working order. ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Soil Absorption System(SAS)(locate on site plan,excavation not required): .�
If SAS not located,explain why:
•
dint MO TO 5 CMe Yap4kn Fe=aJ.x.M1U&no.MWtl System'Ppi 12417
`=- - Commonwealth of Massaotwsetts
Title 5 Official Inspection Form
)I Subsurface Sewage Disposal SSyysstemm Form--Not for Voluntary Assessments
Vrf�2c c1I1CS iyise-t-iu^V 140.
Property Address `_ N h
Comer lbn b owner's Nene
/ ad /fir
7G/
required for every, I-'ot h�/I—/Yl,o�U�c/ • AM G/Gd U - u- /rC UU
page. . . CIWt fe agate Zip Code-. Date of l ',action
D. System Information (cont.) aft 2/2.40/e
Type:
,
❑ leaching pits number:
O leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number,length:
r qO/J
leaching fields 0 C1K1.�'i-5 number, dimensions: 20. x Vo
❑ overflow cesspool number:
❑ innovativelaltematwe system
Type/hame of technology.
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil;conditionof
vegetation,etc.):
F/lE" AC"1x4 0 G•U de-n TGG
D R,
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
• Indlgation of groundwater Inflow - ❑ Yes ❑ No
tons•IVIG 11416 viola Wpeew,Fame Seeds.songs Dispel sy.wn"Pag.160417
Commonwealth of Massachusetts
�_= Title -5 Official Inspection Form
!-_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�) VZo Chi. T.C/L4/tC4
Properly Address r r-ii S
tsName i� �l� «.
InfInform O.+wrs Neme,� ,..�,./ fns �r,/ A
requirdlote L'r/U/� m'w,-' ) A !/X4•40 r/
pagerequired • City/town State Zip Code Date of I pecdon
page.
D. System Information (cont.) . 4//Z_!20 y6'
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): '
•
Privy(locate on site plan): N L4-
Materials of construction:
Dimensions
•
Depth of solids
Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,
etc.):
•
•
Su.11110 TN sWadd W.p.Nun FUT Subsurface 6Fnge Disposal Ssewn.Page 14 of 17
,
Commonwealth of Massachusetts
t Title 5 Official Inspection Form
:Ili Subsurface Sewage Disposal System Forel:Not for Voluntary Assessments
fz C/Vicg,n9Ln/ _7 ka
Property Address
Owner £nW2l/#.£2 /=172-/2./5
O.vners Name
;°`�"rb ;.py .420/2-77/417,D1v.v 14/410/4/00 ,sr//elzorn •"
page. • • •City/Town State Zip Code Date of Inspection
D. System Information (cont.) ir/j.04
Sketch Cf 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:
• hen - etch In the area below
wing attached separately
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ACommonwealth of Massachusetts's
Title 5 Official. Inspection Form
IISubsurface Sewage Disposal System Form•Not for Voluntary Assessments
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••• Property Address _ � �.r
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D.System Information (cont.) �/'/4//2_,0
Site Exam: '
rg-CreC;Slope
su face water
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Check cellar
❑ Shallow wells Z S Lc -C/1/CF�CQ
Estimated depth to high ground water. • feet 40rre r7 ft4Ouh A off-0.-+r
Please Indicate all methods used to determine the high ground water elevation: a-'1 '1 _ /'C_kL
❑
obtained from system design plans on record Oeu&zJL SYrCtr.r-,
If checked,date of design plan reviewed: Date
\
0 Observed site(abutting 9roperty/observation hole within 150 feet of SAS)
lir Checked with local Boad of Health-explain: /.C/Sr
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• Checked with.local excavators,Installers-(attach documentation)
❑ Accessed USGS database-explain: .
You must describe how you established the high ground water elevation: •
f1
•
Beforeflllnu this Ins`pestlon Report,please see Report Completeness Checklist on next page.
Ulna•IVI. ma.r(Add Impeaon Foaeala.adea sewage WPOtei aye.m•Page 10ar
"" Commonwealth of Massachusbtts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
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pa9s. • .CiyRe n - - Ste Zip Cods Oats of Inspection
E. Report ,//
or� Completeness Checklist � Z��d /8
El-lh pe tion Summary A,B, C,D,or E checked
Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
[J System Information-Estimated depth to high groundwater
2.1ketch of Sewage Disposal System either drawn on page 15 or attached In separate file
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15Ya•11'0 TM 6a60W Impaction Form a4OeNO Smut,Deposal eyeea•Page 17 of 17
•
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William J. Sieruta, P.E.
413-549-1817 413427-7244
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.
.1/44,to
al E '
04,
Cc: J. Farris
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