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HomeMy WebLinkAbout0029 WILLOW RUN DRIVE - Health 2,9 WILLOW RUN DRIVE Centerville A= 210-053 SMEAD KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE TRN MIN.RECYCLED INITIATIVE CONTENTIO. Certifi.d Fiber Sourcing POST-CONSUMER www.sfiprogrem.org SFWIM MADE IN USA GET ORGANIZED AT SMEAD.COM Commonwealth of Massachusetts -,i Title 5 Official Insp ection Form ��OP l� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins - Owner Owner's Name information is required for every Centerville MA 02632 September 16, 2019 page. CitylTown 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 A. Inspector Information filling out forms on the computer,use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 Co � Company Address Forestdale MA 02644 City/Town State Zip Code , » 508-509-0802 S112843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 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. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails September 19 2019 Inspector s 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. t5insp.doc•rev.7126f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is Centerville MA 02632 September 16, 2019 required for every page. Cityrrown State Zip Code Date 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: System installed approx 1971. System is 48+-years old. System is fuctioning as designed and has no sign of past hydraulic failure 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not de�rmined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 2 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltr tion or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is r laced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass/nspection 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 i�/❑ ND (Explain below): t5insp.doc•rev.7126=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form 1 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is Centerville MA 02632 September 16, 2019 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms of operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage bickup or break out or high static water level in the distribution box due to broken or obstructed ipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe )are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstructio is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribu 'on box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced [.]/Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owners Name information is MA 02632 September 16, 2019 required for every Centerville State Zip Code Date of Inspection page. Citylrown 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 ' a manner that protects the public health, safety and environment: ❑ The system has a septic tank and so' absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tr' utary to a surface water supply. ❑ The system has a septic tank an AS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic to and SAS and the SAS is less than 100 feet but 50 feet or more from a private water sup y well*". Method used to determine di ance: **This system passes if the ell water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates sent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, pro ded 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 ❑ ® Backup of sewage into facility or system component due to overloaded 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 t5insp.doc-rev.7I26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is required for every Centerville MA 02632 September 16, 2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than '/z day flow ❑ ® 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. El ® 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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 CA. Yes No ❑ ❑ the syst m is within 400 feet of a surface drinking water supply ❑ ❑ the s stem is within 200 feet of a tributary to a surface drinking water supply i El ❑ thefsystem is located in a nitrogen sensitive area(Interim Wellhead Protection ea—.IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �.; 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is Centerville MA 02632 September 16, 2019 required for every page. City/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 CA 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 CA 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? ❑ ® 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? Was the facility owner(and occupants if different from owner) provided with ® El 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 information. For example, a plan at the Board of Health. ® El approximation 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is Centerville MA 02632 September 16, 2019 required for every 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): 330 GPD Description: 6'x 6' leach pit w/2+-' stone 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2018= 104 GPD2019= 72 GPD Detail Sump pump? ❑ Yes ® No August 2019 Last date of occupancy: Date t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is Centerville MA 02632 September 16 2019 required for every State Zip Code Date of Inspection page. CityTrown D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., tc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank pr sent? ❑ Yes ❑ No Non-sanitary waste discharg to the Title 5 system? ❑ Yes ❑ No Water meter readings, if a ailable: Last date of occupancy/ se: Date Other(describe belo ): 3. Pumping Records: Owners records pumped 3-4 years ago. Source of information: Was system pumped as part of the inspection? ® Yes ❑ No 1000 If yes, volume pumped: gallons How was quantity pumped determined? Site tube on truck Maintenance Reason for pumping: t5insp.doc•rev.V2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form i e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i ,. 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is required for every Centerville MA 02632 September 16, 2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® 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: System installed approx 1971 Age of home No files available at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2 Depth below grade: feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): n/a Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official p ffi ial Inspection Form .. � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is Centerville MA 02632 September 16, 2019 required for every Date of Inspection page. CityrTown State Zip Code D. System Information (cont.) 6. Septic Tank(locate on site plan): 1.5 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 8.5' x 4.5'x 5' 1000 gallons Dimensions: 3„ Sludge depth: 4 Distance from top of sludge to bottom of outlet tee or baffle 31" 5"at Inlet, 2"at outlet Scum thickness 1011 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" Dip tube and tape measure How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet concrete baffles in place. Outlet baffle showing corrosion but functioning. Liquid level at outlet invert. Risers bring covers within 6"of grade. Inlet line is cast iron, outlet is orangeburg. Recommend maintenance pumping every two years. 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts rd Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 29 Willow Run Drive Property Address Richard Hodgkins Owner Owners Name information is Centerville MA 02632 September 16, 2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to t of outlet tee or baffle Distance from bottom of scu 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: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owners Name information is Centerville MA 02632 September 16 2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and flo switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (lode on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribut' n to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is Centerville MA 02632 September 16, 2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump cha ber, condition of pumps and appurtenances, etc.): * 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: 1-6'x 6'w/stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is Centerville MA 02632 September 16, 2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level 2.5' below invert at time of inspection. High water staining 18" below invert. 4 rows of holes w/clean stone below invert and above staining. No sign of past hydraulic failure. Riser brings cover within 6" of grade 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration f Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool i Materials of construction Indication of groundwater inflo ❑ Yes ❑ No Comments(note condition soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts ,z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 29 Willow Run Drive Property Address Richard Hodgkins Owner Owners Name information is Centerville MA 02632 September 16, 2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs f hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form . f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is Centerville MA 02632 September 16, 2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 I .1 O 0 i 1 1 I I I i t5insp.doc•rev.MM2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is required for every Centerville MA 02632 September 16, 2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >2 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Accessed local ground water contours and topo mapping. Base of leach pit 8' below grade. Approx high ground water>15' in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 •- w Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Willow Run Drive Property Address Richard Hodgkins Owner Owner's Name information is required for every Centerville MA 02632 September 16, 2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18