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Commonwealth of Massachusetts
Title 5 official Inspection Form -�--
Subsurface Sewage Disposal System Form-:Not for-Voluntary-Assessments
Property Address /l i•..
owner Owner's NameInIbimation is
required for every
pop, City/Town State Zip Code Date of inspection E, t
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.
rrtrportant:When Information A. Inspector
mks«,tforms
t na t onlytabs
key to move your Name of Inspector
cursor-do not E,4,S 5 v,e i/F
use the return Company Name 7 q
key. /
a+ Company Address
SAE City/Town State Zip Code
AR
Sew- S27 - oy Zv�2
Telephone Number License Number
B. Certification
1 certify that:i am a DEP approved system Inspector in full compliance with Section 15.340 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
Inspecto 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
Me buyer,if applicable,and the approving n9auth .
Y•
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.
dinWdoc•rev.71=018 ride 5 Of el Inapecdon Form:Subsurface Sewage Disposal system•Page 1 of 18
�°99� U81-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Qisposal System Form-Not for Voluntary Assessments
Property Address
owner Owner's Name
WwrreWr etion is
te�ired for every
per_ City/Town 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:
ly 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: /
2) Sy ern Conditionally Passes:
❑ One more system components as described in the"Conditional Pass"section need to be
replac or repaired.The system,upon completion of the replacement or repair, as approved by
the Board Health,wig pass.
Check the box for" s", "no"or"not determined"(Y, N,ND)for the following statements. If'not
determined,"please a lain.
The septic tank is metal an ver 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial in tion or a iiltration or tank failure is imminent.System will pass
inspection if the existing tank is rep with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it 1 tructurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than ears old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5kSp doc•rev.7/26/M18 Title s official Inspection Form:Subsurface Sewage oisposal System•page 2 of 18
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage
Disposal System Form-:Not for Voluntary-Assessments -
Property Address���
Oemer Owner's Name
niwmation is
required for every ��S UZ�� -Z z- r 9
Pam- Cityffown State Zip Code Date of inspection
C. Inspection Summary (cont.)
2) Sys Conditionally Passes(cone.):
Pu Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pump arms are repaired.
❑ Observation of se a backup or break out or high static water level in the distribution box due
to broken or obstru d pipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspection if(with provai of Board of Health).
❑ broken pipe(s)are r laced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or re ced ❑ Y ❑ N ❑ ND(Explain below).
❑ The system required pumping more than 4 times a year due to en or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ N Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Ex in below):
3) F Iher Evaluation is Required by the Board of Health:
❑ Conditions st-whi a uire further evaluation by the Board of Health in order to determine if
the system is failing to protec eaith, safety or the environment.
a. System will pass unless Board of Health dote ' in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a mann ich will protect public health,
safety and the environment:
doe'rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sews Disp
osal posai System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
ola w Owner's Name
irrtormation is /�/1a/t/!S
required for every
Pap- City/Town State Zip Code Date of Inspection
C. Inspection Summary (coot.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Ce ool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will . unless the Board of Health(and Public water Supplier, if any)
determines that th system Is functioning In a manner that protects the public health,
safety and environm t:
❑ The system has a sep tank and soil absorption.system(SAS.)and.the SAS is within
100 feet of a surface waters ply or tributary to a surface water supply.
❑ The system has a septic to and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank a SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SA 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,performe t a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of amm is nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are iggered.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
dogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or dogged SAS or cesspool
%SkapAoc-rev.7l2W2018 TNe 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for,Voluntary Assessments
9-Z-rZ04,1f
Property Address
G11Y,oT
®wrier Owner's Name
ragW dfo is 1110115 � DZ�Ul � ZZ-/ 9
requited for every -
PO, cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cons.)
4) System Failure Criteria Applicable to All Systems: (cunt.)
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%day flow
Required pumping more than 4 times in the last year NOT due to clogged or
❑ obstructed pipe(s).Number of times pumped:
11 Any portion of the SAS,cesspool or priory is below high ground water elevation.
❑ f 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.
❑ 4u 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&dft.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 coned the failure.
Nl 5) Lang stems: To be considered a large system the system must serve a facility with a
design flow—olleAR gpd to 15,000 gpd.
For large systems,you m irate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes. No
M ❑ ❑ the system is within 400 feet of a surface water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drin ' water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead on
Area-IWPA)or a mapped Zone it of a public water supply well
takePdoc•rev.7/2812018 We 5 Oiadal Inspection Fomt Subsurfaoe Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form-Not for Voluntary-Assessments=
Property Address
L HYR7-
Owner Owner's Name
intimation is
taquired for every
page. City Town State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
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 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 foilowing for aft 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)
0 ❑ 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
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorpti System(SAS)on the site has
been determined based on: Z.�0.T��s� �a�v,�� 1 j'ZO-CIE f
El f= ®0,
( xisting information. For example pl the Board of Health. 5 ./f
❑ Determined in the field(if any of t e failure criteria related to Part C is at issue
approximation of distance is unacceptable)(310 CMR 15.302(5)1
/o coSr�aG��y
Skajpkdoc•rev.7l2W018 Title 6 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
Property Address
owner Owner's Name
Wormation is
required for everyf ��U� �- Z z'/9
Me. City/rown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms(actual):
S Sf�
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
C/ V CAI ` Y , `—�'L► CJG
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
Seasonal use? Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes �g No
Last date of occupancy: ZOz
Da e
Maly doc•rev.7Y16MM Title 5 Olfidal InspeCdon Fomr.Subsurfeas Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-.Not for Voluntary Assessments
�ll filer/<W� ,4v�
Property Address
Owner Owner's Name L/7'
Jilftmation is
IfmquhW for every tf/tf4/�5 4 lj2G / /_ ZZ_/y
page, Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Typ of Establishment:
Design w(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of des' flow(seats/persons/sq.ft., etc.):
Grease trap pre nt? ❑ Yes ❑ No
Water treatment unit sent? ❑ Yes ❑ No
If yes,discha s to:
Industrial waste holding tank p ent? ❑ Yes ❑ No
Non-sanitary waste discharged to the itie 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? NI I ❑ Yes No
If yes,volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping: � '��----�-
.Aoc•rev.7126=8 Title 5 Ofir9al Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System.Form_--Not for Voluntary Assessments;-
'lD�ar/eni� %ram
Property Address
G# YIV
Owner Owner's Name
kformation is �S/�NN�s
►egWked for every Z Z- 9
P"e, Cityfrown State, Zip Code Date of Inspection
D. System Information (cone.)
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:
/
L �'7 k nv 5,,e )
Were sewage odors detected when arriving at the site? ❑ Yes [4 No
5. Building Sewer(locate on site plan):
Depth below grade: Zfeet
Material of construction:
❑cast iron [A 40 PVC ❑other(explain):
Distance from private water supply well or suction line: Tam Gva7�eVSVt-V1`e G�/� S`
feet b, �jP/ap��y.�I
Comments6n77,ition 7*tng vidence of lea , etc.): (/
AocOkAp •rev.7/26/2018 Title 5 Offiaal Inspection Form:Subsurfaoe Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
s
Title 5 Official Inspection Form
Subsurface Sewage Disposal System_Form Not for Voluntary Assessments-
Property Address
z A/y1�7
Owner Owner's Name
information is
wired for every 14.11t/r 5 -
p City/Towm State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: l
feet
Material of construction:
( ]concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: - 'V�.4
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No N1
Dimensions: g�X u i %5 rZ o
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle '¢
Scum thickness
Distance from top of scum to top of outlet tee or baffle A(14
Distance from bottom of scum to bottom of outlet tee or baffle y/'g
How were dimensions determined? /
Y1d� S �v tRa
tk .� c�ocl 11 yy ood—
ments(on puml omp�i ile#an Duffs e >r afP7condt#41 Ouch"Iliuid levels as rei fed to outieff inidence of leakage, c.j: //
Z h d � a har
Wkqp
doc•rev.7126r2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7e) ��t/��� �✓5
Property Address
Lam`/PT
Owner Owner's Name
information is y A L/
required for every
P"e. City/Town State Zip Code Date of Inspectio6
D. System Information (cunt.)
Nla 7. Grease Trap(locate on site plan):
Depth low grade: feet
Material of nstruction:
❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of o et tee or baffle
Distance from bottom of scum to bottom o utlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet an utlet tee or baffle condition, structural integrity,
liquid levels
s as.related to outlet invert, evidence of leak e,etc.):
Nla 8. Tig r Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below g
Material of construction:
0 concrete ❑ metal ❑fiberglass ❑polyethylene
yl ❑other(explain):
Dimensions:
Capacity.
gallons
Design Flow. gallons per day
Okk .doc•rev.MAf2018 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 -
1D�tZt/�
Property Address
z 6J Y�r
Owner Owner's Name W / / /
bimation is /�/A I
required for every
pale. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4 8. Tight o Holding Tank(coat.)
Alarm presen . ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float hes,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):
P )( P )
Depth of liq7ote
level above ou t invv9rt
Comments if box is level and`d' 'bution to outlets equa,�an evidence of solids carryov�, any
evidence of lead k� to or out of boxtc.):
lG /GX zz
1� e d/ 2 e C--7'//we -e CA-L"
WxwP doc rev-TA018 Title 5 Official Inspection Form Subsurface Sewage
Disposal System•Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official -inspection Form
Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments -
Property Address
L ILI YI°T`
Owner Owner's Name
Irtormation is �, 9 �✓��S OZ�o/
required for every
Me- Cityrrown State Zip Code Date of Inspection
D. System information (cunt.)
'VI 10. Pump hamber(locate on site plan):
Pumps in works order. ❑ Yes ❑ No`
Alarms in working order. ❑ Yes ❑ No*
Comments (note condition of p chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a condition pass.
11. Soil Absorption System (SAS)(locate on site plan,
//excavation not required):
If SAS not located,explain why: (T�tia S4 ,/e fr/Y4 s> /
�g.S C�6- 7- ' c �✓ve�as� /.e�cGf �,�
=6-n a( _d_ G cf;'?e— O lei �Cg 5, as d<_ v7- a S- a'h- c q/i-�r�►� �L
Type:
Aleaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number,dimensions: /
(� overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Znsp.doc-rev.7IM018 Title 6 Olfldal Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary-Assessments
Property Address
L// YP 7-
Owner's Name
hftmation is ��
required for every Y S
page. Cityrro" State Zip Code Cate of inspection
D. System Information (cone.)
11. Soil Absorptio System (SAS)( ont
Comments{ to condition of soil, ns o hydraulic failur , �el of ponding, mp soil ndition of
vegetation,e .): '�P7°hz'/ �7 b
�a vrM 11�v.laa/j
Ale 651a(wrof
d� s� yew ►r/ Less oa� � s L. �9.
` V/A 12. C ools (cesspool must be pumped as part of inspection)(locate on site plan):
f
Number d configuration
Depth—top of li id 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 failur level of ponding,condition of vegetation,
etc.):
t5wsp doc•rev.7/AMI8 Title 5 fKrdW Inspection Fomt Subwftm Sewage Disposal system•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
u Subsurface Sewage Disposal System Fore-Not for--Voluntary Assessments
70 e may v�
Property Address
GAY P;
Owner Owner's Name
kdo mation is
tewkW for every
Pa". Ci ty own State. Zip Code Date of inspection
D. System Information (coat.)
J! 413. r vy(locate on site plan):
Materia f construction:
Dimensions
Depth of solids
Comments(note condition il, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
p doc•rev.7/26M18 Title 5 Otfidal Inspection Fomc Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System-iFonn-Not for Voluntary-Assessments
Property Address
Owner Owner's Name Wbrm is l'
required�for every !`7 y�n/�/�S
Me. Cityfrown State Zip Code Date of Inspection
D. System Information (cons.)
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 r'
drawing attached separately
L wuc r
ObcK �
r
,4, - 3 Z5.� �j -3 33•�
Mmq doc•rev.7/260018 Title 5 Oradal Inspection Form Subsurface D'Sewage
g Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System fort Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is
required for every
PO, City/rown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Check Slope l f
Surface water lfaAA
Check cellar Ca"L q
Shallow wells `TIM-A
2 a rr�
Estimated depth to high ground water: 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)
rVI
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
.ay /
�� wZ, �7�Y�oT7aAy�•/
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
VWwdoc•rev.7/2612018 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•page 17 of t8
Commonwealth of Massachusefts
Title 5 Official Inspection Form
Subsurface Sewage Disposal system:Form-Not for Voluntary Assessments -
NTA411AI�
Property Address Y/4�'7-
QMmer Owner's Name c•
information is /—
for every
p"e, City/Town State Zip Code Date of Inspection
E. Report Completeness Checkilst
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
Wr►sp.doc•rev.7/Ye1 a Title 5 Offidal Inspecdon Forth:Subsurface Sewage Disposal System•Page 18 of 18
P
L O CATION S E A G E PE OMIT 430.
VILLAGE
N S T A L L E R'S NAME b A D D D E S S J. CRAIG MEDEIROS
Trucking & Bulldozing '
142 Corporation Street
0 U I L D E 0 OR OWNER -0828
M elm,s - 1
1/7
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED 3/2 ���
_�tr ���y ��'�
� S� ��
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, , tl�
��� � �� .
R� � � � C
C
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e '� N � �
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r
o �
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Ij Oa�
NoU
THE COMMONWEALTH OF MASSACHUSETTS
-BOARD 0Y HEALTH
------------ 0 F........ . .......................................................
Appliration for DWpotial Works Tvnstr ' n Vamit
Application is hereby-made for a Permit to Construct or Repair an Individual Sewage Disposal
SYS'l .. . ................... ........ .......................................................................................
Loc,4 ress or Lot No.
....... ... .. .................. .................................................................................................
Address
.. ............................... ..................................................................................................
Installer Address
T e of Buildi Size Lot............................Sq. feet
U
Dwelling__ No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
Other—Type of Building .............................No. of persons............................ Showers Cafeteria ( )
Other fixtures ..................................... .......
-------------------------------------------------------------------------------------*-------------*-----
Design Flow..........................................'__gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid'capacity............gallons Length................ Width._.............. Diameter_______---_---_- Depth_._..__.._..._..
Disposal Trench—No..................... Width.................... Total Length,....................Total leaching area....................sq. ft.
Seepage Pit No____________________ Diameter.........._..__..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.................... .. .......*................................... Date.......................................
04 .
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_-___-_______-__--_-___.
44 Test Pit No. 2................minutes per inch Depth of Test Pit..._..........__.... Depth to ground water....................__..
P4 ..........................................................................................................................................................
0 Description of Soil.......
................................................................................................................................................................
..................... .................................................................................................................................................................................
................................................................................................-------------- ........ ..........
— � I- ----- ..........................Nature of Rep ion nsw � w��n a cable.......xoe _Onv_ -U Airs or Alteration 4p
... ........ ...... -------- -
Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary,Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issue
5e�by the board of health.
'4
oig .. ...
ed.- .... .. .... kk&ItOl�-
/.-�ign ------............................................ ................................
..M ate
.
..
. ...
Application Approved By.......... .
. .... ....... ......... ..................................
Date
Application Disapproved for the following reasons:......................................................................................__......................
........................................................................................................................................................................................................
Date
Permit No.... .. .... Issued------:3
-------------------------- .........ram`.....C...............................
Date
No. ....... 1:_ FEs.1.1,`�'.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0?)= HEALTH
------------ --------------.OF........ .... :...'...
Appliratilan for Disposal orko Tonstrulrtilait Frrutit
A plication is hereby made for a Permit toy Construct ( ) or Repair ( an Individual Sewage Disposal
Syst at:,
..... .. L/I.IwV,
..�. y-------•-------•------------' ...............•----_..... ...... ..........
Loc • Address or Lot No.
..... �� .. _.----•----• ..........
-----------------------••---•---- ._ .......-•----.........---....................
•Address
p� Installer y Address
UT e of Buildir}g/ �,, Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a Other—T e of Building W Other—Type g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ----------------•----------------------•--------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity..........._gallonk Length................ Width................ Diameter________________ Depth_.............
x Disposal Trench—No.____________________ Widih.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------------------- Diameter...................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing"tank
aPercolation Test Results Performed by................1-.............................................I% Date........................................
Test Pit No. 1_._____.,:_,,_._minutes per inch Depth of Test Pit____________________ De th�to ground water........................
44 Test Pit No. 2...............minutes per inch Depth of Test Pit.........:_________. Depth do ground water........................
`-----------------------------------------------•-------•--------•-•-•-------..........---...._.----••------___-__-_______-----•-•-----•------...__....._.
ODescription ofSoil .._'.' ==--------------------------------------•-------------•--•--------------:------------•--� .......................................................- _
1 ` " -
U Nature of a irs or Ahteration Answ r w nap cable____ -�'
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system�`m
operation until a Certificate of Compliance h4..
ssu by the board of health.
0. igned. ••••. _•- �Application Approved By.....____. _f__•- -••- • ------------ - ............
Da,•_••'---•----^- -�"'-=------'__Date--•-•---------
t'
Application Disapproved for the following reasons:.. •-------•--
..............................................------------...------------...---------.......-------...-------------•---•-----•----------------..____.---------•--•--------------------•------•••-------
Date
PermitNo.r..........................:.......•-------•-•--------_. Issued_......................................................
Date
r, THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ .......OF............ ..:. .... ..........................................
I/ Tntifiratr of T amptianrr
IS I TO IF ' That t e Individual Sewage Disposal System constructed ( ) or Repaired
by..... .. ............ . ••. --......_ ----- -------------- ...
0� t • Installer
has been ins'falled in accordance with the provisions of F 5 of The State Sanitary Code as/desc 'bf� in the
application for Disposal Works Construction Permit N ____, __'-g`Y±................ dated--... .. .....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............-7..,. ��LL''�• Inspector..... -----------------� ----------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
p
rT(A .....OF.. LY1�!?..:............................................. "
...... ........... FEE .._...__..
rn
-
Permission is hereby grante -�---
to Const ucV,,( or Re pa' ( ) an n ,vidual Sew e is bsal Sy
at No.`_ ` _ .._:. - et-- ---_ _
as shown on the application for Disposal Works Construction Na .'__ Dated....... 2�'�' `'
---- ! ✓ _
:.
Board of Health
DATE.._.. V*6--------_-•------•---------------
FORM 1255 •HOBBS & WARREN. INC.. PUBLISHERS ''~��•