HomeMy WebLinkAbout0100 PEACH TREE ROAD - Health 100 PEACH TREE ROAD
Marstons Mills
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
) N?cur� at-e- Ko
Proped
Address
i
a r6 L S ch Lt,l fe
Owner Owner's Name ✓ f 7
information is r� S �^ I M � C� 07
required for every '/ 6 l
?h,
page. City/Town State Zip Code Date of l4spectibn
Inspection results must be submitted on this form. Inspection forms may not be altered inrany
way. Please see completeness checklist at the end of the form. k
Important:When filling out forms A. Inspector Information 61*-(9908
on the computer, A f"f�, ` ` J AX
use only the tab �/�) 4 I I � i )(�t� �)�--t1
key to move your Name of Inspector
cursor-do not LLC
use the return Company Name
key.
4:1
Company Address
lrtia er3 h at e—
City/Town State Zip Code
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 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
�f b
In pector'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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Fora'
Subsurface Sewage Disposal System Form o Not for Voluntary Assessments
Property Addreess ],
Owner Ca&6L� S h 4-,,1 �7
Owners Name
information is ho f6�s /I haI�y� 0
required for every �Lr 1 `L�
page. 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) Syst 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: �—
�flc�� �� Xe4 C-
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So 'IT C
K
2) System Conditionally Passes: / J
❑ 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 exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
r
Commonwealth of Massachusetts
: p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
I I +e
Prope Address
Owner �[_ L S
Owner's Name
information is '�t yr � ' i Jar-)I q
required for every Y y 1 w�'7 �f 1.� (/Yl �f
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.): �14
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health): NO
❑ 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:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
too �ieccj Tr o cc(
Property A ess
aK O L S ck LLJ-fe-
Owner Owner's Name
information is ''/M�r�rr'� y� �+j.� I c /_ �(p(� Q
required for every �" " � 1
page. City/Town State Zip Code Date If sno Date
C. Inspection Summary (cons.) IVD
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other: _
-F0,j,J
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
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Commonwealth of Massachusetts
!n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
00 I2 c�� 1��� 6 n, C-1
Property Address
rrie,nL Sch. I+C
Owner Owners Name 1 fn,, �f� �f information is /1_ �r S j,,r,�S Ao � ! s Y�r )q C) `�V r ` /I T 7 /;b-19
required for every (i►� 1U� � V /
page. City/Town 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.
❑ 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.
❑ 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 yin Section CA. y�
Yes No /P
❑ the system is within 400 feet of a surface drinking water supply
❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ � the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
Prope Address
Owner Owner's Name /, /
information is f_ ,. S L�,r, c I �S `" R oc?&Ite l/o /q
required for every 6 1 �J VI 1c� mot✓l 1
page. Citylrown State Zip Code Date of Inspection
Co 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)
Q�1 ❑ 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 Absorption System (SAS) on the site has
been determined based on:
❑ Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
I
Commonwealth of Massachusetts
�n Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
too (�o ���
Pro Address I
ch
Owner Owner's Name
information is ` ,„, ^' 1 /_r /,
required for every hi G r J y t//► I I-S Vn)9 0- 1f�7 '7 Q
page. Cityfrown State Zip Code Date of Inspe ion
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):
Description: 1
Number of current residents: 0z
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 [Y No
Water meter readings, if available (last 2 years usage(gpd)): -
Detail:
ee � do 5 Oe M �?e 4 ai
CRD18 q ( 1 yoo 70-4 / ws
C�?CUfq
Sump pump? ❑ Yes 9 No
Last date of occupancy: *"0
ate
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
^1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
Property dress
Owner Owner's Name
information is i. .1 4,6 �M � 1-S � ). 00 �'required for every 1 Y r� r ` J,—Lo
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
2. CommercialAndustrial 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., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
p6h, A Source of information:
Was system pumped as part of the inspection? &A'0 y ❑ Yes No�
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
Tl�e c�"
►�
Property A dress
Owner Owner's Name
information is max )-f6 n-s 1 ( S �� /'] �e�(q
required for every ,�✓ ` l c�V C
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
)f-.
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„dpte installed (if known)and source of information:
3
Were sewage odors detected when arriving at the site? ❑ Yes QQ No
5. Building Sewer(locate on site plan): N14
Depth below grade: feet
Material of construction:
❑cast iron ❑40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
!� Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
loo kafk' nf-'e- K'06,4-
h. �l
Propert Address
, "L 5 ,6
Owner Owne ame /�, /y
information is
required for every �w25knS hq)//S M P' (3 / //7/,--Y)6
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan): J
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
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle W
Scum thickness 02
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
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.):
O �(
aAJ D-
0tiC:� ��o et
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
i= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
d aach 77T,,e-
Prope Address
L sc 4
Owner Owner's Name
information is q,,,, f��.,c � J& �� /�r)/
required for every Y� � / u
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan): 11` q
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at tim 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
p Title 5 official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
loo
Property Address
Owner Owner's ame
information is
every I i} o ) (it 7`1 /,ap/9
required for every l J �YL ` I y�- JL
page. City/Town 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 float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Sox (if present must be opened) (locate on site plan):
q
Depth of liquid level above outlet invert � p
p
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.):
AJi O 0 C'
C 5 Olt i
�N) Cc� dl/iG� 1 J
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
i no eeacl)
Property Ad ess
ul ozb L s cA Lt--.,)�'
Owner Owner's Name
information is ��.r� /�� t !is t'n-Pr
required for every )
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan): - 1
Pumps in working order: N ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, 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, exp ain why/
Type: �J /
leaching pits number: w
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system r
Type/name of technology:
L
cZorn t5insp.doc-rev.7/26/2018 Title 5 Official Inspe Subsurface?wage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
_ 160
Property Ad Zs
LW L wl
Owner Owner's Name
information is h&r5hru /,A! //S Y�/ ��q (Lf�' /
required for every ,{.y�'/ ' L U wx 6 1
page. Cityfrown State Zip Code Date of Inspecfion
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.):
e-A LZ) fi
it
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration /VP
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
campy, Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
u l��re /La-j
Property
�� L � LL, �
Owner Owner's Name / /�.�
equ edlon forlevery ctr6k l� 1 �`� i� ® �� 7//7 1c)o`
page. Cityrrown State Zip Code Date of I nspecf n
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of 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 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
. r n
PmpertyAddress
Owner Owners I wner's Name --------------------
information is
required for every4sp
page. City(fown State ZipCode Date ooi
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
b�l A-A 33
A 2
B C 3, C, ��,2
A
ref
� 1B q
` P 74:a/1-1
i5lnep.00c•rev.7126/2019 Title 5 Of ic(ai bisoeciion Form:Subsurface Sewage bisposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
Property Address
Lj 19—a
Owner Owner's Warne information is ,1 V,G l��n„h� �l, ®`�/
required for every �o�rJ
M17 /96/
page. City/Town State Zip Code Date 6f Inspection
D. System Information (cont.)
15. Site Exam:
[heck Slope
rface water
heck cellar
Shallow wells RIO
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)
❑ Accessed USGS database -explain:
You must describe how you established the high ground wa er elevation:
Q `
Before filing this Inspection Report; please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
Jac) PP6Lh T�j
Property A ess
ua lzo L
Owner Owner's Name
information is JM ara) N C nj //S n f- d�C1F I 9/k)J(3
required for every �/L /y/ � /" ` �'„
page. City/Town State Zip Code Date of Inspe on
Ea Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
E A. Inspector Information: Complete all fields in this section.
B. Certification: Signed & Dated and 1, 2, 3, or checked
(� C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
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
�laj> I
ASSESSORS MAP NO!i e PARCEL `--
L 0 C A T ION S E W A G E PERMIT NO.
VILLAGE
\ I N S T A LLER'S NAME & ADDRESS
B U I L D E R OR OWNER
7 liz *-d CA-, c,,-
D A T E PERMIT ISSUED
DATE COMPLIANCE ISSUED
.z,
c CAS
It
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No...�1..�._�.���� Fps. .--..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�... . .................oF....:........ ,r,�� .. .............................
. ppliration for Dispasal Work,5 Tonatrurfivit 1hrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Sy§lem at: _
_- tt l t, .. � ,s ------`--/-/---ma-y---�--........}� ...- ...... ----.•...-----------...... ..........--
.S.a._ ..! .Y.SALo.cation.Add..r.e•s-s^-'•----•-------- --•-- .l.�cP�ed4.Y.`__-�.�2_�e�J .. o.
2. ...
V
Owner Address------------ �
A
Z.
Installer Address
UType of Building Size Lot_...__I}.��_�__.___Sq. f et
Dwelling—No. of Bedrooms......_��................................Expansion Attic (A® Garbage Grinder Q��
�`4 Other—Type T e of Building No.. of persons............................ Showers
YP g -------------------•------•• ----- .... ( ) — Cafeteria ( )
Otherfix ures ----------•-•-•-•-••-----•--------•-•-----. ---------------------------------.-----------------.....---...-----------....--••-.......------
W Design Flow.......6. ........................gallons per person per day. Total daily flow.......... _ ..................gallons
WSeptic Tank—Liquid capacity-)Q.CWlons Length.'�a"C�_.. WidthA.40.. Diameter--®`.... Depth...�_..q
x Disposal Trench—No............................. Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........�L--___-- Diameter--__ t....... Depth below inlet._:�...... Total leaching area...3 Z-sq. ft.
Z Other Distribution box es Do ' tank ( 1 p
'-' Percolation Test Results Performed by. �!dSi ..../Vt► ....�. _ ...... Date...I�It��i_.�j_._� .s
Test Pit No. 1...4 -..minutes per inch Depth of Test Pit......L0-____ Depth to ground water...LAZTEhX,6xjL"L
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.................................
----•--------------•••-
O Description of.Soil....0--�. --•--- !! Z�. ........�L="-C--•---���... ...
------•-----••--------------•-----•-•-----•-----------••-•--------------•---•-------•--•--••- � cz.4.71=6k C .
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-•------•------------•--------------••-•-------------------•------...--------------.................---------•••--------------------•----------•---------------._....-•----------------...._.__.........
Agreement:
The undersi agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions Imp 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation Jitificate of Compliance h en issued by he o rd of health.
Signed..... ----- ------------
Dat
PPlicat' Approved By.......-• fit .......•-- -• •----------•-------------------------••-•------- ... a<4_4` �------
Date
Application Disapproved for the following reasons-----------------------------•-••---••----------------...------•-----------------•-----------•--•-----.....•••••-
...............................••-----•--•--•--.......------....--------•---------------•-•-••----....-----...-----••-•-•--------------•--•-------••----•------••-••......---•------•-.................
Date
Permit No......-�5.�'....-- f '7 ............ Issued.......................................................
Date
' 1, f
J
a A v
Fps
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
6 /R -- --------------OF F'
'Appliratiou for Dispasaal Works Toustrur#inn, rrmit
Application is hereby made for a Permit to Construct ( kor Repair ( ) an Individual Sewage Disposal
.....................................C Rk ..VA t..L
=� • Location-A dress
#-Et 'L...._.............................................................. ...
Owner
( Gu � x C�C. t PNLO Address �.� l�i iC�J+V UI`> {•�<<t a
dress
....................••...... stall•---•• ._._._............ .--------- �......_........... ... ..`\ ....... .......-------••---•--....------••.
� Installer Address
vType of Building Size Lot... 4?_.0 3•�_____Sq. f t
Dwelling—,No. of Bedrooms............................................Expansion Attic ( J�,)C> Garbage Grinder (I A)O
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ' )
Otheraxtures ..............................................................................................................
W. Design Flow___._.__.'................................_gallons per person per !: �7. Total daily flow............... .........................' gallons
W Septic Tank—Liquid capacity__y�. allons Length.�'.�Z>.. Width'..-Q.. Diameter__.`"...... Depth....
-�
x Disposal Trench—Np. .................... Width....r.............. Total Length............. i... Total leaching area......... ....sq. ft.
Seepage Pit No,---------_�: " Diameter-__-- ......... Depth below inlet._�`.�....... Total leaching area... q. ft.
Z Other Distribution box ( CS D ank ( 0
'-' Percolation Test Results Performed by-12 ` - -...i ----_.
04 Test Pit No. I...-/� --minutes per inch Depth of Test Pit...... c ._._.__ Depth to ground water_.__..._
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
D 0 �•-----t_.c.�v�.-----• ------•......... ................ ....... - -----�---•-------.---
Description of •..............•• �....2'j t L.. '1-- t � l._ �014
(xj ......................�!-��t......---•--==......-.....•--....j..t....,-_.. ..T...... -
UNature of Repairs or Alterations—Answer when applicable.................................:.............................................................
-•------•--------------------------------•----------------•---•--•-----------------.....-•----.....----•----•-----------------------...---------•-----•---------------•-------------•••......•--•------
Agreement:
The unders!*Fle agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions m -E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation rtificate of Compliance has-been issued by the board of health.
e%.......... V
f
licatie Approved B ..........................
• `-�= �/....................................................... •..--�l �!f
PP PP Y . - -
Date
Application Disapproved for the following reasons:-----•---------------•---------------------------------•------•-----------------•---------......-•--•-•--•--•---
--••.......•----•---•.................•--......------•-•••---••--••--•--•...•-•-••-•••--•--.....----...---•......_-•--•-----•-----•---•---•••----••-•----•--•---•-••-•--...--•------••----•----••-------
Date
Permit No.-•-•• �S .�... �T7, Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF................................
Tatifiratr of (Sompliaurr
THIS F he/Individual Sewage Disposal System constructed ( ) or Repaired ( )
t P !w. .a•
t In dller t I�t yV\
-. •---• -••--••• - ------------ ------------------------------•-•---------------------•--•-----•------------------••---------------
-.
has been installed in accordance with the provisions of TITIE5 of The State Sanitary Code a desc.ibed in the
'application for Disposal Works Construction Permit No.__4 _>_"'.!v _ --.. dated_...._-_1- _ ?t t?
- ------
,-.°THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
..v
.'SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF*MASSACHUSETTS
BOARD OF HEALTH
...........................................OF...........-_............................ ...........
No. ate/,.
Maposa1 rr ti#
Permission is hereby granted....... .:.— .....
_
to Construct ( ) or Repair an Individual Sew,ea�e,,D� isposal S stem
Street
as shown on the application for Disposal Works Construction Permit No _r` ated___._ .. - - •- ../ --•-_----___
o rd UF Health
................._
DATE........!Z'- �'�----�*'--..-��•
1,
F,,nRM 1255 HO S & WARREN. INC.. PUBLISHERS'�
3 x Ito X
SST tG'T�E.1�. 5N. I I O I< 1 SOy% _ �19.SCzI�►
? Ae.A
07 00
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.�R OF ,�jH OF r,%
rg WILLIAM ties , PL E yG�. l�2 ..]_ ^T;�IZ vs
C.N Y E SULLIVAN
No.29733
,p No. 19334 O
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