HomeMy WebLinkAbout0933 MAIN STREET (OST.) UNIT #H - Health A/i A. M. 117116 i
DAMES & JACQ UELINE NCI
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Commonwealth of Massachusetts
jibExecutive Office of Environmental Affairs
®epartment of
Environmental Protection
Go.erfa F.Weld. Trudy Coxe
Argeo Paul Cslluce s.ar.+ yi U.Gwwrnor David B. Struhs
Comminioner 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: A_ r.Address of Owner.
Date of Inspection: (If different)
Name of Inspector. PAI
Company Name,Address and Telephone Number.
CER4FICAT A 4A MEIr"T
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
��Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: / Date: / / 7
The System Inspector shall sub a copy of this inspection report to the Approving Authority within thirty.(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes
inspection.
Indicate yes, no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exiMtration .or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) I
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(61.7)292-SW
4
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: S�-
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
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DEPTH TO GROUNDWATER
Depth to groundwater: /2--feet
method of determination or approximation: -��
(revised 8/15/95) 9
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