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134 Title 5 7-11-18
7----In Commonwealth of Massachusetts I _ Title 5 Official Inspection Form eL ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Jr: _ - /3V //UDG/36,010 20410 Pro Address /nDC-u/vE_ eft O1 Owner owners Name mmrmasons � r.s,y-�� N//4 ot0.73 7l// LTO/8 required for every k v a-1, la page.' • • Cayfrown Slate Zip Code Dale flmpection 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. impede"°w"e" A. General Information nag out forms on the computer, '6.JoiVO use oil/the tab 1. Inspector: ` ��e/ 1 cursor moveyour k ,�+1�_��77 key etomovnol tie-1-11/j-1f/( use me return Name of IInnsspedor key. J/,c4-fl/ i"r Chita/te.),P/U /4/6 ib company Name 111 18 Oarar Rz5,4/9 —x` Cranpeny Address J G. i rc<rr tyzss 61"6 s' Gay/foam Stam Zip Code IA Y Jry9 /of 7 sr /osr Telephone Number license Number B. Certification • I certify that I have personally inspected the sewage disposal system at this address and that the information reported below Is true,accurate and complete as of the time of the inspection.The inspeaI ae was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: XPasses 0 Conditionally Passes ❑ Fails ❑ Needs Furth aluati by the Local Approving Authority / .� • 2/i1/�Ole. Int s Signe Dam The system inspector shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,If applicable,and the approving authority. ""This report only describes conditions at the time of Inspection and under the conditions of use at that time.This Inspection does not address how the system will perform In the future under • the same or different conditions of use. lent.two TO 5 aids bpdm emm wWlsa somas o.pW ay.I.m•Pepe 1 of 17 Commonwealth ofMassaLfill's'etts • Title 5 Official Inspection Form )) Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /31/ A-o oflo.o0 xt i O' Pm'w" ii "f1.a ,zj • Owner Name mmw�a Ownah required ler every A-49 777tne(i0Jot) /ld i/o.:3 i//020/ d page' • • GtyRev.,\ Stab zip Code Dale all ocean B. Certification (cont.) Inspection Summary:Check A,B,C,D or E I always complete all of Section D , s A) System Passes: • I have not found any.information which indicates that any of the failure criteria described In 310 CMR 15.303 or In 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: • - D/sr Bax 7`O 8,g xAcn-e a0 - PVC Rfiis-orY Dau Oart'rP eluCET c Y7��t UevrT • B) System Conditionally Passe,s:� ❑ 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,:wdl 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 exfdtratlon 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. Q Y 0 N• 0 ND(Explain below): .r ., • • • • Lila.:rve lb 5 01414 HpWm Form G,Wu4u rtiar papas System.Pap 2 an. , . - �' Commonwealth.of Massaclitibtts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments /.fig 4.040 /, 6.(.iO Property Address M419l L/.c1 h'4E-0.c/ oaTM _ Inform- n b M ,� reiWredforwM' Ae� a/OS? �//o?Q/a page. • . .Cilyrm3T. Stab. ZIp Code Dab of 4�pecti B. Certification (cont.) B) System Conditionally Passes(cont): • • ❑ Observation of sewage backup or break out or high static water level In the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass Inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced 0 Y 0 N 0 ND(Explain below): ❑ obstruction Is removed ❑`Y 0 N 0 ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y 0 N 0 ND(Explain below): • • • 0 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)Areteplaced 0 Y ❑ N. 0 ND(Explain below): ❑ obstruction is removed 0 Y ❑ N 0 ND(Explain below): • • C) Further Evaluation Is Required by the Board of Health: 1 ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system Is failing to protect public health,safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system Is not functioning In a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy Is within 50 feet of a bordering vegetated wetland or a salt marsh Awa•11.10 The Veda sap.ee,Foam sub a y:a sear.qmS System•Paps 3017 • "ei "'"Commonwealth of Massadaliatts Title 5 Official Inspection Form kttiSubsurface Sewage Disposal System Form•Not for Voluntary Assessments 1394a o4o.Jy'' Liiif,C1 • p N.CJJO>pcAior. hi nil Owner owner.Neneinformation Is / y-� / so > / require every N©/c-/ /� j� /O� r%� ��D,SJ �1// ;off® pages Gb?w.n. , , State Zip Code Data of I peaaaaRRR C• Checklist Check if the following have been done.You must indicate"yes or"no"as to each of the following: • Yes No. • X ❑ Pumping Infomialion wasprovided by the owner,occupant,or Board of Health ❑ lA 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? ❑ Xr Have large volumes of water been introduced to the system recently or as part of this Inspection? ❑ �r Were as built plans of the system obtained and examined? (If they were not J'tit available ndteas WA), , 0 Was the facility or dwelling Inspected for signs of sewage back up? ,/4 ❑ Was the site Inspected for signs of break out? • 0 Were all system/components,excluding the SAS,located on site? hi ❑ 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? z - ❑ Wes the reality 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: /9TT/➢-C/•/.£/J ❑ Existing Information:Forexample,a plan at the Board of Health. ld ❑ Determined In the field(if any of the failure criteria related to Part C is at Issue l'i approximation of distance Is unacceptable)[310 CMR 15.302(5)) D. System Information I 1 Residential Flow Conditions: . Number of bedrooms(design): 3 Number of bedrooms(actual): 3 I,L,..1— DESIGN SDESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): 3.36 X/r o c A/OZY/1/7- Citi AJ /6265 4,00..CPd /S7} %. an"/2... (24.siy„Li a .,w. ,OJf/Jeine ado/ r TM 5 of W bgdee Font S W unrw sere Disposal siYen•Page of n • • " . t- Commonwealth of Massa'. Title 5 Official Inspection-Form • Subsurface Sewage Disposal System Form.•Not for Voluntary Assessments /3y 14704060 /20;414 /Z© ) Property Address • M4b �,C.iN'f 7/cool Omer owner Nam. y� ,/�F ^C �j 7k/do's nmlmelbnrequira /)n.e,/ h,�{'iv/o' A%ir Qf'W.7 page • every n. State Zip�e Dale of Inspection page: • -. C'tyRewn, _ B. Certification (cont.) 2. System will fall unless the Board of Health(and Public Water Supplier,If any) determinea thatthe system Is functioning In a manner that protects the public health, v , safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feel of a surface water supply or tributary toa surface water supply. ❑ The system has'a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ Thesystem has a septic tankand 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,perfomled at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. • 3. Other. ' • • • 0) System Failure Criteria Applicable to All Systems: You mat Indicate Wes"or"No"to each of the following for tillInspections• , Yes No ❑ Irl Backup of sewage into facility or system component due to overloaded or J�4 clogged MS or cesspool ❑ ,. �{ Discharge or pending of effluent to the surface of the ground or surface waters f"l due to an overloaded or dogged MS or cesspool ❑ Static liquid level In the distribution box above outlet invert due to an overloaded . , or clogged SAS or cesspool Do kin • Liquid depth in cesspool Is less than 6'below invert or available volume is less then%day flow am•Ino TN Sp WY Fp Wen ECM SuepNb Srvnpe NIP'S Sy,"m•Pao eq l) • Commonwealth of MassaEhbfltts ,p - Title 5 Official Inspection Form r Subsur`face�Sewage Disposal System Form-Not for Voluntary Assessments ProWlt/Atltl Y 4twn /'7 4401C—Fie F hiE0A-1 Owner Owner's Nernst .� w' p In(ormalbn N ' I /7 moi./. /f��] 4(fv/6A required for every ,✓Q/<r /F�`N� /d'v D4—"••� 6Etl page, • . •CllyRown, Slate Zip Code Dale of Insp on B. Certification (cont.) Yes No ❑ ky Required pumping more than 4 times In the last year NOT due to dogged or Y4 obstructed pipe(s). Number of times pumped: ❑ X My portion of the SAS,cesspool or privy is below high ground water elevation. ❑ 1o0‘214 Any pottlon of cesspool or privy Is within 100 feet of a surface water supply or �5 tributary to a surface water supply. - • ❑ a c" My portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 6,Q A My portion of a cesspool or privy Is within 50 feet of a private water supply well. ❑ ❑ • My portion of a cesspool or privy is less than 100 feet but greater than 50 feet pull 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 aro triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑prttq The systems a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ X The system¢a.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 systerd owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,yo�st Indicate either'yes'or-no'to each of the following, in addition to the questions In Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water sugplyl ❑ ❑ the system Is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system Is located In a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered'yes'to any question in Section E the system is considered a significant threat, or answered yes'in Section D above the large system has failed.The owner or operator otany large system considered a significant threat under Section E or failed under Section D shall upg('Ada- system In accordance with 310 CMR 15.304.The system owner should contact the operopiig(p regional office of the Department. Lay.lino - Tee s aqua Iep,Nm Fenn 5.tnta Sewpe Disposal System-Pepe 5 lit. 1 • C".—"Commonwealth of Massaehusiltt$ ikai,g --- --t, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I - A?9 ,W/do Ao J4 lei/4 .6 • Property Mikan AVI4 u ,ur h4c / Cwnet O,nals �,/ 1 �.(,/ _ ...� +� Information la MTZ I7/Y�,74,tJ ' fr o/Qs� //�i /'a/61 required M wary P Petit .ggyroan . slate Zip Code Date of Ina on D. System Information Description: ti . . . Number of current residents: . Does residence have a garbage gdndw? is Yes 0 No Is laundry on a separate sewage system?[If yes separate inspection required] 0 Yes Is No Laundry system Inspected? /'l Yes ❑ No Seasonal use? 0 Yes, No Water meter readings,if available(last .years usage(gpd)): Detail: /ai6 UG /71i O Sump pump? it81 Yes 0 No Last date of occupancy: Date Commerctalllndustrial Flow Conditions: /,0/t/A Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per dey(epd) c .( Basis of design flow(seats/persons/sq.ft.,eta): Grease trap present? 0 Yes No Industrial waste holding tank present? ❑ Yes Q No Non-sanitary waste discharged to the Tide 6 system? ❑.Yes q No Water meter readings;If avallgble: Wa.tut •- Tae egHY„.P.Wyn rant sWwrw Wve.allu»Y 3y.kn•NO N,1 7.1"-t--.- Commonwealth of MassacWOSetts 4 Title 5 Official Inspection Form E ! ( Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /J9 4O)O4o.uo .1M4 V:•, •r• Properly Address A/A0 dd eaA0 oe— //F //c.-404 Owner ovaera Nurse Information la �/�A✓// V/(/ "5/P 12L__01- 1/4.77L �e/O requfred tor wary /• r$ pap.. City/ravm T�.!'r (% State Date o/l pection D. System Information (cont.) Last date of occupancy/use: Date ' Other(describe below): General Information Pumping Records:' Source of information: O�� �' Was system pumped as part of the Inspection? X Yes 0 No -, It yes,volume pumped: /600 OntS gallons How was quantity pumped Otani/tined? /v/C!1 SUS-sd Reason for pumping: /.U,%1t G/10't-) .4'Un NCt 0.60 /-4-50,401A,Ace c/¢s/.tvdoir Type of System: Septic tank,distribution box,soli absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection recyrds, if any) ❑ InnovaUve/Altemauve 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 UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): mina,Ivlp N.5 LMa YypWoa ram SWwbu Sw.N q.N>I Sl+tun.Pep B N 17 Commonwealth of Massachusetts'. *- - Title 5 Official Inspection Form 'IISubsurface SewageDisposalSystem Form-Not for Voluntary Assessments II ' /dv/ /204osave - Property Address Alf,WG,LAM- NcoV mar Owner's Nam* Y- t ��r/ /yam A 0/0,573 ,� Information for every /1/C/�-/ /7//i%�Q /✓/U /��r ///� ���� page.. City/Tony r State ZIp Code Date of Ins phion D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: ti/(.5—P—S Were sewage odors detected when arriving at the site? ❑ Yes' No Building Sewer(locate on site plan): Z7'L ri . . Depth below grade: wet Material of construction: a4 C o cast Iron ❑40 PVC %other(explain): 'lieu( lied serve, Distance from private water supply well or suction line: feet Comments(on condition of Joints,venting,evidence of leakage,etc.): . x,tO.1--Qe.4"/ .Uor.� /J Septic Tank(locate on site'plan): /f r Depth below grade: reel Material of construction: concrete 0 metal 0 fiberglass 0 polyethylene ❑other(explain) Mae enc 5406 cic 44,8An rs-c.e cl/ /0-ti / nes,-t, Sle.9 .7,/duJ 6/-Cc' If tank is metal,list age: years q� is age confirmed kK ed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes No Dimensions: AO id •14.tr. 1/4/61/7/4 40 4 yr U to Sludge depth: aW'OM m.so'tld Wpwla Fart&4uM s.+ea•mFo.a arum•Pig.e of n "� Commonwealth of Massadhbinftts ' e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /3S° /W4o/304)•O kOa.O . P i)roperly /.6UL_ //C / '(1t _ page.ryd b / ravery o*tf/fm/1 !1/f�/ 117 Stale Zip Cod. Dal of Inspection D..System Information (cont.) Septic Tank.(cgnt.) • p r 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 Z� rr 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 Inbert,eyldence of leakage,etc.): nit"AL /5 / 0 GOOl7 Ce/t70, j7O wu C acre-ft ge)Ave—4 t za ny bN D G#$ /8n/I '--G i� • Grease Trap(locate on site plan): V N// Depth below grade: feet Material of construction: ❑concrete 0 meta! 0 fiberglass 0 polyethylene 0 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 lea•11110 TIM 6016JN Inspection Fart&Amato Song Disposal SyN.,n•Peps 10 N 17 "P'Commonwoalth of Massachusbtls Title 5 Official Inspection Form Subsurface Selvage Disposal System Form-Not for Voluntary Assessments /3ei41.2 o4 G.vo /1©i'1:e7 pro m " %11-4.40al4)A- /ALO /t) Ovmer Oman's Name Inafoaat ary ! / / fl/n f1p/Qot-1 //f1 /c ./// /0 pap, - GprRomn. ,, State ➢p Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank Must be pumped at time of inspection)(locate on site plan): Depth below grade: • d°. *LiA Material of construction: ❑concrete 0 metal 0 fiberglass 0 polyethylene 0 other(explain): Dimensions: Capacity: • gallons Design Flow. gallons per day Alarm present: 0 Yes ❑ No Alarm level: Alarm In working order. 0 Yes 0 No Date of last pumping: Dna Comments(condition of alarm and float switches,etc.): Attach copy of currant pumping contract(required).Ip copy attached? [] Yes Q No 151m•11110 Ilk 9110d SP*"Fulrt aWnwlw POOP oW?Pn sywm•Fa^,1i q n V'-'' .. Commonwealth of Masslchusetts _ Title 5 Official Inspection Form !it Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /3 9 Ao4U6o u,o"ko/!D • Property Aedre ama /�i,4,a�u.�. . /"tea 4cJ Information b - Cameo ' % ,J s_j y / page.required for every Nt� /� , /%, Cod {// /?ra� paps. • Cigrtown, State Zip Code . Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): a . Q. ri Depth of liquid leveabove outlet Invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): el) 4' ,t ,)"-!✓/J CL /,f-4CJY✓ /A.) oco-n/7f,C/ Cfl' Geze4o, /1/414j Sae /zA'/tel P ./1 to,�/,4 91...)c'tJ hoer y4-,e__ (jiocniir_45`. 2 a •S' edcup fers /Air r751exc.O \ \ \ Pump Chamber(locate on siteplan): •0,f-ii' Pumps In working Order: ❑ Yes ❑ No Alarms In working order: •• ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): r if SAS not located, explain why: t3 t'/is G'C/i-esti ,C/.1=C.e4 /C9 -r //O i • aW IV10 TIN 50112121 W{.Ylm Fomt SMureu Sone pW W ayMen•Pp.12 o(17 • -.•..e, - Commonwealth of Massbd'husetts � Title 5 Official Inspection Form c , ,II Subsurface Sewage Dlsposal System Fond-Not for Voluntary Assessments Prop.MMdress ,C 1,4Dc-C 00,- l/SO U as 0.4nthine .Ir:yW rffuiver/ riwax,,o /o•✓ .' A1-' o'OS.a 746//Adie pant � rJyyi?yet, State ��. , Delon/11won D. System.Information (cont.) .. Type: ? a . ❑ leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: !69 x 46 ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: \ Comments(note condition of so0,signs of hydraulic failure, level of ponding,damp soil,conditionof vegetation,etc.): ' i • A-A0 prb A-len-t s '4,0 r .0 7771 /CC7,v! noel/7.c/.0 ®.0 /xA7r1 y` /2 .Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Q ti/'S1 Number and configuration Depth—top of batik!to Inlet Invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of constmciion Indication of groundwater Inflow ❑ Yes ❑ No ea.IVO N.IOWA eea.elan Font 6W,M✓e Se.+C.DkP anwn.FN.0 an Commonwealth of Massachu$etts fi Title 5 Official Inspection Form E AQ - T! Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /3y Sjimn.ga<4 - %20n% n,_ •••: Prepedy Address ltiAt--0.Fe/A.fr VAce,4) Owner Owns?*name IZL wL ,1J6,C.rw-n-/+-0 /.cJ A') eva 3 7//i oz0/C5' papa. . • DiVrown, State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): • . > S • Privy(locate on site plan): d ,ffJ 4 Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): • et/mime N.5 Wed Mean Foi t&OwW.ammo Deposal Milan•P.,p.145515 ._.' 1 ' Commonwealth of Mas;achosetts �el_, Title 5 Official Inspection Form II Subsurface Sewage Disposal System Form_ Not for Voluntary Assessments /t3 ?/.lvr✓o 1450,u p aiAt 0 Property Adckess / r,WN r,p,_/•tiCr- /7ct,,OwnxOwner's Name Intonation is required for ovary 44,477-#1/1",t.,/, la-c) to . Q/a 7/���e w0> ' Glyfroen State Zip Code Date of Inspection D. System Information (cont) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including Ues to at least Iwo permanent-referencelandmarks or benchmarks.Locate all wells within 100 feet. Locate where pub water supply enters the building. Check one of the boxes below: nd-sketch In the area below ❑ drawing attached separately /1-5- 6UIG/ ii/ es • L., &e10 /1co�1 / /0 � t,t / / C 41, rn e /c -11 f:?t . . , £ , OI1NPet.4:5,0' .s'/ toL ,�wiAntiPotic b $/.v6L� Gofuf SC wi n/ ALO27.5 /mow e 5 S // p v tf inc scree , o a)/n7�Se/FIe••t¢lors' Bont-r in r ,4e 27.0 1 rvi rill f=ig. A cc;rezT $C 2g 3 r G/E/al Pi/S2-40poreoy C AD 30, 3 --_ SD 3i. r 0 Eacn.vy¢1-to r/Ps '7/i//2o,'t pir cam•iv, \ nssonesapwa,rnreawur6aswa•olwa+a+em..ww.tsan -'• Commonwealth of Massach's'btts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • • Property "/144''..0 omwibn tt/-Uin //)EO. ) PInib.ry �ac-J7n , "tin 0,64:4 4,0/ Pita. • "f] .City/roen . Sets lip Code Data of Inspection E..Report Completeness Checklist 7nectign Summary:A,B,C, D,or E checked • spection Summary D(System Failure Criteria Applicable to All Systems)completed ystem Information-Estimated depth to high groundwater g-S crotch of Sewage Disposal System either drawn on page 15 orattached In separate file • Pine•In _ Ws IOWA Ymp.din Fenn 4eewM1a 6...B.Disposal System rigs 17un