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89 Title 5 Inspection Form 2020Commonwealth of Massachusetts _ --Title 5 Official Inspection For �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma. 01060 Owner Owner's Name information is required for see above Ma 01062 05/28/20 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. Inspector Information forms on the computer, use Ray Champagne only the tab key Name of Inspector to move your Whiteley Septic Service cursor - do not Company Name use the return key. 21 Old County Rd. 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. ❑ Company Address Southampton Ma 01073 Needs Further Evaluation by the Local Approving Authority Cityrrown 413-527-0057 State Zip Code S14118 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 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. t51nsp.doc • rev. 7/2 612 01 6 Title 5Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma. 01060 Owner's Name see above Cityrrown C. Inspection Summary Me 01062 05/28/20 State Zip Code Date of Inspection Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 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: This system is an older system but working properly. The outlet baffle was repaired as part of the inspection with hydraulic cement. The leach pit is dry and clean at this inspection 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes"% "no" or "not 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 ❑ NO (Explain below): l5insp.doc • rev. 7/26120f8 Title 50tfcial Inspection Form: Subsurface Sewage Disposal System • Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (v y 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma 01060 Owner Owners Name information is required for see above Ma 01062 05/28/20 every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ 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): ❑ 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: t5lnsp.doc • rev. 7/26/2018 Title 5Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 18 Commonwealth of Massachusetts � - -r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (T� u ' 89 Autumn Dr. Florence Me. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma 01060 Owner information is Owners Name required for see above Ma 01062 05/28/20 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning 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: 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc • rev. 7/26/2018 Title Oficial 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 (P 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma. 01060 Owner Owner's Name information is required for see above Ma 01062 05/28/20 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section C.4. Yes No ❑ ❑ 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 El El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well t5lnsp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma. 01060 Owner Owner's Name information is required for see above Ma 01062 05/28/20 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or "no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? El ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? El ® 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. ® El in the field (if any of the failure criteria related to Part C is at issue approximation approximation of distance is unacceptable) [310 CMR 15.302(5)] t5lnsp.doc • rev. 712612018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 18 Commonwealth of Massachusetts _ Title 5 Official Inspection For -1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma. 01060 Owner Owner's Name information is required for see above Ma 01062 05/28/20 every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): estimate3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): estimate 300 Description: A concrete 1000 gal septic tank with concrete baffles ( Outlet repaired as part of this inspection) into a 750 gal leach pit that was dry at this inspection. The system is vented thru roof. Number of current residents: Does residence have a garbage grinder? Does residence have a water treatment unit? If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: 9 ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No unknown ® Yes ❑ No presently part time t5lnsp.doc • rev, 7/26/2018 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma. 01060 Owner Owner's Name information is required for see above Me 01062 05/28/20 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Water treatment unit present? If yes, discharges to: Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Other (describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Gallons per day (gpd) scheduled at repair and inspection 1000 gallons maintenance and reDair of ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ® Yes ❑ No t51nsfe.doc • rev. 712812018 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J' 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma. 01060 Owner Owner's Name information is required for see above Ma 01062 05/28/20 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other (describe): tank directly to leach pit Approximate age of all components, date installed (if known) and source of information: 35+ Were sewage odors detected when arriving at the site? 5. Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): 14" feet ❑ Yes ® No Distance from private water supply well or suction line: Cyt water 10' + feet Comments (on condition of joints, venting, evidence of leakage, etc.): no evidence of leakage observed t5insp.doc • rev. 7/26/2018 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 or 18 Commonwealth of Massachusetts -_ ---, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma. 01060 Owner Owner's Name information is required for see abo every page. Cityrrown D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal If tank is metal, list age: Ma State ninag cry wue 12" feet ❑ fiberglass ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 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 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 34" 2" hook ❑ Yes ❑ No Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend pumping schedule of 2 yrs. All levels are correct . t5insp.doc • rev. 7/2612018 Title S Oficial Inspection Form: Subsurface Sewage Disposal System • Page 10 of 78 Commonwealth of Massachusetts r -Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma. 01060 Owner Owner's Name information is required for see above Ma 01062 05/28/20 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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 feet ❑ polyethylene ❑ other (explain): Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Capacity: Design Flow: ❑ polyethylene ❑ other (explain): gallons per day ISlnsp.doc • rev, 7/2612018 Title 5Orfcial Inspection Form: Subsurface sewage Disposal System • Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For P Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Autumn Dr. Florence Me. 01062 Property Address Edward Gallivan 71 State St. Northampton Me. 01060 Owner information is Owner's Name required for see above Ma 01062 05/28/20 every 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 Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert no d box found 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.): t5lnsp.doc • rev. 7/2612018 Title 5Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Autumn Dr. Florence Ma, 01062 Property Address Edward Gallivan 71 State St. Northampton Ma. 01060 Owner Owner's Name information is required for see above Ma 01062 05/28/20 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): t51nsp.doo • rev. 7126/2016 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 18 * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1x750 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t51nsp.doo • rev. 7126/2016 Title 5 Official 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 l 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma. 01060 Owner Owner's Name information is required for see above Ma 01062 every page. cltyfrown State lrnnP n— 0in .,,,.— ..a --0 ----.:-- .0yomGiiii uirormatlon (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.): no signs of hydraulic failure observed -- lawn area soil is sandy 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 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.): t5lnsp.doc • rev, 72612018 Title 5 Official Inspection Form: subsurrace sewage Disposal System • Page 14 of 18 Commonwealth of Massachusetts =�t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma 01060 Owner Owners Name information is required for every page. see above Ma 01062 City(rownState Zip Code D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids 05/28/20 Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t51nsp.doe • rev. 7/2642018 Title 5Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 18 c Commonwealth of Massachusetts Title ici 1 Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Autumn Dr. Florence Me. 01062 Property Address Edward Gallivan Owner information is Owner's Name required for see above Ma 01062 05/28/20 every page. City/Town State Zip Code Date of Inspection u. System intormation (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 tftsp.tloc • rev, 7/26/2018 Title 5 Official inspection Form: Subsurface Sewage Disposal System • Page 46 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Autumn Dr. Florence Ma. 01062 Property Address Edward Gallivan 71 State St. Northampton Ma. 01060 Owner's Name see above Clty/Town D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: Ma 01062 05/28/20 State Zip Code Date of Inspection 4-5 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 water elevation: 2 sump pumps but dry and sandy soil area and drainage pipe found in rear yard Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5imp.doc • rev. 7/2612018 Title S Official Impecfion Foam: Subsurface Sewage Onposal System • Pego 17 of 16 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Autumn Dr. Flnranro nn., n,..., Owner ` —lu %�auivan i1 State St. Northam ton Ma. 01060 information is Owner's Name required for see above every page. ciry/Town Ma 01062 State Zip Code • --f'�. L �%Rjjjvilu <eness checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank — Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doo • rev. 7/26/2018 Title 5 Official I11pec0on Form: Subsurtace Sewage Disposal System • page 18 of 18