HomeMy WebLinkAboutInspection Report 2011 Aug 24 09/15/2011 10: 76 FAA 5084281613 . . PATRICK M OCONNELL . �001/062
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09/15/2611 10: 17 FAX 5068281613 PATRICK M OCONNELL �602/062
� Commonwealth of M��ssachusetts
Title 5 Official Inspection ��orm
Subsurfaee SewaBe Oisp��aal System Form -Not for VoluMriry Assessments
40 Pleasant Street __.,
Vrope�ly Address
Susan Dace� __
par�r Owner's Name
iMormatian is SOuth VaRnoUth MA Oi?664 AUgust 24 2019
requLed�ot Ck lTown State Z77 Code Dele oF InspeRlon
eve�N Pa9e. y '
B. Certific�tion (cc nt.)
Inspection Summary; Glieck A,B,C,D or E I always complete all of Sectlon D
A) System Passes:
� I have not tound ai r��nformation which indicates that a:ny of the failure criteria described
in 310 CMR 15.30'!or In 310 CMR 15.304 exist.Any 1l4ilure crlterla not evaluated are
indicated below.
Comments,
� Tank is not in need of I�imping at this time based on obsaved accumulated solids relalive to outlet
tee, lexchinC sYstem i;_unctionina oroperly.
B) System Condltionally Passes:
❑ O��e or more syste r� components as tlescribed in the'Conditionel Pass" section need to be
replacc�d or repairtnl. The system, upon completion of the replacement or repair, as approved by
the Board of Healt i will pass.
Check the box For"ye:" "no"or"nat determined"(Y, N, NC'1)for the tollowing statements. If"not
detertnined,"please e�;��laln.
The septic tank is meti i and over 20 years old'or the septic tank(whiether metal or not) is
structurally unsound, e�hlbits substantial infiltration or exfl'tretion or tank failure Is imminent. System
wili pass inspection if tie ezisting tank is replaced with a a�mD�Ying septic tank as approvad by the
Board of Health.
"A metal septic tank�i I pass inspection if�t is structurally sound, ool ieaking and if a Certificate of
Complience indicating t iat the tank is less than 20 years C Id is available.
❑ Y ❑ N ❑ N� (Explain below):
TNe 5�mc al Inepenbn Fam:SubvAace Sv�ege Ditpoeel SyHem-Pa➢e 2 d 17
ISlni �'HI10
09/75/2D11 10'. 18 FAX 5064281613 PATRICK M OCONNELL m 601/001
�� � , --- _ .... 11
�� Commonwealth of Ma;�;s9onusect�eCt1011 F��fCYt
Titie 5 Aff�c� G�� �nsp
SubsuAace Sewage 6ispoe:d System Form-Not for Voluntarr Assessmrnts
a0 PI�?Stree,t „-_—'
� PropeKY�resb
Susan Dace� -- -- --��
p,Hn� owner's Neme MA 021�r{ Au ust 24, 2011
tnTormetlo�ie Sotlth YaffnO�th -� �--���" Siate 21P Code Dele of I�epectlon
AGulra7lor C.ryrt�� �
eoery peBB- —�� I
G Checklist
Check i1 the following h.�'e been done. You must indicate"/es"or"no" as to each of tha following:
Yes No
� � Pu r ping information was p�ovided by ;he owner, occupant, or Board of Healtn
� � We �e any of the system components pumped out in the previous iwo weeks?
� �] Ha: the system received normal flows in the previous two week period?
❑ � H��e large volumes of water been intr�duced to the system recently or as part of
thi;inspection?
W�: e as built plans of the system obtained and examined7 (If they were not
� � au a ilable note as N!A)
� � W�;the tacility or dwelling Inspected ''or signs of sewage beck up9
� �] W 3 s the site inspectetl for slgns of bn�ak out�
� �] W=_�e all syseam components, excluding the SAS, located on site7
� � V6=re the septic tank manholes uncovered, opened, and the interior of the tank
i�;�acted for the condition of the baifles or tees, material of construction,
di i iensions, depth of liquid, depth of rlutlge Bnd depth of scum7
� ❑ V�e s the facility owner(antl occupan�s if differenR from rnune�) P�ided with
in7�rmation on the proper maintenance of subsurface sewage disposal systems7
T �:size and locatlon oi the Soll A4rsorptlan SYstem (SAS)on the site has
b��;n determined based on:
� � E c sting in�Ormation. For example, a p>lan ai the Board of Health.
� � C=te�mined in the field (if any of the tailure criteria related to Part C is at iBsue
anroximation of dlstance is unacce�table) [310 CMR 15.302(5)]
�--
D. Sys'tem Inform:ition
ResldeMlal Flow Co illtlons: 4 in hse, 1 in
` 5 Nurnbe�of beclrooms (actual): ga�
� 7r,� Number of bedrooms (iesign). 550
���.V
dESIGN flow based c r 310 CMR 15203 (for example: 1 10 gpd x#��f bedrooms):
Tiib 5 Oflclal IroPe«wn F°M'�guoeur�ece Sewaps OI�ea18y���•PaOe 6 A 1�
IBIx•11110
09/15/2011 10 �. 16 FAX 5064PB1613 PATRICK M OCONNELL �601I602
� Commonwa�alth of M�.ssachusetts
� - Title 5 Offici'�al Inspection F�orm
Subsurtace Sewage Disp c sal System Form -Not for Volunt ary Assessments
40 Pleasant Street
Propedy Addiess ^
Susan Dacay .__!
Ownc r Owners IVame
�nfomiatlon Is South Yarmouth MA O:t68a August 2a, 2011
roqulietl tw — --�—
��paBa �i�y��� State Zlo Code Date of Inspection
D. System Inform�ition
D65cdption:
Number of current resic I�mts: Unknown
Does rnside,nca ha�e a!larbage grinder7 ❑ Yes � No
Is laundry on a separat:sewage system7 [if yes separate nspection required] ❑ Yes � No
Laundrysysteminspeca�d? ❑ Yes ❑ No
Seasonal use7 � Yes ❑ No
Water meter readings, i f avallable(last 2 years usage (gpd"): 834,000 gal.w/
� � � irriga[ion syst.
� Detail:
�� — --,._
Sump pump? ❑ Yes � No
Last date of occu anc Currently
P Y Occupied.
Commurclal/lnduatrlal i�low Condltlona:
Type of Estahlishment:
Design flow(based on :� 0 CMR 15.203): oaiwns�;r dey(god)
Basis of deslgn flow(se�tslpersonslsq.k., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holtling t ank present7 ❑ Yes ❑ No
Non-sanitary�waste disc t arged to the Title 5 system7 ❑ Yes ❑ No
water me[er readings, i �vailable:
61ne-nnv TkN 5 OlAckl mce=llon Fo�m:Sibs�rtau SewOe UuOeui SnUm•�uw 7 A 17
09/15/2011 10: 19 FAX 5084261613 PATRICK M OCONNELL �602/602
�� � � . i �["��e� 1F� ,
� Commonwealth of Ma�.sachusetts
Title 5 Official Inspection F'orm
SubsurFace Sewage Dlspu�al System Form -Not for VoluntUry Assessments — J-
40 Pleasant Street _� —.--- --- �
Proverry Aaerou _ _._ �
Susan Dace�_..._—�...---- � �---�'.---,.-----�------
Ow�c r Owner'e Namn MA O:t664 AugUSt 24 2011 _
Intortuatlon is � South Yarri�OUth �-� --'
--- '--�' �- �--�—�–� � Slate 2ipCode Daleoiln9peqion
requ�ied Far CIly/TOwp �
every Oe9a� '�
D. Syst�em Inform�ition (cont.) �
Sketch Of Sewage Dis»sal System. Provide a view of[hf sewage disposal system, Including 6es ro
where p b�li curater�suF{fy e�ters the bu Idkng Check ne`f the boxeslbelowW�thin 100 feet. Locate
� � hand-sketch in the urea below �
❑ dr�winp attached :��oaratelv
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; ��07/14/2009 52�0 A 1114 29 0 29 69.72 48.72
.. I. �I07/212008 3337420 A 1085 1W 0 187 362.74 361.14
��07/�/2007 297256 A 898 21�uc%v 0 217 448.74 42Z74
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. ... .07/30V2004 � 14644 0 0 0 0 27.77 27.77 ....I
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� SEP 15 2Qi1 :
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� ,.
Thursday,Sep 15,2011 01:37 PM �
M �I
� Commonwealth of Massachusetts pq7 �-` � �
Title 5 Official Inspection Form ��a , � �L��
Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments �
40 Pleasant Street
�ii_�;��i i-i ��f�������.
Property Address � -
Susan Dace ¢
� Owner Owner's Name •
information is South Ya�mOuth MA 02664 Au ust 24, 2011
required tor 9
� every page. Cdy/Town State Zip Code Date of Inspedion
Inspection resuits must be submitted on this form. Inspection forms may not be aitered in any
way. Please see completeness checkiist at the end of the form.
''"P°"a"`: A. General Information
When filling out
forms on the
computer,use �, InSpecto�:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the retmn
key. Septic Inspection Services Co.
� CompanyName
�+ 189 Cammett Road
� � Company Address
Marstons Mills MA 02648
"v" CitylTown State Zip Code
508-428-1779 S112855
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 inspection
was pertormed 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:
� Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
��1
. � �
�� � August 24, 2011 Job# 11-142
Ins ector's Signafure � 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 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 pertorm in the future under
the same or different conditions of use.
�5ins•HHO Title 5 ORicial lnspeclron Form Subsurlaca Sewage Oisposal Syslem•Page 1 011]
. � � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Pleasant Street
Property Address
Susan Dacev
Owner Owner's Name
intortnation is SoUth Yarmouth MA 02664 Au ust 24, 2011
required tor _ 9
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/a/ways complete all of Section D
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:
� Tank is not in �eed of pumping at this time, leaching system is functioning properly.
f �,5° '
��
B) System Conditionaily 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
wiil 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):
ISins•11/70 Title 5 OHival Inspection Fwm�.Su�sutlace Sewage Diapose15yslem•Page 2 af 17
� � Commonweaith of Massachusetts
� Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments
40 Pleasant Street
Property Address
Susan Dacey
Owner Owner's Name
iniormation is South Yarmouth MA 02664 Au ust 24, 2011
required for 9
every page. City/Town State Zip Code Date of Inspection
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 ❑ 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):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Heaith 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
ISns•11H0 Ti11e 5 ORicial Inspenron Fwm.SuDsurlece Sewage Disposal Syslam•Page 3 0(tI
� � Commonweaith of Massachusetts
� Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments
' 40 Pieasant Street
Property Address
Susan Dacey
Owner Owner's Name
required for'S South Yarmouth MA 02664 August 24, 2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. 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 surtace water supply or tributary to a surtace 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, pertormed 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:
D) 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
� � Static liquid level in the distribution box above outlet invert due to an overloaded
or ciogged SAS or cesspool
� � Liquid depth in cesspool is less than 6" below invert or available volume is less
than_day flow
ISins•11/10 Tille 5 Oflicial Inspaclion Fortn:Sobsurfaca SewaBe Disposel Syslam�Pape 9 0l 17
� � Commonweatth of Massachusetts
Title 5 Officiai Inspection Form
Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments
° 40 Pleasant Street
Property Address
Susan Dacey
Owner Owner's Name
information is South Yarmouth MA 02664 Au ust 24, 2011
required for 9
every page. City/Town State 2ip Code Date of Inspection
B. Certification (cont.)
Yes No
� � 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.
� � Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surtace water supply.
❑ � Any portion of a cesspool or privy is within a Zone 1 of a public 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 quaiity analysis. [fhis
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 faciiity with a design flow of 2000gpd-
t0,000gpd.
� � 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.
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, you must 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 supply
❑ ❑ the system is within 200 feet of a tributary to a surtace drinking water suppiy
� � 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 of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional o�ce of the Department.
15ins•11H0 Tille 5 OHival bvspaclqn Forcn�.SuDeuAaca Sewaga Oisposal Syslem•Paga 5 of 17
, � Commonwealth of Massachusetts
� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Pleasant Street
Property Address
Susan Dacey
Owner OwneisName
iMo�mation is South Yarmouth MA 02664 Au ust 24, 2011
required for _ 9
every page. Ciry/Town State Zip Cotle Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
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)
� ❑ 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#ot bedrooms): 550
G ��5� -�
1 )�/ T �J4�
ISins•71H0 ��v , / Tille 5 OHicial Inspxlion Fotm�.Sobsur(ace Sewage Disposal Syslem•Pepa 6 of 17
O�
• � Commonwealth of Massachusetts
� Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments
` 40 Pleasant Street
Property Address
Susan Dacey
Owner Owner's Name
intormation is South Ya�mouth MA 02664 Au ust 24, 2011
required for 9
every page. CiyRown Slate Zip Code Date ot Inspection
D. System Information
Description:
Number of current residents:
Unknown
Does residence have a garbage grinder? ❑ Yes � No
� ✓ Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes � No
�,j(� Laundry system inspected? ❑ Yes ❑ No
4�
� Seasonal use? � Yes ❑ No
�°�S� ._ Water meter readings, if available (last 2 years usage (gpd)): N/A Irrigation �
��J �. System. �
� Detail:
Sump pump? ❑ Yes � No
Currently
Last date of occupancy: Occupied.
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15203): Ganons per day�ypd�
Basis of design flow (seats/persons/sq.k., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present7 ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
l5ire•11I10 Tllle 5 OKcial Inspeclion Form:Subsurlace Sewaga Diaposal Systam•Pege 7 d 17
• � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments
' 40 Pleasant Street
Property Address
Susan Dacey
Owner Owner's Name
r f�uma�t�(�nris South Yarmouth MA 02664 August 24, 2011
9
every page. Cdy/fown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: oate
Other(describe below):
Ge�eral Information
Pumping Records:
Unknown
Source of information: —
Was system pumped as part of the inspection9 ❑ Yes � No
If yes, volume pumped: qauons
How was quantity pumped determined?
Reason for pumping:
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 approvai.
❑ Other(describe):
t5ins•HHO Tiile 5 OHicia�inspeciion Form.Subsudace Sewage Dispoul SyNem•Pega 8 of 1]
• � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Pleasant Street
Property Address
Susan Dacev
Owner Owners Name
information is South Yarmouth _ MA 02664 August 24, 2011
required for
every page. City/fown State 2ip Code Date ot Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Installed 6/7/01
Were sewage odors detected when arriving at the site? ❑ Yes � No
Building Sewer(locate on site plan):
Depth below grade: �
teet
Material of construction:
❑ cast iron � 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: �
feet
Material of construction:
� concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metaf, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10.5'long x 5.8'wide- 1000 al.
Sludge depth: 2��
ISins•11/10 Ti�ie 5 Oflicial InspeMion Form�SubsuRaca Sewege Uisposel Sysiem•Fege 9 0l 77
, • � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments
' 40 Pleasant Street
Properry Address
Susan Dacey
Owner Owners Name
infortnation is
required for South Yarmouth __ MA 02664 August 24, 2011
every page. City/Town Stale Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffie 30"
Scum thickness �
Distance from top of scum to top of outlet tee or baffle 6��
Distance from bottom of scum to bottom of outlet tee or baffle �3
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
\�w�f,r. liquid levels as related to outlet invert, evidence of leakage, etc.):
\" SC" Liquid level was found at bottom of outlet invert tees were intact and clear.
'C�,�
Grease Trap (locate on site plan):
Depth below grade: teec
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: Dace
ISins•11/10 Tille 5 OHicial Inspeclion Fam:SubwAaco SeweBe Oispasal System•Page 10 d 77
• � Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments
40 Pleasant Street
Property Address �
Susan Dacey
Owner pwners Name
iniormation�s South Yarmouth MA 02664 Au ust 24, 2011
required for _ 9
every page. City/Town State Zip Code Date of Inspedion
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:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: oa�e
Comments (condition of alarm and float switches, etc.):
'Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•t i/10 Tilie 5 OHicial Inspeclion Fam�.SuDsurtars Sewega Disposal Systam•Page 71 0l 17
. • � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments
40 Pleasant Street
Property Address
Susan Dacey
� Owner Owner's Name
information is South Yarmouth MA 02664 Au ust 24, 2011
required for 9
every page. City/lown State Zip Code Date o�Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above 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.):
No solids or high stains present. Liquid level was at bottom of outlet pipes.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
ISins•11H0 Tille 5 OHkial Inspection Form-Sobsurlaca Sewega Oisposal Syslem•Pega 12 0l t7
, � G� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments
` 40 Pleasant Street
Property Address
Susan Dacey
Owner Owner's Name
intormation is South Yarmouth MA 02664 Au ust 24, 2011
required for 9
, every page. City/Town State Zip Code Date oi Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
� leaching chambers number: 15 Infiltrators.
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Area of SAS was probed with no evidence of saturation found.
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
ISins•f 1/10 Title 5 Oflicial Inspenlon Form�.SuDsurfece Sewape Disposal Syatam•Page 13 of 1]
, • � Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'f 40 Pleasant Street
Properry Address
Susan Dacey
Owner Owner's Name
information is South Yarmouth MA 02664 Au ust 24, 2011
requiretl for 9
every page. City/rown 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.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, tevel of ponding, condition of vegetation,
etc.):
�`�"�s'����� Tifle 5 ONkial Inspeclron Fam�Subsutlace Sewege Disposal Sys�em•Peya tA of 17
� � Commonweaith of Massachusetts -
� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
" 40 Pleasant Street
�� -- ---- ---
Praperty Address
----- - - __. _._...—----
Susan Dacey__
Owner Owner's Name -_._. _ _.. . .. . . . .. . .._ ___..__—.__ — _._--___..
information is South Yarmouth MA 02664 Au ust 24, 2011
required for —._. 9 _
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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 aii 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 separatery
.','.',',', ' ' ,',',',',',
.'.'.'.'�'� ' . '.'.';.'.
�'�`�'�'�`����`���... ,
. . . , . . . . . . . .'.'.
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. . , . . . . , , ,`.`.
15 3 Front
Yard
38
✓ � 37
��
J`
� ��
, ' � Commonwealth of Massachusetts
Title 5 Official inspection Form
a Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments
40 Pleasant Street
Property Address �
Susan Dacey
Owner Owner's Name
intormation is South Yarmouth MA 02664 Au ust 24, 2011
requiretl for _ 9
every page. City/Town State Zip Code Date of Inspedion
D. System Information (cont.)
Site Exam:
� Check Slope
� Surtace water
� Check ceilar
� Shallow wells
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: 9n/00
Date
❑ Observed site (abutting propertylobservation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, instailers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Perc test performed on 5/3/00 found water at 126". Plan on file specifies adjusted groundwater at el.
3.4 and bottom of SAS at el. 8.49.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ine•7 iH0 Tille 5 ORicial InsO�ion Forcn�SuEsurlace Sewage Disposel Syslem•Page i6 0l 17
. � Commonwealth of Massachusetts
� Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments
40 Pleasant Street
Property Address
Susan Dacey
. Owner Owner's Name
iniormation is South Yarmouth MA 02664 August 24, 2011
required for —
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
� Inspection Summary: A, B, C, D, or E checked
� Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
� System Information— Estimated depth to high groundwater
� Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 OHicial Inspeclion Form.SubsuAam Sawege Disposal Syslem•Paga t7 0l 17