HomeMy WebLinkAboutPages 1, 15 of Inspection Report �
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Title 5 4fficial Inspection Form
� SubsurFace Sewage Disposal System Form-Not for Voluntary Assessments
� � '� 22 Station Ave
Property Address
Chris Thomas
��� Owner's Name
information is SounFt Yarmautlt MA Q2664 7-17-45
required for every _
p�e. CitylTown State Zip Code Date of Inspection
las¢ectiori sesutts must be salsmitted ori t4�is form.Mspe�tion forn�s may not be altesed is►any
way. Please see completeness checklist at the end of the form.
Importarrt:When ,q. Genera� �Rtorrrtatlon
filling out forms `N��n�uup�ir�i�
on the computer, ```�������,�,ZH�F I�1qssO����.
use only the tab 1. Inspector: �_�.•' '•9C� '�
key to move your �o,- `•,yG�
cursot-do not =�: JAMES '•u'=
James D.Sears =�� ��_
use the return Name of Inspector : v: EARS
� ��
_ :�`
key. �;m The Inspector Man ;�,=._�_ � � * � ___ _ '
1�1 ��—� �� :
r�y Company Name ---- -- -- -- ���'l` Rrif , .,�p`��r--
P.O.BOX 7S4 --- --......._ ����i�� 5 t N SP�G���`��
__....�.__ - -- ---___ - !'mm�nn _---
Company Address
� West Yarmauth �- --- — - 02673___._
_ ____.._.._... ---- ___-- —----...--- -
Citylfown State Zip Code
508-364-�F398 S1623
Telephone Number license Number --- �-
B. Cert�fication
1 certify that I have personally inspected the sewage disposal system at this address and that the
irrforrrratiorr reported betow rs trtre, aocurate artd vomp�ete as o€tne tirrre of the rrrspection. Tfte rnspectroR
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 i
Title 5(310 CMR 15.000�.The system: ';
❑ Passes � Conditionally Passes ❑ Fails
I
❑ Needs Further Evaluation by the Local Approving Authority
�
�Z.�a. `'� 7-21-15
spedor'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 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 doss not address how the system wift pert'ortn in tf�e future under
the same or different conditions of use.
i5ins•3/13 Title 5 Offiaal InspeGio�Fartn:Subsurface Sewage Disposal System•Page 1 of 17
_ S h.a� n 1-1�ar�r�• - Ca�e.. �.1-h� S��-3(��- 39�17
�} - - "' � Commonwealth of Massachusetts
Tit�e 5 Off`iciat �nspection �orm
� Subsurface Sewage Dispesal System Form-Not for Voluntary Assessments
22 Station Ave
Property Address — � �-------------
Chris Thomas
Owner Ownei s Name —--- -- - --- - ------- ----
infoRnation is South Yarmou6Ft �li4 02664 7-47-?5
required for every _�.
page. Citylfown State tip Code Date of Inspedion
D. System Information (cont.}
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, inctuding ties to
at least two perrrtarrer�t reference Jarrdrrtarks or berrchmarks. l.ocate at1 eae�ts►vrthlrr �Oa feet Locate
where pubfic water supply enters the building. Check one of the boxes below:
�' hand-sketch in the area below
� drawing attached separately
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ISms•3J73 Title 5 Olfioal hspection Form-.SuOsurface Sewage Drsposal System•Page t5 ot 17 -
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