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Loommonweastn or massamusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Rosemary Lane
Property Address n
Nancy Johnson AD
Owner's Name
West Yarmouth
City/Town
MA 02673
State Zip Code
12/6/15
G3 OMW D
Jr i; -4
HEALTH DEPT.
Date of Inspection
1
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.
A. General Information
1. Inspector:
TrPvnr Kellett
Name of Inspector
TK Septic Inspections
Company Name
3R Vacation Lane
Company Address
West Yarmouth
City/Town
508-579-5502
Telephone Number
B. Certification
MA
State
S113744
License Number
02673
Zip Code
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 performed based on my training and experience in the.proper function and maintenance of on site
sewage disposal systems. l 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
Inspector's Signature
12/12/15
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 perform in the future under
the same or different conditions of use.
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
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t�\ �.ommonwea�in or nnassacnusens
��� Title 5 4fficial Inspectian Form
f �1 Subsurtace Sewage Disposaf System Form -Not far Voluntary Assessments
,1
12 Rosemary Lane
Property Address
Nancy Johr�son
Owner Qwner's fVame
informatian is West Yarmauth MA 02673 12f6/95
required for every
�yQ, City/Town State Zip Code Date of Inspection
D. System tnformation
Description:
This is a standard title v with a tank d box and 3)each chambers
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes � No
Is laundry on a separate sewage system? (Include iaundry system inspectian � �r� � No
information in this report.}
Laundry sys#em inspected? ❑ Yes � No
Seasanal use? ❑ Ye.s � Na
Water meter readings, if availabie (last 2 years usage(gpd}}: ���
Detail:
�C'71� : i1� , bpa
�� �� � 3� � ���
Sump pump? ❑ Yes � No
Las#date of occupancy: current
Date
Commercia!lEndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): cauons r da
PQ Y(9Pd?
Basis of design flow{seats/persons/sq.ft.,etc.}:
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ Na
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ Na '
Water meter readings, if available:
t5ins-3713 Titfe 5 O(ficial lnspection Fomr�bsurface SeHage Disposal Slstem•Page 7 of 17