HomeMy WebLinkAboutInspection Report 2016 Jan 28 � ` G3C�C���C�/GD _
� Commonweaith of Massachusetts
Title 5 Official Inspection For ��`} `:'� ��'6
SubsurFace Sewage DispoSal System Form-Not for Voluntary Asse smep�qLTH DEPT. �'L
12a 8�12B Rosemary Ln West Yarmouth MA
Properfy Addr�s
Nancy L Johnson TR Go West Yarmauth Series Four LLC PO Box 342
Owner Owner's Name
information is HYANNIS MA 02601 1/28/2016
required for every
page. City/Town 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 A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Joseph M Martins
use the retum Name of Inspector
key.
� Accu Sepcheck
� Company Name
17 Northside Dr
Company Address
� South Dennis MA 02660
City/Town State Zip Code
508-385-5891 SI 147
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 tfie inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 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
1/29/2016
spector's Signature Date
The system inspector shall submit a copy of this inspection repart ta 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•3/13 Title 5 ORaaI Inspec6on Form:$ubsurface Sevvage Disposal S�rstem•Page 1 of 17
. ,
� Commonweaith of Massachusetts
Titie 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
12a 812B Rosemary Ln West Yarmouth MA
Properry address
Nancy L Johnson TR c/o West Yarmouth Series Four LLC PO Box 342
Owner Owne�'s Name
information is HYANNIS MA 02601 1/28/2016
required for every
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always 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:
B) 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 faiture 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 ❑ ND(Explain below):
REPLACE DISTRIBUTION BOX
t5ins•3/13 Title 5 Officia{Irspaction Fortn:Subsurface Sewage Disposal System•Page 2 of 77
� Commonwealth of Massachusetts
Title 5 4fficial inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 12a 8�126 Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR c!o West Yarmouth Series Faur LLC PO Box 342
Owner QwnePs Name
information is HYANNIS MA 02601 1/28l2016
required for every
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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 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
t5ins•3/13 TiUe 5 Offidal Inspection Fartn:Subsurface Sewage Disposal System•Page 3 of 17
� Commonwealth of MassachuseHs
Title 5 Official Inspection Form
Sut�urface Sewage Disposal System Form-Not for Voluntary Assessments
12a 8�12B Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR c%West Yarmouth Series Four LLC PO Box 342
Owner Owner's Name
information is HYANNIS MA 02601 1/28/2016
required for every
page. Citylfown 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,
safetyr 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.
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 cesspoof
� � Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
� � Liquid depth in cesspaol is less than 6"below invert or available volume is less
than '/2 day flow
t5ins-3M 3 Title 5 Offici�Inspection Fartn:Su6surface Sewage Disp�al System•P�e 4 oF 17
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
12a 8�12B Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR Go West Yarmouth Series Four LLC PO Box 342
Owner Owner's Name
information is HYANNIS MA 02601 1/28/2016
required for every
page. CitylTown State Zip 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 af 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 surtace water supply or
tributary to a surface 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 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 2000gpd-
10,OOOgpd.
� � 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 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 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 office of the Department.
t5ins•3l13 Title 5 Official lnspedia�Fortn:Subsurface Sewage Disposal System•Page 5 of 17
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
SubsurFace Sewage Disp�al System Form-Not for Voluntary Assessments
12a 8�12B Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR Go West Yarmouth Series Four LLC PO Box 342
Owner pwners Name
information is HYANNIS MA 02601 1/28/2016
required for every
page. Citylfown State Zip Code 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 informatian 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 f�om 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): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Tif1e 5 Oifici�Inspedion Form:Su�xface Sewage Disposal System•Page 6 of 17
� Commonweaith of Massachusetts
Title 5 Official Inspection Form
SubsurFace Sewage Disposal System Form-Not for Voluntary Assessments
12a 8�126 Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR c/o West Yarmouth Series Four LLC PO Box 342
Owner Owne�'s Name
information is HYANNIS MA 02601 1/28/2016
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
1000 GALLON TANK, DBOX, 3 FLOW DIFFUSERS W 2'STONE
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes � No
Is laundry on a separate sewage system?(Include laundry system inspection � Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes � No
Water meter readings, if available(last 2 years usage(gpd)):
DetaiL-
THERE IS NO LAUNDRY
Sump pump? ❑ Yes � No
1/28/2016
Last date of occupancy: �ate
Commercial/Industrial Flow Conditions:
Type of Establishment: N�A
Design flow(based on 310 CMR 15.203): �auo�s per day(9Pd�
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Olfiaal Inspection Fortn:Subsurface Sewage Disposal System•Page 7 of 17
� Commonwealth of Massachusetts
Title 5 Officiai inspection Form
SubsurFace Sewage Disposai System Form-Not far Voluntary Assessments
12a 812B Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR Go West Yarmouth Series Four LLC PO Box 342
Owner pNmer's Name
information is HYANNIS MA 02601 1/28l2016
required for every
page. Citylfown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: p�e
Other(describe below):
General lnformation
Pumping Records:
Source of information: PER YHD: PUMPED ON 10/12l2012,10/27/14,
1/3/2016
Was system pumped as part of the inspecfion? ❑ Yes � No
If yes, volume pumped: yanons
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/Altemative 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):
t5ins•3/13 Title 5 O(fiaal Inspedion Fortn:Subsurface Sewage Disposal System•Page 8 of 17
� Commonwealth of Massachusetts
Title 5 Officiai Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y� 12a&12B Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR c/o West Yarmouth Series Four LLC PO Box 342
Owner OwnePs Name
intormation is HYANNIS MA 02601 1/28/2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
31 YEARS: INSTALLED 1985 PER YHD
Were sewage odors detected when arriving at the site? ❑ Yes � No
Building Sewer(locate on site plan):
Depth below grade: �
feet
Material of construction:
� cast iron �40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 5
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
NO EVIDENCE OF LEAKS
Septic Tank(locate on site plan):
pepth below grade: 0.5
teet
Material of construction:
�concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: y��
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 4'10'X8'6"X5'7" 1000 gall.
Sludge depth: ��
t5ins•3/13 Title 5 Offiaal Inspec6on Form:S�surface Sewage Disposal System•Page 9 of 17
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
SubsurFace Sewage Disp�ai System Form-Not for Voluntary Assessments
12a&12B Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR c/o West Yarmouth Series Four LLC PO Box 342
Owner Owner's Name
information is HYANNIS MA 02601 1/28/2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to battom of outlet tee or baffle
33"
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 14
How were dimensions determined? CORETAKER
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
HAS PRECAST INLET TEE IN GOOD CONDITION, HAS PRECAST OUTLET TEE IN FAIR
CONDITION. LIQUID LEVEL IS 48"AT OUTLET INVERT. NO EVIDENCE OF LEAKAGE.
Grease Trap(locate an site plan):
Depth below grade: N/A
feet
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: p�
t5ins•3/13 Title 5 Offiaal InspecGon Form:Subsurface Sewage Disposal System-Page 10 of 17
� Commonwealth of Massachusetts
Title 5 4fficial inspection Form
� SubsurFace Sewage Disp�ai System Form-Not for Voluntary Assessments
12a 8�12B Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR Go West Yarmouth Series Four LLC PO Box 342
Owner pNmer's Name
information is HYANNIS MA 02601 1/28/2016
required for every
page. Citylfown State Zip 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: N/A
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: �ate
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Ofiaal Inspedion Fortn:Subsurface Sewage Disposal System•Page 11 of 17
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
SubsurFace Sewage Disp�ai System Form-Not for Voluntary Assessments
M � 12a 8�12B Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR c/o West Yarmouth Series Four LLC PO Box 342
Owner Owners Name
information is HYANNIS MA 02601 1/28/2016
required for every
page. Citylfowm State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level abave outlet invert AT 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.):
DBOX SIDES ARE BREACHED AND NEEDS TO BE REPLACED, NO SIGN OF SOLIDS
CARRYOVER OR BACKUP IN BOX OR PIPES. ONE PIPE IN ONE PIPE OUT.
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.):
N/A '
�If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SA5) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Se`wage Disposal System•Page 12 of 17
� Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
12a 8126 Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR c%West Yarmouth Series Four LLC PO Box 342
Owner Owne�s Name
information is HYANNIS MA 02601 1/28/2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number.
� leaching chambers number. 3
❑ leaching gal�eries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
EXAMINED STONE ADJACENT TO CHAMBER. STONE IS CLEAN. NO PONDING. NO SIGN OF
HYDRAULIC FAILURE. REMOVED SOME ROOT MASS FROM THREE OUTLET PORTS AND
SOME GRIT FROM THE HEX DISTRIBUTION CHAMBER SUMP. GRADE TO SAS TOP IS 35".
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
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
t5ins-3/13 Tide 5 Olfici�Inspedion Fortn:Subsurface Sewage Disposal System-Page 13 of 17
� Commonwealth of Massachusetts
Title 5 Officiai Inspection Farm
� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
� � 12a&12B Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR�o West Yarmouth Series Four LLC PO Box 342
Owner _Owner's Name
information is HYANNIS MA 02601 1/28/2016
required for every
page. CitylTown 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 construcfion: N!A
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5ins•3N3 Title 5 Offiaal Inspecction Fortn:Subsurface Sewage Disposal System•Page 14 of 17
� Commonwealifi of Massachusett;s
Title 5 Officiai Inspection Form
SubsurFace Sewage Disposai System Form-Not for Votuntary Assessments
12a 8�126 Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR cJo West Yarmouth Series Four LLG PO Box 342
�e� Owne�s Name
`r`f°`"'a�.°`��s HYANNIS MA 02601 1/28/201fi
required ior every
P�• Cit�rffoam State Zip Code Date of Inspection
D. System Information (cont.)
Sketctr Of Sewage Disposal System: Provide a view of the sewage disposat system, including ties to
at least finro permanent reference landrnarks or benchmarks. Locate afl welis within 100 feet Locate
where public water supply enters the buiiding.Che,ck one of tl�e boxes below:
� hand-sketch in the area belaw
❑ drawing attached separately
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t5ms•3Fi3 TAIe 5 tM�iaf
M�an Famr S�tat�Se�e Uiaposa131'stertr•Page 15 of 17
� Commonweaith of Massachusetts
Title 5 Official Inspection Form
SubsurFace Sewage Disposal System Form-Nat for Voluntary Assessments
12a&12B Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR c/o West Yarmouth Series Four LLC PO Box 342
Owner Owners Name
information is HYANNIS MA 02601 1/28/2016
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
� Check Slope
� Surface water
� Check cellar
� Shallow wells
Estimated depth to high ground water: 5'7
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained ftom system design plans on record
If checked, date of design plan reviewed: oate
❑ Obsenred site(abutting property/observation hole within 150 feet of SAS)
� Checked with local Board of Health-explain:
FILE
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain: :
You must describe how you established the high ground water elevation:
1. PER 2/22/1996 INSPECTION BY T_ WILLIAMS : HAND AUGER TO 3.0' BELOW SAS. NO
GROUNDWATER ENCOUNTERED. 2. GRADE TO SAS BOTTOM IS 4.4'. 3. MIW29A
ADJUSTMENT IS 1.7 FOR MIW29A. SEPARATION IS: (4.4+3.0)-1.7= 1.3
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System•Page 16 of 17
I
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposai System Form-Not for Voluntary Assessments
12a&126 Rosemary Ln West Yarmouth MA
Property Address
Nancy L Johnson TR c%West Yarmouth Series Four LLC PO Box 342
Owner Owner's Name
information is HYANNIS MA 02601 1/28/2016
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•3/13 Title 5 Official Inspedion Fortn:S�surface
Sexiage Disposal System•Page 17 of 17