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LEGEND �
� DATE OF AERIAL PHOTOGRAI'HY: 4/26�/198!
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��v 27 2015 10:58 Jim The Inspector Man 5085349919 page 1 ' _
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Commonwealth of Massachusetts
� � � � � �
. � T�tie 5 �ff�cial tnspection Form :..._. ���: _: : __�_.r.�. _, _,
� Subsurtace Sewage Disposal System Farm-Not for Voluntary Assessments
{ - - - _.._ --�4{��`��3g
79 Ellis Circie ` __. — — � --
Propertyr Address
Liilian O'b�ien �-- — — .— — .— ,. — --- — — .—..—� —
Owner Owner's Name
informat�on is Yarmouth ort MA 02675 11-24-15 . _ _ ._
roquired for evey C��� -�----- --- -- -- - Stete Zip Code Date of Inspection
page, Y
(nspectian results must be submitted on this form. Inspection forms may not be altered in any
way. Please see compieteness checkiist at the end of the forrn. -
� - .—� .
Important:When
{ fl8ing oui torms A• General Informatian �� ',,,, y3��3 �*��..� �'��� �
on the computer. � c,('� �\ � j�} '(�� �
use only the tab �, inspector. ,;,���z '�4 � �,,�
key ta move your t � S��j' �-� �
cursor-do not James D.Sears �� `'
use the rolum ——— — — --•—— -�— �- —. __._..._ .__—. __.._„-,��c.�,�.-
Name o(Inapector o� ..,�� �
k�y' Ca ewide Ente rises LLC � ���`� _.� ___..� �� — —���� -�-�
�`�� � _ —�.�,
�/f1„a I I Compam+Name � -- --— j,�,✓,,,L
��� 153 Commercial Street ___ �'`� �
��--
Company Address — —^ J— — �-- � — �(,,w��
{ � Mashpee ---� -- MA ----.—.� 02649 �' ..
CnyRown State Zip Code /
508-�477-8877 S1623 __ — — �' ��
Telephone Number License Number
______��-� ��-� -
B. Certification
!certify that I have personally inspeoted the sewage dispos system at this address and that the
information reported below is true, accurate and complete as of the time of the in5pection. The inspection
was pertormed based on my training and experience in the proper function and maintenance of on site
sewage disposal systerns. I am a DEP approved system inspector pursuant to Section 15.340 af
Title b(390 CMR 15.000).The system:
� Passes ❑ Conditionally Passes ❑ Fails
❑ Needs FuRher Evaluation by the Local Approving Authority '
` 11-24-15
� �.---_.._ .�— .— - — — —,.�...._ �.
spedor's Signature Date
The system inspector shali submit a copy of this inspection repart to the Approving Authority (Board
of Health or DEP)within 30 days of compie4ng this inspection. If the systern is a shared system or
has a design flow of 10,OQ0 gpd or greater, the inspecto�and the systern owner shali submit the
report to the appropriate regional affice of the DEP. The original should be sent to the systern owner
and capies sent to the buyer, if applicable, and the approving authority.
*""`This report only describes conditions at the time of inspection and under the conditians of use
at that time.This inspectlon does not address how the system will pe�form In the ftrture unde�
the same or different conditions of us�. '
ISins•8H3 r ine 5 Offiaal Inspeqion Form:SubsuRaae Sewtpe Dispasa!System•Papa 1 0('�
__— �