HomeMy WebLinkAboutInspection Report 2016 Jul 26 - SEE REVISED REPORT I
• I� 12T ---T�,
� Commonwealth of Massachusetts P�2,,,� R�C�iV�U ;
� Title 5 4fficial Inspection Farm AI�G 09 201�
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;,H�A4TH.D�RT. -
' M � 1 Point of Rocks Road Yarmouth Port ��xr
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is Yarmouth Port MA 02675 7/22/2016
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 �. �nspector: ,�J�`� r�
key to move your �
cursor-ao not Joseph M Martins
use the return Name of Inspector �
key. �7 �
� Accu Sepcheck
� CompanyName
17 Northside Dr
Company Address
� South Dennis MA Q2660
CitylTown State Zip Gode
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 the inspeetion. The inspection
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
Title 5 (310 CMR 15.000).The system:
❑ Passes ����aSses ❑ Fails
� Needs Further Evaluation by the Local Approving Authority
8/6/2016
In ector'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 does not address how the system will perForm in the future under
the same or different conditions of use. '
t5ins•3tt3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
� Commonwealth of Massachusetts
� Title 5 Official Inspection Form
SubsurFace Sewage Disposal System Form -Not for Voluntary Assessments
��M , �� 1 Point of Rocks Road Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
intormation is Yarmouth Port MA 02675 7/2212016
required for every
page. C�YRo� 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"Canditional Pass"section need to be
replaced ar 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 j
unsound, exhibits substantial infiltration or e�ltratian or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a camplying septic tank as approved by the Board of '
Health.
*A metal septic tank will pass inspection if it is structurally sound, not teaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
CRACKED CONCRETE TEE NEEDS TO BE REPLACED W PVC TEE AND GAS BAFFLE
t5ins•3113 Title 5 Official Inspection Fortn:Subsurface Sewage Disposal Syshxn•Page 2 of 17
� Commonwealth of Massachusetts
� Title 5 Official Inspection Form
SubsurFace Sewage Disposal System Form -Not for Voluntary Assessments
��,� , 1 Point of Rocks Road Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is Yarnlouth Port MA 02675 7/22/2016
required for every
page. Gity/Town State Zip Code Date of Inspection
B. Certification (cont.}
❑ Pump Chamber pumps/alarms 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 Boarcl of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (F�cplain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (F�cplain 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):
❑ braken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain belaw):
C) Further Evaluation is Required by the Board of Health:
� Conditions exist which require further evaluation by the Board of Heafth in order to determine if
the system is failing to protect public health,safety orthe 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•3t�3 Title 5 Official Ins�tion Fortn:Subsurface Sewage Disposal System•Page 3 of 17
� Commonwealth of Massachusetts
� Title 5 Official Inspection Form
SubsurFace Sewage Disposal System Form -Not for Voluntary Assessments
�M , 1 Point of Rocks Road Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is Yarmouth Port MA 02675 7/22/2016
required for every
page. ��Y�o� State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Heafth(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 surface water supply ar 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 fram 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 ather failure criteria are triggered.A capy of the analysis must
be attached to this form.
3. Other:
H-'10 COMPONENTS (DBOX AND SAS CHAMBER) LOCATED IN FRONT DRIVEWAY. ALSO
TOWN WATER LINE IS LESS THAN FOUR FEET FROM SAS.
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 panding of effluent to the surface of the ground or surface waters
due to an overloaded or clagged SAS or cesspool
� � Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspoo(
. � � Liquid depth in cesspool is less than 6° below invert or available volume is less
than '/Z day flow
t5ins•3/13 Title 5 O(ficial Inspection Fortn:SubsurFace SeYvage Daposal Systern•Page d of 17
� Commonwealth of Massachusetts
� Title 5 t�fficial Inspection Form
_ SubsurFace Sewage Disposai System Form -Not for Voluntary Assessments
�M , � 1 Point of Rocks Raad Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is Yar'mouth Po►t MA 02675 7/22/2016
required for every
pa9e. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
� � Required pumping more than 4 times in the last year NQTdue to clogged or
obstructed pipe(s). Number of times pumped:
❑ � Any portian of the SAS, cesspoal or privy is below high ground water elevation.
� � Any portion of cesspool or privy is within 10Q feet of a surface 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 af a cesspool or privy is within 5Q 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,OOOg�xl.
� � The system fails. I have determined that one or more of the above failure
criteria exist as described in 31 d CIUIR 15.303,therefore the system fails.The
system owner should contact the Board of Heafth 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 20Q 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 o�ce of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
� Commonwealth of Massachusetts
� Title 5 4fficial I nspection Form
SubsurFace Sewage Disposal System Form -Not for Voluntary Assessments
M , 1 Point of Rocks Road Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is Yamlouth Port MA 02675 7122/2016
required for every
page. City/Town 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 information was provided by the owner, occupant, or Board af Health
❑ � Were any of the system components pumped out in the previous two weeks?
� ❑ Has the system received normal flows in the previous finro week period?
� � Have large volumes af 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 inspe�ted for signs of break out?
� ❑ Were all system components, exGuding 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 subsurtace 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 bedraoms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15203 (for example: 110 gpd x#of bedrooms): 33Q
t5ins•3/13 Title 5 O(ficia�Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
� Commonwealth of Massachusetts
� W Title 5 Official Inspection Form
e SubsurFace Sewage Disposal System Form -Not for Voluntary Assessments
�,M , 1 Point of Rocks Road Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is Yarmouth Port MA 02675 7/22/2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1 Q00 GALLON SEPTIC TANK, DISTRIBUTION BOX AND 2 FLOW DIFFUSER 16'X22'X1.1' STONE
VOLUME
Number of current residents: �
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)): n
Detail:
2015: 2014:
Sump pump? ❑ Yes � No
Last date of occupancy: 7l22/2016
Date
Commercial/Industrial Flow Condrtions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): �auons per day l9Pd�
Basis of design flaw(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•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
� Commonwealth of Massachusetts
� Title 5 Official Inspection Form
" Subsurt'ace Sewage Disposal System Form -Not for Voluntary Assessments
G M s� '� 1 Point of Rocks Road Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is Yarnlouth Port MA 02675 7/22/2016
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancyluse: Q�e
Other(describe below):
General lnformatian
Pumping Records:
Source of information: PUMPED LAST YEAR PER OWNER
Was system pumped as part of the inspection? ❑ Yes � No
If yes, volume pumped: 9anons
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 operatian 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•3l13 Title 5 Official Inspec6on Fortn:SubsurFace Sewage Disposal Systern•Page 8 of 17
� Commonwealth of Massachusetts
� r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r M ,� 1 Point of Rocks Road Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is Yarmouth Port MA Q2675 7/22/2Q16 '
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:
26 YEARS. INSTALLED 1990. PER YHD
Were sewage odors detected when arriving at the site? ❑ Yes � No
Building Sewer(locate on site plan):
Depth below grade: eet
Material of construction:
❑ cast iron � 40 PVC ❑ ather{explain):
Distance from private water supply well or suction line: 6
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
OK NO LEAKS
Septic Tank(locate on site plan):
Depth below grade: �
feet
Material of construction:
� concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: APP 5X6X8.5 1 QOOG
3�,
Sludge depth:
i5ins•3/13 Title 5 Official Inspection Form:Subsurface S�wvage Disposal Sys�m•Fage S af 17
� Commonwealth of Massachusetts
� Title 5 Official 1 nspection Form
" SubsurFace Sewage Disposal System Form -Not for Voluntary Assessments
M , � 1 Point of Rocks Road Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is Yarmouth Port MA 02675 7/22/2Q16
required for every
page. City(fown State Zip Code Date of Inspection
D. System information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of autlet tee or baffle
31"
Scum thickness
0"
Distance from tap of scum to top of outlet tee or baffle ��
Distance from bottom of scum to bottom of outlet tee ar baffle
14"
Haw were dimensions determined? CORETAKER
Comments (on pumping recommendations, inlet and outlet tee or baffle candition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
HAS PVC INLET TEE W WALL BAFFLE; HAS CONCRETE OUTLET TEE IN FAIR TO GOOD
CONDITON�rith SMALL CRACK. IT NEEDSTO BE REPLACED. LIQUID LEVEL IS 48"AT OUTLET
INVERT.
Grease Trap (locate on 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: Qace
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sear�qe Disposal Systern•Page�0 of 17 '
� Commonweaith of Massachusetts
� � Title 5 t�fficial Inspection Form
SubsurFace Sewage Disposal System Fonn -Not for Voluntary Assessments
M ,� 1 Point of Rocks Road Yarmouth Pork
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is YaPRtOuth Poft MA 02675 7/22/2016
required for every
page. Gity/Town State Zip Code Date of Insp�tion
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: NIA
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions
CapaCity: gallons
De5igfl FIOW: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Ye5 ❑ 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•3f13 Title 5 Otficial Inspection Form:Subsurface Sewage Disposal System•Page 11 of tt
� Commonwealth of Massachusetts
� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M , � 1 Point of Rocks Raad Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is Yarmouth Port MA 02675 7122J2016
required for every
page. City/Town 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 above outlet invert AT INVERT
Comments (note if box is level and distribution to outlets equal, any evidence af solids carryover, any
evidence of leakage into or out af box, etc.):
H-10 DBOX IN DRIVEWAY, COVER WAS BROKEN AND WAS REPLACD. NO EVIDENCE OF
LEAKAGE. BOX IS IN GOOD SHAPE. :
Pump Chamber{locatg 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 warking order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 O(ficial Inspection Fortn:Subsurface Sewage Disposal Systern•Page 12 of 17
� Commonweaith of Massachusetts :
� Titie 5 Official Inspection Form
SubsurFace Sewage Disposai System Fonn -Not for Voluntary Assessments
ti , 1 Point of Rocks Road Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is Yamlouth Port MA 02675 7/22/2Q16
required for every
page. City/Town State Zip Code Date af Insp�tion
D. System Information (cont.}
Type:
❑ leaching pits number:
� leaching chambers number:
2
❑ 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.):
H-10 FLOW DIFFUSERS IN DRIVEWAY. NO SIGN OF HYDRAULIC FAILURE. NO STAINING
ABOVE INVERT.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and canfiguration
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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
� Commonwealth of Massachusetts
� Title 5 Official Inspection Form
SubsurFace Sewage Disposal System Form -Not for Voluntary Assessments
� 1 Point of Rocks Road Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rodcs Road
Owner Owner's Name
information is Yarmouth Port MA 02675 7/22/2016
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 af vegetation,
etc.):
Privy(locate on site plan):
Materials of construction: N/A
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•31�3 Trtle 5 Official Uspection Fortn:Subsurface S�,wage Disposal Systern•Page 14 of 17
•� Commonweatth of Massachusetts COn1D t7lAl���
� Titie 5 t�fficial Inspection Form �'�s
Subsurtace Sewage Dispasat System Form-Not for Volurrtary Assessments �'�'�'�
1 Point af Rodcs Road Yarmouth Part '
Property Address
Catherine Anderson 1 Point af Rocks Road
. Owner Owner's Name
information is YarmOuth Port MA 02675 7122l2016
required for every
�9e C�{y/Toyy� State Zip Code Qate of I�spectiort
D. System information {cont.)
Sketch Of Sewage Disposal System: Provide a view af the sewage disposai system, including ties to
at least two petmanent reference landmarlcs or benchmarks. Lacate ali weils within 100 feet. Locate
where publicwater supply enters the building.Check one of the boxes below:
� hand-sketch in the area below
❑ drawing attached separately
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t5iru•3YI3 Title 5(Nficiat Inspection Farrn:Subsudace Seywage Disposal9ysffirn•Page'IS of 17
�� Commonwealth of Massachusetts
� Title 5 Official Inspection Form
Subsurface Sewage Disposai System Form -Not for Voluntary Assessments
� M , 1 Point of Rocks Road Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner OwnePs Name
information is Yarmouth Port MA 02675 7/22/2Q16
required for every
pa9e_ City/Town State Zip Code Date of inspection
D. System Information (cont.)
Site Exam:
� Check Slope
� Surface water
� Check cellar
� Shallow wells
+-11.1
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 recard
If checked, date of design plan reviewed: 7�y1990
Date
❑ Observed 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:
MUTIPLE TEST HOLES DONE ON SITE.TEST HOLE USED IN DESIGN SHOWS 4.0 FROM
BOTTOM OF SAS TO PERCHED WATER OR AT LEAST 11.1'ADJUSTED FROM TH#6.
INSPECTOR MEASURED GRADE TO SAS BOTTOM AT 3.1'. SEPARATION MATH: 11.1-
3.1=8.0'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspec6on Form:Subsurface Sewage Disposal System•Page 16 of 17
� Commonwealth of Massachusetts
� Title 5 Official i nspection Form
SubsurFace Sewage Disposal System Form -Not for Voluntary Assessments
�M , 1 Point of Rocks Road Yarmouth Port
Property Address
Catherine Anderson 1 Point of Rocks Road
Owner Owner's Name
information is Y8mlouth POIt MA 02675 7/22/2016
required for every
page. City/Town State Zip Code Date of Insp�tion
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 Infarmation—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 lnspection Form:Subsurface Sewage Disposal Systern•Page 17 of 17