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Subsurfac�8rwa�DisP°���°�FO�'Not for Voiuntary Assessme�ffi �q(."[���� South Yatmouth M-60 P- ; 214 Oid Main � �?"�, k' .� '� Prop�rh��� iG9nn@1h DO r �� own�rs�ame .�a 28 �0'12 ` . ���y 214 Old Main Str+eet.South Yannouth � �� wa ot in�psaion s P�• CNylT°wn �' �nspaction resu�s must be submittsd on ri+is form•ln�sPs����y not be alt�ared in any ; checkii�at tlts and o�the torm. ; way.PNase sa� � �,� A. General Information O p ��.�. C�O p� � � we onl�►the+m ,. ��sp�: ,, k�ey tio mae Y�ur �I aasa-ao na Tro Wilfiams use ths r�tum N�ns of Impec� I �' Tro V1�Iliams � � I � �� I � 19 Humme��rive ' � � comparni�� � 02660 I i� South Dettnis � z�a� c�r°""` s1682 ; 508 385•1300 �� ; Tewphons N�nb� ' ! � B. Ce1t�flCatiOn � � at this aaldress and that thg � I oertifY that I have pe�aonaNY��pac�ed ttte sswa9e disposa�$Y�� The insp� I beio�w is true,aocurafie and comi�e as of the�me of the inspectbn- �on s�e ' Mfor�r�atlon��my trainu�and experience in tt�e proPer functi�on and�15.340 a� I �age disposal systems.i am a DEP app�'oY�=Y�inspact�P��� �I Title 5�310 CIiAR 15.000)•The sYs�m� I Pa� [� �or�itlona{ly Passes ❑ Fa� ' � [) Needs Further Evaluation bY 1he Local APPro+►in9 Autho�itY , ' June 28 2012 S �, ,,�:s�.�.T � The sys�em inspec�oc sh�N submit a copy of this inspec�ion.�ePort to the Ap�����m or of He�th or DEP)with�n 30 days of comple�n9 this inspecGon.lf the sysbem has a design flaw of 10�000 9Pd or 9�ea��.the���°f$nd tl�e systiem awner sh�t submi�tt� • report�o tl�e appnoPriate r's9ionai ofFice af the DEP.The ong'�nal shoutd be seM tio the system awner a���nt tio the buyer,if appilcebte,and the approving authority '*""This n�w�t onhl d�scribss cond�a�r�ss Maw the syste►m witi�perfonn in ths future under at that tUne.This 1r�pe�� the sam�or dlffennt conditio�o�use. � TNM 5 OIIfdM��Subw+�t�o�S��Oipow SyM�n'P�p�t d 17 r�n.•��no f i t a $� Commonweakh of Massachuset� ' Titie 5 Officiai inspection Form ! subsurf.ce saM►ag.oisposs�sysam Fom�.Not�Or vaunt�►asse�amencs '� 214 Old Main Stir�eet, Soutl�Yarrnouth M-80 P-243 �� Ks9f1�i9�11 DOY�B �� Owners N�ms ���, 214 Oid Main Stroat. South Yarmoutl� MA 02664 Jwie 28.2012 �; p�p. Ciq►/rown St� Zlp Cods Dw of irnipodion C. Checkiist ; , Ch���IV������.You must indk�be"yes"or rn����IIC�A��4�o IVNV�II�. i I Yes No ` I BI ❑ Pumping in�formadon was provided by the awner�oawp�rt.or B�r�d of Health p � Were any of the syabem oompone�s pumped out�n the provbus twa weeks� i , ❑ � Has the syatem reoehred nort�at flows in the pr+evious two w�eek period? I Have teu�valumes of wate�been intr+oduoed to the sys�em revently or as part of � ❑ i� ���? C Wer�e as bu�t pians of the system obtained and sxamined?(If they w�ere rwt I � ❑ a�vailable no�e ss W/A) , � ❑ Was ths tac�lity or dw�g inapeded f�signs of sewage bsdc up? � ❑ VVas the si6e inepecbed for signs of breek outi7 �, , � [] were aa sy�em oomponents,exduding�,e sns,�oc�ted on silce? � p wene tl�,e Se�ic tank manriolea uncoverod,opensa,ana the in�ia at tne tank f jn�d f�the t�ondi�i of ths b�s or�s�rt�o�oons�u�� � dimensions,depth of liquid,depth of sludge and depTh of sc�im? � Was the facN�yity owner(and oocupar�a if dif�enent trom owner)P��� I � ❑ infortnatbn on the propar mairrtenance of subsurtaoe sewage disposd sys�ems? � The sira and loc�tlon of tl�e Soil Absorptlon Systian(gAS)on the s�e has baen detertninad�sed on: � � ❑ Exisdn9 int�onma�on.For e�cample.a pian at the Bo�nd of Fteaith. ' � � ❑ Oetiermined in the iield(if any of the fa�ure cxi�aria retatiad t�PaR C ia ffi issue , appnoximatlon of d'�tatx:e is unacveptabie)I310 CMR 15.302(5)] ' D. System tnfonr�ation R�sid��Fiow cond�Ions: Number ot bedrooms(�n): 4 Number of bedrooms(acd�al): 4 i DESIC3N flaw based on 310 CMR 15.203(for examp1e: 110 gpd x�of bedrooms): �� aw•»no na.aon�wwrp.abnco�e�wrha�.�.aownow a�n•v.o.ed n ! � �'�.�v-a�� �, �� -� ; � • � � . CONiMONWEAL'I'H OF M�,.SSACI�JSETTS E�LECUTIVE OFFICE OF ENVIRANMENTAL AFF I� I�� C�O QO �� rn�ax�.rrr oF Friv�orr�.rrrar.P���ox pC� 2 0 1999 ONE WII�TER 3TREE'1'�$03TON MA 02108 (61?)29'b5500 • • HEALTH DEPT. . �xvmr co� s� DAVID 8-STSUfiB Il1tGE0 PAUL CELLUCCI C�r � U S�lBSt�ACE SEWAGE DISPOSILL SYSTEII�NSP�CTIOM FORM �/j/I�!� Z D�/� PART A /���i r C�77F7ci►'[TOI�r �a�.�:o?�� 6�l�'I Q rn St w,„.d o� -�'r�i�7�iy+a.-� � i pO�� $O�'j► Ar�'7tJVf'� Addnas vf Ower: � o.�.��= 9/�O�'� /�j. ar�`i+�s .S• �ra��o�l� mft- oZ66 y M•�+•or�+�:�""�"� `�P ��s.�o o�n�s.s rs�o c���.000� t�en a DEP sri� i Coew�+t� c • Aq r.t A7� O.t6 L D I ��� T�Mpiw�Nisrib�: ` •- ���� N �t ti+is iddr.s:and tFMt th�intwmNlon►�Pa'hd bdow is uw.acwrst� ; !e�rtlh�i h�w P�rton�IlY fnsP���s�w"�'dtfpO� �� in tl�P►aMr innction aad � snd compiat�u af ttro dnu of insp�etlon. Th�insP��P�Ofm�d bas�d oa my t�ai�it�p�nd�� � msiritenau�ot on-sit�s�wap�disposd srata�s. Th�sysbm: `� Pas:�s ' "— �y Pa:s� ' • � N�ds FuttMr Ev�tion B�1F►�Loe�f ApWovi�O Aud+ority ' _ Fsis � �: �?� � , � � Iiu�p�eoPs pibmit a copy ot tldss M�e�da^*�P°�tO tlu Approvi�+p Aathaitf►tBoud of H��Itl+or OEP1wHNn tl�iK11(30t•deYs ot Th�Systen I�ap�oc is a shu�d srstan a hss s d�sl�n tbw of 10.000 ppd o�9nst�r.tl+�(n�etor u�d fhs systan owc� compl�n0�s insp�etian. If tM syat�m etli�of th�OsP�=d�°���' Th��ntl shoufd�bt sent'to1lls . -�ll submit tM rePort to the apProP�ate f�pio�u� • ' • systNn owt���nd eopi�s sent to th�bupK•i!sPP�•a�d tM s�rovi���Y' iitpTES AND COMMB�'fS ,T', c Tq.,k Sys�e� w�s �v,rpp� �'r"e� ' �. .s�P / I 7�"t»P.s ♦r, /r!'9� . / �/� �. ' q� •g� �v�,. �s�e �L+�CCPP�S G��S:f., o •� . . 3� � �P4 G� �'I 7E' 1� .- Qv�dr�. P A�r .s s�w- �p��L �v • f a,�vrJ�R•�T �i � ��"��� '� S' !o w s W /�ovr`' /a✓� �r'y -� S �P t arN�n�� �►'�q i,�a l� Co v�r- Q � �au�2 ��. ' aC�¢�vew� Pv✓ ! revised 9/2/98 � r.�`1�t1� ; �lt�r�drf, jP4c� � i� . i.�r+'iwed oe R«rdc�e►�pe� � f . , � i . ; �i sussw+��c�sFwace asPosac sYs�wsr�n�w�w i PItRT C SYSTAR WFORMAIIQN �h�= � �� Z14 Old Manz St,South Yarmou�,1NA ow of in.p.nien: T�� f September 22,1999 p,pw�mo�ss , D���.p.d.lb�d►oorn. �M b�droo�eis t Flom�r ot b�drooms(acatNl:� Total DESION fbw 'P'D �I� Nwnh�of a�er�nt rssld�e►ts• oare.p�qrina�r iws or nol:�,0 `�,�" �tundry ts�pKaR�tY�m1 h►y or no1��i�•��1rts,s�pw��nsP�cdon•r�quind �wndr�►a�t�m Msp�ec�d �r�s a no1 �S W S��u A�—G4/M<�'� �,�...�ris a�,•�.o �fP d�o9,a�o QGPl� � , Wsta nub.t��dG,ps.N.,,.�6t.uss!twu y�..�s�s�0.(W�d1: �S f suRw Pumv tws o.no1:1�Q . �9 7���� ,. �m d.t,�a�,►:��ec� � Typ�of asN66shmerK: � pKypn flow: aod t 6as�d on 15.203) I, Bssis o!dyi�a tbw Qtat!tr�p►fa�ntt t1►�s a no} h�dustdM YYrst�Holda�Un1c pnsMt:( Nonsa�ar�►wast�d=ehw�M to ' •b syst�m:(Y+s or no1_ • Wat�►nNt�r►��'i�s.if� r. � Last d�n of occup ' i _ se�ib�) � d�t�of oa�tPu�e�►t Q61tERAL O�PORI{IIATTON �� ,v�r� e�-�-. ' � �:«�.�.of� � : � � • a? - �36V ' 99b� �35� l9�4 'ZZYS � sr.�.m p,�P.e.:o.re ot�w�+�tr��o•�o�� Iq 46 --a�s9 N�r�s,�nns purnp�d:� aapons R�ason fat pu�inp: � rn�oF strS7� I _L/ s.ptla tank�dfste�udoe boxboU.�:o�ption syse.m ' �,_ S�pt�e�sspod I _._ ��s�°°� ' SA�nd sYst�en fri=a no) p11r�s.att�eh P��+�PK����:•it anyi ' _� UA T�hnolo�►�ta.Atqch copy ot up to dat�op�ntfon and m�nt�nsnc�cannct Tipht Unk Copy ot OEP APp►ovd 4� APPRQ701AAZE GE at d eanpon�s.daa�nsW�d�it�cnownHnd aourw�tiMan��tbn:�Q�S• --..f�K ST�� no .— 3 u�91 �2 sys r� ' L/hJ•J pR,� �A� p,,f- � a- y.��s Swrp�adors d�t�et�d wMn•anivirq aR 1M aia:�ns a noS�� ' .�,�5�L��� ! N ��7. . ,I I ; � 2 8 r.ie t ot lt � revised 9/ /9 � i , . � , � j SL�S1lRFJlCE SEIAIAtiE DISPOSJtL SYSIEY!lSPECTION FaRY ', g11iR C 81►5't'�II�iDlq�IlT10N fooeti�n�� �V Adb�s: �1mp�c�on: ,Z�,�4�5�.South Yatmou�,lyq � �ep�eml�a'22,1999 i SKETCH OF SEWAQE DRSPaS/��SY8'1'61�: � � tnelud�W+to st but twc P�nna+ant��irr�ncs ia�dma►ks a Mndrnarlcs loeat�att wNts whhM t00'tLoesb w�ar�pub6e wster nPp�Y eomes iMo hovsel � � i i � �� � � ! ____. o � . �, � o � G D � F�oar i � . ; �� � �� � �o � Uls�4 ; tN �� �C � �f7'• gC } - ! �� � ' � ' �'� =�3;B D� �5' . � �! �� =�3' ,8�.-�t � ; �F'= 6'1; �F=�a' ,�. _ � , - Z7s ; a� :6� � revised 9/2/gg t,�e io or s� i �