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Inspection results must be submitted on this form. Inspection forms may not be altered in any way. �"
A. General lnformation
1. Property Information: MAP 49—PARC 4
59 SWAN LAKE ROAD —WEST YARMOUTH, MA 02673
Property Address
WHITEHEAD, RONALD
Owner's Name
59 SWAN LAKE ROAD
Owner's Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
JAN UARY 8, 2007
Date
2. Inspector: ;
JAMES D. SEARS
Name of Inspector
A & B CANCO
Company Name
350 MAIN STREET
Company Address
WEST YARMOUTH MA 02673
CitylTown State Zip Code
508-775-2800
Telephone 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 inspection. The inspection was pertormed 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 � Conditionally Passes � Fails
� Needs Further Evaluation b the Local Approving Authority
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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. �
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D. Certification (cont.)
59 SWAN LAKE ROAD
Owner's Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JAN UARY 8, 2007
Date of inspection
Inspection Summary: Check A, B, C, D or E!a/ways compiete all of Section D
A) System Passes: N/A
� 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: N/A
� 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.
Answer yes, no or not determined (Y, N, ND)in the � 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 structuralty
unsound, exhibits substantial infiltration or exfiltration or tank failure 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.
ND Explain:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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B. Certification (cont.)
59 SWAN LAKE ROAD
Owner's Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JAN UARY 8, 2007
Date of inspection
B) System Conditionally Passes(cont.): N/A
� 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
� obstruction is removed
� distribution box is leveled or replaced
ND Explain:
� 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
� obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health: N/A
� 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 wilt protect public health,safety and
environment:
� Cesspool or privy is within 50 feet of a surtace water
� Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Not for Voluntary Assessments
�` Subsurface Sewage Disposal System Form
B. Certification (cont.)
59 SWAN LAKE ROAD
Owner's Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JANUARY 8, 2007
Date of inspection
C) Further evaluation is required by the Board of Health (cont.): N/A
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,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 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 5Q 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 coliform bacteria
indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3.Other:
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B. Certification (cont.)
59 SWAN LAKE ROAD
Owner's Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JANUARY 8, 2007
Date of inspection '
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 surtace of the ground or surtace waters due to an ���;
overloaded or clogged SAS or cesspool
� N/A Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
� � Liquid depth in flows is less than 6" below invert or available volume is less than
'/day flow
� � Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped: .
� � Any portion of the SAS, cesspool or privy is below high ground surface water elevation.
� N/A Any portion of cesspool or privy is within 100 feet of a surtace water supply or tributary
to a surtace water supply.
� N/A Any portion of a cesspool or privy is within a Zone 1 of a public welL
� N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
� N/A Any portion of a cesspool or priry 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.]
YES No
� The system is a cesspool serving a facility with a design flow of 2000 gpd— 10,000 gpd. :
Yes No
� � 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.
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Title 5 Official Inspection Form:Subsudace Sewage Disposal System �
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B. Certification (cont.)
59 SWAN LAKE ROAD
Property Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JAN UARY 8, 2007
Date of inspection
E) N/A-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 surtace 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 15.3Q4. The system owner should contact the appropriate regional office of the
Department. '
Title 5 Official Inspection Form:Subsudace Sewage Disposal System
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C. Checklist
� 59 SWAN LAKE ROAD
Property Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JANUARY 8, 2007
Date of inspection
Check if the fotlowing 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 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?
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� � Have large vo�umes of water been introduced to the system recently or as part of this
inspection?
� � Were as built plans ofthe system obtained and examined?(Ifthey 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, including 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 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)].
Title 5 Official Inspection Form:Subsudace Sewage Disposal System i
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D. System Information
59 SWAN LAKE ROAD
Property Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JANUARY 8, 2007
Date of inspection
Residential Flow Conditions:J
Number of bedrooms(design): 3 Number of bedrooms(actual): 330
DESIGN flow based on 310 GMR 15.203(for example: 110 gpd x#of bedrooms): 3
Number of current residents: 2
Does residence have a garbage grinder? � Yes � No
Is laundry on a separate sewage system?[if yes separate inspection is required] � Yes � No
Laundry system inspected? � Yes � No
Seasonal use? � Yes � No
Water meter readings, if available(last 2 years usage(gpd)): 2005—124,000 GAL
2006-135,000 GAL
Sump pump? � Yes � No
Last date of occupancy: PRESENT
Commercialllndustrial Flow Conditions: N!A
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
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:
Last date of occupancy/use:
Date �
Other(describe): �
Title 5 Official Inspection Form:Subsudace Sewage Disposal System
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+ D. System Information (cont.)
59 SWAN LAKE ROAD
Property Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JANUARY 8, 2007
Date of inspection
General lnformation
Pumping Records: ✓
Source of Information: 1998—2002-2004
Was system pumped as part of the inspection? � Yes � No
If yes,volume pumped: '
gallons
How was quantity pumped determined?
� Reason for pumping:
Type of System:
� Septic tank, soil absorption system
� Single cesspool
Overflow ces
s ool
❑ p
� Privy
� Shared system(yes or no)(if yes, attach previous inspection records, if any)
� Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract
(to be obtained from system owner)
� Tight tank.Attach a copy of the DEP approval.
� Other(describe): '.
Approximate age of all components, date installed(if known)and source of information:
1993—PERMIT#93-135
Were sewage odors detected when arriving at the site? � Yes � No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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D. System Information (cont.)
59 SWAN LAKE ROAD
PropeRy Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JANUARY 8, 2007
Date of inspection
Building Sewer(locate on site plan): ✓
Depth below grade: g°
feet
Material of construction:
� cast iron � 40 PVC � other(explain)
Distance from private water supply well or suction line:
feet
Comments(on condition ofjoints, venting, evidence of leakage, etc.): '
GOOD PVC SCH 40
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: 1000-GAL PRE CAST
Sludge depth: 10"
Distance from top of sludge to bottom of outlet tee or baffle 20"
Scum Thickness 2��
Distance from top of scum to top of outlet tee or baffle 12" '
Distance from bottom of scum to bottom of outlet tee or baffle 16"
How were dimensions determined? ASBUILT—TAPE&SLUDGE JUDGE.
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D. System Information {cont.)
59 SWAN LAKE ROAD
Property Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JANUARY 8, 2007
Date of inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid
levels as related to outlet invert, evidence of leakage, etc.):
TANK AT WORKING LEVEL, INLET TEE — OUTLET BAFFLE.
TANK& COVERS AT 10" NO SIGN OF LEAKAGE.
Grease Trap (locate on site plan): N/A
Depth below grade:
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
Date
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): N/A
Depth below grade:
Material of construction:
� concrete � metal � fiberglass � polyethylene � other(explain)
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� D. System Information (cont.)
59 SWAN LAKE ROAD
Property Address
WEST YARMOUTH MA 02673
CitylTown State Zip Code
WHITEHEAD, RONALD
Owner's Name
JAN UARY 8, 2007
Date of inspection
Tight or Holding Tank (cont.) N/A
Dimensions
Capacity:
gallons
Design Flow:
gallons per day '
Alarm present: � Yes � No
Alarm Level: Alarm in working order: � Yes � No
� Date of last pumping:
Date
Comments(condition of alarm and float switches, etc.):
*Attach a copy of current pumping contract(required}. Is copy attached? � Yes � No
Distribution Box (if present must be opened) (locate on site plan): N/A .
Depth of liquid level above outlet 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.):
Pump Chamber(locate on site plan): N/A
Pumps in working order: � Yes � No
Alarms in working order: � Yes � No
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D. System Information (cont.)
59 SWAN LAKE ROAD
Property Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JAN UARY 8, 2007
Date of inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required): ✓
If SAS not located, explain why:
,
Type:
� leaching pits number:
� leaching chambers number. 2
� leaching galleries number: .
� leaching trenches number, length:
I � leaching fields number, dimensions: I
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� overtlow cesspool number:
� innovativelalternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
LEACHING IS TWO (2) FLOWS WITH 3' STONE, FLOWS ARE 20" BELOW GRADE.
LEACHING IS FULL, NOT WORKING - NEED TO REPLACE LEACHING.
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� D. System Information (cont.)
� 59 SWAN LAKE ROAD
'' Property Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JAN UARY 8, 2007
Date of inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A
Number and configuration
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
Comments(note condition of soil, signs of hydraulic failure, fevel of ponding, damp soil, condition of vegetation,
etc.):
Privy (locate on site plan}: N/A
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
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� D. System Information (cont.)
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I 59 SWAN LAKE ROAD
Property Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JANUARY 8, 2007
Date of inspection
Sketch of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at
least two permanent reference landmarks or benchmarks. Locate ali wells within 100 feet. Locate where
public water supply enters the building.
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D. System Information (cont.)
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; 59 SWAN LAKE ROAD
� Property Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
WHITEHEAD, RONALD
Owner's Name
JAN UARY 8, 2007
� Date of inspection
� Site Exam:
Slope
Surface water
Check cellar
� Shailow welis
� Estimated depth to ground water: 6
iPlease indicate al1 methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:
Oate '
� Observed site(abutting property/observation hole within 150 feet of SAS)
� Checked with local Board of Health—explain:
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� Checked with local excavators, installers—(attach documentation) '
� Accessed USGS database—explain:
You must describe how you established the high ground water elevation: �
TEST HOLE 6' WATER 34" BELOW BOTTOM OF FLOWS. �
USGS MIW-29 ZONE B 1'-4" ADJ.
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