HomeMy WebLinkAboutInspection Report 2017 Apr 28 I
,,May 07 2017 22;06 Jim The InspectAr Man 5085349919 page 2 �
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� Commonwealth of Massachusetts �
� v � Title 5 Official inspection Form ,
Subsu�face Sewage Disposal System Form-Not fo�Voluntary Assessments �
80 Grandview Drive
Property Address �
Bernadette O'Brien
Owner Owner's Name `
information is South Yarmouth MA 02664 4-28-17
required for every
page, CitylTown State tip Code Date of Inspection
B. Certification (cont.) ;
Inspection Summary: Check A,B,C,D or E/always complete all of Section D F
A) System Passes:
❑ I have not found any information which indicates that any �f 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:
Failed Leaching, The system is a 1000 Gal. Tank D Box and f�ve chambers. ,
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B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be i
replaced o�repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box far"yes", "no"or"not determined° (Y, N, ND)for the following statements. If"not �
determined," please explain,
The septic tank is matal and over 20 years old'or the septic tank{whethe�metal or not) is structurally �,
unsound, exhibits substantial infiltration orexfiltration 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 saund, 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):
t5na.doc•rev.6116 Ti11e 5 OH�cid Inapedion fam:Subsuriece 3ewa9e Disposal System•Pag�2 of 17
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� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Nat for Voluntary Assessrnents
80 Grandview Drive
Property Addross
Bemadette O'Brien
Owner Owner's Name
;ntormation is gputh Yarmouth
required for every MA 02664 4-2$-�7
R�e• �rtyRO'"� State Zi Code D
P a
ce of Ins ction
PQ
B. Certification (cont.) '
❑ Pump Charnber pumpslala�rns not operational. System will pass with Board of Health approval if
pumpslalarrns are repaired. '
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high stafic 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):
❑ dist�ibution 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
systern will pass inspection if(with approval of the Board of Health�: '
❑ broken pipe(s}are replaced ❑ Y ❑ N ❑ ND(Exptain below):
❑ obstruction is removed ❑ Y ❑ N ❑ Np (Explaln belOw); !
C) Further Evaluation is Required by the 8oard of Health:
❑ Conditions exist w�ich require further evaluation by the Board oF Health in order to determine if '
the system is failing to protect public health, safery or the environrnent.
1. System will pass unless Board of Health determines in accoMance with 310 CMR '
15.503(1){b)that the system is not functioning in a manner which will protect public health,
safety and the envlronmeM: �
❑ Cesspool or privy is within 50 feef of a surface water
❑ Cesspool or privy is within 5Q feet of a bordering vegetated wetland or a salt marsh '
t5fns.doe•rev.6116 ��
Tfllv S Olfidel Inapecfion Form:Subs�MaCe Sewape Dispasel System•Pape 3 of t7 '
, May 0� 2017 22,06 Jim The Inspector Man 5085349919 page 4
� Commonwealth of Massachusetts
• �� � Title 5 4fficiai Inspection Form
� Subsurface Sewage Disposal Sy6tem Form-Not for Voluntary Assessments
80 Grandview Drive
Property Address
Bemadette O'Brien
Owner pwners Name
informatlon is gauth Yarmouth
required tor every MA 02664
page. C�ty/Town 4-28-17
State Zip Code Date af Inspection
B. Certification (cont.�
2. System will fail unless the Board of Health (and Pubiic Water Supplier, if any)
determines that the system i�functioning in a manner that protects the public health,
safety and environrnent:
❑ The system has a septic tank and soil absorption system jSAS�and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply. '
❑ The systern 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 sepEic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well'i
Method used to determine distance:
*"This system passes if the weN water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of amrnonia 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. �ther:
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D) System Failure Criterla Applicable to All Systems: I
You m , indicate"Yes"or"No"to each of the follvwing for all inspectlons: ;
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 cesspool '
� � Static liquid level in the distribution box above autlet invert due to an overloaded '
or clagged SAS or cesspool
,
� � Liquid depth in � is less than 6" below invert or available volume is less
than �da flow ,��/�t���rti� �
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� Commonwealth of Massachusetts
Title 5 afficial Inspection Form
Subsurface Sewage Disposal System Fortn-Not for Voluntary Assessments
' 80 Grandview Drive
Property Address
Bernadette 0'Brien
Owner Owner's Name
infortriation is ry South Yarmouth
required for eve MA 02664 4-28-17
page. ���y�ow►� Stale Zip Code Date ot 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 of tirnes purnped:
❑ ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ,
� � Any porGon of cesspool or privy is within 100 feet of a surface water suppty 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 qualiry anafysis. (Thia
system passes if tha well water analysis, performed at a DEP certified
laboratary,for fecal coliform bacteria indicates absent and the presence
of ammonla nkrogen and nitrate nitrogen is equal to or less than 5 ppm, '
provided that no other fallure critaria are triggered.A copy of the analysis
and chain of custody muat be atteched to thls form.]
� � The system is a cesspool senring a facility with a design flow of 20QOgpd-
10,OOOg pd.
� � The system faila. I have determined that one or more of the above failure �
criteria exist as described in 310 GMR 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 Systoms: To be censidered a larg�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 fallowing, in additian to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
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❑ ❑ 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 I I of e public water supply well
1f you have answered"yes"to any question in Section E the system is considered a sign�cant threat,
or answered"yss"in Section D ab�ve 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 5hall upgrade the
system in accordance wifh 310 CMR 15.304.The system owner should contact the app�opriate �
regional office of the Department.
l5ins.doC•rev.8l76 Tltle 5 OKeial Inspoctlon Form:Subsurface Savape Dicposal System•Page 5 af 17 �I
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, May 07 2017 22;07 Jim The InspectAr Man 5085349919 page 6
� Commonwealth of Massachusetts
� �-� Title 5 Official inspection Form
Subsurtace Sewage Disposal System Form-Not for Voluntary Assessments
80 Grandvlew Drive
� Property Addr�ss
eernadette O'Brien
Owner pv,mers Name
information is Soufh Yarmouth
required for every MA 02664 4-28-17
page. c�h+lrown State Zip Code Date of Ir�spection
C. Checklist
Check if the folfowing 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 iwo weeks?
❑ � Has the system received normal flows in the previous iwo week periad?
� � Have large volurnes of water been introduced to the system recently or as part of
this inspection?
� � We�e as built plans of the system obtained and examined?(If they were no�
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 conditi�n of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth af scum? `
� � Was the facility owner(and occupants if different from owner}provided with
informatian on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorptian Syatem(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)j j
D. System Information ;
Resfdential Flow Conditions: �
Number of bedrooms(design): 3 Number of bedrooms(actual): 3 ,
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 4
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FeGGion Form:SubauAace SOwape Disposal System•Page 8 of 17 �
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, May 07 2017 22;07 Jim The Inspector Man 5085349919 page 7
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Sut�urFace Sewage Disposal System Form -Not for Voluntary Assessments
8Q Grandview Drive
Property A+ddress
Bernadette O'Brien
Owner Owner's Name
infartnation is South Yarmouth MA 02664 4-28-17
required forevery
prye. CitylTown State Zip Code Date of Inspectton '
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and Fve chambers
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 systern inspected? ❑ Yes � No
Seasonal use? ❑ Yes � No
Water meter readings, if available(last 2 years usage(gpd)j: 2015-142,OOOGaI
2Q16-137,OOOGaI s
Detail: :
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Sump pump? ❑ Yss � No
Last date of occupancy: NA
Date
CommerciaUfndustriaE Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15,203): Gallons per day(gpd> '
Basis of design flow(seatslpersonslsq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank p�esent? ❑ Yes ❑ No '
Non-sanitary waste discharged to the Title 5 systern? ❑ YeS ❑ No
Water meter readings, if avaifable. ;
ISns.doc•rev.6/16 Ti11e 5 Otffdal hapection Fortn:SubwRace Sewage Diepoeal System�Pope 7 0l 17
, May 07 2�17 22;08 Jim The Inspectr�r Man 5085349919 page 8
� Commonwealth �f Massachusetts
• _ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Grandview Drive
Property Address
Bemadette 0'Brien
Owner pWner's Name
information Is SOuth Y8RIt0uth
required for every MA 02664 4-2&17
pege, CityR'cwn State Zip Code Date of Inspection
D. System Information (cont.) '
Last date of occupancy/use: ��e ,
Other(describe below): '
General Information
Pumpi�g Records:
Source of information; NA
Was system pumped as part of the inspection? ❑ Yes � No '
If yes, volurne pumped:
gauo�s
How was quantity pumped de#ermined7 '
Reason for purnping:
Type of System:
� Septic tank, distribution box, soil absorption systern
❑ Single cesspool
❑ OverFlow cesspool
❑ Privy '�,
❑ Shared system(yes or no) (if yes,attach previous inspection records, if any)
❑ InnovativeJAlternative technology.Attach a copy of the current opera�ion and
maintenance cantract(to be obtained from system owner)and a copy of latest
inspection of the f!A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval. ;
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❑ OEher(describe): I
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, May 07 2017 22;08 Jim The Inspector Man 5085349919 page 9
� Commonwealth of Massachusetts
Title 5 Ufficial Inspection Form
& Subsurtace Sewage Disposal System Fvrm-Not for Voluntary Assessments
80 Grandview Drive
Property Address
Bernadette 0'Brien
Owner Owr�er's Name
iniormation is ry South Ya�rnouth
required tor eve MA 02664 4-28-17
Pa9e, CitylTown State
Zip Code Date of Inspection
D. System Information {cont.)
Approximate age of all components, date installed(if known)and source of information:
Tank 1979 permit�78- 108/Leachin 1984 permit#84-429
Were sewage odors detected when arriving at the site? ❑ Yes � No
Buflding Sewer(locate on site plan): .
9'-4"
Depth below grade: teec
Material of construction_
❑ cast iron �40 PVC ❑other(explain}:
Dishance from private water supply well or suction line: feet
Comments(on condition ofjoints, venting, evidence of leakage, etc.):
Pipeing is 4"PVC SCH 40.
Septic Tank(iocate on site plan);
Depth below grade: $��"
t�et
Material af construction:
�cancrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) i
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If tank is metal, list age: j
years f
Is age canfrrmed by a Certiticate of Com liance? attach a co of certificate f
p � PY ) ❑ Yes ❑ No j
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Dimensions: 1000 Gal. Precast �
Sludge depth: a° �
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, May' 07 2017 22;09 Jim The InspectAr Man 5085349919 page 10
� Commonwealth of Massachusetts
� �-� o Title 5 Official Inspection Forrn
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° 80 Grandview Drive
Property Add ress '
Bernadette O'Brien
Owner pwnePs Name
information is gputh Yarmouth MA 02664 4-2$-17
required forevery
page. City/Town State Zip Code Date of Inspection
D. Systerr� Information (cont.)
Septic Tank(cont.} �',
Distance from top of sludge to bottom of outlet tee or baffle Zs
Scum thickness
0"
Distance from top oP scum to top of outlet tee or baffle
8"
18"
Distance from bottom of scum to bottom of outlet tee or baffle '
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments(on purnping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at wortcing ievel. Tank at 8'-6"below grade w�nlet cover at 9" and autlet cover at 44". In and
outlet tee's. Tank may be H-20.
�
Grease Trap{locate on site plan):
Depth below grade: reec
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethytene ❑other(explain):
Dirnensions '
Scum lhickness
Distance From top of scum to top of outlet tee or baffle
Qistance from bottom of scum to bottom of outlef tee or baffle
Date of las#pumping: ,
Date
t5ina.doc•rev.6116 TiUe 5 Official Inspedian Form:Subwrfaoe aewaga Disposaf Sys�em•Page 10 af 17
, May 07 2017 22:09 Jim The InspectAr Man 5085349919 page 11
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
SubsurFace Sewage Disposal System Form-Not for Voluntary Assessments
80 Grandview Drive
Prope�ty Addroas
Bernadette OBrien
Owner Owner's Name
infprmation is South Yarmouih
r$q ered for every ����n MA 02664 4-28-17
9 State Zip Code Date of Inspection
D. System Information {cont.) '
Comments (on pumping recommendations, inlet and outlet tee ar baffle condition, structural integrity, '
liquid Isvels as related to outlet inveR, evidence of leakage, etc.);
Tight or Holding Tank(tank must be pumped at time of inspection){locate on site plan):
Depth below grade:
Material of oonstr-uction:
❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑other(expfain):
Dimensions: !
Capacity: �
gallons
Design Flow: ''
gallons perday i
Alarm present: ❑ Yes ❑ No '
Alarm level: Alarm in workit�g order: ❑ Yes ❑ No
Date of last pumping: �a�e
Comments(candition of alarm and float switches, etc.):
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*Attach copy of current pumping contract(required), Is copy attached? ❑ Yes ❑ No �
151ns.dac•nv.6�16 l
TNIe 5 Officis�Inspection Fam:SuEsurfece Sewage Dispoeal Systom•Pape f 1 of 17 k
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May 07 2017 22:10 Jim The Inspector Man 5085349919 page 12
� Commonwealth of Massachusetts
_ - Title 5 Official Inspection Form
= Subsurtace Sewage Disposal System Form -Not for Vofuntary,4ssessments
80 Grandview Drive
Property Address
Bemadette C1'Brien
Owner . pwner'S Name
iniorrroation is gputh Yamlouth
required for every MA 02664 4-28-17
page. CitylTown Stafe Zip Code Date of Inspettion
D. System Information {cont.)
Distribution Box if resent must be o en
{ P p ed)(locate on site plan): ,
Depth of liquid level above outlet invert Over
Comments(nofe if box is level and distribution to outlets equal, any evidence of soiids carryover, any
evidence of leakage into or out of box, etc.}:
D Box is 16"x21"-8'-9" Below grade w/two lines out. Wall's are gone on box. Level in box up into
outlet lines. Water and sludge in box black H-10-Box
Pump Chamber pocate on site plan}:
Pumps in working flrder. ❑ Yes ❑ No"
Alarms in working orde�, ❑ Yes ❑ No*
Cornments(note condition of pump chamber, condition of pumps and appuRenances, etc,): ;
" If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS){locate on site plan, excavation not�equired):
If SAS not located, exptain why:
15ina.doC•rev.6/Sfi
Tille 5 OKcial Inspec�on Fortn�SuhsuAaee Sewage Diaposai 9ystqn•pxp 12 0l 17 �
May' 07 2017 22�10 Jim The Inspector Man 5085349919 page 13
� Commonwealth of Massachusetts
Titie 5 Official Inspection Form
Subsurtace Sewage Disposal System Form -Not far Voluntary Assessments
�
80 Grandview Drive
Property Address
Bernadette O'Brien
�^ef Owner's Name
, infOrmati0n i9
South Yarmouth
required tor eve MA 02
ry 664 4-28-17
C /Town .
page. �ty
State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
� leaching chambers numbec 5
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dirnensions�
❑ overflow cesspool number:
❑ innovative/alternative system
Typelname of technology�
Comments{note condifion of soil, signs of hydraulic failure, level of ponding, damp soit, condition of
vegetation, etc.j:
Leachin is five flows. Box over full, camera out line's. Lines tull black slud e. Need to re lace.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan);
Number and configuration ,
Depth—top of liquid to inlet invert �
Depth of solids layer ,
Depth of scum layer ,
Dimensians of cesspool �
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No '
t5in9.doc-rev.6116 Tille 5 Offlclal InspeWan Fwm:Subsu�face Se po Sysppm.p �.
"n6�0 ti p� p�13 of 17 �
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� Commonweaith of Massachus�tts '
Titie 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Grandview Drive
Property Address '
Bernadetfe O'Brien
Owner pwr�er's Name
information is
required for every SOuth Yarmouth MA 02664 4-28-17
page. CitylTown State Zip Code Date of Inspedion �I
D. System Information (cont.) '
Comments(note condition of soil, signs of hydraulic failure, levet of ponding, condition oF vegetation,
eEc.):
Privy(locate on site plan):
Materials of construction: '
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic faiiure, level of ponding, condition of vegetation,
etc.):
�
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May' 07 2017 22:10 Jim The Inspector Man 5085349919 page 15
� � Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-IVat for Voluntary AssessmenEs
80 Grandview Drive
Property Addreeass
Bernadette O'Brien
Owner Owner's Name
intormation is South Yarmouth MA 02664 4-28-17
requlred Torevery
P�• ��YR� 51ate Zip Cade Date of Inapection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanenf reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
� hand-sketch in the area below
❑ drawing attached separately
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Sewape Dispoeal Syspen•Pepa 15 of�7
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May 07 2017 22,10 Jim The Inspector Man 5085349919 page 16
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, May' 07 2017 22;11 Jim The Inspector Man 5085349919 page 17
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
8D Grandview Drive
Praperty Address
Bern�dette O'Brien
Q"'"6f Owners Name
IniAermalion is South Yarmouth
re uired for every MA 02684 4-28-17
page, City/Town State Zip Code Date cf Inspec;tbn
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water '
❑ Check cellar
❑ Shallow wells
Estimated depth to i�ground water: 11'
teet
Please indic�te all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: �0 -17-7B
Date
❑ Observed siEe(abutting propertylobservation hole within 150 ieet of SAS)
❑ Checked with locaf Board of Health •explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
G.W. per desiQn plan 10- 17-78 11'G W i
Before filing this lnspectian Report, pleaae ase Report Completeness Checklist on next page.
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TPoe 5 0lfirwl InepeGion Form:Subsurfece 3ewage Dlspowl SysNm•Paps 76 of 17
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� � Commonwealth of Massachusetts
' - Title 5 Official Inspection Form
� Subsurtace Sewage Dispasal System Form-Not for Voluntary Assessments
80 Grandview Drive
Property Address
Bernadette O'Brien
Owner pwner's Name
information is South YarmOuth
required for every MA 02664 4-28-17
pa�. ���01"" State Zip Code Date of Inspection
E. Report Completeness Checklist
� inspection Summary:A, B, C, D, or E checked
� Inspection Summary D(Systern Failure Criieria Applicable to All Systems} completed
� System Inforrnation—Estimated depth ta high groundwater
� Sketch of Sewage Disposal System eithe�drawn on page 15 or attached in separate file
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t8ins.doc•rev.6l16 �
TiUe 5 Officlal Incpecyon Form:Subcur/ece SewaQe Diaposal Syatem•Psge 1 T of 17
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