HomeMy WebLinkAboutPages from Conditional Inspection Report _ �
� � Commonwealth of Massachusetts CoND6?1oN�L
.- � Title 5 Official Inspection Form p��
SubsurFace Sewage Disposal System Form-Not for Voluntary Assessments
'*M � 77 Route 28(System#1 _ _____ _ _
Property Address
The Village Group
Owner Owner's Name
information is Yarmouth Ma 02664 8-11-16
required for every —
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the baxes below:
� hand-sketch in the area below
❑ drawing attached separately
AC�25'
ALKW Aa32'
AE�38'G"
AF•28'
BC•�9'
BD�34'9"
BE��6"
� BF•39'�,�
C D E
�
DIRT ROAD
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t5ms•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17
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� Commonwealth of Massachusetts
� Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form -Not for Voluntary Assessments
77 Route 28 (System#1)
Property Address
The Village Group
Owner Owner's Name
information is Yarmouth Ma 02664 8-11-16
required for every
page. CitY�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 Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
� distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
D-box is in poor condition and must be replaced.
❑ 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 ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ 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 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•3/13 Title 5 Otficial Inspeclion Form:Subsurface Sewage Disposal System•Page 3 of 17