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Home My WebLink AboutInspection Report 2017 Jun 16t � ' r E'�.�*�a� k;,',�, �� Commonwealth of Massachusetts t..�� Title 5 Official Inspection Form �u�� w� � �� SubsurFace Sewage Disposal System For�n-Not for Voluntary Assessments !-(r-G,i � .�.. Tr-! f��=,' � �< 80 Rt 28 �� Property Address �;" Geor e Deli iannides 44 Atlantic Ave Swam scott Ma. 01907 �� ,,R Owner Owner's Name infom,ation is West Yarmouth Ma. 02673 6-16-17 required for every page. City/Town State Zip Code Date of Inspection Inspection resutts must be submitted on this form. lnspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information o filling out forms � � I �"� �`�o � on the computer, use only the tab 1. Inspector: �� key to move your cursor-do not David J.Bumie S�� '� kee the retum Name of Inspector �� y �- � David J.Bumie Title five Ins tions �- gyy Company Name � 3 Perry's Way � Company Address � E. Harwich Ma 02645 Citylfown State Zip Code 774-216-1440 SI 386 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 belaw is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the prope�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 \```��v��N��nuu�, � �, � ail�r°�sses ❑ Fails .� �`` � •�. •.�' t' '. ❑ Needs Further Eva��i b�i ��ca��ving Authority =o: BURNIE �:�= = G'' #SI386 ��= y* ' �� •'�-: 6-16-17 Inspector's nature �i�� ' •'''G �� Date ��i�� S I N Sp��`��t The system inspector shall su�fwi[��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 owne�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 onty describes conditions at the time of inspection and under the conditions of use at that time.This inspection dces not address how the system will pertorm in the future under the same or different conditions of use. t5ins•3/13 TiUe 5 Otfidal Inspection Fam:Subsurface Sewage Disposal System•Page 1 of 17 � ' Commonwealth of Massachusetts Title 5 Official Inspection Form � SubsurFace Sewage Disposai System Form-Not for Voluntary Assessments 80 Rt 28 Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 Owner Owner's Name information is West Yarmouth Ma. 02673 6-16-17 required for every page. City/Town 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 informatian which indicates that any of the faiture criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. �� Comments: _.�-a Conditional Pass. This is a restaurant with a 1500 al rease tra 5000 al se tic tank distribution 9 9 p, 9 P , box and a leaching trenches. The septic tank is leakin . B) System Conditionally Passes: « n � One or more system components as described in the Conditional Pass section need to be replaceci or 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 unsound, exhibits substantial infiltration or e�lt�ation 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. � Y ❑ N ❑ ND(Explain below): The septic tank is leaking at the seam or the weep hole. t5ins•3M 3 Title 5 Oficia!Inspecbon Form:Subs�uFace Sewage Disposal System•Pape 2 ot 17 ' � ' Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposai System Form-Not for Voluntary Assessments � 80 Rt 28 Property Address Geor�e Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 Owner Owner's Name information is west Yarmouth Ma. 02673 6-16-17 required for every page. City/Tow� 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 beiow): ❑ 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 faiting 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)(bj that the system is not functioning in a manner which will protect public health, safety and the environment: ; ❑ Cesspoo!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 Offidaf tri spection 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 � 80 Rt 28 Property Address George Deligiannides 44 Atlantic Ave Swampseott Ma. 01907 Owner Owner's Name information is West Yarmouth Ma. 02673 6-16-17 required for every page. City/Town State Zip Code Date of inspecxion B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplisr, 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 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 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 fecat 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 must be attached to this form. 3. Other: 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 facilityr or system component due to overloaded or clogged SAS or cesspool � � Discharge or ponding of effluent to the surface of the ground or surtace waters due to an overloaded or clogged SAS or cesspool � � Static liquid level in the disfibution box above outlet invert due to an overloaded or clogged SAS or cesspool � � Liquid depth in cesspool is iess than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Otfiaal Inspedion Farm:Subsurface Sewege Disposal System•Page 4 of 17 � ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposai System Form-Not for Voluntary Assessments 80 Rt 28 Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 Owner O�nrner's Name information is West Yarmouth Ma. 02673 6-16-17 required for every Raye, City/Town State Zip Code Date of 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 times pumped: ❑ � Any portion of the SAS, cesspool or privy is below high ground water elevation. � � Any portion of cesspool or privy is within 100 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 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 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,OOOgpd. � � 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. 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 200 feet of a tributary to a surface drinking water supply � � the system is located in a nitrogen sensifive 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 shalt upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Otfiaal� nspection Form:Subsurface Sewage Disposal System�•Page 5 of 17 � ' Commonweaith of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '�c 80 Rt 2$ Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 Owner Owner's Name intormation is West Yarmouth Ma. 02673 6-16-17 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, axupant, 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? � � Have large volumes of 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 inspected for signs of break ouY? � ❑ 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 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 bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•3/13 TiNe 5 Offiaal Inspection Fortn:Subsurface Sewage Disposal System•Page 6 of 17 � ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disp�ai System Forqn-Not for Voluntary Assessments 80 Rt 28 Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 �er Owner's Name information is West Yarmouth Ma. 02673 6-16-17 required for every page. Citylt'own State Zip Code Date of Inspection D. System Information Description: 1500�allon grease trap. 5000 gallon septic tank.distribution box and 3 3x55 trenches. Number of current residents: Does residence have a garbage grinder'? ❑ Yes ❑ No ls 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)): Detail: Sump pump? a a�� No �-r� o��. L a s t d a t e o f o c c u p a n c y: p�e CommerciaUlndustrial Flow Conditions: Type of Establishment: Restaurant 4750gpd Design flow(based on 310 CMR 15.203): �anons per day tgpa> Basis of design flow(seats/persons/sq.ft., etc.): 95 seats 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: 2016= 0 gallons.......2015=9000 ' gal=25gpd t5ins•3/13 Title 5 Ofhaal Inspedion Fortn:Subsurface Sewage Disposal System-Page 7 of 17 I � � Commonwealth of Massachusetts Titie 5 Official Inspection Form Subsurface Sewage Dispasal System Fortn-Not for Votuntary Assessments �•� 80 Rt 28 Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 Owner Owner's Name information is West Yarmouth M8. 02673 6-16-17 required fo�every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2015 Last date of occupancy/use: �ate Other(describe below): Closed for 2016=0 gallons General fnformation Pumping Records: Source of information: see last page for pumping records Was system pumped as part of the inspeetion? ❑ Yes � No If yes, volume pumped: yauo�s 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 inspe�ction records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and rrjaintenance contract(to be obtained from system owner)and a copy of latest inspection of the 1/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. � Other(describe): Grease Trap. 1500 al. i t5ins•3/13 Title 5 Offici�hspedion form:Subsurface Sewage pisposal System•P age8of17 � � Commonwealth of Massachusetts � Title 5 Official Inspection Form a SubsurFace Sewage Disposal System Form-Not for Voluntary Assessments �t 80 Rt 28 Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 Owner Owner's Name information is required for every West Yarmouth Ma. 02673 6-16-17 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: System installed 1985...prior report. Were sewage odors detected when arriving at the site? ❑ Yes � No Building Sewer(locate on site plan): 22" Depth below grade: feet Material of construction: ❑cast iron �40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(an condition of joints, venting, evidence of leakage, etc.): Normal as to what we could view Septic Tank(locate on site plan): Depth below grade: see below. feet Material of construction: �concrete ❑ metal ❑fiberglass ❑polyeth lene y ❑other(explain} 5000 gallon septic tank. Inlet under pavement. No Access, outlet ta grade. tee in place. tank is leaking. ' � If tank is metal, list age: ; years � Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No � Dimensions: � ; Sludge depth: j , t5ins•3113 � TiUe 5 Officiaf�nspection Fam:Subsurface Sewage Oisposel System•Page 9 of 17 I � � Commonweaith of Massachusetts Title 5 Official Inspection Form SubsurFace Sewage Disposal System Form-Not for Voluntary Assessments 80 Rt 28 Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 Owner Owners Name informaUon is required for every west Yarmouth Ma. 02673 6-16-17 page. CitylTown State Zip Code Date of Inspedion D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness � Distance from top of scum to top of outtet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendafions, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank is teaking . t couldnot measure Grease Trap(locate on site plan): Depth below grade: grade. tank is at normal liquid level jMaterial of construction: ! � �concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): � � j � Dimensions: 1500 � a1" ' Scum thickness Distance from top of scum to top of outlet tee or baffle 4" �� Distance from bottom of scum to bottom af outlet tee or baffle see last page Date of last pumping: �ate It5ins•3/13 Title 5 Officiat Inspection Form:Subsurtace Sewage Disposal System•Page 10 of 17 � � Commonweaitt� of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposai System Form-Not for Voluntary Assessments � 80 Rt 28 1 Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 Owner Owner's Name information is West Yarmouth Ma. 02673 6-16-17 required for every page. Citylfown State Zip Code Date of Inspedion 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.): ST leaking needs to be repaired. also inlet is under pavement. should install cover to rade. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: galtons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ 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•3/13 Title 5 Official Inspection Fortn:Subsurface Sewage Disposal System•Page 11 of 17 � � Commonwealth of Massachusetts Titie 5 Official Inspection Form SubsurFace Sewage Disposaf System Form-Not for Voluntary Assessments �t 80 Rt 28 Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 Owner OwnePs Name information is required for every W�st Yarmouth Ma. 02673 6-16-17 page. C�tYR�n State Zip Code Date of Inspec�ion D. System Information (cont.) Distributian Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Normal level. 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.): None , working as designed. Pump Chamber(locate 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.): *If pumps or alarms are nat in working order, system is a conditiona!pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: located and no standin water in pipes t5ins•3l13 Title 5 Offiaal Inspection Forrn:Subsurface Sewaye Disposal System•Page 12 of 17 � � Commonweaith of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '�f 80 Rt 28 Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 019Q7 Owner Owner's Name information is West Yarmouth Ma. 02673 6-16-17 required for every page. Citylfown State Zip Code Date of Inspedion D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: � leaching trenches number, length: 3. 3x3x55 ❑ 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.): Dry. the leaching has not received any liquid for at least a year. 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 Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 � TAIe 5 Offidal Inspec�on Fam:Subswface Sewage Disposal System•Page 13 of 17 � � Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �t 80 Rt 28 Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 Owner Owners Name inFormation is West Yarmouth Ma. 02673 6-16-17 required for every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.} Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): None , dry P�ivy(locate on site plan): Materials of construction: , Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3M 3 TiUe 5 OffiCi�Inspedion Form:Subsur(ace$e�nrage Disposal System•Page 14 of 17 ;� . • � � � �� $'Oc7 - .�_�� :�� „�� D Boa� - �� li�a�t � � - � �S�e�rtet� � . . . � ,` _ . � . - y� � _ f� . , . I I i �� u�r�� .!!�t. , � . ..,��ws�.= . . � �w� ua� . R,�fie ?� L.�: �� . - � rt�t T• Seie Da� ��7 �� BN�ei M Virl�01�n� I � f � - ; i � � Commonweaith of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Rt 28 Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 Owner OwnePs Name informatiort is west Yarmouth Ma. 02673 6-16-17 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 boxes below: ❑ hand-sketch in the area below � drawing attached separately t5ins•3/13 Title 5 Olfidal kes�6on Fortn:S�uxFaoe Saw�age pisposal System�Pape 15 ot 17 � 3 ; �' Commonweaith of Massachusetts , ' Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I � � , �~ 80 Rt 28 � Property Address George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 � Owner Owner's Name � infom►ation is West Yarmouth Ma. 02673 6-16-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: � Check Slope � Surface water � Check cellar � Shallow wells Estimated depth to high ground water: 14' per test hole 1985 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ Observed site(abutting property/observation hole within 150 feet of S�4S) � Checked with lacal Board of Health-explain: prior report and test hole on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: � Test hole 1985.. grade elevation is 22.80 bottom of the leaching is at elevation 16.67 test hole was � dry to elevation 8.8'this is a seperation of 6.13' � — i�'�� l� ��1i�v �9 i �,�� c� 7 l' -- . �'9 . Before filing this Inspection Report,please see Report Completeness Checkfist on neut page. t5ins-3l13 Title 5 Otfiaal In spection Form:Subsurface Sewage Disposal3ystem•Page 16 of 17 I l � � � Commonwealth of Massachusetts � Title 5 Official Inspection Form � Subsurface Sewage Disposai System Form-Not for Voluntary Rssessments � ; 80 Rt 28 { Property Address j George Deligiannides 44 Atlantic Ave Swampscott Ma. 01907 � Owner Owner's Name information is West Yarmouth Ma. 02673 6-16-17 required for every page. CitylTown State Zip Code Date of Inspedion E. Report Completeness Checklist � Inspection Summary: A, B, C, D, or E checked � Inspection Summary D(System Failure Criteria Applicable to All Systems)completed � 5ystem Information—Estimated depth to high groundwater � Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file � � i ' i i i t5ins•3/13 Title 5 Offidal Inspacdon Form:Subsurface Sewage Disposal System•Page 17 of 17 1 I i � � � • i , ' I I � � YARMOUTH AEALTH DEPT. As of o5/31/97 �� I "�"P� °� 80 ROUTE 28 1 PARCEL• .107 � KRASION LLC I DATE OF SALE:02/25H3 DE$CRIP710N C#LL,t;pplS 9/3/2014 T 4775 ND RNER EMARONMENTAL 11/5R013 4127 RIVER F.I�MRONMENTAL 10J22%2013 T/BARNS PIJINT 1500 ND RIVER EM/IRONMENTAI 1H8J2013 T 1458 VID J BI�WIE MGMT INC 1/18/2018 4399 DAVID J BURNIE UAGMT'INC j 1/8/2010 T 1453 .O'1.pUC,HLiN l 1/8l2010 123Q .O'LOUGHLIN � 1/8/2010 3�8 .O'LOUf3HLIN 623/Z009 T 1429 IDElMACOMBER � 8/t1l2008 T 1458 COMBER 8/11J2006 24�8 IDEIIIAACOMBER 8/11@008 �� 11/2i/2008 �OF 2 1000 ,A 3 B 11/21/2008 �1 pF 2 3999 O,A d�B ��mnoo6 �sas Nco.�as �rs�rmo> >4ea o �r��rzoo�sT u�s 7t31/2001 2� 818ROOG T �,� 8R5l19�7 T iS91 D-CAPE 325J7997 1547 p-GPE 2/2aH9D0 I � � i � � � , � ► � , � i ;