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Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7
HEALTH DEPT:
i 44_,‘,2Z-5356 15 Brookhill Lane, West Yarmouth M -30 P-204
Property Address
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Owner Elaine McCarthy
Owner's Name
information is
229 Jefferson Street, Dedham MA 02026 September 11, 2018
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
important:When A. Inspector Information
filling out forms
on the computer,
use only the tab Troy Williams
key to move your Name of Inspector
cursor-do not Troy Williams Septic Inspections
use the return
Company Name
key.
19 Hummel Drive
All.. 1 Company Address
South Dennis MA 02660
City/Town State ZipCodeIMII (508)385- 1300 SI682
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); I have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. 121 Passes
(4 41 e '
2. 0 Conditionally Passes
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3. I Needs Further Evaluation by the Local Approving Authority —
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4. 0 Fails 1 C-C;6
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7:_,JSeptember 11, 2018 ifo
Inspector's Signature Date 6z , c_re,vc
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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.cloc•rev.7/26/2018
Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 18
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I ;, Commonwealth of Massachusetts eNJA-L J�i411ON
Title 5 Official Inspection Form
., Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
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W 15 Brookhill Lane,West Yarmouth M-30 P-204
Property Address
i Elaine McCarthy _! _
Owner - - - -— - ---
Owner's Name
information is 229 Jefferson Street, Dedham MA 02026 September 11, 2018
required for every �._ --__ p
--
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
1
1 14. 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
be ow
0 drawing attached separately
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15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18