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i)VVICI AL INSI'E(."IION I�l)It►vI -- Yr [i'()St 8/U1.11N`I'ARtY ASSIiSSIVIEN`I`S
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( 1t_It'1`11t��'A'I`r( N (continued)
rroperfy Address: 20 Capt.Bearse Road
South Yarmouth,MA
0%v'lc►' Richard Van Steen
Date o[Iuspectfot►'November 8,2007
inspection Slauuu:u y: (=heels or / ALWAYS complete all of Section I)
A. System Passes:
I have not fnund any intilimatjon wbiclt indicates dial ►y of the {hiluie Criteria tlescribetl in 310 CMIR
15.103 ui in 310 CNtli 15.30,1 exist. Any failure efileiiit ii evaluated uic indicated below.
('ounncnts.
B. System Conditionally Passes:
One ui ul(►re syslcut cut puneuls as described in the"Conditional Pass"section need to be replaced Of
repaired.The system, upon completion of the replacement or repair, as approved by the floaid of llealth, will pass.
•
Answer yes, no ur'nol tleleiu►iuetl(Y,N,lyl)) in the______ for the following stateulcnts. If"not determined" please
explain. .
'FIte septic tack is foetal and over 20 years old* or die septic lank(whether iueta or not) is structurally
unsound, exhibits substantial Infiltration or ex filtration or I ulk failure is imuliucul. System will pass inspection it the
existing tack is replaced with a complying septic tank as appruvetl by the Board of ilcalth.
Metal septic tank will pass inspection if it is structurally sound, not leaking and ail (;ertllictlte o{ Cunlpliagt e
indicating that the lack is less than 20 years old is availuli►le.
NI)explain:
_Y _ Obsefvaijon of sewage backup or break out (f 14lr sialic water level in the distribution box duel()broken of
obstrrleted pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Ilealtb):
✓ broken pipes) ale replaced
obstruction is feulovetl
distiibutinn box is leyeletl or replaced
NI)explain: •
11/4/ _ "I`lae system ietpiired trumping more titan tl tistieS a year due in brokeal nr obstructed pipe(s).The system will
Dass inspection if(with approval of die Hoard of health)..
llrt►kell pipe(s)are replaced
ubstri ctiun is teitmvetl •S - pe--t. 5 L VS./. COLsA.'�s5./..�h
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NO explain: ScfiUQ , l
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()IiI"ICIAI, INS IlI! 11U1\1 je()ItM -- NOT leOIt 'y()I.IJN`I•Afor ASSI+SSMI NTS
SUII3SIJItI�A('1 Sp:VVA(yI', I Isr4a fo, SyS rtvl INSPF:C'I I()N i4)12M
SyS I'I!►YI INr()ltl9A'I•ION (cuntiiiuetI)
20 Capt.Bearse Road
I'roperly Atltlressc South Yarmouth,MA
Richard Van Steen
Owner; November 8,2007
Date of •
InslicclI i :
SICIil'l'elt Ole 111srtiSA1.SYS►I?tvl
1'iovicle a sketch of the sewage disposal system tot:4 liug lies to;Il least two peifllaiCnl reference landmarks ter
beuclooaiks. locate all wells within I00 fret. I.iicale where Public water supply enicis IPC bttiWiug.
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