HomeMy WebLinkAboutCover Page of 05-13-2016 Inspection Report Commonwealth of Massachusetts
_-- _ ' Title 5 Official Inspection Form RECEIVED
_��- 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Y425 Clinton Dr
Property Address irakij�!
Linda Scotti 2411 North Fairfax Dr Arlington VA 22201
77 A
Owner Owner's Name 1100, 4.�r`-
information is Yarmouth ort MA 02675 5/13/16 l
required for every P �� � : � �. ,_i4 P.;,,,,,,-'
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. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Jason Bumie
use the return Name of Inspector
key.
JB Septic Inspections and consultation
lerso Company Name
248 Camp St Unit K4
'few X Company Address
W.Yarmouth MA 02673
City/Town State Zip Code
774-268-0857 S5011
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 below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper 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: a t/lie 2f�A 51,101 )4, p "`C nys H
t c—to 735.
❑ Passes ® Conditionally Passes El Fails Ka-
i 13
El Needs Further Evaluation by the Local Approving Authority --D . OC
"�1 _� 5/13/16 t 12 l Sc JS
J i Date
___.1").; --
r shall submit a copy of this inspection report to the Approving Authority(Board
-� :hin 30 days of completing this inspection. If the system is a shared system or
`
v 5 10,000 gpd or greater, the inspector and the system owner shall submit the 14-
ate regional office of the DEP. The original should be sent to the system owner
e buyer, if applicable, and the approving authority.
ribes conditions at the time of inspection and under the conditions of use
pection does not address how the system will perform in the future under
.1-1��..� S ;conditions of use.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17