HomeMy WebLinkAboutPages from Inspection Report; Assessor's Info; Floor Plan Sketch • ru kpa
Commonwealth of Massachusetts P"1 Lt1OEIU rEIt
Title 5 Official Inspection Form „NfV �, ;
-�- Subsurface Sewage Disposal System Form-Not for Voluntary Assessment
HEALTH DEPT.
5 Zephyr Drive
Property Address '.
Ciolek, Michael Trust ,„-
,
Owner Owner's Name
information is
required for every Yarmouth MA 02675 10/27/2011
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 Brian K. Tilton
use the return Name of Inspector
key.
The Building Inspector of Cape Cod, Inc.
Company Name
PO Box 307
Company Address
P I Eastham MA 02642
City/Town State Zip Code
508-255-9343 SI4392
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:
® Passes 0 Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/27/2011
I spector's Signature Date
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 is a shared system or
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 should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface
Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
• ' = e' Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments
--00 5 Zephyr Drive
Property Address
Ciolek, Michael Trust
Owner Owner's Name
information is
required for every Yarmouth MA 02675 10/27/2011
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
®
0 Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
• 0 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?
• 0 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?
• 0 Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
®
0 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 subsurface 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): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 455 Actual
GPD
t5ins•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 6 of 17
•
Commonwealth of Massachusetts
• t --- r/ Title 5 Official Inspection Form
v Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
14
j 5 Zephyr Drive
Property Address
Ciolek,Michael Trust
Owner Owner's Name
information is Yarmouth MA 02675 10/27/2011
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:
Z hand-sketch in the area below
❑ drawing attached separately
W
DWELLING
•
B
11
PORCH
1 . Al=45' BI=23'
S
NOT TO SCALE 1,000 A2-46' B2=26'
11411111114
GST A3=17 83=55'6"
2• A4=18'3" B4=75'10"
0 A5=21'3" 05=65'
5 (3)500 Gal.Chambers �r
SLOPE
W/4'Stone
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
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