HomeMy WebLinkAboutInspection Report 2020 Mar 23 tik 7-8
Commonwealth of Massachusetts ?1%0 n�1L esu l
_, _F Title 5 Official Inspection Form APR 0 7 2020
Subsurface Sewage Disposal
_�,_ g System Form -Not for Voluntary Assessments
— 1. HEALTH DEPT.
49 Highland St West Yarmouth MA SCANNED
Property Address Oy/o1(202L1 egAoq_ O ', a
Laurina Bamocky 49 Highland St
Owner Owner's Names OA)
information is West Yarmouth MA 02673 3/23/2020
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 Armando Pantoja
key to move your Name of Inspector
cursor-do not Accu Sepcheck
use the return Company Name
key.
17 Northside Drive
vtim,5 Company Address
South Dennis MA 02660
City/Town State Zip Code
jitter 508-385-5891 SI 14296
Telephone Number
p 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. ❑ Passes
2. El Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ►/ Fails
3/30/2020
Inspector'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 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.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1,6
49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described ' the "Conditional Pass"section need to be
replaced or repaired. The system, upon com• -tion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not dt i' -d" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 ye;rs old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltrati• or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is repl-ced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass ' spection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that t - tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
•
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
i
Commonwealth of Massachusetts
c -_ -
Title 5 Official Inspection Form
7.---,,Ali__,-,ti
_- — r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Highland St West Yarmouth MA
Property Address
Laurina Bamocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass wit =oard of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static ater level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settl-', or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced IP Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replac,d ❑ Y ❑ N ❑ ND (Explain below):
AP
❑ The system required pumpi . more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspectio if(with approval of the Board of Health):
❑ broken pipe(s) a'- replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is emoved ❑ Y ONO ND (Explain below):
3) Further Eval -,tion is Required by the Board of Health:
❑ Condit'! s exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
sP F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c
° --- ' 49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetat:: wetland or a salt marsh
b. System will fail unless the Board of Health (and Publ' Water Supplier, if any)
determines that the system is functioning in a manne at 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 . .urface water supply.
❑ The system has a septic tank and SAS and e SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS nd the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and •S and the SAS is less than 100 feet but 50 feet or
more from a private water supply wel .
Method used to determine distance
AP
**This system passes if the well " ater analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates abse' and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provider that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) 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 facility or system component due to overloaded or
clogged SAS or cesspool
❑ �� Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
i
Commonwealth of Massachusetts
_F Title 5 Official Inspection Form
== = Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ ® 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) Large Systems: To be considered a large system the system must serve a facility with
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the followin. ' addition to the
questions in Section C.4.
Yes No Ar
❑ ❑ the system is within 400 feet • . surface drinking water supply
❑ ❑ the system is wi 00 feet of a tributary to a surface drinking water supply
❑ ❑ the sys is located in a nitrogen sensitive area (Interim Wellhead Protection
A -: — IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
W F Title 5 Official Inspection Form
�
. fey
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/
-,- 49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section C.4 above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes"or"no"for each of the following for all inspections:
Yes No
® ❑ 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?
® ❑ 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 o t?
® ❑ Were all system components xslttdffig 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 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V
49 Highland St West Yarmouth MA
Property Address
Laurina Bamocky 49 Highland St
Owner Owner's Name
information is
required for every West Yarmouth MA 02673 3/23/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): N/A Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Description:
SYSTEM CONSISTS OF TWO CESSPOOLS.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes Z No
Water meter readings, if available (last 2years usage 52 GPD
9 9 (gpd)):
Detail:
2019: 19,000 G ; 2018:_19,000•,__G
Sump pump? ❑ Yes ® No
Last date of occupancy: 3/23/2020
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
M= V. Title 5 Official Inspection Form
ey-: Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
p-,� 49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/2020
required for every
Cit /Town
page. Y State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per•-y(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ® No
Water treatment unit present? ❑ Yes ® No
If yes, discharges to:
Industrial waste holding tank present? AP ❑ Yes No
Non-sanitary waste discharged to the Title 5 s .tem? ❑ Yes ® No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: PUMPED 1/29/2019
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
ia Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
--,Ti
49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
❑ Septic tank, distribution box, soil absorption system
® Single cesspool
® Overflow cesspool
Cl Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
AGE UNKNOWN. HOUSE BUILT IN 1937 PER ASSESSOR
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: "2
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
{
• Commonwealth of Massachusetts
• 4r=i1 -=I " Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Yy �r
We
r 49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth
required for every MA 02673 3/23/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: NO SEPT TANK
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass • •olyethylene ❑ other(explain)
If tank is metal, list age: AP
years
Is age confirmed by a Certificate of Com• ance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
Distance from top of sludge . bottom of outlet tee or baffle
Scum thickness
Distance from top of =cum to top of outlet tee or baffle
Distance from be om of scum to bottom of outlet tee or baffle
How were di 'ensions determined?
Comment (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid le -Is as related to outlet invert, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
�, F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t, f Or,
d/ 49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/2020
required for every
page. City/Town State Zip Code Date of Inspectio
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: NO GRr•SE TRAP
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ ',olyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or bafll;
Distance from bottom of scum to bottom of outlet�tltr e or baffle
Date of last pumping:
Date
Comments(on pumping recommendations, in -t and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evide e of leakage, etc.):
i
8. Tight or Holding Tank (tank m st be pumped at time of inspection) (locate on site plan):
Depth below grade: NO TIGHT TANK
Material of construction:
❑ concrete ❑ etal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/2020
required for every
page. City/Town State Zip Code Date of InspectioP
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in workin• •rder: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
f\'`
*Attach copy of current pumping contra« required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be • •ened) (locate on site plan):
Depth of liquid level above outlet i ,ert NO DISTRIBUTION BOX
Comments (note if box is level a►. distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out if box, etc.):
•
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
. cam, Commonwealth of Massachusetts
m- ' F Title 5 Official Inspection Form
AirSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
.� 49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/21 1
required for every
page. City/Town State Zip Code Date nspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, cond' •n of pumps and appurtenances, etc.):
w
* If pumps or alarms are not in orking order, system is a conditional pass.
11. Soil Absorption System -,AS) (locate on site plan, excavation not required):
If SAS not located, ex. .in why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
Z overflow cesspool number: 1
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!'" 49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
LIQUID LEVEL WAS OVER ALL PIPES-A FAILURE CRTIERIA
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1 MAIN
Depth—top of liquid to inlet invert OVER ALL PIPES
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes 0 No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
CESSPOOL HAS LIQUID LEVEL ABOVE PIPES.NOT FUNCTIONING AS INTENDED. THIS IS A
FAILURE CRITERIA.
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
* Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
— 49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/ t 0
required for every
page. City/Town State Zip Code Dat- 4 Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: NOT APPLICA:
NOT APP ABLE
Dimensions
Depth of solids NOT •PLICABLE
Comments(note condition of soil, signs of hyd •ulic failure, level of ponding, condition of vegetation,
etc.):
NOT APPLICABLE
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
• c Commonwealth of Massachusetts
FA
*, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is
required for every West Yarmouth MA 02673 3/23/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
• P Y
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or henrhmarks. Locate all wells within 1 o feet. L orate where public water Supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
LI drawing attached separately
W
REI
Cr-#'*-. 1
Ai.: i3.s' Bj . 21, S'
At =11.54 82 = 31
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System.Page 16 of 18
•� Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Highland St West Yarmouth MA
Property Address
Laurina Bamocky 49 Highland St
Owner Owner's Name
information is West Yarmouth
required for every MA 02673 3/23/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
j It Check Slope
/� Surface water
►� Check cellar
Shallow wells
Estimated depth to high ground water: —g
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: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
8 Accessed USGS database- explain:
GOOGLE MAPS, CAPE COD COMMISSION GROUNDWATER CONTOUR MAP
You must describe how you established the high ground water elevation:
SITE ELEVATION IS— 10'ASL . GROUNDWATER CONTOUR IS APP 4'ASL SEPARATION FOR
CESSPOOLS NOT DETERMINED DUE TO FAILURE.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
i '�
Commonwealth of Massachusetts
_. F Title 5 Official Inspection Form
-; - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.P
49 Highland St West Yarmouth MA
Property Address
Laurina Barnocky 49 Highland St
Owner Owner's Name
information is West Yarmouth MA 02673 3/23/2020
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
►� C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
0 D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
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