HomeMy WebLinkAboutInspection Report 2020 Mar 02 M RECEIVED
• �, Commonwealth of Massachusetts (� g�
Title 5 Official Inspection Form MAR 1 3 2020
* :'j Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�, -'� �N E HEALTH DEPT.
30 Holly Lane, South Yarmoiuth, MA 02664 d ct o7 2.0 2.02'!
o Pa-icb
Property Address cPT( .e"1te.3 AY,
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031 ftie ar.''
Owner Owner's Name
informrequired tionSouth Yarmouth, MA 02664 03/02020
requi.ed 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.
Im''° ''hen A. Inspector Information
filling out forms
on the computer, REID C. ELLIS
use only the tab
key to move your Name of Inspector
cursor-do not ELLIS BROTHERS CONSTRUCTION
use the return Company Name
key.
orai
23 ENTERPRISE ROAD
Company Address
YARMOUTH PORT MA 02675
City/Town State Zip Code
mei, 508-362-6237 S121891
` 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 main nance of on-site sewage disposal systems.After conducting this inspection I have determined
that the ystem:
1. Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. 0 Fails
J
In or'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.
t5rap.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 1 or 18
Commonwealth of Massachusetts
l� . �� Title 5 Official Inspection Form
ii -+,'- 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° , =,. ' 30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is
required for every South Yarmouth, MA 02664 03/02A020City/Town
page. 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: M
Cb I have not foun any information which indicates that any of the failure criteria described
idin 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
1171
0 One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes","no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years okl*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or ex'lltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it¢structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y 0 N 0 ND(Explain below):
t5thsp.doc•rev.712612018 rile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
,, Commonwealth of Massachusetts
w.7-2- '-1-_ , Title 5 Official Inspection Form
-�'— Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
!_
30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is South Yarmouth, MA 02664 03/022020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont)
2) System Conditionally Passes(cont.): �j "
O Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or breakout or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
O broken pipe(s)are replaced ❑ Y 0 N 0 ND(Explain below):
O obstruction is removed 0 Y 0 N 0 ND(Explain below):
O distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
O broken pipe(s)are replaced 0 Y 0 N 0 ND(Explain below):
O obstruction is removed 0 Y 0 N 0 ND(Explain below):
3) Further Evaluation is Required by the Boa of Health:
O Conditions exist which require further
Tic by the Board of Health in order to determine if
the system is failing to protect public hea , safety or the environment.
a. System will pass unless Board of H ith determines in accordance with 310 CMR
15.303(1)(b)that the system is not fu ning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/2672018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 3 d 18
•
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,� 30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is South Yarmouth, MA 02664 03/0212020
for every
Page-
CityRown State Zip Code Date of Inspection
page.
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 =- ot surface water
❑ Cesspool or privy is within 50 fee of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is function ng in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soi absorption system(SAS)and the SAS is within
100 feet of a surface water supply or trib r ry to a surface water supply.
❑ The system has a septic tank and SA• and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SA• and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SA• and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analy s, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the pr= nce of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other =ilure 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
1111:11( 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
t5stsp.doc•rev.72612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'4' 30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is South Yarmouth, MA 02664 03/04020
pa gee-
. for every City/Town State Zip Code Date of Inspection
Pa
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 dogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6"below invert or available volume is less
13:::/ than 6 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.
Elle z 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 .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.aiur
/ / 5) Large Systems: To be considered a large sys the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes" r"no"to each of the following, in addition to the
questions in Section C.4.
Yes No
❑ 0 the system is within 400 fee of a surface drinking water supply
❑
0 the system is within 200 fe of a tributary to a surface drinking water supply
❑ ❑ the system is located in a ni en sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped ne II of a public water supply well
t5insp.doc•rev.712812018 Title 6 Official Inspection farm:Subsurface Sewage Disposal System•Page 5 of 113
•
Commonwealth of Massachusetts
' Title 5 Official Inspection Form
jj Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
It
-- - 30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is South Yarmouth, MA 02664 03/02/2020
Page.
for every 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 normalter flowsintrin the previoustothtwo week peri
nod?
❑ Have large volumes of wabeen oduced e system recetly or as part of
this inspection?
❑ Were as built plans of the system obtained and examined?(If they were not
available note as NIA)
❑ Was the facility or dwelling inspected for signs of sewage back up?
ge, 0 Was the site inspected for signs of
break out?
0 Were all system components,(ecluding the SAS, located on site?
le 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?
P( ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
/t/ The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
0Existing information. For example, a plan at the Board of Health.
0
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 Tdle 5 Official Inspection Fan:SliSuface Sewage Disposal System•Page 6 of 18
• Commonwealth of Massachusetts
)-±= Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is South Yarmouth, MA 02664 03/0212020
required for every
Page. CityRown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual):
07.20
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
itAJil6
Number of current residents:
Does residence have a garbage grinder? 0 Yes No
Does residence have a water treatment unit? 0 Yes [VNo
If yes,discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes [ No
information in this report.)
Laundry system inspected? 0 Yes [?(No
Seasonal use? [ Yes 0 No
Water meter readings, if available(last 2 years usage(gpd)):
Detail: Alai,* if ofi -,4/
I /VW_ ././i4Mlii r(r
cO/q gf 99 A74d
Sump pump? Yes No
Last date of occupancy: .004- 44/74
t5nsp.doc•rev.7/26/2018 The S Diktat Inspection Form:Subsurface Sewage Disposal System•Pape 7 of 18
Commonwealth of Massachusetts
= -F Title 5 Official Inspection Form
- § Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4 30 Holly Lane, South Yarmoiuth,MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is South Yarmouth, MA 02664 03/0212020
Page. for every City/Town State Zip Code Date of Inspection
pa
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:Type of Establishment ////4
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft,etc.):
Grease trap present? 0 Yes 0 No
Water treatment unit present? [] Yes 0 No
If yes,discharges to:
Industrial waste holding tank present? 0 Yes 0 No
Non-sanitary waste discharged to the Title 5 system? 0 Yes 0 No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
F
3. Pumping Records:
Source of information: Gi '
p'mas,a�d 8-2/-/ d=✓o�v G `°is G
...2/94174as system pumped as part of the inspection'? Yes No
If yes,volume pumped: 445:,-/
gallons
How was quantity pumped determined?
Ii
Reason for pumping:
15insp.doc•rev.7/28/2018 The 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 8 of 18
Commonwealth of Massachusetts
0 Title 5 Official Inspection Form
-4.11!- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'r.. 30 Holly Lane,South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is South Yarmouth, MA 02664 03/022020
required for every
Pa9e. City/Town State Zip Code Date of Inspection
D. System Information (cont)
4. Type stem:
Septic tank, dietributie9-bex,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes,attach previous inspection records, if any)
❑ Innovative/Altemative 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: y
Were sewage odors detected when arriving at the site? 0 Yes iNo
5. Building Sewer(locate on site plan):
1311
Depth below grade: feet
Material of construction:
Ekeast iron ❑40 PVC 0 other(explain): 7
Distance from private water supply well or suction line: /9'
feet
Comments(on condition of joints,venting,evidence of leakage,etc.):
id .174 al1440---
77/6 Aeozi ales-24/-6W Di/1 hvifiz&A)
t5insp.doc•rev.712612018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
. • Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is South Yarmouth, MA 02664 03/02020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan): ,� /.
Depth below grade: //'l` �'�'' 6 " //e
Material of construction:
(concrete 0 metal 0 fiberglass 0 polyethylene 0 other(explain)
pee-64S/ / 1 bw r;,SL 7,1 - 41/97x7
If tank� I, Ist age:
I/fiLls ag con by a Certificate of Compliance?(attach ace�4rs
of cerhfi)e) d ❑ Yes 0 o
Dimensions:
,./44/14., �? � F46 4/I
3I/
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
c7
Distance from top of scum to top of outlet tee or baffle
a
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
iP,frifg Al/b /9- ,i4) -A' 7P-
,i1/.444 171-40A/4 /2?- <. 5 11
7 - bi
//f/ 7*' �r�G1/ d 6/14,1"
t5i+sp.doc•rev.7/262018 Title 5 . tropection Fonn:Subsurface Sewage Disposal System•Page 10 d 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
tt Subsurface Sewage Disposal System Form Not for Voluntary Assessments
ILII 30 Holly Lane, South Yarmoiuth, MA 02664
_...)
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is South Yarmouth, MA 02664 03/0020
required far every ofd
page. City/Town State Zip Code Date Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan): /t/
Depth below grade: feet
Material of construction:
0 concrete 0 metal 0 fiberglass 0 polyethylene 0 other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tree or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
8. Tight or Holding Tank(tank must be puma time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete 0 metal 0 fit rgiass 0 polyethylene 0 other(explain):
Dimensions:
Capacity: gallons
Design Flow.
gallons per day
t5insp.doc•rev.7!26/2018 Tdle 5 Orel Inspection Ram:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
*_ _0 Title 5 Official Inspection Form
)1
- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is
required for every South Yarmouth, MA 02664 03/032020
Page- City/ own State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.) /(0/4—
Alarm
v 4-
Alarm present 0 Yes 0 No
Alarm level: Alarm in working order. ❑ Yes 0 No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes 0 No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any
evidence of leakage into or out of box, etc.):
i • 4, ffV G l'hire
c441_,4 /41#1_ AU #0' 1 #,. 1 /01)X-ri 6/La/
t5urep.doc•rev.7/262018 Tale 5 Official Inspection Form:Sterface Sewage Disposal System.Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
y _ 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
+
30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W& Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
required for every South Yarmouth, MA 02664 03/012020
page. City/Tow n State Zip Code Date Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order. 0 Yes 0 No*
Alarms in working order. 0 Yes 0 No*
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located, explain why:
aø( (
Asz.o' 4+ D 4541/e 444-41
/V
Type:
❑ leaching pits number
leaching chambers number. 41
❑ leaching galleries number
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number
❑ innovative/altemative system
Typelname of technology:
t51isp.doc•rev.7/1612018 Title 5 Official Inspection Form:Subsuface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
---4-..4,_-64 Title 5 Official Inspection Form
*41___.-----7--
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,,,1_,—, 30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is ,
required for every South Yarmouth, MA 02664 03/02,2020
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.):
17/4-__ / ditil/Via a go eim/iy__. 4--,:4097,- A/0, ii2,ei_t ote
•fil difx-xvz4 - -4;14.A.— x/- YeAle--- 7.:;/.;".6/ 6", P4-174-0--
.....k
-sj `-- A°_' 7 6. ,fie � ." e-, %
,44 7 d,la, 7/742. 0 lei r;<J .ift- dA,$4 .
12. Cesspools(cesspool must be pumped as of inspection)(locate on site plan):
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer -
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow 0 Yes 0 No
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
i
t5insp.doc.rev.W26/2018 Title 5 Official Inspection Pare:Subsurface Sewage Disposal System•Page 14 of 18
. ', Commonwealth of Massachusetts
.ke Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
. „._._.... ,
30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is
e
every South Yarmouth,
MA 02664 03/022020
Page. City/Town State Zip Code Date of Inspection
D. System information (cont.)
4/
13. Privy(locate on site plan): ,"lT
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5insp.doc•rev.7r28/2018 Title 5 Olid
Inspection Form:Subsurface Sewage Disposal •Page 15 of 18
.. Commonwealth of Massachusetts
Title 5 Official Inspection Form
-Alk-1-77-7 a D�Subsurface Sews;_�! g poral System Form-Not for Voluntary Assessments
It .."' 30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is South Yarmouth
required for every MA 02664 03/022020
page. City/Town State Zip Code Date ooff Inspection
D. System Information (cont)
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 uilding. Check one of the boxes below:
a hand-sketch in the area below
0 drawing attached separately ,4 �
._._/key . - . —
f 6votiklk!
4 __
11
zik 30
.,
fr 414,
ep ,,f_
k 1 0
A 1 . 2 ,6 fir°
r
ild.i
13 , 3. 411? --
s -
t5insp.doc•rev.7126/1018
The 5 Official trrspection Form:Subsurface Sewage Disposal System.Page 16 of 18
.
Commonwealth of Massachusetts
* t F Title 5 Official Inspection Form
, _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W&Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
inforrequired
is South Yarmouth,
required for MA 02664 03/042020
Page. CityiTown State Zip Code Date of inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope .0.4L Y—Z
❑ Surface water #2'1
❑ Check cellar /747.4--ft ' L ‘9"--441-'4/C.-
0
9 '4/�❑ Shallow wells ,r/4
O.
/
Estimated depth to high ground water. 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
O 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)
03/
Accessed USGS database-explain:
&� Z/e.GZ j aZrtl r+/t (IA'
/ /ii/ /6 , /f �.,. _.f2-- p.. c%
You must describe how you established the high ground water elevation:
0,____.*7-- Z-- &---"-S" rtie/z
214 ci_e -74-4-1-e 0//404(-7 .-Xt1/ °.
v tei•en144711,-A 13'
, 4--T o9 fir'
��n2�
Before filing this inspection Report,please see Report Completeness Checklist on next page.
t5erep.doc•rev.71282018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 17 of 18
•
Commonwealth of Massachusetts
_ _6 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' .-, 30 Holly Lane, South Yarmoiuth, MA 02664
Property Address
Jonathan W& Kay J May, 10 Candlewwood Drive,Amherst, NH 03031
Owner Owner's Name
information is South Yarmouth
required for every MA 02664 03/0212020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
tiA. Inspector Information:Complete all fields in this section.
L7 a Certification: Signed&Dated and 1,2, 3, or 4 checked
eC. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
(Failure Criteria)and 6(Checklist)completed
. System Information:
D :
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
t5msp.doc•mv.7/282018 The 5 018rid Inspection Form:Subsurface
Sewage Disposal Sym•Pape 18 of 18