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HomeMy WebLinkAboutInspection Report 2020 Mar 06 . M1° - :tk Commonwealth of Massachusetts pro KL- ' ,,,.=J 31. •%} Title 5 Official Inspection Form MAR 2 4 2020 M Subsurface Sewage Disposal System Form-Not for VoluntaNg ry Assessments HEALTH DEPT. 4,_ 85 North Main Street Property Address X07�202G P(z4OL'ra » r 7-, , tita Zachary Hunter 31�a-......, Xe:rr. aeVteuJ a 1, 6 Owner Owner's Name -4 c.,.,.„, ..a information South Yarmouth Ma 02664 31612020 required for emery City/Town State Zip Code Date of Inspection ire, 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. I"' •'"Ie'1 A. inspector Information filling out forms on the computer, Sean M. Jones use only the tats —... key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Belden Lane AtCompany Address CentervilleMa 02632 City/Town — State Zip Code iffAlll 774-248-4850 smjonestitle5©gmail.com, SI 4522___..__. sean@smjonestitle5.com 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. ►5 Passes 2. 0 Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. 0 Fails 0 3/6/2020 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.712812018 Title 5 Official Inspection Form:Subeu lace Sewage Disposal System.Page 1 of 18 • Commonwealth of Massachusetts Title 5 Official Inspection Form +tk Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 North Main Street Property Address Zachary Hunter Owner Owner's Name information a South YarMa 02664 3/6/2020 required for every _ ..mut-Ito 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: w 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: The property located at 85 North Main St South Yarmouth is served by a Title V septic system consisting of a 1500 gallon septic tank,distribution box and 4x LC-6 leaching chambers. The system was found to be in paper working condition at the time of inspection. 2) System Conditionally Passes: 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 old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration 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 is 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): tnap;doc•mr.T128/2018 Tim 5 Official Inspection Form:Subwxfece Sewage Disposal System•Page 2 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments $ : 85 North Main Street Property Address Zachary_Hunter Owner owner's Name isformattat a South Yarmouth Ma 02664 3/6/2020 required for every page. Cltytrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): 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 break out 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): ❑ broken pipe(s)are replaced 0 Y 0 N 0 ND(Explain below): ❑ obstruction is removed 0 V 0 N 0 ND(Explain below): ❑ distribution box is leveled or replaced 0 Y 0 N 0 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): ❑ broken pipe(s)are replaced 0 Y 0 N 0 ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions 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 1 .30 (1)(D)that the system M not functioning in a manner which will protect public health, safety and the environment: t£ tp s oc•rev 7/26/2018 rile 6 Moat trapecbors Formsubawtaca Sewage otaposai System•Pane 3 ot 13 Commonwealth of Massachusetts •� 47 Title 5 Official Inspection Form +a; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • " 85 North Main Street Property Address Zachary Hunter Owner Owners Name iMartnad nis fur e required faevery South Yarmouth Ma 02664 3/612020 __..__. 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 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 functioning in a manner that 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 a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply welt". Method used to determine distance: "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 must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You muse Indicate"Yes"or"No"to each of the following for a inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15a'up. •rev.1 18 Till 5 Oflxaal hispet.tion Fw m.SuGa of,u Sewage bispasai Sysiern•Page 4 d 18 Commonwealth of Massachusetts ® a 1 Title 5 Official Inspection Form i - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1/4„ - ` 85 North Main Street Property Address Zachary Hunter Owner Owner's Name informations South Yarmouth Ma 02664 3/6/2020 required for every pais- City/TownCity/TownState Zip Code Date of inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to Ali Systems: (cont.) Yes No ❑ eStatic 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: • 0 Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ el Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ IN 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. ❑ e 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 lees 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.] ❑ ►l The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 The system fail .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 a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section C.4. Yes No O 0 the system is within 400 feet of a surface drinking water supply ❑ 0 the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well drep.doc-rev.712512018 Tee 5 Mud Inspection Form.Subsurface Sewage S{spoea SYS'Page 5015 Commonwealth of Massachusetts >° * tiTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments F ' "--q.4 85 North Main Street Property Address Zachary Hunter Owner Owner's Name r On is requiouth Yarmouth Ma3/6/2020armou02664 required far ovary S _...._.�e_ �...�.._._ 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 t under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner I 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 ` ►.4 0 Pumping information was provided by the owner,occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? =4 ❑ 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 ❑ ►_4 this inspection? ►,i ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) 0.4 0 Was the facility or dwelling inspected for signs of sewage back up? ►,e 0 Was the site inspected for signs of break out? ii? 0 Were all system components,excluding the SAS, located on site? I 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? �,1 ❑ 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: ►�4 0 Existing information. For example, a plan at the Board of Health. I Determined in the field(if any of the failure criteria related to Part C is at issue 0 ❑ approximation of distance is unacceptable)[310 CMR 15.302(5)1 t5gep.dcc•rev.7138/2018 TM.5 Official krspectiort Form Sewage Diepoeel System•Page 8 of 18 Commonwealth of Massachusetts ,i Title 5 Official Inspection Form a ` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 4, 85 North Main Street Property Address Zachary Hunter Owner Owner's Name information is South Yarmouth Ma 02664 3/6/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 333 gpd DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): provided Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ►.1 No Does residence have a water treatment unit? 0 Yes ►i1 No If yes,discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? 0 Yes ►;i No Seasonal use? 0 Yes El No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2018=47,000 total=129 gpd 2019=51,000 total = 140 gpd Sump pump? 0 Yes ►5 No Last date of occupancy: pent 1Sawp.d •rev,71 18 Title 5 Office*Inspection Form;Subsurface Disponee System•Page 7 of 18 Ctx Commonwealth of Massachusetts Title 5 Official Inspection Form fit Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 North Main Street Property Address Zachary Hunter Owner Owner's Name requwed ter South Yarmouth Ma 02664 3/6/2020 requir ._._ page. City/Town 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 day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes 0 No Water treatment unit present? 0 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): 3. Pumping Records: Source of information: no records sisnce tank installed 4/2/2015 Was system pumped as part of the inspection? ❑ Yes ►=+ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: I t,5m4,de c•my:7/2812018 Tales 5°Moat Inspection Form Subsurface Sinew Dittpaal System•Page 0 018 e ................. Commonwealth of Massachusetts t} ,g Title 5 Official Inspection Form ,''' _1.6 -- ..,i: Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �► 85 North Main Street Property Address Zachary Hunter Ovvner Owner's Name infonmation is South Yarmouth Ma 02664 3/6/2020 required for every _ _. , City/Town State Zip Code Date of Inspection D. System Information (cont.) 4, Type of System: e Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ 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: system installed 4/2/2015 Were sewage odors detected when arriving at the site? 0 Yes ►.4 No 5. Building Sewer(locate on site plan):. Depth below grade: 2 feet Material of construction: 0 cast iron ►:! 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage, etc.): Joints in good condition, no leakage,vented through roof. We've=•rev.7120/2018 Title 5 Official Inspection Fonn Subsurface Sewage Disposal System•Pape 9 or 18 I I . y Commonwealth of Massachusetts '4 * / Title 5 Official Inspection Form , _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , .,..i` 85 North Main Street Property Address Zachary Hunter Owner owner's Name information South Yarmouth Ma 02664 3/6/2020 rewired for even, _ -- _---- City/Town State Zip Code Date of Inspection D. System Information (cont.) 6, Septic Tank(locate on site plan): 1 Depth below grade: iiiet Material of construction: re concrete 0 metal ❑fiberglass 0 polyethylene ❑other(explain) If tank is metal, list age: Yore Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) 0 Yes 0 No 1500 gallons Dimensions 5" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 10" Distance from bottom of scum to bottom of outlet tee or baffle Opened covers and took How were dimensions determined? measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet,tank was not leaking and was structurally sound. 1 15wMp.doc•rev:Tests Tate 5(!there'Insp.ckm Farm Subsurface Sewage Disposal System`Page toot 18 1 I Commonwealth of Massachusetts !, Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments + 85 North Main Street Property Address Zachary Hunter Owner Owner's Name infomtatum is South Yarmouth Ma 02664 3/6!2020 required for every pag C y State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: 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 tee 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 pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete 0 metal ❑fiberglass 0 polyethylene 0 other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5ms.d •rev.7P18/2116 Tills official inspection Form:%anodic.Sewage Disposal System•Page 11 of¶5 Commonwealth of Massachusetts 47 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • 85 North Main Street Property Address Zachary Hunter _ Owner Owner's Name istsrmation is South Yarmouth Ma 02664 3/6/2020 required for everyPa9e . City(town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont) Alarm present: 0 Yes 0 No Alarm level: Alarm in working order: 0 Yes 0 No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): 1 *Attach copy of current pumping contract(required). Is copy attached? 0 Yes 0 No 9. Distribution Box(if present must be opened)(locate on site plan): 0" 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.): Distribution box was level and in good condition with no rot Water level was even with outlet invert with no signs of past backup. 154esp doe•rev 7I221201R Title 5 O 5cial IrepetSon Farm Subsurface Sewage Disposal Syslem•Page 12 of 1R Commonwealth of Massachusetts p . it ' Title 5 Official Inspection Form ti ,w - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1/4`�:. ,..f A 85 North Main Street Property Address Zachary Hunter Owner owners Name informations South Yarmouth Ma 02664 3/6/2020 required for every Pte. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: Q Yes 0 No* Alarms in working order. 0 Yes ❑ 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: Type: leaching pits number ►_t leaching chambers number 4x LC-6 leach chambers ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. - -- ❑ innovative/alternative system Type/name of technology: t5mcp.doc•rev.7/28T2O113 Idle 5 Officod Inspectron Form:Subsurface Sewage Disposal System•Page 13 of 16 l I Commonwealth of Massachusetts , . . # Title 5 Official Inspection Form j -- * Subsurface Sewage Disposal System Form-Not for Voluntary Assessments „ { 85 North Main Street Pmmperty Address Zachary Hunter Owner Owner's Information required terwry South Yarmouth Ma 02664 3/6/2020 1 pa9 .. City/Tov , State Zip Code Date of Impaction tion D. System Information (cont.) 11. Sohl Absorption System(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): s.a.s. consists of 4 LC-6 precast leaching chambers in a 33511'x l'trench. Leaching facility was located and opened and was found to have 6"standing water(50%)with no stain line higher.Access cover is on a riser I 12. Cesspools(cesspool must be pumped as part 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.): temp Tee S Official Impecton Form: Deposal System•Paye 14 of 18 da�ray.7/202018 �i 4 Commonwealth of Massachusetts g� * l't Title 5 Official Inspection Form o - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i - `' 85 North Main Street Property Address Zachary Hunter Owner owner's Name informonrequirataed for every South Yarmouth Ma_......_ 02664 316/2020 Page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 15insp. rev,7/28/2018 Title 5 OThcid Inspectose Pam:Subsurface Sewage Disposal SYS•Page 15 of 18 4 ' l Commonwealth of Massachusetts '''. si Title 5 Official Inspection Form o1414,„ , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `^ = 85 North Main Street Property Address Zachary Hunter Owner Owner's Name information is SOt armouth Ma 02664 .___...._ 3/6/2020 required for every ein State Zip Code Date of Inspection 1 ice• 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 building. Check one of the boxes below: g hand-sketch in the area below 0 drawing attached separately I C ('\\\''''' .! 131 2-4. 112- .3t ` - ` i)3 41 ' Wit' LIi Pry liotho f tkNrp.rac•rw.712612018 Tide 5 Waal!mascara Pone Subsurface Sewage Disposal System•Page 16 of 18 1 Commonwealth of Massachusetts :I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 North Main Street Property Address Zachary Hunter Owner Owner's Name Information is South Yarmouth Ma 02664 3/6/2020 Pte: _.a.. required!for efrery City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Co Check Slope ❑ Surface water O Check cellar ❑ Shallow wells 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: 12/91/2014Date . ❑ 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) ❑ Accessed USES database-explain: You must describe how you established the high ground water elevation: a) Design plan dated 12/11/2014 states that no groundwater was encountered at 12?'and system is designed to have 5'+seperation between bottom of s.a.s. and adjusted high groundwater. b)property is elevated considerably compared to surrounding_area Before filing this Inspection Report,please see Report Completeness Checklist on next page. tan*fl •rw.7126/2018 Tate 6 Mal Mapleton form Subsurface Sewage Disposal System•Page 17 of 18 I 1,' Commonwealth of Massachusetts „ : '1 Title 5 Official Inspection Form a! _. " Subsurface Sewage Disposal System Form-Not for Voluntary Assessments :::,, 85 North Main Street Property Address Zachary Hunter Owner Owner's Name information is required for every South Yarmouth Ma 02664 3/6/2020 page, City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: CI A. Inspector Information: Complete all fields in this section. I- B.B. Certification: Signed&Dated and 1, 2, 3, or 4 checked L C. Inspection Summary: I 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed D.System Information: 1 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 tbatep.doc•rev.712612016 TM.5 Official Inspection Form Subsurface Sewage Disposal Syi em•Page 16 or 18