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HomeMy WebLinkAboutInspection Report 2020 Mar 13 Y M Commonwealth of Massachusetts P/(P Ll[i 71, :, Title 5 Official Inspection Form MAR 31 2020 f v Subsurface Sewage Disposal System Form-Not for Voluntary Assessments HEALTH DEPT. _ 793.Route 28 .: - ' . Property Address cm/08A ozo patoa.Ta i '''''' is,-;:' .-.,;-"it' Sanji Kanaagara r? yEw 114 Def _ : ° Owner _._ _ _ ®wner's Name information is Yarmouth requinrd far very _�-- _ r. MA 02664 3 13-2020 page Cltytrown t 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. tillingouutfo When A. inspector information on the computer, use only the tab David J Burnie key to move your Nome of Inspector cursor-do not Northeast Construction use the retun _ _______ _._ -r _ —Company Name _ . PC Box 2350,32 Sara Ann Lane- Company Address Brewster MA 02631 - City/Town State Zip Cods — -, Telephone Number _ . ._ __.____. ___. _-. 774-218-144061388 = _ __ __ License Number B. Certification I certify that I am a DEP approved system inspector in full compliance with Section 16.340 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. kr. Passes a,,e01ii, r-.,. a 2. 0 Conditionally Passes 3. 0 Needs Further Evaluation by the Local Approving Authority ,-= 4. 0 Fails .+ F �� . e'er -.. r/Ip r, tt.ii ', _ __ . i 3-13-2020 ef's W � fy ~—_- The system spector 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 not*:This report only describers 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. 5 .rw.7/26M316 TAW 6 Millisf it1400 i9r+Nor- &WV@€h6bsttnn+Poo@ I of 46 Commonwealth of Massachusetts A/ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 793 Route 28 Properly Address Sanji Kansagare_ Owner Owners Nemo information b required for every Yarmouth _ MA 02884._ 3-13-2020_ Pogo, City/Town __-- _ Stets Zip Code — Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 8. 1) System Passes: ►;a 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 system is workingas designed on this day. 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 exflltration 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. 0 Y 0 N 0 ND(Explain below): ttoitst:a6•rsv.7/IV3016 lilkt§MSiel Impttbeft fro w,tilitYRAIEV kawisigu tl*p**!syr•Poo 2 et 1g Commonwealth of Massachusetts Title 5 Official Inspection Form s b y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 793 Route 28 Property Address Sanji Kansagara Owner Owner's Name information is Yarmouth --- MA 02884 3-13-2020 nquked for every Page City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont): 0 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): O obstruction is removed 0 Y ❑ N 0 ND(Explain below). • distribution box is leveled or replaced ❑ Y 0 N ❑ ND(Explain below): ❑ The system required pumping more then 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 ❑ N 0 ND(Explain below): ❑ obstruction is removed ❑ Y 0 N 0 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 15.303(1)(b)that the system is not functioning In a manner which will protect public health, safety and the environment: M/rop:eoe•rar,7/26/2018 Q MOM lug on Form Si bsurkiss ®eanp®isposN!Whom Pena 1 s118 Commonwealth of Massachusetts r Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14= J. 793 Route 28 Property Address SanJi Kansagara Owner Owner's Nana information Yarmouth requ►red for every sm MA 02884 3-13-2020 Par, City/Town State Zip code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water O Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fall 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, 0 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 lets 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 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 mat Indicate'Wes"or"No"to each of the following for a Inspections: Yes No © _ Backup of sewage Into facility or system component due to overloaded or clogged SAS or cesspool ❑ +4 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.ave•rev:7126/2416 Ufa 6®Niall Inapan ort Perin Ilitme®oa&maw rsispanal gys •Poem 4 of 14 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '''._ _w. ' 793 Route 28 Property Address Sanji Kansagara _ - -_ - _ Owner _ Owner's Name Information is Yarmouth » . _: MA _ 02864 3-13-2020. ...-- required for every PP1190, City!Town State Zip Code Date oinspection _ — � 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 4 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped; ❑ ►a Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ c. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ 2 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ►i Any portion of a cesspool or privy is within 60 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 hiss than 6 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ 0The system is a cesspool serving a facility with a design flow of 2000 gpd 10,000 gpd, ❑ ki. The system Bo. I have determined that one or more of the above failure criteria exist as described In 310 CMR 16.303,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 ❑ 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 16hNp,doc•rev,726/2016 Igo 5 Iroprlaion Pun;Substsfaco bewsp O bpdr;M Swum•Poo 5 a 1B 1 ., Commonwealth of Massachusetts . s lw Title 5 Official Inspection Form Subsurface Swag.Disposal System Form-Not for Voluntary Assessments 1/401/4 793 Route 28 Property Address Sanji Kansagara __„� ___ owner , _.. n -- —_-- --- Owner's Name intorrnetion Is required for every Yarmouth MA 02664 3-13-2020 Page, Cityfrown 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. 8. You must indicate"yes"or"no"for each of the following for all inspections: Yes No C. 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? ►. 0 Has the system received normal flows in the previous two week period? ❑ 14 Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ w Were as built plans of the system obtained and examined?(If they were not available note as N/A) 0.1 ❑ Was the facility or dwelling inspected for signs of sewage back up? ►:4 0 Was the site inspected for signs of break out? . 0 Were all system components,excluding the SAS, located on site? s 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? �-4 ❑ 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 Boll Absorption System(SAS)on the site has been determined based on: ra 0 Existing 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)1 Ibroop,aoo-rev:7/ZCfW i8 THIS b&Wel Irispabon form,Wharfage forma plop al Wim•page 8 of rd • Commonwealth of Massachusetts Title 5 Official Inspection Form 40, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C 793 Route 28 Property Address Sal Kansagara Owner Owner's Name rvery — — information is Yarmouth MA 02664 3-13-2020 Paiet City/Town state— Zip Code Data of inspection D. System Information 1. Residential Flow Conditions: N/A Number of bedrooms(design): — Number of bedrooms(actual): DESIGN flow based on 310 CMR 18,203(for example: 110 gpd x#of bedrooms): Description: Motel Number of current residents; Motel Does residence have a garbage grinder? 0 Yes 0 No Does residence have a water treatment unit? 0 Yes 0 No If yes,discharges to: is laundry on a separate sewage system?(Include laundry system inspection 0 Yes 0 No information in this report) Laundry system Inspected? 0 Yes 0 No Seasonal use? 0 Yes 0 No Water meter readings, if available(lest 2 years usage(god)); Detail: Sump pump? LI Yes No Last date of occupancy: Date Win*deo tee,7/26/201$ nes 5 Orem!snowier)Form Steserface Woes nepossi Mies•Pip 7 of 15 A:=‘ Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 793 Route 28 Property Address SaniKansagara Owner Owner's Name information Is Yarmouth MA 02664 3-13-2020 City/Town State Zip Code Date of Inspection D. System Information (cont.) 2, Commerclainndustrial Flow Conditions: Type of Establishment: Motel 110 gal per bedroom x 20 bedrooms, Design flow(based on 310 CMR 15,203): 2200 redPired 2212 Provided Basis of design flow(seats/pervons/sq,ft,etc): N/A _ Grease trap present? 0 Yes e No Water treatment unit present? [3 Yes ri No If yes,discharges to: Industrial waste holding tank present? 0 Yes it..4 No Non-sanitary waste discharged to the Title 5 system? 0 Yes i4 No 2019 m 541,000m 1482gpd Water meter readings, if available: 2016m704,000 mg 1929gpd Last date of occupancy/use: Lu_urrent _ Other(describe below): Motel,use may chane each day. 3. Pumping Records: Source of information: Per owner on Feb 6 2020 Was system pumped as part of the Inspection? 0 Yesk...4 No if yes, volume pumped: _ gallons How was quantity pumped determined? _ _ Reason for pumping. _ t8srisp doe$rtry 7/26/1616 fit*b Meal In sfraareft 1.ofro*bowfin*aftsgo thopoomi tlystoot$ or 111 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 793 Route 28 Property Address Sanji Kansagara _ Owner Owner's Name intonation is required for every Yarmouth . . MA _ 02664 3.13-2020 asp City/Town State -Zip Code Date of Inspection D. System Information (cont) 4. Type of System: Septic tank, distribution box, soil absorption system O Single cesspool O Overflow cesspool O Privy El Shared system(yes or no)(if yes,attach previous inspection records, if any) O 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 o Tight tank.Attach a copy of the DEP approval. Other(describe): Md pump cbs b 1,1,mleliching Eetsure dosing Approximate age of all components,date installed(if known)and source of information: Coastal engineering plan dated 9-21.10 Were sewage odors detected when arriving at the sits? 0 Yes r,t No 5, Building Sewer(locate on site plan): 41, Depth below grade: 4" Material of construction: o cast iron 4 40 PVC 0 other(explain): 10+ Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,40.4 Normal as to what we can view •folv 1/242018 fit*§Offitul IhrOfielagti tOFM§tibtqlfgad&WOW O#pJ §tigkam P8(0§ I@ 1,1\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 793 Route 28 Property Address Sanji Kansavara Owner Owner's Name information is yarmouth MA 02864 3-13-2020 required for every _ _ Past difyfrown State Zip Code Date of inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Grade_ Depth below grade: feet Material of construction; concrete 0 metal 0 fiberglass 0 polyethylene 0 other(explain) 2 septic tanks, 1-4600 gal end 1,-2800 If tank is metal,list age: _ years Is ageconfirmed by a Certificate of Compliance?(attach a copy of certificate) 0 Yes 0 No 2800 Dimensions: 4500& Sludge depth 0 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 0 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural Integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Both tanks are at normal working levels,all tees are in place.There Is no sign of leaking .The tanks werePumded on Feb e and refilled with no detectable sludge and or scum %tray fiat•rav 1/26/2 ie.a Nagai lastioataan Patfa fiabsatfaaa&yaw Otapaaai*atom•Paa*10 at 1@ Commonwealth of Massachusetts Title 5 Official Inspection Form s; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � t-A- ' 793 Route 28 Property Address Sanji Kansagara _ _ Owner Owner,Nana —,-- information is Yarmouth rewgtriradfor+,every .,,_� th.r. MA 02664 3.13-2020 CitylTown PAP, 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 oust tee or battle � . 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: -- _T Material of construction: 0 concrete 0 metal 0 fiberglass Li polyethylene 0 other(explain): Dimensions: Capacity: —_ gallons Design Flow: peliana par day ifinsadoo•rev,7/2812019 rifle S Moat Inspedon Penw Ase@ Mow Dtspomoi gya ,, Page rt 418 ts Commonwealth of Massachusetts }• Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 793 Route 28 Property Address Sanji Kansagara_ Owner Owner's Name information required for every Yarmouth_-- MA__ 02884 3-13-2020 page. Cityrrown 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 Ej No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): 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): Depth of liquid level above outlet invert None 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.): Pressure dosing system,no distribution box •rev,?Wail§ TM 6 5yst*fit•Poo i$of i6 • Commonwealth of Massachusetts _L,1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 793 Route 28 Property Address Sandi Kansagara — Owner's tine -- ,--_ _ --___ Owner information it Yarmouth required for every _ _ MA_.. 02684 313-2020 page, City/fown Sits Zip Cods law of lmspactem D. System Information (Cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ►4 Yes 0 No* Alarms in working order: ► Yes 0 No* Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Clean and in working order. - *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: located, Type: ❑ leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number: _ ❑ leaching trenches number, length: = leaching fields number,dimensions: 4845x.8 ❑ overflow cesspool number ® innovative/alternative system Typeiname of technology: //26,2018 tit*6 Official liaivictianF®IRtStagigdtie Wage Dogma#y nt•Pap 16 at 1# Commonwealth of Massachusetts ck Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 793 Route 28 Property Add rens Sanljl Kansagera Owner Owner's None information is inquired fors Yarmouth _ MA sw 02864 _ 3=13.2020_.. City/Town Page. Stet* ZIP Cods Cato of Inspection D. System Information (cont.) 11, Snit Absorption System(SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soli,condition of vegetation, etc.): Viewed leaching lines with sewer camera. lines were clean and drain holes were also clean.The observation port was opened and there was no standing water. 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.): OSA*.dietw.-zatelook TAW Oftlo l impactor,foot est &Y •P000 14 of 1O Commonwealth of Massachusetts ' -7--*404--.74 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 793 Route 28 Pr operty Address SpjlKansagara Owner Owner's Nem information is required for every Yarmouth MA 02684 3-13-2020___ psgt city/Town Stats Zip Cods Dste 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,): Aro ti6e f6v mormis fig*6 Offuesi 6161#066@rtireutr6utfaft SM OW Diepe§e4 froy6tott•Nem 1§et itt Commonwealth of Massachusetts - Title 5 Official Inspection Form v Subsurface Sewage Disposal System Poem-Not for Voluntary Assessments ---P-- 1 •77-T , 793 Route 28 Property Address San i Kansagara _ -._ Owner information is owners fume required for every Y�ir .outh ,_____-- _ M,4� 02664 . 3-13-2020 .._..._�. . page, Citylrown State Zip Code bate of 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 building. Check one of the boxes below: ii,‹ .2., k / T - -----> 1 } 1 t \ . ASSESSORS MAP 33 PARCEL. 77 1 EXISTING 1 , li POOL EXISTING 4,500 GAL \ 1 TIG TANK (S,T, t) ;` - } ti, ti a � 0 EXISTING 2,� GAt. P SEPTIC TANK 0 ; :1 mm > ( s 2; > \ V. ...7,T 77:::..."' m ,... m...j , ,M.1 '. �.."`''''Arra-- -• , ----- --- EXISTING y mm—mem .. # �_�s,...mmm .-> ....... {+3 ,000 G c; tI'tlAm m�m��.m— -.v otal maa..msr9 nr 0- y - �, srasc -=mrsmvt-v m zs 'r_ fs p�� /r/ytfj tarm !!�� (l C 0 ovretfi PIPE w i . ASSESSORS MAP PARD, 78 S ROAD I- - -- HOWE 4 Commonwealth of Massachusetts ` - 0 Title 5 Official Inspection Form 1Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 793 Route 28 Owed),Address-- _ Sanji Kansagara Owner Owner's Name _ information is required for wary Yarmouth MA 02864 3-13-2020 page. City/Touwi State ZIP .Gode ___ . Date of inspection- ., D. System Information (cont.) 15: Site Exam: Check Slope ►4 Surface water ►� Check cellar of 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: 9 21-10_ Date Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Plan dated 9-21-10 0 Checked with local excavators, installers-(attach documentation) �) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Coastal Engineering Plan dated. 9-21-10 shows ground water at 10'The seperation of the leaching field to ground water is as follows,The bottom of the leaching field is at elevation 9.00 the mounded high ground water Is at elevation 3.82 this allows for a seperation of 5,1V The Estimated high ground water is at elevation 3.88 this allows for a seperation of 5.32' Before filing this Inspection Report,please see Report Completeness Checklist on next page, Mew dee•rev:/126,1016 fele 6Offieui Irtevieteere Form thrisitirteft how*.Dogmata, l7risterrt•Pee@ 1f df 16 Commonwealth of Massachusetts (f- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments A= 1i- 793 Route 28 __ --- Property Address Owner Sand Kansagara 6yN+ne1'{Name afortmtion is Yarmouth Yarm required for every Yarm MA---__ 02664 3-13-2020 Pa= Citywn State Zip Code Date of Inspection E. Report Completeness Checklist Complete ail applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section, ►_r 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 D.System Information: For 8: TightlHolding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 18 or attached For 15: Explanation of estimated depth to high groundwater Included litres6 demrtiv title 6 006660 kir rearm 666666966&wa ge 166,66a!gysito•0000 VIA 10