HomeMy WebLinkAboutInspection Report 2024 Mach 26sr..i.Commonwealth of Massachusetts
Title 5 Official lnspection Fofnt
Subsurface Sewage Disposal System Form - Not for Voluntary Alsetisnl'ents
43 Hemeon Rd
eroperty eddress
Owner
information is
required for every
page.
Llrla R99!e q'o Cape Bealtl
Owne/s Name
West Yarmouth 02673
2p Cooe '-3-26-24
City/Town Date of lnspection
A. lnspector Information
Michael Sears llAR 2S 2024
lmponant: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do nol
use the return
key.
Name of lnspedor
Jim The lnspector Man HEALTH DEPT
Company Name
P. O. 8ox 784
company Aa*ess
West Yarmouth
City/Town
508-292-5931
tvta 02673
Zip CodeState
st14430
Telephone Number License Number
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Tifle 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:
B. Certification
'1. I Passes
2. n Conditionally Passes
3. E Needs Further Evaluation by the Local Approving Authority
4. E Faits
3-26-24
lflspector's Signature
-...,$\tiiii'i{ft,1"
s--=L', 'urcunei 7%',,; FJ SEARS iq
=
ffi;its
/
The system inspector shall submit a copy of thrs inspection report to the Approving Authority (Boardof Health or DEp) within 30 days of compteting this inspection. tf the system has;de;ig; fiil;i'10,000 gpd or greater, the inspector and the system owner shall submit the report to tnE afpiofriateregional office of the DEP. The original form should be sent to the system owner and copies sent tothe buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under theconditions of use at.that time. This inspection does not address how the system will performin the future under the same or different conditions of use.
15hsp doc ' rev 7261201 I r[b 5 offic.] rnspeclion Form subslrfac€ sewage Disposs system . page 1 of 16
Ma.
State
lnspection results must be submitted on this form, lnspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Date
5*l. Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd.
Linda Roche c/o c-ePe Beallv
Pr.qp!rtyAddreis
Owner
information is
required for every
page.
Owner's Name
West Yarmouth IVIA,
State
02673 3-26-24
Citynown Zip Code Date of lnspection
C. lnspection Summary
lnspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
X I have not found any information which indicates that any ofthe failure criteria described
in 310 CMR 15.303 or in 31 0 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is rn working order at time of inspection
2) System Conditionally Passes:
! One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion ofthe repl;rcement or reparr, 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. lf "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 trru E ND (Explain below):
l5insp doc . rev 7/26/2018 T I e 5 Otricial lnspeclion Form Subsudace Sewage D sposal Sysrem . page 2 of 1 6
sftN Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurrace Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd.
Owner
information is
required for every
page
Property Address
_L1ll!!1Bo!h,e c& rl?pe Ee?LtyOwnels Name
West Yarmouth
City/Town
t\4 a
State
02673
Zfuooe
3-26-24
Date of lnspeclion
C. Inspection Summary (cont.)
2) System Conditionally Passss (cont.):
Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
I 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 tr Y D N E ND(Explainbelow)
f] obstruction is removed E Y tr ru E ND (Explain below)
tr distribution box rs leveled or replaced tr V n N E ND (Explain betow)
E 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 reptaced
tr obstruction is removed
E v ! N fl ND (Explain betow)
trY Eru E ND (Explain betow)
3) Further Evaluation is Required by the Board of Heatth:
! Conditions exist which require further evaluation by the Board of Heatth in order to determine ifthe system is failing to protect public health, safety or the environment.
a. system wilr pass unless Board of Health determines in accordance with 310 cMR15303(1Xb) that the system is not functioning in a manner which will protect public health,safety and the environment:
lsinsp.doc rov 7/26/2018 Tile 5 Ofrcial lnsp€ctron Fom Subsudace S4ags Disposstsy3t€m. pag€ 3 ot iS
5}. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Owner
information is
required for every
page City/Town
Subsurface Sewage Dispoeal System Form - Not for Voluntary Assessments
43 Hemeon Rd.
Froperty eaaress
LjdaRoele c/o q_?pe &9!!tyOwner's Name
West Yarmouth Ma 02673
Zip Code
3-26-24
Date of lnspec{ion
C. lnspection Summary (cont.)
Cesspool or privy is within 50 feet of a surface water
n Cesspool or privy is wjthin 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.
fl 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.
D The system has a septic tank and SAS and the SAS is less than 100 feet but S0 feet or
more from a private water supply well"-.
Method used to determine distance:
c. Other:
4) System Failure C teria Appticable to Alt Systems:
You must indicate ,,Yes', or ,,No,, to each of the following for all inspections:
Yes No
x
a
** 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 egual
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy ofthe analysis must
be attached to this form.
!
Backup of sewage into facility or system component due to overloaded orclogged SAS or cesspool
Discharge or ponding of effruent to the surface of the ground or surface watersdue to an overloaded or clogged SAS or cesspool
TUe 5 Officiat tnspecrion Form Subsurface Sewage Dbposatsystam, page4 ot 18
lsnsp doc. rcv 7/26/2018
Stale
n
Owner
information is
required for ev€ry
page.
lli Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd.
iroperty Address
Linda Roche c/o Cape Realty
Ownels Name
West Yarmouth
Citynown
Ma 02673State Zip Code
3-26-24
Date of lnspecton
C. lnspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
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 pasaes 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.J
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 determjne 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
tr tr
tl
the system is within 400 feet of a surface drinking water supply
n the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (lnterim Wellhead Protection
Area - IWPA) or a mapped Zone ll of a public water supply well
Tille 5 Ofrcral lnsp€ction Fonn Subs!d.:€ S€$/a!€ DEposalSysren. Pago5 ot lB
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 IVOTdue 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 ol a public water supply
well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
xtr
tr
lsinsp doc. rcv 726i2018
Yes No
!a
trx
trX
trx
!x
trX
trxnx
x
trtr
5}, Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd.
Property Address
Linda Roche c/o &ealtyOwner's Name
West Yarmouth
en-yn6wn
Ma
State Date of lnspection
Owner
information is
required for every
pa0e
6
C. lnspection Summary (cont.)
lf 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 fail;d. The
owner or operator of any large system considered a signiflcant threat under section c.5 or failed
under section c.4 shall upgrade the system in accordance with 310 cMR 1s.304, The system owner
should contact the appropriate regional office of the Department.
You must indicate "yes" or "no" for each of the following for a/ inspections:
Yes No
A D Pumping information was provided by the owner, occupant, or Board of Heatth
tr X Were any of the system components pumped out in the previous two weeks?
X n Has the system received normal flows in the previous two week period?
T'l M Have large volumes of water been introduced to the system recenfly or as part ofLJ rz'J this inspection?
tr tr ffiiffi?:[rj:iilithe svstem obtained and examined? (lrthey were not
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened, and the interior of the tankinspected for the condition of the baffles or tees, material of construction,
drmensions, depth of liquid, depth of sludge and depth of scum?
W_as the.facility owner (and occupants if different from owner) provided withinformation on the proper maintenance of subsurface sewage disposal systems?The size and tocation of the Soil Abso.ption System (SAS) on the site hasbeen determined based on
Existing information. For example, a plan at the Board of Health.
Determined in the fierd (if any of the fairure criteria rerated to part c is at issueapproximation of distance is unacceptabte) [310 CMR i5.302(5)]
xtr
xtr
trtr
X
x
lSmsp.doc. rcv 7/262018 Tills 5 otlicial lnspecton Fo.mr Subsu.rac. S6wag6 Dasposat Sysrsm , pag6 6 ot 1O
Title 5 Official Inspection Form
02673
Zip CoOe--
3-26-24
5}. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd.
Owner
information is
required for every
page.
Property Address
Linda Roche c/o Cape Realty
Owner's Name
West Yarmouth
City/Town
t\4a 92673 __
Zip Code
3-26-24
State Date of lnspeclion
D. System lnformation
1. Residential Flow Conditions:
3Number of bedrooms (design)Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Description:
330
2
ls laundry on a separate sewage system? (lnclude laundry system inspection
information in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd))
Detail:
E ves X tto
E ves I tto
Sump pump?
Last date of occupancy
E Yes E 11s
Present
Date
lsin8p.d,rc. rev 72612010 Tille 5 olrioarhspecron Form subsurfaco seeag€ Dispos3lsystem. pa!€ 7 of 1E
Number of current residents:
Does residence have a garbage grinder?
Does residence have a water treatment unit?
lf yes. discharges to
EvesX No
EYesX No
!yesX ruo
NA
i}' Commonwealth of Massachusetts
Title 5 Official lnspection Fonn
Owner
information is
required for every
page.
43 Hemeon Rd.
eroperty nOOress
Linda Roche c/o Cape Realty
Owner's Name
West Yarmouth
City/Town
Ma 02673 3-26-24
State Zip Code Date of lnspeclion
Non-sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use:
Other (describe below):
Gallons per day (gpd)
nyesE No
EYesE ruo
E yes E tto
n Yes E tto
Oate
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection?
lf yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
2022
E ves X tto
gailons
lSnsp doc . rev 7262018 Till€ 5 Ofliciat tnspe.tiofl Fom SubsLdace Sslage DisposalSystem. page I of 1A
Subsurface Sewage OiBposal System Form - Not for Voluntary Assessments
D. System lnformation (cont.)
2. Commercial/lndustrial FlowConditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Water treatment unit pre3ent?
lf yes, discharges to:
lndustrial waste holding tank present?
.'.j...Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurtace sewage Disposal Systom Form - Not for Voluntary Assessments
43 Hemeon Rd.
Property Address
!!!de Reghe c1o rQepg Ree.!!L
Owner's Name
West Yarmouth
Owner
informalion is
required for every
pa9e.
Ma 02673
Zrp Code
3-26-24
City/Town Date of lnspeclion
D. System lnformation (cont.)
4. Type of System:
A Septic tank, distribution box, soil absorption system
tr Single cesspool
tr Overflow cesspool
tr Privy
tr Shared system (yes or no) (ifyes, attach previous inspection records, if any)
! lnnovative/Alternative technology. Attach a copy ofthe current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the l/A system by system operator under contract
tr Tight tank. Attach a copy of the DEP approval.
tr Other (describe):
Approximate age of all components, date installed (if known) and source of information
1-28-12 # 12-08
State
Were sewage odors detected when arriving at the site?
5. Building Sewer (locate on sjte plan):
Depth below grade:
n Yes X ttto
20"
feet
Material of construction:
E cast iron El CO PVC ! other (explain):
Distance from prjvate water supply well or suction line feet
Comments (on condition ofjoints, venting, evidence of leakage, etc.)
lsnsp doc . rev 7/2612018 Tille 5 Ofliciar tnsp6crion fom Subsudace Sswag€ DisposatSFt6m. pagego,18
.l-\ CommonwealthofMassachusetts
Title 5 Officia! lnspection Form
Owner
information is
required for every
page
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd.
Property Address
Linda Roche c/o Cape Realty
Ownels Name
west Yarmouth
City/Town
t\ra
State
02673
2[coae
3-26-24
Date of lnspection
D. System lnformation (cont.)
6. Septlc Tank (locate on site plan)
Depth below grade:
Material of construction:
fi concrete E metal
1500 gal
10"
teet
n fiberglass fl polyethylene ! other (explain)
lf tank is metal, list age
ls age confirmed by a Certificate of Compliance? (attach a copy of certificate) E VesE ruo
Dimensions: ASqseL
Sludge depth 2"
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 8"
Distance from bottom of scum to bottom of ouflet tee or baffle 18"
How were dimensions determined? QqlsJ-lulge' lqpe
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,Iiquid levels as related to ouflet invert, evidence of leakage, etc.):
system is a 1500 gal tank with inlet tee and ouflet tee in place, both covers are .10,, below grade
lsinso doc. rev 7262018 Tille 5 Ofiio6t tnsp€.tion Fom: Subsudac.J Sgwage DisposalSFrem. pag€ 10 o,10
y_.4r5
Owner
information is
required for every
page City/Town
1}. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd.
Property Addr6ss
Linda Roche, c/o Cape Realty _
Owner's Name
West Yarmouth
State
Ma UZOIS
zp CoOe
3-26-24
Oate of lnspection
D. System lnformation 1cont.1
7. Grease Trap (locate on site plan)
Depth below grade:
Material of construction:
E concrete E metat E fiberglass E polyethylene E other (explain)
Date
Dimensions:
Scum thlckness
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:
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:
I concrete E metal
Dimensions:
Capacity:
Design Flow
0allons
gallons per day
Title 5 Official lnsp€ctim Fm Sub.ufe S*Ege Di.poEl Sy.tm . Pag. 1l or lalsinsp.doc. rcv 72612018
! fiberglass ! polyethylene ! other (explain):
A Gommonwealth of Massachusetts
Title 5 Official lnsPection Form
Subsurface sewalle Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd.
Property noorLss
Linda Roche c/o Cape Realty
Owner
info.mation is
required lor every
page.
Owner's Name
West Yarmouth
City/Town
lvla.
State
02673 3-26-24
zip Code Date of lnspeclion
D. System lnformation (cont.)
8. Tight or Holding Tank (cont.)
Alarm present:
Alarm level:
EYes Eruo
Alarm in working order:n ves fl No
Date of last pumping: Dare
Comments (condition of alarm and float switches, etc.)l
* Attach copy of current pumping contract (required). ls copy attached? [ Yes E tto
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.):
D Box is 16x16 with 2 outlet lines, cover is 12" below grade
0
Ginsp.doc. rev 7/2612018 Ttle 5 omaal lnspeclion Form subsdac€ s€wage orsposet systsrn , pag€ 12ot 1E
9. Distribution Box (if present must be opened) (locate on site plan):
tril,i\Commonwealth of Massachusetts
Title 5 Official lnsPection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd
Property Address
Linda Roche cln CaPg Realty
Owner
infomation is
required for every
pa9e.
Owner's Name
West Yarmouth
City/Towo
Ma 02673
ZP CoOe
3-26-24
State Date of lnspection
D. System Information (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: fl ves E ruo'
Alarms in working order: ! Yes E llo'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
. lf pumps or alarms are not rn working order, system is a conditional pass.
1 1. Soil Absorption System (SAS) (locate on site plan, excavation not required)
lf SAS not located, explain why:
Type:
tr
a
tr
tr
tr
tr
tr
leaching pits
leaching chambers
leaching galleries
leaching trenches
leaching fields
overflow cesspool
innovative/alternative system
Type/name of technology:
number:
number:
number:
number, length:
number, dimensions.
number:
10
15 nsp doc. rev 7/2612018 Tille 5 Ofiicial lnspeclDn Fom Subsuda@ S ag€ DisposalSystem. P€g€ 13o( 18
j;r Gommonwealth of Massachusetts
Title 5 Official lnsPection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd
Property Address
Linda Roche c/o Cape Realty
Owner
information is
.equired for every
page.
Ownels Name
West Yarmouth
City/Town
Ma 02673 3-26-24
State Zip Code Date of lnspection
D. System lnformation (cont.)
1 1. Soil Absorption System (SAS) (cont.)
comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SnS i" to Hi-Cap lnfilltrators, chambers are clean and dry with no sign of failure
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 oesspool
Materials of construction
lndication of groundwater inflow ! Ves ! ruo
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
tsinsp do. ' r6v 7/252018 Till6 5 Ofticial lnspedon Fom Subsurtac€ S€waoB Oisposal System ' Pags 14 of18
SL. CommonwealthofMassachusetts
Title 5 Official lnsPection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd
Property Address
Linda Roche cYo Cape Realty
Owner
informataon is
required for every
page
Owner's Name
West Yarmouth Ma 02673 3-26-24
City/Town State Zip Code Date of lnspection
D. System lnformation (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
IsinsD d@. r6v 7,26r2o1a T'lre 5 OtfE.l l..peclion Fo6 Su&urfe@ Sw60€ Di.posl Syst€h . p6oo 15 ot lB
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Owner
lnformation is
required for every
page
5flt Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd.
Propeny Address
Linda Roche c/o Cape Realty- _Ownels Neme
West Yarmouth Ma.
state
02673
Zip CodeCity/Town
3-26-24
Date of lnspection
D. System lnformation (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view ofthe 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:
X hand-sketch in the area below! drawing attached separately
i), a;e R44/(6o:
)tt/ ?/
Zfia d./f ?J: I
lz,8 cA t'A
4ra:
//"
s{f
D-Bot 4C
fr t 3fi1
o?
{lt
I t ?7
fJ A s?./ a
btrt S_tt-_
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t
rsmso doc . rev 7/26/2o1a T le 5 oflioat tnsp€don Fo1n: Subsudac€ S€wage DBpo6ai Sysrsm . paos 16 oi lB
1}'., Commonwealth of Massachusetts
Title 5 Official lnspection Form
Owner
information is
required for every
page
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd.
Prodtly Address
l4lS8gche c/o Cepg Rery
Owne/s Name
West Yarmouth
City/Town
Ma.
State
02673
Zip Code
3-26-24
oate ot tn!p-ai*
D. System lnformation (cont.)
'15. Site Exam:
X Check Slope
I Surface water
I Check cellar
X Shallow wells
Estimated depth to high ground water:132"
tr
n
feet
Please indicate all methods used to determine the high ground water elevation
X Obtained from system design plans on record
12-15-11lf checked, date of design plan reviewed Oate
Observed site (abutting property/observation hole wtthin 150 feet of SAS)
tr Checked with local Board of Heatth - explain
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the hlgh ground water elevation
No ground water per plan
Before filing this rnspection Report, prease see Report compreteness checkllst on next page.
t5rnsp doc . r.v 7/261201 I Tirre 5 Orrr.et tnspecrron Fonn Subsut.c€ S€wage Oispos€tSysi€fi. page 17 ol18
5(:., CommonwealthofMassachusetts
Title 5 Official lnspection Form
Owner
information is
required for every
page City/Town
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Hemeon Rd.
Property Address
Li!{a Rgche c/o qapq LealtyOwnels Name
West Yarmouth Ma 02673 3-26-24
State Zip Code Date of lnspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
X A. lnspector lnformation: Complete all fields in this sectron.
X B. Certification: Signed & Dated and 1 , 2, 3, or 4 checked
I C. lnspection Summary:
1 ,2, 3, ot 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
X D, System lnformationl
For 8: TighUHolding 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
Isi^sp doc. r6v 7D6lr013 Td6 s ollE6r hspechon Fom sub3urra6 s€wage oispolatsrrem . prgo 16 ot 16