HomeMy WebLinkAboutInspection Report 2024 March 21,e . Commonwealth of Massachusetts
Title 5 Officia! lnspection Form
RECEIVED
APR 12 ?O?4
}IE{ITH DEPT.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Mayer
Owner
info.mation is
required for every
page.
Owner's Name
South Yarmouth Ma 02664 312112024
City/Town State Zip Code Date of lnspection
lnspection results must be submitted on this form. lnspection forms may not be allered in any
way. Please see completeness checklist at the end of the form.
A. lnspector lnformation
Sean M. Jones
lmportant: When
fllling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the retum
key.
Name of lnspeclor
S.l\4.Jones Title V Septic Inspectton
Company Name
74 Beldan Lane
Company Address
Centerville Ma 02632
City/Town
774-2484850 s
sean@smjonesl!
mjonestitle5@gmail.com,
tle5.com License Number
State
st 4522
Zip Code
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 atthe 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. E Passes
2. n Conditionally Passes
3. E Needs Further Evaluation by the Local Approving Authority
q. X raits
3121t2024
lnspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Heittn or DEp) within 30 days of completing this inspection- lf 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
regionaioffice ot tne Oep. 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 thaatime. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
r5insp.doc . .ev 7/262018 T,ile 5 Otroal lnsp€crron F{m: Suburlace sdage DisPosl Slstem ' Page 1 of 1a
E
F-l
i[. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Mayer
Owner
information is
required for every
page.
Owner's Name
South Yarmouth N4a 02664 312112024
City/Town 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:
! 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 crileria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
f] One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion ofthe 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. 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 ot
Compliance indicating that the tank is less than 20 years old is available.
EY trN E ND (Explain below)
lsin+ doc . lev 7/2S,?01E Irtle 5 Ofict, l.spedi@ Fm: Subs{dae S€*age DasPcal Sysleo . Pag€ 2 or 1E
-stiate -
€\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface SGwage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Mayer
Owner
information is
required for every
page.
Owner's Name
South Yarmouth
City/Town
Ma 02664 3t21t2024
Zip Code Date of inspection
C. lnspection Summary (cont.)
2) System Conditionally Passes (cont.):
E Pump Chamber pumpyalarms not operational, System will pass with Board of Health approval if
pumps/alarms are repaired.
E Observation of sewage backup or break out or hlgh static water level in the distnbution 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):
tr broken pipe(s) are replaced tr v n N f] ND (Explain below):
! obstruction is removed n Y tr N E ND (Explain below):
! distribution box is leveled or replaced tr Y tr N E 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 ofthe Board of Health):
tr broken pipe(s) are replaced D Y tr N tr ND (Explain below):
tr obstruction is removed fl Y tr u tr ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
E 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(1Xb) that the system is not functioning in a manner which will protect public health,
safety and the environment:
tsinsp.d@ . Ev 72612018 Ide 5 Oni.ial lnspeclron Foflr: S!b6u.fa@ Sryage Oisposl Slstem ' Page 3 of 18
State
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Properly Address
Karen Pike & William Mayer
Owner
information is
requi.ed for every
page.
Owner's Name
South Yarmouth Ma 02664 3121t2024
City/Town Zip Code Date of lnspection
C. lnspection Summary (cont.)
tr 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:
I 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 ol a public water
supply.
I 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 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 ofthe analysis must
be attached 10 this form.
c. Other
4) System Failure Criteria Applicable to All Systems:
You must indica or "No" to each of the following for al! inspections:
Yes No
T-.t M Backup of sewage into facility or system component due to overloaded orr'-r rzJ clogged SAS or cesspool
r-t M Discharge or ponding of effluent to the surface of the ground or surface watersLJ zr due to an overloaded or clogged SAS or cesspool
tsinsp.d@ ' rev. 7/2612018 Trie 5 Ofxjal lnsge.lirn Fmr sub$rfa@ s*age O6posal syslem ' Page 4 oLI
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
State
,f Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
P.operty Add.ess
Karen Pike & William Mayer
Owner
information is
required for every
page.
Owner s Name
South Yarmouth
City/Town
Ma 02664 3t21t2024
State Zip Code Date of lnspection
C. lnspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
x
trEnx
trtr
trx
!x
trana 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. ffhis
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 ofthe 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 Ei!g. 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 conect 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 the system is within 400 feet of a surface drinking water supply
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
fiue 5 Oltoal l.spection Fom: Sxb6u,fae Sewaqe Oispoel System ' Paqe 5 of 18
Static liquid level in the distribution box above outlet invert due to an ovedoaded
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 Mf due to clogged or
obstructed pipe(s). Number of times pumped: _.
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone '1 of a public water supply
well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
!
D
lSnsp d@. @v 7/26/2014
n
xtr
tr
Owner
inlormation is
required tor every
page.
i},, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Kargn Erke &lryllE4 lUeyCrOwner's Name
South Yarmouth I\ila 026M
2ip c6ae
3t21t2024
City/Town State Date of lnspection
6
G. 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 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.
You must indicate "yes" or "no" for each of the following for a/ inspections:
Yes No
X tr Pumping information was provided by the owner, occupant, or Board of Health
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-.1 M Have large volumes of water been introduced to the system recently or as part ofLr zlr this inspection?
M T-.1 Were as built plans of the system obtained and examined? (lf they were not
available note as N/A)
X n Was the facility or dwelling inspected for signs of sewage back up?
X n Was the site inspected for signs of break out?
X tr Were all system components, excluding the SAS, located on site?
X tr Were the septic tank manholes uncovered, opened, and the interior ofthe tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
x
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 ofthe Soil Absorption System (SAS) on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
Determined in the fleld (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)l
trN
I
lsinsp.dd. ev. 7,26201a Itle 5 Official Inspection Fqm: Subsudace S*age Disposal System . Page 6 of 18
5},. Commonwealth of Massachusefts
Title 5 Official lnspection Form
Property Address
Karen Pike & William Mayer
Owner
information is
required fo. every
pa9e.
Ownels Name
South Yarmouth Ma 02664 3t21t2024
City/Town State Zip Code Date of lnspection
D. System lnformation
1. Residential Flow Conditions:
Number of bedrooms (design)2 Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms):
Description:
?
?Zo gpt
Number of cunent residents:
Does residence have a garbage grinder?
Does residence have a water treatment unit?
lf yes, discharges to:
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:
Water usage not obtained
2
EvesX ruo
n vesX ruo
nvesX No
E ves X rvo
E ves X r.to
Sump pump?
Last date of occupancy
E Yes X tlo
Cunent
Dale
15insp doc ' rev 7/26/2018
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Tille 5 Olficial .spetion Fom: Subsurlace Ssage Disposa! System ' Page 7 oI 1 8
4. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Mayer
Owner
informalion is
required for every
page.
Owner's Name
South Yarmouth Ma 02664 3121t2024
City/Town State Zip Code Date of lnspection
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 present?
lf yes, discharges to:
lndustrial waste holding tank present?
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)
EvesE to
E Yes ! tto
EYesE ruo
E Yes E tto
Date
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:
tr Yes x No
gallons
tSinsp doc . ev.7/262018 Title 5 Oflicial lnspection Fom Subsurra@ Sryase DisposlSyslem. Page I of18
*. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Mayer
Owner's Name
South Yarmouth Ma 02664 312112024
City/Town State Zip Code Date of lnspection
D. System lnformation (cont.)
4. Type of System:
tr Septic tank, distribution box, soil absorption system
tr Single cesspool
n Overflow cesspool
tr Privy
tr Shared system (yes or no) (if yes, attach previous inspection records, if any)
tr lnnovative/Altemative technology. Attach a copy ofthe cunent operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection ofthe 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
system installed 121221 1993
Were sewage odors detected when aniving at the site?
5. Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
E cast iron X 40 PVC ! other (explain)
Distance from private water supply well or suction line:
E vesX No
1.5
feet
feet
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
Sewer line was video inspecled and found to have standing water due to being settled approx 5' from
the tank.
tsinsp doc. rev 7/26/2018 Tr0e 5 Ofictal lnspeclron Fqm: Subsurface S*age Dasposl System . Page 9 ol 18
Owner
information is
required for every
page.
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Property Address
Karen Pike & William Mayer
Owner
information is
required for every
page.
Owner's Name
South Yarmouth t\4a 02664 312112024
City/Town State Zip Code Date of lnspectaon
D. System lnformation (cont.)
6. Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
X concrete f] metal
10'
! fiberglass ! polyethylene E other (explain)
Ieet
lf tank is metal, list age:years
lsage confirmed by a Certificate of Compliance? (attach a copy of certificate) E yesE tto
Dimensions: l ooo gallons
Sludge depth
Distance from top of sludge to boftom of outlet tee or baffle
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
Measurements were not taken
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence ot leakage, etc.):
Tank was in good condition. Water level was even with outlet invert but inlet pipe invert was 2" under
water. lt is assumed that the septic tank was installed backwards which would result in the outlet
elevation being higher than the inlet pipe elevation. Outlet baffle was intact but is conoded.
t5insp.dc. rcv. 7/262018 Title 5 OfRcial lnspecrion Fom: subsurla@ Sryage Dispo$l System . Page 10 of 18
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
How were dimensions determined?
4,. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Oisposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Mayer
Owner
information is
required for every
page.
Owner's Name
South Yarmouth Ma 02664 3t2112024
City/Town State
D. System lnformation (cont.)
7. Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
E concrete ! metal ! fiberglass ! polyethylene ! other (explain):
feet
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 baffie 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 E metal
Dimensions:
Capacity:
Design Flow:
gallons
gallons per day
Irta 5 Ofrc&'l rnsp€clion Fom: Sut6urtae Sdee DisrGal Syslom . Pss€ 1 1 or 18Itnsp.doc. lee. 72612018
Zip Code Date of lnspection
! fiberglass ! polyethylene E other (explain):
fl. Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Mayer
Owner
information is
required for every
page.
Owner's Name
South Yarmouth
City/Town
Ma 02664 3t21t2024
State Zip Code Date of lnspection
D. System lnformation (cont.)
8. Tight or Holding Tank (cont.)
Alarm present
Alarm level:! ves E tto
Date of last pumping Date
Comments (condition of alarm and float switches, etc.)
- Attach copy of cunent pumping contract (required). ls copy attached? E Yes E ruo
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0'
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 video inspected and found to have heavy scum/sludge buildup.
isinsp doc . rev 7/26/2018 Tite 5 Otrcial lnsp€.liq Fdm: Subsurlace S age Dasposal Syslem'Page 12ol18
Title 5 Official lnspection Form
! Yes ENo
Alarm in working order:
5}' Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Mayer
Owner
information is
required for every
page.
Owner's Name
South Yarmouth
City/Town
Ma 02664 3t21t2024
Zip Code Date of lnspection
D. System lnformation (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: f] Yes E t'to-
Alarms in working order: E Yes n lto-
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
. lf pumps or alarms are not in 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:
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:
4lnfiltrators
Itnsp.de . ev. Z2Sl201 8 r'ide 5 Offioal lnspection Fm: Sutardae S4age Disgoel Syslem ' Psge 13 oI18
State
Type:
tr
x
tr
tr
tr
tr
tr
f Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Mayer
Owner
information is
required for every
page.
Owner's Name
South Yarmouth Ma 02664 3t21t20?4
State Zip Code Date of lnspection
D. System Information (cont.)
'l 1. Soil 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. is 4 lnfiltrators. Leaching facility was video inspected and was found with standing water to the
top leaving inadequate availble leaching resulting in a failing inspection.
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
lndication of groundwater inflow n yes Eruo
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.d6 ' .ev. 7/26/2018 Trde 5 otrEial lnspeclion Fm: Subslrfae Ssage Disposl Syslem . Page 14 ot 18
5\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Mayer
Owner
information is
required for every
page.
Owner's Name
South Yarmouth
City/Town
NIa o2664 3t21t2024
State Zip Code Date of lnspection
D. System lnformation (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.):
lsinsp.d@. ev 7/2612014 Tftle 5 offcial Inspeclion F(m: Sub6urlae S@age Dispoelsystem. Page 15of 18
5}. Commonwealth of Massachusefts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Mayer
Owner's Name
South Yarmouth Ma 02664 312112024
City/Town State Zip Code Date of lnspection
D. System lnformation (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 ofthe boxes below:
hand-sketch in the area below
drawing attached separately
taitr
i.Ar\C-
Ik 9
()0 A( Lo''
R\ rY
AL 11
92- ls
A3 /o
83 ZY
)Ll
tsinsp.do.. rcv 72612018 Tide s OfEial lnspection Form:Subgudace Se{age DispoelSystem. Page 16 ol la
Owner
information is
required tor every
page.
t-l { l-
1]_., CommonwealthofMassachusetts
Title 5 Officia! lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Ma
Owner's Name
South Yarmouth
I
Owner
information is
required for every
page.
Ma 02664 3121t2024
City/Town State Zip Code Date of lnspection
D. System Information (cont.)
15. Site Exam:
E Check Slope
! Surface water
E Check cellar
E Shallow wells
Estimated depth to high ground water:feet
tr Obtained from system design plans on record
lf checked, date of design plan reviewed:Dale
tr ObseNed 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 USGS database - explain:
You must describe how you established the high ground water elevation
System fails inspection, groundwater elevation was not established.
Before filing this lnspection Report, please see Report Completeness Checklist on next page.
l5ircp dd. rev 7/26/2018 Tiil€ 5 Otrcial lnsp€lion Fom: Sub6urlace Saage Disposat System , Page 17 of 18
Please indicate all methods used to determine the high ground water elevation:
tr
5}. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Shallow Brook Rd
Property Address
Karen Pike & William Mayer
Owner
information is
required for every
page.
Owner's Name
South Yarmouth
City/Town
l\ila 02464 3t21t2024
Slate Zip Code Date of lnspection
E. Report Completeness Ghecklist
Complete all applicable sections of this form inclusive of:
X A. lnspector lnformation: Complete all fields in this section.
X B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
I C. lnspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
X D. System lnformation:
For 8: TighVHolding 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
tsinsp.de. €v 7/26/2018 -Iitle 5 Oflicial r.specrim F(m: slb6urhe Se*age Oispoet System . pago 18 c, t8