HomeMy WebLinkAboutInspection Report 2024 April 11fo' Commonweatth of Massachusetts
Title 5 Official lnspection Form
Owner
information is
required for every
page.
Subsurface Sewage Dispoaal System Form - Not for Voluntary Assessmenls
12 Brggzy Polnt
Property Address
Judd & Caroline Schneider
owneiJ Himi
South Yarmouth Ma 02664 4-'t-?4
City/Town State Zip Code Date of lnspection
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.
lmportant: \ ,/hen
flllang out forms
on the computer,
use only the tab
key to move your
cuasor - do not
use the return
key.
A. lnspector lnformation
Michael Sears
Name of lnspector
Robert B Our Co INC
Company Name
363 Whites Path
Company Address
South Yarmouth
APR 1 0 2024
H EALTH DEPT,
Ma 02664
Zip CodeCity/Town
508477-8877
State
st14430*.4
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); I have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspectton I have determined
that the system:
1. E Passes
2. E Conditionally Passes
3. E Needs Further Evaluation by the Local Approving Authority
a. I raits
%*-4-1-24
lnspector's Signature Date
-,-",a*$U!ti'{%
Sse j MICHAEL 1.?.n -z
===-
j SEARS :q=
7ts*i uo sr r++:o ,f-.=
a;:+N
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of compteting this inspection. lf the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office ofthe DEP. The original form should be sent to the system owner and copies sent to
the buyer, if appljcable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under theconditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
tsi.sp doc . rev 7/26/2018 Title 5 Otricial laspection Fom Subsurtace Sewage Oisposatsysr6m. page t oi18
5$' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Owner
information as
required for every
page.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Breezy Point
Property Address
Judd & Caroline Schneider
Owneis Name
South Yarmouth 4-1-24
State
Ma 02664
Zip cooe Date of lnspectionCity/Town
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 of the failure criteria described
in 310 CMR 15.303 or in 3'10 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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 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. 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 inflltration 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 ot
Compliance indicating that the tank is less than 20 years old is available.
trv trN E ND (Explain below)
l5nsp doc . r6v 7/26/2018 Title 5 Oficial lnspeclion Fom Subsudace Sewage Disposal Systern . Page 2 ol 1A
System is in working order at time of inspectlon
xfu. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Breezy Point.
Property Address
Judd & Caroline Schneider
Owner
information is
required for every
page
Owner's Name
South Yarmouth
City/Town
02664
Zip Code Date of lnspeclion
Ma.
State
4-1-24
C. lnspection Summary (cont.)
2) System Conditionally Passes (cont.):
E Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
E Observation of sewage backup or break out or high static waler 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 ! Y tr tl E ND (Explain below):
tr obstruction is removed E Y tr U n ND (Explain below):
tr distribution box is leveled or replaced tr Y ! 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 of the Board of Health):
n broken pipe(s) are replaced n Y tr X E ND (Explain betow):
tr obstruction is removed E Y ! N E ND (Exptain betow):
3) Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determtne 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:
15 nsp doc . rov 72612018 Tltle 5 OlfE6 inspoction Form Slbsudacg Sswag6 orsposat Synem . page 3 ot 18
A Commonwealth of Massachusetts
Title 5 Official Inspection Form
Owner
information is
required for every
page.
72 Breezy Point
Property Address
Judd & Caroline Schneider
Owner's Name
South Yarmouth Ma 02664 4-1-24
State Zjp Code Date of lnspection
G. lnspection 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:
E 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.
E 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.
n 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 wellt'.
Method used to determine distance:
c. Other:
4) System Failure Criteria Applicable to All Systems:
You rcl! indicate "Yes" or "No" to each of the following for 3l! inspections:
Yes No
T.] |',| Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Tt M Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
lsnsp doc ' rsv 7/26/2018 T 16 5 Ofiicisl l.speclion Fonn Subsudaco Sewage Disposal Systeh . Pase 4 or l a
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
n
*' This system passes if the well water analysis, performed at a DEP certtfied 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.
$' Commonweatth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 *eezy Point.
Prope.ty Address
Judd & Caroline Schneider
Owner
information is
required for every
page
l\ila 02664
Zip Code
4-1-24
City/Town State Date of lnspection
C. lnspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
trx
trx
!xnx
tra
tra
trx
!B 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. flhas
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered, A copy of the analysis
and chain of custody must be attached to this form.l
The system is a cesspool serving a facility with a design flow of2000 gpd-
10,000 gpd.
The system fails. I have determined that one or more ofthe 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, tn addition to the
questions in Section C.4.
Yes No
x
xn
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,VOf due to clogged or
obstructed pipe(s). Number of times pumped: _.
Any portion ofthe SAS, cesspool or pravy 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.
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
Tirt€ 5 Officiat tnspeclion Fom Subsudac6 Sewag€ DisposatSystem. page 5ot 1E
trtr
trD
trtr
l5nsp doc . rev 7/26/2018
Ownerb llarne
South Yarmouth
tr
Owner
information as
required for every
page.
1fu' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage oisposal System Form - Not for Voluntary Assessments
Z?geelv!q!!.
Property Address
Judd & Caroline Schneider
Ownefs flame
South Yarmouth
Cr ffown
Ma 02664 4-1-24
State Zip Code Date of lnspeclion
6
lf you have answered "yes" to any question in Section C.5 the system is considered a significant
threal, or answered "yes" to any question in Section C.4 above the large system has faaled. 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 offlce of the Department.
You must indicate "yes" or "no" for each of the following for a/ inspections:
Yes No
! X 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?
n X Has the system received normal flows in the previous two week period?
T-l M Have large volumes ofwater been introduced to the system recently or as part of
this inspection?
l',| n Were as built plans of the system obtained and examined? (lf they were not
available note as N/A)
X tr Was the facility or dwelling inspected for signs of sewage back up?
X tr Was the site inspected for signs of break out?
X ! Were all system components, excluding the SAS, located on site?
X tr Were the septic tank manholes uncovered, opened, and the anterior 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?
tr Was the facility owner (and occupants if different from owner) provided with
informatlon 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 field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [31 0 CMR 15.302(5)]
tr
xtr
t5 nsp doc..ev 7/262018 T lle 5 Off . a lnspection Formr Slbsurlace S6wage Orsposat Sysiem . Pege 6 of 16
C. lnspection Summary (cont.)
x
x
5fu' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Owner
information is
required for every
page.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Breezy Point.
Property Address
Judd & Caroline Schneider
Ma 02664
State Zip Code
4-1-24
Date of lnspection
D. System !nformation
1. Residential Flow Conditions:
2 2Number of bedrooms (design)Number of bedrooms (actual)
DESIGN flow based on 310 CMR '15.203 (for example: 110 gpd x # of bedrooms)
Description:
220
0Number of current 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:
EYesXNo
E Yes X tto
E ves X tto
!ves[ruo
fi ves ! tto
2022- 42000 gat
2023- 41000 gal
Sump pump?
Last date of occupancy
EYesE No
NA
Date
lsmsp d@. rev 7/2612018 Tnb 5 OficEl lnsp€cIion Form Subsrta@ Seag€ OisposatSystem, PagsT ot 18
Owner's Name
South Yarmouth
a"yr-' "*"
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Ueezy Point.
Property Address
Judd & Caroline Schneider
Owner
information is
required for every
page
Owner's Name
South Yarmouth Ma 02664 4-1-24
City/Town State Zip Code Date of lnspeclion
D. System !nformation (cont.)
2. Commercial/lndustrial Flow Conditions:
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)
nvesE ruo
!Yes! wo
nves!ruo
! ves ! 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:
NA
E ves X tto
gallons
l5nsp doc . rev.7/2612018 Tille 5 Ofiioai lnspeclon Fom: Subsurfacs Sewags DGposat Sysrern . page 8 of 18
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Breezy Point.
Property Address
Judd & Caroline Schneider
Owner
information is
required for every
page.
Owner's Name
South Yarmouth lil a 02664 4-1-24
City/Town Stale Zip Code Date of lnspection
D. System !nformation (cont.)
4. Type of System:
X Septic tank, distribution box, soil absorption system
! Single cesspool
tr Overflow cesspool
tr Privy
tr Shared system (yes or no) (ifyes, attach previous inspection records, if any)
tr lnnovative/Alternative technology. Aftach a copy of the 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 ofthe DEP approval.
tr Other (describe):
Were sewage odors detected when arriving at the site?
5. Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
n cast iron X 40 PVC ! other (exptain)
Distance from private water supply well or suction line:feet
Comments (on condition ofjoints, venting, evidence of leakage, etc.)
to
feet
tstrsp da. , Gv 2612018 Tiile 5 Ofiioartnspechon Folrn:Subsudace Sewago D6pos6lSystem. page 9 ot 18
Approximate age of all components, date installed (if known) and source of information:
9-3-09 # 09-167
E YesX ruo
5}' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Bteezy Poinl.
Property Address
Judd & Caroline Schneider
Owner
information is
required for every
page
Owner's Name
South Yarmouth t\,4a 02664 4-1-24
City/Town State zip Code Date of lnspeclion
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
I concrete E metal
'1500 gal tank
6',
! fiberglass ! polyethylene E other (explain)
feet
lf tank is metal, list age years
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or bame
Scum thrckness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
I
18"
Sludge judge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integraty,
liquid levels as related to outlet invert, evadence of leakage, etc.):
1500 gal tank with in tee and out tee in place, both covers are at grade
tSnsp doc ' r6v 7/262018 T e 5 Ofi,ciai l.speclion Fom Subsuda@ Sewage Osposat System . pago 10 or lB
ls age conflrmed by a Certificate of Compliance? (attach a copy of certificate) ! yes n ruo
1500
29',
0
8"
1},. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Oisposal System Form - Not for Voluntary Assessments
72 eezy Point.
Owner
information is
required for every
page.
Property Address
Judd & Caroline Schneider
Owneas Name
South Yarmouth
City/Town
Ma 02664 4-1-24
State Zip Code Date of lnspeclion
D. System lnformation (cont.)
7. Grease Trap (locate on site plan)
Depth below gradel
Material of construction:
E concrete E metal
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance ftom boftom 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 E metal E flberglass ! polyethylene ! other (explain)
Dimensions:
Capacity:
Design Flow
gallons
gallons per day
Tille 5 OlYicial lnspection Fom Subsrrface S€.{ags Dispost Sysrem . pag€ I 1 or j Blsinsp doc . rev 7/2612018
E fiberglass ! polyethylene E other (explain):
feet
5ft. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Breezy Poinl.
Property Address
Judd & Caroline Schneider
Owner
informatlon is
required for every
page
Owner's Name
South Yarmouth lvla 02664 4-1-24
City/Town State Zip Code Date of lnspection
D. System lnformation (cont.)
8. Tight or Holding Tank (cont.)
Alarm present:
Alarm level:
Date of last pumping:
E Yes Eruo
Alarm in working order:! Yes !ruo
Date
Comments (condition of alarm and float switches, etc. )
* Attach copy of current pumping contract (required). ls copy attached? ! Yes E ruo
9. Distribution Box (if present must be opened) (locate on site plan)
0Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of so ds carryover, any
evidence of leakage into or out of box, etc.).
D Box is 20x20 with 4 outlet lines, cover is 6" below grade
tsinsp d@.rev 7/262016 Tilis 5 Ofirc61 lnsp€.llon Fom: Subsudace Sewage Oisposai Syslem . page 12 ot 18
1fu' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Property Address
Judd & Caroline Schneider
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Po int.
Owner
information is
requared for every
page.
Owner's Name
South Yarmouth t\4a 02664
Zip Code
4-1-24
City/Town State Date of lnspectlon
D. System lnformation (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: X Yes E tlo.
Alarms in working order: X Yes E No'
Comments (note condition of pump chamber, condjtion of pumps and appurtenances, etc.):
Pump chambeer is in working order with steel cover at grade
- 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:
Type
tr
tr
tr
tr
x
!
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:
15'x20'
tslnsp d@. rev 7/26/2018 Title 5 Olliciar tnspection Fom Subsudace S6wa9e Dispos€t System . page 1 3 ot 1 8
7? ]te9?:t
5$' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Brcezy Poinl.
Property Address
Judd & Caroline Schneider
Ownels Name
South Yarmouth
City/Town
02664
Zip Code
D. System lnformation (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is 15'x20'field with stone, lines 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 liqurd to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
lndication of groundwaler inflow E Yes Ewo
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
lsmsD doc . rev 7/262018 Trlle 5 Offlciallnspecton Fom Slbsudace Sewage Dsposatsysrem, page j4 ot lB
Owner
informataon is
required for every
page
lvla.
State
4-1-24
Dale ol lnspection
4' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Weezy Point.
Property Address
Judd & Caroline Schneider
Owner
information is
required for every
page.
Owneis Name
South Yarmouth lvla 02664 4-1-24
City/Town State Zip Code Date of lnspection
D. System lnformation
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of pondang, condition of vegetation,
etc.):
lsnsr d@. r6v 7/251/201a Tdle 5 oif,c€l tnspedion Fom subsldac€ saag€ oispoetsysto. page 15ot 18
Owner
information is
requared for every
page.
5fu. Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l? Breezl Pglnl!.
Property Address
JJdd & Caroline Schneider
t\4a 02664
7ip code
4-1-24
ciiynown State Date of lnspection
D. System lnformation (cont.)
14. Sketch Of Sewage Disposal System:
Provide a vlew 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:
hand-sketch in the area below
drawing attached separately
Ownefs Name
South Yarmouth
xI
,I
t
Ta
n
c0
tsnsa doc . t6\ 7D6t2A1a lille 5 Officiel lnspectrcn Form. Subsurfa@ S*age Dsposatsysrem . page 16 or 18
Title 5 Official lnspection Form
At rs.o
$r 16.$
la eo'qBtioS
l s r,9.L
8J lo.t
R$ St.a
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1}' Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Breezy Point.
Property Address
Judd & Caroline Schneider
Owner
information is
required for every
page-
Owneis Name
South Yarmouth 02664 4-1-24
City/Town Zip Code Date of lnspeclion
D. System lnformation (cont.)
'15. Site Exam:
X check Slope
X Surface water
X Check cellar
X Shallow wells
Estimated depth to high ground water:6',
feet
Please indicate all methods used to determine the high ground water elevation
X Obtained from system design plans on record
3-18-09
Date
n Observed site (abutting property/observation hole within 150 feet of SAS)
tr Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
n
tr
You must describe how you established the high ground water elevation
SAS is a raised field
Before filing this lnspection Repon, please see Report completeness checklist on next page.
t5msp doc . r€v 7/262018 Tirl€ s Otrioatlnspect on Fom Subsurfa@ Sowago Disposatsysrem. pag6 j7 otjS
Ivla.
State
lf checked, date of design plan reviewed:
A' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Breezy Poinl.
Property Address
Judd & Caroline Schneider
Owner
information is
required for every
page.
Ownels Name
South Yarmouth lvla 02664 4-1-24
C jty/Town 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 section.
X B. Certification: Signed & Dated and 1,2, 3, or4 checked
X C. lnspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Crateria) and 6 (Checklist) completed
I D. System lnformation:
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
Is'nsD doc. rev 7/26/2018 T'll€ 5 Oflcial lnsp6ction Fom SLrbsudace Sowsge Oisposar Sysiem . pao6 16 oi t B