HomeMy WebLinkAboutInspection Report 2024 April 5A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurtace Sewage Disposal System Form - Not for Voluntary Assessments
55 Jefferson Ave
Property Address
Renaud Alissa R
O$rner
inrormafion is
required ior ewry
page.
Owne/s Name
West Yarmouth MA 02673 4t5t24
City/Town State Zip Code Date of lnspedaon
lnapection results mu3t be submitted on this fom. lnspection forms may not be altered in any
way. Please see completeness checklist at the end of the fom.
lfilfifrffiHl"" A. lnspector lnformation
Mathieu Rebelloon the computer,
use only the tab
key to move your
cursor - do not
use the .etum
key.
Name of lnspedor
Rebello Septic Service
Company Name
30 Norse Rd
Company Address
South Dennis MA 02660
City/Town
774-722-0271
State
st-'14140
zip Code
Telephone Number License Number
B. Certification
2. E Conditionally Passes RECEIVED
APR 10 2024
HEALTH DEPT.
3. n Needs Further Evaluation by the Local Approving Authority
a. D Fails
4t5124
lns s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. 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 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.
Ptease note: This report only dBcribes conditions at the time of inspection and under the
conditions of use at thaa time. This lnspection does not addrcss how tho system will perlorm
in tho future under the samo or different conditions of use.
Ilhsp.doc. rev. 72Gr2O1a Tr!€ 5 C'indd hsp6cdoo Form: sub.(fr* s€'..g6 orspos€l syslan'Pao€ 1 or 16
I certify that: I am a DEP approved By3tem inspector in full compliance with Soction 15.3t1,0 of Title 5
(310 CMR 15.000); I have personally inspected the sewage disposal system at the property address
listed above; the information reported betow is true, accurate and complete as of the time of my
inspection; and the inspection vyas 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. X Passes
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Jefferson Ave
Property Address
Renaud Alissa R
O,vner
information is
.6quired for every
page.City/Town State Zip Code Date of lnspedion
C.lnspection Summary
lnspeclion 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 310 CMR '15.304 exist. Any failure criteria 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 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 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 inspeclion 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 trN E ND (Explain below)
tsinsp.doc.,sv 726'2018 Tit6 5 Orrcial lmp€clion Fdm: Subsdacs Sg{rage Disposal Syst.6 ' Pag6 2 ol 18
Owne/s Name
West Yarmouth MA 02673 4t5t24
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Diaposal System Form - Not for Voluntary Assessments
55 Jefferson Ave
Property Address
Renaud Alissa R
Ol/ner
information is
requi.ed ior evory
page.
Owner's Name
West Yarmouth MA 02673
City/Town State Zip Code Date of lnspedion
! Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
n broken pipe(s) are replaced tr Y ! N ! ND (Explain below):
n obstruction is removed tr Y tr N E ND (Explain below):
tr distribution box is leveled or replaced f] Y tr N ! ND (Explain below):
! The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
n broken pipe(s) are replaced trY trN tr ND (Explain below):
n obstruction is removed tr Y n N I NO (Explain below):
3) Further Evaluation is Required by the Board of Health:
E Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determinea in accordance with 310 cMR
15.303(1Xb) that the system is not functioning in a manner which will protect public health,
safety and the envi.onment:
i5in9 doc . rsv 72612018 Ti{o 5 Ofidd lnsp6dion Fo.m: Sub$rts.s S€lr€ge or.po3al Sysl6m . Page 3 ol 18
C. lnspection Summary (cont.)
2) System Conditionally PasseE (cont.):
! Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
4t5124
5f. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fo]m - Not for Voluntary Assessments
55 Jefferson Ave
Property Address
Renaud Alissa R
Owner
informalion is
required for ev9ry
page.
Ownels Name
West Yarmouth
City/Town
l\ilA 02673 4t5124State Zip Code Date ot Inspedion
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 sall marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determineE that the system is tunctioning in a manner that protocE the public health,
satety and environment:
n 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.
I The system has a septic tank and SAS and the SAS is within a Zone 1 of 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 of the analysis must
be attached to this form.
4) System Failure Criteria Appllcable to All Systems:
You re! indica or "No" to each of the following for ql! inspections:
Yes
n
tr
No
x
x
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surf,ace waters
due to an overloaded or clogged SAS or cesspool
Tid€ 5 O6.id l.Ellocton Forlhr 9n'ltrfao6 S€'"aO€ OEp'6d Sv3lgn ' P4P 4 o' 1Et5inq &lc. rev 726/2016
n
c. Other:
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fo]m - Not for Voluntary Assessments
55 Jetferson Ave
Owner
information is
requir€d for every
page
Owneis Nam6
West Yarmouth MA 02673 415t24
City/Town State Zip Code Date ot lnspedion
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
nanx
trxnxnx
trx
ntrnx Any po(ion 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
systom passes if the well water analysb, performed at a DEP certified
Iaboratory, for fecal coliform bacteria indicates absent and the preaence
of ammonia nitrogen and nltrate 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 facllity with a design flow of 2000 gpd-
10,000 gpd.
The system h!!9. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Sy8tems: To be considered a large system the system muat 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
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 rVOf 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 ls 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
trtr
ntr
!tr
lsinsp de. rev 7/26/2018 l'lrle 5 Ofici.l lnsp€do.' Fom. Subsryra6 Sde€6 Oispo$at Syrlom. Ps!€ 5 ol18
Property Address
Renaud Alissa R
xtr
5s' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Jefferson Ave
Property Address
Renaud Alissa R
Ownefs Name
West Yarmouth
City/Town
MA 02673 4t5t24State Zip Code Oate of lnspedion
6
C. lnspection Summary (cont.)
lf you have answered'yes" to any question in Section C.5 the system is considered a significant
threat, oranswered'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/ inapections:
Yes No
X D Pumping information was provided by the owner, occupant, or Board of Health
tr tr Were any of the system components pumped out in the previous two weeks?
tr X Has the system received normal flows in the previous two week period?
T-.1 M Have large volumes ofwater been introduced to the system recently or as part of
this inspection?
|!,l T-] 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?
A tr Was the site inspected for signs of break ouP
X tr Were all system components, excluding the SAS, located on site?
tr n 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?
x tr Was the facility owner (and occupants if different hom owneo provided with
information on the proper maintenance of subsurfiace sewage disposal systems?
The size and locatlon 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) [310 CMR 15.302(5)l
tr tr
!x
tsinsp.doc. rov 726,2018 Iitb 5 Official losp€ction Fom: Sub3]jrt@ Sawa!6 o,3poel Syslom . Pa!€ 6 dr 18
Owner
information is
required for every
page.
5$. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Di6posal Syotem Form - Not for Voluntary Assessments
55 Jefferson Ave
Property Address
Renaud Alissa R
Owner
infgrmation is
required for every
page.City/Town
MA 02673 4t5t24
State Zip Code Date of lnspection
D. System lnformation
1. Residential Flow Conditions:
3Number of bedrooms (design)Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms)
Descripilon:
No plans on file with BOH
330
0Number of cunent residents:
Does residence have a garbage grinder?
Does residence have a water treatment unit?
lf yes, discharges to:
ls laundry on a separate sewage system? (lnclude laundry system inspection
rnformation in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd))
Detail:
E Yes El tto
E Yes El tto
E Yes EI t'to
n ves El tto
!vesXHo
Sump pump?
Last date of occupancy:
n Yes X tto
6 monlhs +
Date
rsinsp.doc. rcv 7262018 Titls 5 Otrd€l tup€cton Fo.m: S'rb$na6 S€{ra!€ Oispos€l Sy3l6m. PagF 7 of 18
Owne/s Name
West Yarmouth
A Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Jefferson Ave
Property Address
Renaud Alissa R
Owner
information is
required for every
page.
Owne/s Name
West Yarmouth MA 02673 4t5124
City/Town State Zip Code Date of lnspeclion
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)
EvesENo
! Yes ! tto
Evesn ruo
! ves 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:
reg. maint done last done about year ago
E ves E tto
gallons
r5iNp.6c ' r€v 72612018 1l!6 5 Otrod lfisp€dion Fom Subslrface S€lN€€€ Dkpo$l Syslem . Paga E or 1E
D. System lnformation (cont.)
2. Commerciaulndustrial FlowConditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/personYsq.ft., etc.):
A Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fo]m - Not for Voluntary Assessments
55 Jetferson Ave
Property Address
Renaud Alissa R
O,vner
information is
requited for evory
page.
Owner's Name
West Yarmouth MA uzotS 415t24
City/Town Stat6 Zip Code Date of lnspeclion
D. System lnformation (cont.)
4. Type of System:
A Septic tank, distribution box, soil absorption system
tr Single cesspool
tr Overflow cesspool
tl Privy
tr Shared system (yes or no) (if yes, attach previous inspection records, ifany)
D lnnovative/Alternative technology. Attach a copy of the cunent operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the l/A system by system operator under contract
tr Tight tank. Attach a copy of the DEP approval.
tr Other (describe):
Were sewage odors detected when arriving at the site?
5. Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
E cast iron X ao pvC E other (explain)
Distance from private water supply well or suction line:
! ves I t,to
24"
feet
N/A
feet
Comments (on condition ofjoints, venting, evidence of leakage, etc.)
ioints tiqht,proper venting, no evidence of leakaqe.
tsinsp &rc' r€v 72@018 Iid6 5 Ofrdal ln$€ct on Fom: SLbsrrac. Sar"ry Oispel Systm . Pag.9 ol18
Approximate age of all components, date installed (if known) and source of information:
1985
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Jefferson Ave
Property Address
Renaud Alissa R
Owner
information is
r€quired for every
page.
olrnels Name
West Yarmouth
City/Town
MA 02673 4t5t24
State Zip Code Date of Inspedion
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
X concrete E metal
18"
! fiberglass ! polyethylene E other (explain)
lf tank is metal, list age
ls age confirmed by a Certificate of Compliance? (attach ecopyof certificate) ! ves fl Ho
Dimensions:1000q
Sludge depth:1'
Distance from top of sludge to bottom of outlet tee or baffle 35"
Scum thickness 0"
Distance from top of scum to top of outlet tee or bame
Distance from bottom of scum to bottom of outlet tee or baffle 14"
How were dimensions determined?gulgq lrldge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic tank should be pumped at least once every 3 years for proper maint. Tee's in place. Liquid
level equal with outlet invert. No evidence of lea e
tSnsp.doc. rev. 71262018 Tit€ 5 Ofidal lnspgclion F(n: SubedE S€kag6 Oispos€l Systan . Pag€ 10 ol18
feet
years
8"
A Commonwealth of Massachusetts
subaudace Sewage Olsposal System Form - Not for Voluntary Assessments
55 Jefferson Ave
Property Address
Renaud Alissa R
Ofiler
inlomation is
rsquired for every
page.
Own6r's Name
West Yarmouth
City/Town
MA 02673 415124
State Zip Code Date of lnspedion
D. System lnformation (cont.)
7. Greaso Trap (locate on site plan):
Depth below grade:
Material of construction:
! concrete n metal
N/A
! fiberglass ! polyethylene E other (explain):
feet
N/ADimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Oistance from bottom of scum to bottom of outlet tee or bafffe
Date of last pumping:
N/A
N/A
N/A
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.):
N/A
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
N/A
N/A
Dimensions:
Capacity:
Design Flow:
N/A
N/A
gallons
N/A
gallons per d8y
Tils 5 Oitdsl ln podion Form: SuDoJrt c. Soyrage 0ispo6al Syn€m , psgo 1, of jBl5ine do.. rsv 726,2018
Title 5 Official lnspection Form
I fiberglass n polyethylene n other (exptain):
A Commonwealth of Massachusetts
Title 5 Officia! lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Jefferson Ave
Property Address
Renaud Alissa R
Orvner
information is
roquired ior every
p8ge.
Owner's Name
West Yarmouth 4t5t24
City/Town State Zip Code Date of lnspedlon
D. System lnformation (cont.)
8. Tight or Holding Tank (cont.)
Alarm present:
N/A
! Yes nno
I Yes E r,lo
Date
Comments (condition of alarm and float switches, etc.)
N/A
" Attach copy of cuffent pumping contract (required). ls copy attachedZ E yes E No
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.):
D-box is solid, level, with no evidence of carryover.
lsin3p..loc . rev. 7t262018 Tiile 5 Otrclar hrp.ction Form Suberhc6 S*ags Disrosst syst6m . pag3 12 of 18
MA 02673
Alarm level:
Date of last pumping:
Alarm in working order:
N/A
5s. Commonwealth of Massachusetts
Title 5 Official lnspection Form
SubEurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Jefferson Ave
Property Address
Renaud Alissa R
Owner
information is
required for every
pag€.
Owner's Name
West Yarmouth
City/Town
MA 02673 4t5t24
State Zip Code Date of lnspection
D. System lnformation (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order n Yes n ruo'
Alarms in working order: E Yes E t'lo'
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:
N/A
Type
tr
x
tr
n
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:
2-flowsdiffusers
w 3' stone
tr
lsinsp doc . rov. 726201 8
tr
ri& 5 Oficial lnlp.dtm Fom: Su&ud6c€ S€wag6 Oisposal Sysm. Pago 13 oa 18
5fl,. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Sub6u sce Sewage Oisposal Sy6tem Fo]m - Not for Voluntary Assessments
55 Jefferson Ave
Prop€rty Add.ess
Renaud Alissa R
O,vner
information i9
required tor every
page.
Owneis Nam€
West Yarmouth MA 02673 415124
City/Town State Zip Code Date of lnspecl{on
D. System lnformation 1cont.)
11. Soil Absorytion System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
no signs of hydrau[c I4lCLe, q S[pC]lqAg ?t boJtom ql SAS at time of inspection.
12. Ce6spool6 (cesspool mustbe 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 ! Yes f] tto
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp doc. .6v 7/26,2018 Tit€ 5 Oflicial lnsF.rion Form: Suhldaco S€wage Oispo!5t Systom . p6g€ 14 ot 1a
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurfacc Sewage Disposal System Form - Not for Voluntary Assessments
55 Jefferson Ave
Property Address
Renaud Alissa R
Omer
infomation is
required for every
page.
Owne/s Name
West Yarmouth
City/Town
MA 02673State zip Code Date of lnspedion
D. System lnformation (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
N/A
N/A
l5iftp .loc . Ev 726il2018 Tili.5 Oftctd h.p€ds Form: Sublrrfle S€llaq€ Oispolat St5lem . pac€ 15 or i6
4t5t24
5$' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Diaposal System Fo]m - Not for Voluntary Assessments
55 Jetferson Ave
Property Address
Renaud Alissa R
Owner
information is
requir€d for every
paoe.
Owne/s Name
West Yarmouth MA 02673 4t5124
City/Town State Zip Code Date of lnspedion
D. System lnformation (cont.)
14. Sketch Of Sewage Dbpoeal System:
Provide a view of the sewage disposal system, including taes 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
0rtvt 1
$^,,t y"td
A B
I
3
trI
4 I o B+"
rlY,t' t It,to'
3
i1-lt 1- 3Y
3- 3l,o' 3- tl t
o
o
tsinsp doc. rsv 72612018 Titro 5 Ofhcial lnsp€dion Fo.m Sub{rr6c€ S€'rag€ Oispo€al Systsm. pag616 ot 10
i:l EI
ss. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Jefferson Ave
Owner
information is
requirBd for ev€ry
page.
Owner's Name
West Yarmouth
Cityffown
MA 02673 415t24
State Zip Code Date of lnspedion
D. System lnformation (cont.)
15. Site Exam:
X Check Slope
X Surface water
X Check cellar
El Shaltow wells
Estimated depth to high ground water:5'+ seperation
feet
u
tr
Please indicate all methods used to determine the high ground water elevation
A Obtained from system design plans on record
2t21t85lf checked, date of design plan reviewed
X Observed site (abutting property/observation hole within 150 feet of SAS)
D Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You muEt describe how you established the high ground water elevation:
Hand augered 5'below SAS with no groundwater encountered. Septic system is designed per plan
giving proper seperation
Before fillng this lnspection Report, please see Report Complotene3s Checklist on next page.
6ln+ doc. ruv 7,?&2oia TiU6 5 Ofioill hspcrion Form: Subsldac. S€weg6 DlBpos€t Syslsm . pag. 17 o, 18
Property Address
Renaud Alissa R
Oate
5$' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewago Dispo8al System Form - Not for Voluntary Assessments
55 Jefferson Ave
Prop€rty Address
Renaud Alissa R
Owner
information is
required for every
p89e.
Orner's Name
West Yarmouth 02673 4t5124MA
City/Town State Zip Code Date of lnspedion
E. Report Completeness Checklist
Complete all applicable sectiom of this fom inclusive of:
X A. lnspector lnformation: Complete all fields in this section.
I B. Certification: Signed & Dated and 1 , 2, 3, or 4 checked
EI C. lnspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
X 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
l5'n5p doc . rev. 726/201 I Titl€ 5 Oridal lnsp€crioo Fonn: Subsudaca Ssvr6!€ Obpo6al SFlem. paq€ iE ot 1B