HomeMy WebLinkAboutInspection Report 2024 April 5A Commonwealth of MassachusetG
Title 5 Officia! lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Keel Cape Dr
Property Address
Desmond Thomas J
o1ivner
iniormation is
requir6d for every
page.
Owner's Name
South Yarmouth MA 02664 4t5t24
City/Town State Zip Code Oate of lnsp€ction
lnapection results must be submitted on this form. lnspection forms may not be altered in any
way. Ploase see completeness checklist at the end of the tom.
A. lnspector lnformation
Mathieu Rebello
lmportanL When
filling out foms
on the computer,
use only the tab
key to move your
cu6or - do not
use the retum
key.
Name of lnspedor
Rebello Septic Service
Company Name
30 Norse Rd
Company Address
South Dennis MA 02660
City/Town
77 4-722-0271
State
st-14140
Zip Code
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 inspection I have determined
that the system:
'1. I Passes
2. n Conditionally Passes RECEIVED
APR 10 2024
HEALTH DEPT.
3. E Needs Further Evaluation by the Local Approving Authority
4. n raits
r'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.
Please note: This report only d$cribes conditions at the time of inspection and under the
conditions of use at that time. This inspection doos not address how the system will perform
in the future under ths aame or different conditlons of use.
r5insp.,oc. rev 72612014 Tit6 5 Crllicid lnsp€dr.on Fqmr Sub$da.e S€*ag€ oispossrsysrm. PagB 1 of 16
"Effi
4t5t24
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Sub3urface Sewage Dbposal System Form - Not for Voluntary Assessments
21 Keel Cape Dr
Property Addresg
Desmond Thomas J
Owner
information is
requirgd ior ev€ry
page.
O/Yner's Name
South Yarmouth MA
City/Town
02664 415t24
State Zip Code Date oI Inspedion
C. Inspection Summary
lnspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6
1) System Pa$e8:
2) System conditionally Passes:
D One or more system components as described in the'Conditional Pass'section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for'yes', 'no' or'not determined" (Y, N, ND) for the following statements. lf'not
determined," please explain.
The septic tank is metal and over 20 years old'or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank fuilure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
' A metral septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
fl Y DN I ND (Explain belorv):
tsinsp doc. rov 7/26t2018 Tirle 5 Oficial lnsp€dion Form Subslrfaco Sasage Di3posarSysram. P.!€ 2 or 18
X I trave not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
5$' Commonwealth of Massachusetls
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2'l Keel Cape Dr
Property Address
Desmond Thomas J
Owner
information is
required for every
page.
Ov,/ner's Name
South Yarmouth MA 02664 415t24
City/Town State Zip Code Date of lnspection
C. lnspection Summary (cont.)
f] 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 inspectron if (with approval ot Board of Health):
n broken pipe(s) are replaced fl Y n N fl ND (Explain below):
tr obstruction is removed tr Y tr N D ND (Explain below):
n distribution box is leveled or replaced tr Y I N f] ND (Explain below):
n 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):
tr broken pipe(s) are replaced n V tr N n ND (Explain below):
tr obstruction is removed tr Y tr tl fl ND (Explain below):
3) Further Eyaluation is Requircd by the Board of Health:
I Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is lailing to protect public health, safety or the environment.
a. System will pass unleas Board of Health determines in accordance with 310 CMR
{5,303(lXb) that the system is not functionlng in a manner which wlll protect public health,
safety and the environment:
isicsp d@. r6v 7l26r2ola
Title 5 Official lnspection Form
2) System Conditionally Passes (cont.):
! pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpyalarms are repaired.
Ille 5 Oftcial ln8pet@ Fomr Subsuda@ S€*ag. Dispoel Systs . Page 3 of 18
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Sub6urface Sowage Dlsposal System Fo]m - Not for Voluntary Assessments
21 Keel Cape Dr
Prop€rty Address
Desmond Thomas J
Owner
inrormation is
required for every
page.
Oflne/s Name
South Yarmouth
City/Town
MA 02664 415124
State Zip Code Date of lnspedion
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 anyl
determines that the system is functioning in a manner that protects the public health,
safety 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.
D 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.
I 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.
c. Other:
tl) SFtem Failur€ Criteria Applicable to All Sy6tems:
You must indica or "No" to each of th6 following for al! inspectioN:
Yes No
T-] |v1 Backup of sewage into facility or system component due to overloaded ort'J r'r/ clogged SAS or cesspool
Tt |!,l Discharge or ponding of effluent to the surface of the ground or surfuce waters
due to an overloaded or clogged SAS or cesspool
tsin3p doc . r6v. 7/26,2018 -IiUe 5 Oii.iel l.sp.dion Fom: Subsufac€ Sewage ObposalSystem. Pag€ 4 ot l8
tr
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Property Address
Desmond Thomas J
Owfler
information is
required for every
page.
Owne/s Name
South Yarmouth MA 02664 415t24
City/Town State Zip Code Date of lnspedion
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
tratrxna
tra
nanxtratrtr 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. [fhis
system passes if the well water analysis, performed at a DEP ccrtified
laboratory, for fecal coliform bacteria indicates abaent and the presonco
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria arc 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 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 determine what will be
necessary to correct the failure.
5) Large Systems: To be consid€rcd a large system the system must aerve a facility with a
design floyv of 10,000 gpd to 15,000 gpd.
For large syslems, 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 weter supply
I 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
Tit€ 5 Off<nl ln.p€did Fo.m: Sub&dae S&!g€ Diipq*t Sy.t6m . pag6 5 ot 18
Static liquid level in the diskibution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" b€low invert or available volume is less
than % day flow
Required pumping more than 4 times in the last year AlOf 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 teet 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.
x
x
!
n
tr
t5insp doc . r6v 726t201a
tr
Subsurface Sewage Disposal Sy6tem Fo]m - Not for Voluntary Assessments
21 Keel Cape Dr
5s' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Sub8urtace Sewage Oisposal System Fom - Not for Voluntary Assessments
2'l Keel Cape Or
Property Address
Desmond Thomas J
Orner
inlormation i9
required for svsry
p89e.
Own6/s Name
South Yarmouth MA 02664 415t24
City/Town State Zip Code Date of lnspedion
b
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 al, 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?
A tr 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 of
this inspection?
M r-l Were as built plans of the system obtained and examined? (lf they were not
available note as N/A)
A tr Was the facility or dwelling inspected for signs of sewage back up?
X n Was the site inspected for signs of break out?
tr tr Were all system components, excluding the SAS, located on site?
A tr Were the septic tank manholes uncovered, opened, and the interior of the tenk
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
x n Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption Systom (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)]nx
l5nrp doc..ev 726/2018 Tido 5 Crfhoal ktsp6<rio. Form: SL66uda6 Sa ?g€ Disposd Systm . psg€ 6 ot 18
C. lnspection Summary (cont.)
x tr
5s, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subaurface Sewage Dlsposal System Fom - Not for Voluntary Assessments
21 Keel Cape Dr
Property Address
Desmond Thomas J
Owner
intomation is
requiGd for every
page.
Oungr's NamE
South Yarmouth
City/Town
MA 02664 4t5t24State Zip Code Date of lnspedion
D. System lnformation
1 . Residential Flow Conditions:
Number of bedrooms (design)N/A Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms)
Description:
No plans on file with BOH
4
440
Number 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:
1-2
EYesX wo
n ves X tlo
EYesB ruo
[] Yes I tto
EvesB No
Sump pump?
Last date of occupancy
n ves X tlo
current
Oate
l5inlp doc . rev. z2d201a Titl6 5 Otncial lnspedion Fom: Subsurf€c€ Serra!€ Oisposal System ' Pa!6 7 ol 1a
5s. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sowage Dlsposal System Form - Not for Voluntary Assessments
21 Keel Cape Dr
Owner
infomation is
required for every
page.
Owne/s Name
South Yarmouth MA 02664 415t24
City/Town State Zip Code Date of lnspedion
D. System lnformation (cont.)
2. Commerciaulndu3trialFlowConditions:
Type of Establishment:
Design flow (based on 310 CMR 1 5.203):
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:
Othor (describe below):
Gallons per day (gpd)
E Yes fl trto
n Yes E tto
Eves! Ho
E vesn No
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:
reg. maint done
EvesE No
gallons
lsinsp.doc ' rev. 72612018 Ti 6 5 Official lmp€clion Fom: Subsldac€ S€walE Dispos.l Syslam . Pa!€ I ol 18
Property Add.6ss
Desmond Thomas J
5fu. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Keel Ca Dr
Property Address
Desmond Thomas J
Owner
inlormation is
r3quired for every
page-
Owner's Name
South Yarmouth MA
City/Town State Zip Code Dat6 of lnspeclion
D. System lnformation (cont.)
4. Type o, System:
X Septic tank, distribution box, soil absorption system
n Single cesspool
! Overflow cesspool
! Privy
tr Shared system (yes or no) (if yes, attach previous inspection records, if any)
tr lnnovative/Altemative technology. Attach a copy ofthe curent 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 inslalled (if known) and source of information
House built 1982. Septic tank and leach pit believed to be installed in 1982. D-Box replaced 2020
IvesBNo
24"
feet
feet
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
, no evidence of leakage.ioints tight, proper ventino
Titl6 5 Ofiicial hpo.rion Fom: Sub8url&€ S€wag6 Oilpo$l Syst€m . Pag6 9 of 18
02664 4t5t24
Were sewage odors detected when aniving at the site?
5. Building Sewcr (locate on site plan):
Depth below grade:
Material of construction:
E cast iron X 40 PVC E other (explain):
Distance from private water supply well or suction line:N/A
lsinsp doc. reY 72612018
A Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Dlsposal System Form - Not for Voluntary Assessments
2'l Keel Cape Dr
Property Address
Desmond Thomas J
Owner
information is
required for every
page.
MA 02664 4t5t24
City/Town State Zip Code Date of lnspedaon
D. System lnformation (cont.)
6. Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
E concrete ! metal
t6
feet
lf tank is metal, list age:yearli
ls age confirmed by a Certificate of Compliance? (attach a copy of certificate) ! Yes ! No
Dimensions 1000q
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or batfle 35"
1"
Distance from top of scum to top of outlet tee or baffle o
Distance from bottom of scum to bottom of outlet tee or batfle 14"
How were dimensions determined?
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 kage.
lsinsp doc . r€v. 72€r'm18 Tlll€ 5 Official lnsp€drd Formr Subsudaca S*tsg€ OFpos€l Sy3l6,n . page 1O ot 1O
Ownefs Name
South Yarmouth
! fiberglass ! polyethylene E other (explain)
Scum thickness
sludqe iudqe
5fo' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Dispoaal System Form - Not for Voluntary Assessments
21 Keel Cape Dr
Property Address
Desmond Thomas J
Owner
information is
required for every
page.
Ownels Name
South Yarmouth MA 02664 4t5t24
City/Town State Zip Code Date of lnspeclion
D. System lnformation (cont.)
7. Grease Trap (locate on site plan)
Depth below grade:
Material of construction:
n concrete I metal
N/A
! fiberglass I polyethylene E other (explain):
feet
N/ADimensions
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping 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:
E concrete fl metal
N/A
N/A
fl fibergtass E polyethylene I other (explain)
Dimensions:
Capacity:
Design Flow:
N/A
N/A
gallons
N/A
gallons per day
TiU6 5 Officael l6p6clion Fo.m: SuDsurf# Sswage Oisposal Sy6i€m. Pags 11 ol18t5in+ doc . rev. 7/26/m18
A, Commonwealth of Massachusetts
Subsurface Sewage Disposal System Fo]m - Not for Voluntary Assessments
21 Keel Cape Dr
Property Address
Desmond Thomas J
Owner
information i6
required for sv€ry
page.
Owner's Name
South Yarmouth
City/Town
MA 02664 4t5t24
State Zip Code Date of lnspedion
D. System lnformation (cont.)
8. Tight or Holding Tank (cont.)
Alarm present:
Alarm level:
Date of last pumping:
N/A
EYes nNo
fiYes EHo
Date
Comments (condition of alarm and float switches, etc.):
N/A
* Aftach copy of current pumping contract (required). ls copy attached? E yes D tto
L 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.
lsinsp doc. r6v 72612018
Title 5 Official lnspection Form
Alarm in working order:
N/A
Tr0e 5 Omod hsp€crion Fo.n: subud@ saagE oispossl sysr€m' Pa!6 12 ot 1E
5s' Commonwealth of Massachusette
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Keel Cape Dr
Property Address
Desmond Thomas J
Owner
information is
required for every
page.
Owne/s Name
South Yarmouth
City/Town
MA 02664 4t5t24
State Zip Code Date of lnspedion
D. System lnformation (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: ! Ves I Ho"
Alarms in working order: D Yes E No-
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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
lf SAS not located, explain why:
N/A
Type
x
tr
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:
1€'x6'Wstone
rsinsp doc. rsv 726/2018 Tlle 5 Oftdd hsr€dion Fo.m: Subsudace S€vEg€ oispoei Sysl n.Pag€13ol18
5s' Gommonwealth of Massachusetts
Title 5 Official Inspection Form
Subeurface Sewage Dbposal System Fo]m - Not for Voluntary Assessments
21 Keel Cape Dr
Property Address
Desmond Thomas J
Owner
information is
required for every
page.
Ownefs Name
South Yarmouth MA 02664 4t5t24
State Zip Code Date of lnspeclionCity/Town
D. System lnformation (cont.)
11. Soil Abeorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetiation, etc.):
nosignsof hydraulic failure. 1' of ponding at bottom of SASattimeof 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 ! Yes Eruo
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
lsinsp.doc . r6v. 7/26/20'18 Titl6 5 Officirl lnspadion Formr Subsurfacs S€-ag6 DBposEt SFI€m , Pags 14 of l8
5$' Commonwealth of Massachusette
Title 5 Official Inspection Form
Subsurface Sewage Dieposal System Form - Not for Voluntary Assessments
21 Keel Cape Dr
P.operty Address
Desmond Thomas J
Owner
information is
required for overy
page.
Ownels Name
South Yarmouth MA 02664 4t5t24
City/Town Stat6 Zip Code Date of lnspedion
D. System lnformation (cont.)
13. Privy (locate on site plan):
Materials of construction:N/A
Dimensions N/A
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
tsinsp.doc ' rov 7/26/2018 T o 5 Ofrcial ln3p.clm Form: Suburfaco S6$q€ Orpo:al Syslom . Pag€ 15 ol la
5[, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Dbposal System Form - Not for Voluntary Assessments
21 Keel Cape Dr
Property Address
Desmond Thomas J
Owner
information is
requirsd for every
pa9e.
Owner's Name
South Yarmouth MA 02664 415t24
City/Town State Zip Code Date of lnspedion
D. System lnformation (cont.)
14. Sketch Of Sewage Disposal SyEtem:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
I hand-sketch in the area below
! drawing attached seperately
koLY^'J
0crL
Io
olAIoAl"
r- lr,(
I'30. t'
I
l- 20
't' 13'
3 -x('
\{' l'l .6
3 33
I q-q1.6
Y
l5in9 doc . .6v. 7,26.2018 Til€ 5 Otnciai lns,€dlol) Fom: Su!6'Jrfe S6.ag€ Oisposal Sysl6.n . Paso 16 or 18
I3
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurfece Sewage Diaposal System Form - Not for Voluntary Assessments
21 Keel Cape Dr
Property Address
Desmond Thomas J
Owner
information is
required fgr every
page.
Owne/s Name
South Yarmouth MA 02664 4t5t24
City/Town State Zip Code Oate of lnspection
D. System lnformation (cont.)
15. Slte Exam:
I Check Slope
X Surface water
X Check celler
I Shallow wells
Estimated depth to high ground water:5'+ seperation
feet
Please indicate all methods used to determine the high ground water elevation:
tr Obtained from system design plans on record
lf checked, date of design plan reviewed:Date
X Observed 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:tr
You must describe how you established the high ground water elevation
Hand augered 5' below SAS with no groundwater encountered
Before filing this lnspection Report, please see Report Completeness Checklbt on next page.
tsinsp &!c. rev 7/2612018 Tit€ 5 Otfdal ltupedion Formr Subsrftac€ S€!va!€ Dispossl Syslom . Pags 17 or 18
tr
A Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Sy3tem Form - Not for Voluntary Assessments
21 Keel Cape Dr
Property Address
Desmond Thomas J
O,vner
intormation b
required for every
page.
Owner's Name
South Yarmouth MA 02664 415124
City/Town State Date of lnspedion
E. Report Completeness Checklist
Complete all applicable sectione of thi3 form lnclu6ive of:
X A. lnspector lnformation: Complete all fields in this section.
I B. Certification: Signed & Dated and 1 , 2, 3, or 4 checked
El c. lnspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) 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
6insp doc . rcY 72612018 Trd€ 5 Ofi*l hspeclro.t Fonn: Sto6urfaca 5€'r.9B Oisposd SFr€rn . P6go 18 of 16
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