HomeMy WebLinkAboutInspection Report 2024 Mar 20A Commonweatth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fo]m - Not for Voluntary Assessments
4 Barnes Ln
Prop€rty Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 114 Waterville Valley, NH 03215
OrYner
information is
required for every
page.
Owner's Name
West Yarmouth MA 02673
City/Town State Zip Ccde Date of lnspedion
lnspection rosults must be aubmifted on this fom. lnspection fo.ms may not be altered ln any
way, Ploase see completeness checklist at the end of the form.
A. lnspector lnformationlmportant: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - 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 4-722-027 1
State
sl-14140
Telephone Number Lic€nse Number
B. Certification
I certify that: lam 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. X Passes
2. ! Conditionally Passes
3. ! Needs Further Evaluation by the Local Approving Authority
a. n rais
RECElVED
APR 10 2024
HEALTH DEPT,4*/3t20t24
lnspector'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 describos condltions at the time of inspection and under the
conditions of use at that time. This inspoction does not address how the system will porform
in the future under the same or different condftlona of u6e.
l5i6sp cloc. lsv 72612018 Titl€ 5 Oficial hsp€.lon Form Subsurfe S€wag€ Dirposal Sy.lsm . Ps!€ 1 or 16
3t20t24
Mathieu Rebello
ffi Zip Code
A Commonwealth of Massachusetts
Subsurface Sewage Disposal Systom Form - Not for Voluntary Assessments
4 Barnes Ln
Property Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 1 14 Waterville Valley, NH 03215
City/Town
MA 02673 3t20t24
State zip Code Date of lnspection
C. Inspection Summary
lnspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6
1) System Passes:
I 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:
! 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 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.
nY trN E ND (Explain below):
lsinsp doc . r€v 72ry2018 Tirl6 5 Oiicial lmp€€1ion Form: Subsuda.s S€w.96 Oisposar Systom ' Pags 2 of 18
Title 5 Official lnspection Form
Owner
infomation is
required for every
page.
olflner's Name
West Yarmouth
A Commonwealth of iiassachusetts
Title 5 Official lnspection Form
Subsurface S€wage Olsposal System Fo.m - Not for Voluntary Assessments
4 Barnes Ln
Property Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 1 14 Waterville Val ley, NH 03215
Olrn6r
information is
required for every
page.
Ownel,s Name
West Yarmouth MA 02673
City/Town State Zip Code Date of lnspedion
G. !nspection 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 water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, seftled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
n broken pipe(s) are replaced n Y ! N n ND (Explain below):
tr obstruction is removed tr y fl tl D ND (Explain below):
tr 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 (wlth approval of the Board of Health):
tr broken pipe(s) are replaced trY trN n ND (Explain below)
n obstruction is removed trY nN n 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 systom is not functioning in a manner which will protect public health,
safoty and tho environment:
tsinsp &rc. rev Z261118 Tiu€ 5 Official lmp€clion Fom: Subsuda.€ S€sag€ oispGal Sysl6B . Pege 3 or 18
3nu24
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntery Assessments
4 Barnes Ln
Propsrty Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 1 14 Waterville Valley, NH 03215
O,vner
information is
r€quirgd for every
page.
Owne/s Name
West Yarmouth MA 02673 3t20t24
City/Town 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 Hoalth (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects th6 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 ol 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.
! The system has a septic tank and SAS and the SAS is less than 1OO 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:
4) System Failure Criteria Applicable to All Systems:
You rel! indicate "Yes" or'No" to 6ach of the following for all inspectiom:
Yes No
n EI Backup. o_f sewage into iacality or system component due to overloaded or! clogged SAS or cesspoolir x ?JTr:T""J"n:x'#;l;flffs'Si5"?*Xrrsrhesroundorsurfacewaters
t5mp.doc. rBv. 72612018 Tit€ 5 Olti.tl h.poclion Fo.m: SLbs!.ia Sar,ag€ Olpocd Synrtr. Pa€.4 ot 18
n
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subcurface Sewage Dlsposal Systom Form - Not for Voluntary Assessments
4 Barnes Ln
Property Add.ess
Tsoukalas Petros C/O Stephan ie Erb-PO Box 114 Waterville Valley, NH 03215
O^rner
information is
requi.ed for every
page.
Owne/s Name
West Yarmouth MA 02673 3t20t24
City/Town State Zip Code Date oI lnspedion
C. !nspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
nxnx
trx
trx
ntrnx
trx
DA 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. fihie
system passes if the well water analysis, performed at a DEP certilied
laboratory, for fecal colifom bactoria indicates absent and the preaence
of ammonia nitrogen and nitrate nitrogon is equal to or less than 5 ppm,
provided that no other failure critcria ar€ triggored. A copy of the analyris
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 systom 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 consldered 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
n tr the system is within 400 feet of a surface drinking water supply
tr
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 ofthe 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.
x
x
tr
tr
tr
lstnsp d6. r.v 712612018
!
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
Titb 5 Otf.i.l |rEp.do6 Fdm Suba,tE S€!aO. Diipo.al Sy3lem . Pe!.5 ol 18
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Barnes Ln
Property Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 114 Waterville Valley, NH 03215
MA 02673 3120t24
City/Town State Zip Code Date of lnspedion
6
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 afl inspections:
Yes No
X n Pumping information was provided by the owner, occupant, or Board of Health
n X Were any of the system components pumped oul in the previous two weeks?
tr B Has the system received normal flows in the previous two week period?
rt M Have large volumes of water been introduced to the system recently or as part oft-J this inspection?
M Tt Were as built plans of the system obtained and examined? (lf they were not
available note as N/A)
X ! Was the facility or dwelling inspected for signs of sewage back up?
X tr Was the site inspected for signs of break out?
X tr Were all system components, excluding the SAS, located on site?
X 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
x tr
trX
tsinsp.d,cc ' rev. 226,2018 TiU€ 5 Oliclal lnspscliorFon : Subsudaco Sef,,ag€ Dispo6al Systsm. Pag66 of 18
Owner
infomation is
requirgd for every
page.
Owne/s Name
West Yarmouth
C. lnspection Summary (cont.)
tr Was the facility owner (and occupants if different from owneo provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the 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
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Barnes Ln
Property Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 114 Waterville Valley, NH 03215
ol,vner
information is
required for every
page.
Ownea's Name
West Yarmouth MA 02673
City/Town State Zip Code Date of lnspedion
D. System lnformation
1 . Residential Flow Conditions:
Number of bedrooms (design)Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms)
Description:
3
330
0Number of cunent residents:
Ooes residence have a garbage grinder?
Does residence have a water treatment unil?
E ves I tto
IvesX No
Sump pump?
Last date of occupancy
n ves E t,to
vacant for few
months
15in6p.doc . rcv 72612018 Titl€ 5 Oficial lftpoclion Form: Sub&rdac€ S6wrg6 Oisposal Sy8t€m , Peg6 7 or 1E
3t20n4
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:
IvesI No
E ves E tto
nyesBNo
5s' Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Barnes Ln
Property Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 114 Wateryille Valley, NH 03215
Owner
infomation is
required for every
page.
Owne/s Name
West Yarmouth MA 02673 3t20124
City/Town State Zip Code Oate of lnspedion
D. System lnformation (cont.)
2. Commercial/lndustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/pe6ons/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)
n ves fl tto
E vesn No
nYesn ruo
EYes! ruo
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
n Yes fl tto
gallons
l5in p.doc . rev. 7/26/201 8 Iiil€ 5 Oiidal lnspe€tion Fonnr Subsuface SsMgE Dispos€lSystem. Page 8 of 18
5$. Commonwealth of Massachueetts
Title 5 Official lnspection Form
Subsurface Sewage Dispo8al Sy3tem Form - Not for Voluntary Assessments
4 Barnes Ln
Property Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 1'14 Waterville Valley, NH 03215
Otr?ner
information is
requied for every
page.
Owner's Name
West Yarmouth MA 02673 3t20t24
State Zip Code Date of lnspec{ion
D. System lnformation (cont.)
4. Typo of System:
A Septic tiank, distribution box, soil absorption system
! Single cesspool
tr Overflow cesspool
il Privy
tr
tr
n
Shared system (yes or no) (if yes, attach previous inspection records, if any)
lnnovative/Altemative technology. Attach 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
Tight tank. Attach a copy of the DEP approval.
Other (describe):
Approximate age of all components, date installed (if known) and source of information
Septic tank, SAS 1981 D-Box replaced 2/24
Were sewage odors detected wlren arriving at the site?
5. Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
fl cast iron I 40 PVc E other (explain)
Distance from private water supply well or suction line:
E Yes B tto
18"
feet
N/A
feet
Comments (on condition of joints, venting, evidence of leakage, etc.)
lsinsp doc ' rev 7/26/2018
oints ti venti
Till6 5 Ofrdal lnsp€ciiorl Fomr Sub3uftco S€wa€E Oispo8al Sy.t6m. Peg€ 9 of 18
no evidence of I
City/Town
5s' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Dbposal System Fom - Not for Voluntary Assessments
4 Barnes Ln
Property Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 114 Waterville Valley, NH 03215
Owner
information b
required for every
page.
Owner's Name
West Yarmouth MA 02673 3t20t24
City/Town State Zip Code Oate of lnspedion
D. System lnformation 1cont.;
6. Septlc Tank (locate on site plan):
Depth below grade:
Material of construction:
X concrete ! metal
12"
! fiberglass ! polyethylene I other (explain)
feet
lf tank is metal, list age years
ls age confirmed bya Certificate of Compliance? (attach acopyof certificate) ! yes ! ruo
Dimensions:
Sludge depth:
Distance from top of sludge to bottom 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
How were dimensions determined?
10009
35"
8"
4"
1'
'14"
sludgejudge
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 leakage.
lsinsp.doc. rev 712612018 Titl€ 5 Omciallnsp€cton Fom: Subsudac€ Scr,aq€ Oispos€l Syst€rn. P69o 10 of 18
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subaurface Sewage Disposal Sptom Form - Not for Voluntary Assessments
4 Earnes Ln
Property Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 114 Waterville Valley, NH 03215
O,vnea
iniomation is
r€quired for every
p4,e.
Owne/s Name
West Yarmouth MA 02673 3t201?4
City/Town State Zip Code Date of lnspeclion
D. System lnformation (cont.)
7. Groase Trap (locate on site plan):
Depth below grade:
Material of construction:
E concrete E metal
N/A
! fiberglass fl 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:
N/A
N/A
N/A
N/A
N/A
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 n metal
N/A
N/A
[ fiberglass E polyethylene E other (explain)
N/A
N/A
gallons
N/A
gallonE per day
Tile 5 Oficial lrsp€ctjon Form: Subsurf6c6 S€waOs Oispo8at Syllam . Pa0€ l1 ot 18l5insp doc ' rav 7/26/2018
Date
Dimensions:
Capacity:
Design Flow:
5$' Commonwealth of Maesachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Barnes Ln
Property Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 1 14 Waterville Valley, NH 03215
O\xnet
intormation is
rBquired ior 6v€ry
page.
Owner's Name
West Yarmouth MA 02673
City/Town State Zip Code Oate ol lnspedion
D. System lnformation (cont.)
8. Tight or Holding Tank (cont.)
Alarm present:
N/A
E Yes E tto
Alarm in working order:
N/A
BYes EHo
Date
Comments (condition of alarm and float switches, etc.)
N/A
* Aftach copy of cuffent pumping contract (required). ls copy attachedZ 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.):
D-box is solid, level, with no evidence of carryover
r5i6sp c,o. ' rcv 7262018 Titl6 5 Ofrod hsp€dion Form: Subssrta.€ S€wago DBpossr Sysrm . Psg€ 12 ol lS
3t20t24
Alarm level:
Date of last pumping:
5$' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Owner
infomalion is
required for every
page.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Barnes Ln
Propgrty Address
Tsoukalas Petros C/O Stephanie Erb-PO 9ox :l 14 W!lel!!!!el{Cllej- !H ql?1q
Owneis Name
West Yarmouth 02673 3t20t24
City/Town State Zip Code Date of lnspeclion
D. System lnformation (cont.)
10. Pump chamber (locate on site plan):
Pumps in working order: I Yes E No'
Alarms in working order: ! Yes E No-
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* lf pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
lf SAS not located, explain why:
N/A
Type:
tr
tr
!
tr
tr
n
tr
leaching pits
leaching chambers
leaching galleries
leaching trenches
leaching fields
overflow cesspool
innovativeialternative system
Type/name of technology:
number
number:
number:
number, length:
number, dimensions
number:
2-flows W3'
stone
tsinsp.doc. r6v 726201 I Tille 5 Omdal lnsp€dion Form: Suburfac€ S€r€g€ Oisposai System. Pas€ 13 ol18
MA
5$. Commonwealth of Massachusette
Title 5 Officia! lnspection Form
Property Address
Tsoukalas Petros C/O Step hanie Erb-PO Box 114 Waterville Valley, NH 03215
Owne/s Name
West Yarmouth
City/Town
MA 02673 3t20t24
State Zip Code Date of lnspedion
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.):
no signs of hyd raulic failure. 0" of ponding at bottom of SAS at time of 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 E Yes n lto
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
tsinsp.do. . r€v. 726201 I Tiilo 5 Ofiici€l lnsp€clion Fom: Subsurta.€ Soyrags OisposalSysl6m. Pag€ 14 ol 18
Subsurface Sewage Dlsposal System Fo]m - Not for Voluntary Assessments
4 Barnes Ln
Owner
information is
requirgd for evgry
page.
5fu, Commonwealth of Massachusette
Title 5 Official lnspection Form
Subeurface Sewage Disposal System Form - Not for Voluntary Assessments
4 Barnes Ln
Property Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 114 Waterville Valley, NH 03215
Orvnet
information is
required ior every
page.
Owne/s Name
West Yarmouth MA 02673 3t20t24
City/Town
D. System lnformation (cont.)
13. Privy (locete on site plan)
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
lsinsp doc ' rov 726201 I Tit6 5 Ofiicial lhsp.crion Form: Suburfac€ S6wage oispossr Sy6rsm ' Pago 1s dr 1a
State Zip Cod6 Dats of lnsp€clion
Materials of construction:
5$' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Dlsposal System Form - Not for Voluntary Assessments
4 Barnes Ln
Property Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 114 Waterville Valley, NH 03215O ner
information is
required for every
pa9e.
Ownefs Name
West Yarmouth MA 02673 3t20t24
City/Town State Zip CodE Date of lnspeclion
D. System lnformation (cont.)
14. Sketch Of Sewage Disposal Sy3tem:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells vvithin 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
X hand-sketch in the area belowI drawing attached separately
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A I
4,
tr e,.rl 3
*+"
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3-36
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ts'nsp.doc. r6v. 724m18 Tit 5 Ori.ial lrcpoction Fom: Subrudacs S6vag6 Dispo3ar Syst€m . Pago 16 of 1 I
I
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Property Address
Tsoukalas Petros C/O Stephanie Erb-PO Box 1 14 Waterville Valley, NH 03215
Oarn6r
information is
required for every
page.
Ownels Name
West Yarmouth MA 02673 3t20t24
City/Town State Zip Code Date of lnspedion
D. System lnformation 1cont.)
15. Sito Exam:
X cnecr Stope
E] Surface water
B Cneck cetlar
Xl Shallow wells
Estimated depth to high ground water:5'+ seperation
tr
n
Please indicate all methods used to determine the high ground water elevation
X Obtained from system design plans on re@rd
419t81
Date
tr Observed site (abutting property/observation hole within 150 feet of SAS)
n 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:
Septic system is designed per plan giving proper seperation from bottom of SAS to ground water
Hand augered 5' below SAS with no GW encountered
Before fillng this lnspection Report, please see Report Completeness Checklist on next page.
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Subsurface Sewago Disposal System Form - Not for Voluntary Assessments
4 Barnes Ln
feet
lf checked, date of design plan reviewed:
gfu' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal Syotem Form - Not for Voluntary Assessments
4 Barnes Ln
Property Address
Tsoukalas Petros C/O Steph anie Erb-PO Box 114 Waterville Valley, NH 03215
Of,ner
information is
required for evory
page.
Owne/s Name
West Yarmouth MA uzotS 3t20t24
City/Town State Zip Cod€Date of lnspedion
E. Report Gompleteness Checklist
Complete all applicable sections of thb form inclusive ofl
I A. lnspector lnformation: Complete all fields in this section.
I a. 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: 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
lsinsp do. ' 6v 71262018 rr& 5 Offcial hsp€ctjo. Form Subsu.taca Se*aoe Djlpos€tSy8tsm. PaO€ 18or tE