HomeMy WebLinkAboutInspection Report 2024 April 15s-\commonwealth of Massachusetts RECEIVED
Title 5 Official lnspection Form ^??
?'t20?4
Subsurface Sewage Disposal System Form - Not for Votuntary AssessmflEALT H DEPT.
54 Stiation Avenue, South Yarmouth, MA 02660
Property Address
Robert P Kennedy & Noelle M Slavin
Owner
intormation is
raquirad Ior every
page.
Owne/s Name
South Yermoulh MA 02664 04t15t2024
City/Tgwrl Slate Zip Code Date of lnspection
Inspection reeults must be submittEd on this form, lnspection forms may not be altered in anyway. Please ses completeneas checklist at the end ot the form-
A. lnspector lnformation
Reid C. Ellis
lmportant When
filling out forms
on the corrputer,
use only the tab
key to move your
qjrsor - do not
use the retum
key.
Name of lnspedor
Ellis Brothers Const. Co
Company Name
23 Enterprises Road, P. O. Box 59
Company Address
Yarmouth Pod MA 02675
,"*/1 City/To$/n
508-362€237
Slete
st2189
Zip Code
Telephone Number License Nurnbe,
B, Certification
I certify that: I am a DEP approved system inepector in full compliancs with Sectlon 15.3110 of Tifle s(310 cMR 15.000); I have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurale and complete as of the time of myinspection; and the inspection was performed based on my training and experience in the prop'er function
and maintenance of on-site sewage disposal systems. After conducting this inspection I hive determined
that the tystem:
1. EJ Passes
2. ! Conditionally Passes
3. n Needs Further Evaluation by the LocalApproving Authority
4. ! Fails
4
Signature Date
The system inspeclor shal, submit a copy of th;s inspection repod to the A wrcving Authority (Boad
of Health or DEP) within 30 days of mmpleting this inspection. lf the system has Jdesign flow of
10,000 gpd or greater, the inspector and the system owner shall submlt the report to th; appropriate
regional ofrice of the DEP. The original form should be sent to the system ouner and copiei sent to
the buyer, if applicable, and the approving authority.
Please note: This roport only doscribes conditions at tho time of inspection and under theconditions of use at that time. This inspection doog not addrcss how the system will perform
in the future under the same or different conditions of uee.
15insp doc ' rev 71262018 Tilh S Oin.i6l ln.{Ec!d Fm-_' &bsrdaca S.89. OispG€l Sylr.rl. p.9. 1 ot 16
Sr-\Commonwealth of Massachusetts
Property Address
Title 5 Official lnspection Form
Subgurrace Sewage Dispoeal System F-orm _ Not for Voluntary Assessments
Owlrer
information is
required for every
page.
Owne/s Name
City/Town
MA 02664 04t15t2024Slate Zip Code Date oI lnspectionc.rnspection Summary
'l) System Pa6ses:h
I have not fou
in 310 CMR l5.30
indicated below.
Comments:
2) System Conditionally passes:
D One or more system components as des in the "Conditional pass'section need to bepletion of the replacement or repair, as approved by
(Y, N, ND) for the following statements. lf .not
' A metal septic tank will pass inspection ifCompliance rndicating that the tank is less
iti structurally sound, not leaking and if a Certificate of20 years old ls available
! ND (Exptain low)
ny information which indicates that any of the failure criteria described3 or in 310 CMR 15.304 exist. Any failure criteri" notirrir"tJirJ
replacod or repaired. The system, upon
the Board of Health, wilt pass.
Check the box for'yes', "no, or "not determidetermined," please explain.
The septic tank is melal and over 20 years old or the s€ptic tank (whether metial or not) is structurallyunsound, exhibits substantial anfiltration or tion or tank failure is imminent.System will passinspection if the existing tank is replaced with complying septic tank as approved by the Board ofHealth
Dv Eru
15in$,doc.my 7€512018 Id.5 OitciC tn p.cjo Fo6: Sub6l.f e S:Ma. Oi.posa Sysi.m . p.g. 2 ot 1a
lnspeclion Summary: Complete 1, 2, 3, or S and all of 4 and 6.
!L\Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Propeny Address
Robert P Kennedy & Noelle M Slavin
Owrer
informalion is
requiled for every
page.
Ownels Name
South Yarmouth MA 02664 04t15t2024
City/Town State Zip Code Date of lnspection
C. lnspection Summary (cont.)
2) System Conditionally Pass6 (cont.):
E pump Chamber pumps/alarms not ope
pumps/alarms are repaired.
,"(4"will pass with Board of Health approval if
E Observation of sewage backup or break out high static water level in the diskibution box due
to broken or obstruc{ed pipe(s) or due to a n, settled or uneven distribution box. System will
pass inspection if (with approval of Board of
n broken pipe(s) are replaced
n obstruction is removed
n distribution box is leveled or
E The system required pumping more than 4
system will pass inspection if (with approval
n broken pipe(s) are roplaced
es a year due to broken or obstructed pipe(s). The
the Board of Health):
n Y fl N n No (Explain below):
alth)
nv
nY
trv
trtl
XN
trN
E ND (Explain below):
E ND (Explain below):
n ND (Explain below):
D obstruction is removed IY trN tr ND (Explain below)
3) Further Evaluation is Requit€d by the Boa Health:
E Conditions exist which require further eval by the Board of Health in order to determine if
the system is failing to protect public hea safety or the environment.
Ith determines in accordance with 310 CMRa. Systam will pa6s unless Boatd of
15.303(1Xb) that the system ls not fu
eafety and the environment:
ning ln a manner which wlll protect public hoalth,
t5in9.doc. rcv.726/2018 'rile 5 ltlrp.nion Forin: Subsurfac. Scr€g€ OiBpGd Syslefr . Pr96 3 ol 18
5fu' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Oisposal System Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Property Address
Robert P Kennedy & Noelle M Slavin
Ov,ner
infomation is
required for every
page.
Olnels Name
South Yarmouth
Cily/Town
MA 02664 04t15D024
State Zip Code Date oi lnspeclion
C. lnspection Summary (cont.
D Cesspool or privy is within
D Cesspool or privy is within 50 of a bordering vegetated wetland or a salt marsh
'uM*n"n*no
b. Syst€m will fail unleBstho Board
dstsrmines that thoGystem is functi
satoty and onvlronment:
! The system has a septic lank and so absorption system (SAS) and the SAS is within
100 feet of a surface water supply or to a surface water supplyfl The system has a septic tank and
supply.
n The system has a septic tank and
supply well.
n The system has a septic tank and
and the SAS is within a Zone 1 of a public water
and the SAS is within 50 feet of a private water
Health (and Public Water Supplier, if any)
ing in a manner that protacts the public health,
and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*'
Method used to determine dislance:
'* This system passes if the well water ana is, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the p nce of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other
be attached to this form?
lure criteria are triggered. A copy of the analysis must
c. Other:
Yes
tr
n {
Backup of sewage into facility or system component due to ovedoaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc. rev. 726/2018 T {e 5 Ofi .id lnipedion Fom: Slbsudace S€*ag! Dispos.l SysD6. Page I ol 18
4) System Failure Criteria Applicable to All Systeme:
You trEl! indicats "Yes" or "No" to each of tho following tor 4! lnspections:
1}.. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage OEposal System Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Property Address
Robert P Kennedy & Noelle M Slavin
Owner
information is
.equired for every
page.
Owne/s Name
South Yarmouth MA
City/Town
02664 04t15t2024
Slale Zip Code Date of lnspedion
;V
D
tr
!
n
tr
tr
n
trtrtrn
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 then.4 times in the laet year,rrOTdue to clogged or
obstructed pipe(s). Number of times pumped:
-.Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
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 woll water analysis, perfonned at a DEP certified
laboratory, for fecal coliform bacteria indicates abEont and the presence
of ammonia nitrrgen and nitmte nitrogen is equal to or 1633 than 5 ppm,
provided that no other fallur€ criteria aro triggered, A copy of ths 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
cystem owner should contact the Board of Health tc determine what will be
/il necessary lo co
5) Laqe Syetems: To be considered
design flow of 10,000 gpd to '15,000 gpd.
For large systems, you must indicate either'yes
questions in Section C.4
Yes No
n tr the system is within 400 fei
"::':;.,ffi^,^"
system must aerve a facility with a
or ,no' to each of the following, in addition to the
ft of a surface drinking water supply
I
f of a tributary to a surface drinking water supply
litrogen sensitive area (lnterim Wellhead Protection
lZone ll of a public water supply well
l, ,,"*.r, ,- sirbsldac! Ss*a!. osposd Sysl€.n . P69e 5 or 18
I
lsn9.doc . .ev. 7/26/2018
the system is within 200 fei
lhe system is located in a r
Area - IWPA) or a mapped
]id€ 5 Oi6.
C. lnspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
{
n
tr
5fo, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurfaco Sewage DispoBal Syst€m Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Property Address
Robert P Kennedy & Noell€ M Slavin
Or,vner
infomation is
requirBd for every
page
Owneis Name
Sotnh Yarmouth 02664 04t1512024
City/Town State Zip Code Date of lnspeclion
C. lnspection Summary (cont.)
lf you have answered "yes'to any question in Section C.5 the system is mnsidered a significant
threat, or answered'yes" to any question in Section C.4 above the larqe system has failed. The
owner or operator of any large system considered a significanl threat under Section C.5 or failed
under Section C.4 shall upgrade the system in accordance with 310 CMR 15.3M. The system owner
should contact the appropriate regional office of the Department-
6, You must indicate "yes" or "no" for each of the following for a/ inspections:,7
"J
No
n "/
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined? (lf they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
tr
n
tr
!
DI
V
Was the site inspected for signs of break out?,..//Were all system components,'Ccluding the SAS, located on site?
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?
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 Abaorption System (SAS) on the site has
been determined based on:
Existing information. For example, a plan at the Board of Heatth.
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)]
lsinsp.doc ' l8v. 72620l E Iit. 5 Ofirid lrupedion Fom Subslda.4 S€wEg. Di.!o5.1 Svsrem ' Pase 6 ol 18
5|r Commonwealth of Massachusetts
Title 5 Official lnsPection Form
Subsurface SewagE Disposal Systom Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth' MA 02660
Prope,ty Address
Robert P Kennedy & Noelle M Slavin
Owneis Name
South Yarmouth MA 02664 04t15t2024
City/rTown State Zip Code Date of lnspection
D. System Information
Reeidential Flow Conditlons:
Number of bedrooms (design): A
DESIGN flow based on 310 CMR '15.203 (for
Description
Number of bedrooms (actual)
ple: 110 gpd x # of bedrooms):
/
2eo
a4 / c/4r/J z 3
Number of cunent residents:
Does residence have a garbage grinder?
Does residence have a water lreatment unit?
lf yes, discharges to
ls laundry on a separate sewage system? (lnclude laundry system inspection
information in thiq.report.)
Laundry system insPected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:"/tk5Lk- /63
3a 69
I ves
E Yes
{*"6"
a v." {xo
! Yes */*"-/."
! ves
nfi.
n Yes No
J
Sump pumP?
Last date of occupancy;/rrrt-rut/**b fi*.Date
lsin?.doc' r.v. 72@016
liio 5 Otficid lftp.dion Form: Slbsudact S€wsg' Oisposd Svdsin ' P'g€ 7 ol18
Owrer
information is
requircd for every
page.
4a{'3"
Commonwealth of Massachusetts
Title 5 Official lnsPection Form
Subsurface Sewage Dispoeal System Form ' Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Property Address
Robert P Kennedy & Noelle M Slavin
)wner
nformation is
equired for every
)age.
Owneds Name
South Yarmouth MA 02644 04t15t2025
Slate Zip Code Date of lnspeclionCityflown
D. System lnformation (cont.)
,4,2. Commercial/lndustrialFlowConditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.fl., 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 s
Water meter readings, if available:
Last date of occupancY/use:
Other (describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection?
lf yes, volume PumPed:
How was quantity pumped determined?
Reason for PumPing:
tr No
/fco
&-?ru,t-
GallonE per day (gPd)
m?
l--l Yes l-l No
E Yes E tto
fl Yes E No
nvesn uo
Date
?//,4/"
t".
r5ins.dc. ' ruv 726€018
'Iina 5 O6.id lrup.dion Fo'm Sublunaca Sos'q6 Oispo'€l Syst'm'Pag6 I ol 18
5}, Commonwealth of Massachusetts
Title 5 Official [nspection Form
Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Property Address
Robert P Kennedy & Noelle M Slavin
Olmor
information is
required for every
page.
owne/s Name
South Yarmouth MA 02664 0411512024
Slale Zip Code Date of lnspectionCity/ToMr
4. Typs of
D. System lnformation (cont.)
Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
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 obiained 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):
tr
D
!
n
tr
D
Approximate age of all ponents, date installed (if known)and source of information:
t4A+5 AIJ L"'*x Qtc. I P
Aq- l5l r^rstqlt "Drtz, {-b-qq
wLrJ r"*.i" oiorsGiected when aniving at the site?
Buirding Sewer (rcr;ate on stte ft) Ohfu &"J
Depth below grade: ' I '
Material of constru clion. //
n cast iron dqo pvc fl other (explain)
Distance from private water supply well or suction line:
! Yes {*.
5 bu
feel
feet
ts, venting, evk)eace of , etc.):c
tsin€9.doc' rev. 712612016
Commenhs (on conditbn of iotn
-t<
ri. 5 oltl.id lrEo.ction Fo.n s!!.r,t c. s€wrB! olPoiC s_yiisn' Pagc I of 18
1$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Dirposal System Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Property Address
Robert P Kennedy & Noelle M Slavin
Ol/l/rrer
information is
required for e\.ery
page.
Owne/s Name
South Yarmouth MA 02664 04t15t2024
City/Town State Zip Code Date of lnspection
D. System lnformation 1cont.)
6. Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
-JIU concrete L_.,] metal
feet
! fiberglass ! polyethyl n other (explain)
./7"
o "n7r
d,tA
of Compliance? (attach a copy
zr<ls)dz Q,ap^rs/a)
6Lr
4,t"x**:;:c",,n"","yea
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
Oistance from bottom of scum to bottom of outlet tee or baffle
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.):
fle.f,rorL tfis
/a/ fr* tt al
?
"/J
AS
rsinso.doc ' rev. 72612018
r1*,
/t-/
Tii.e 5 Ofi.ial lnlooc,jon Forh Subludace S€w6oe Oboosd System'Pao3 10 ol lS
lil.774*-&t /,-,Do,,
*I
7-4<- *4, '
s' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurtace Sewage DEpoeal System Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Owner
inlormation is
Gquired for every
page.
Owne/s Name
South Yarmouth MA 026M O4t15t2024
Cityfiown State Zip Code Date of lnspeclion
D. System lnformation 1cont.;
7. Grease Trap (locate on site plan)
Depth below grade:
Material of construclion:
! concrete E metal
feet
Dimensions:
Scum lhickness
Distance from top of scum to top of outlet tee
n lass ! polyethylene E other (explain)
baffle
Date
and outlel tee or baffle condition, structural antegrity,
Distance from bottom of scum to bottom of tee or baffle
Date of last pumping:
Comments (on pumping recommendations, in
liquid levels as related to outlet invert, eviden of leakage, etc.):
8. Tight or Holding Tank (tank must be pum at time of inspection) (locate on site plan)
Depth below grade:
Material of conslruction:
fl concrete E metal liberglass E polyethylene D other (explain)
Dimensions:
Capacity:
Design Flow:
gallons
gallons per day
5 C!fiod lnsoactm Fo(fr sulsudaca s€vlgE olpotd sydem. Prg6 11 ol 18lsinsp.doc. Ev. 726/2018
Property Address
Robert P Kennedy & Noelle M Slavin
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subeurface Sewage Disposal System Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Property Address
Robert P Kennedy & Noelle M Slavin
Owner
information is
requircd lor every
page.
O\ meis Name
South Yarmouth
Cily/Town
MA 02664 04t15t2024
State Zip Code Date of lnspedion
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present:
Alarm level:
Date of last pumping
E Yes E llo
Alarm in working order:Yes D No
Comments (condition of alarm and float switch
Date
, etc.):
'Attach copy of cunent pumping contract (req ired). ls copy attached? fl Yes E Ho
9. Distribution Box (if Pres€nt mu8t be opened) (locate o ite plan)
*/aDepth of liquid level above outlet invert
Comments (note if box is level and distribution to ou
evidence of leakage into or out of box, etc.):
equal, any evidence of carryover, any
*/
o/z
i/agn
b.'1
E-Ba. z-./a 4
l5rnsp.doc ' rev. 726/2018 Tilc 5 Ofidd lffp.cljon Fom: Sub6un.c! Soergs OisPosal Sv$6m'P39o 12 of'tB
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage DiaPoaal System Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Propedy Address
Robert P Kennedy & Noelle M Slavin
Owner
information is
required for every
page.
MA 0266,4 04t15t2024
State Zip Code Date of lnspectionCity/Town
D. System lnformation (cont.)
'10. Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order
! Yes n lo-
! Yes n No'
ition of pumps and appurtenances, etc.):
,4
Comments (note condition of pump chamber,
" lf pumps or alarms are not in working order, s is a conditional pass
lf SAS not located,a%mm^)
/L',
tl ll/nP SoZv // i)x/a /o
Type
tr
{
n
n
n
leaching pits
leaching chambers
leaching galleries
leaching trench6s
leaching fields
overflow cesspool
innovative/altemative system
Type/name of technology:
number:
number:
number:
number, length:
number, dimensions
number:
.f
tsin3p.rl.c . Etr 7126?2018
n
]ii. 5 Oltcjd hsosctidl Fdrn: Slbeitra€. S.r.gs Oi'po6'l Svsan ' Ptge 13 ol18
Owne/s Name
South Yarmouth
11. Soll Absorption Sy8tom (SAS) (locate on site plan, excavation not required):
n
5f\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal Systom Form - Not for Voluntary Assessments
Station Avenue, South Yarmouth, MA 02660
Property AddrEss
Robert P Kennedy & Noolle M Slavin
Owner
information is
required for every
page.
OMe/s Name
South Yarmouth MA 02664 04t15t2024
City/Town State Zp Code Date of lnspeclion
D. System lnformation 1cont.;
1 1. Soil Absorption Sy8tem (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
,,/.Jo by'orl^Cfr/sl)
b.e
a 7qr
u
C,ahn /e
4.,/e ,4,s 4 742 ii?gefntai ,4 CtVe&t ,1,0 h4)ftp.1
12: Cesspoo
rkct+anv1,o*@
nspection) (locate on site plan):ls (cesspool must be pumped
Numb€r and configuration
Depth - top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of @sspool
Materials of construciion
lndication of groundwater inflow I Yes D tto
Comments (note condition of soil, signs of ydraulic failure, level of ponding, condition of vegetation,
etc.)
Z,/.45 /o?b 7V1-
l5inso doc. rev, ?262018 ]i!e 5 Otti.lsl Insoedjon Fom' Subsldrce S€tr"q€ DsDosd Svnen' Paoe 14 ot 18
5s' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage DispoEal System Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Property Add.ess
Robert P Kennedy & Noelle M Slavin
Owner
information is
required for every
page.
Owne/s Name
South Yarmouth MA 02664 o4t15t2025
State Zip Code Date of lnspediooCily/Town
D. System lnformation
13. Privy (locate on site plan):
Malerials of conslruction:
Dimensions
(cont.),rh
Depth of solids
Comments (not€ condition of eoil, signs of
etc.):
failure, level of ponding, condition of vegetation,
t$n9.doc . rex 712612018 nne 5 O6cjd lnsp.clo.i Forn: Sutr$rac. S.ws!€ Orsposel Svsrdr ' Paqo 15 o' 16
5s. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Property Address
Robert P Kennedy & Noelle M Slavin
Ovrne/s Name
South Yarmouth 02664 0411512024
City/Town State Zip Code Date of lnspection
D. System lnformation (cont.)
'14. Sketch Of Sewage Disposal Syst6m:
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:
MA
{^
w
E and-sketch in the area belowE drawing attached separately
floed Laa olP
Ne'l eart
(rl v
,qb.
*
4
f""*Ogr l,6l
4.t l8!+"A.z. i?:t'A.s./0'+'4.4.t?.'2"
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Tine 5 ofioJ hsoedion For: 3-6$da.e s.Ega o9o!c Systs ' Pag6 16 c{ 18rrns.dos. rev.71262018
-J-
Slafibl AYa
O!,rner
information is
required for every
page.
t
I
e-\Commonwealth of Massachusetts
Title 5 Official lnsPection Form
Subaurface Sewage Dbposal System Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Property Address
Robert P Kennedy & Noelle M Slavin
)umer
nformation is
equired for every
lage.
Owneis Name
South Yarmouth MA 02664 0/.t15t2024
Stale Zip Code Date of lnspectionCity/Town
D. System lnformation 1cont.;
15. Sito Exam
Check Slope
Surface water
Check cellar
Shallow wells
Estimated depth to high ground watsr
;tq ffid,{'
feet
PleaseindicateallmethodsUsedtodeterminethehighgroundwaterelevation
tr obtained from system design plans on record
lf checked, date of design plan reviewed:
n Observed site (abutting propeMobservation hole within 150 feet of SAS)
tr Checked with local Board of Health - explain:
"t USGS - explain
rrYet<-/*?/
hd&q s ?^p..6.q+ /44tr /.2 /q.?
Date
You muat describe how You established the hig water elevation
d*J .h qround
i 2o' tbuafia-
4ou#o
,r4 80'
/.2 /?'q
bs:6
Before filing this lnspection Report, please see Report Completeness Checklist on next page'
tsntAdoc' r.v. 7/261014 Id.5 Otis.l ln$.dion Form: S{bqrdae S'w'C' Os@ttl Svds'Pcg' 17 ot 18
Checked with local excavators, installers - (attach documentation)
5L\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
54 Station Avenue, South Yarmouth, MA 02660
Property Address
Robert P Kennedy & Noelle M Slavin
fomalaon is
equiEd for every
)age.
Owneis Name
South Yarmouth
City/Town
MA 02664 04t15t2024
state zip code Date oI lnspeclion
E. Report Completeness Checklist
Complete all applicable sectlons of this form inclusive of:
A. lnspector lnformation: Complete all fields in this section
B. Certification: Signed & Dated and 1, 2, 3' or4 checked
d C, lnspection Summary:
1, 2, 3, or 5 mmpleted as aPpropriate
4 (Failure Critetia) and 6 (Checklist) compteted
d 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 €stimated depth to high groundwater included
tsinsp.doc. rev. 726/2018 llle 5 Offdd kt|p.di6 Fo.m: Sqbd,fa.. Ss*€gt Orsgo6d Svst€'n ' Peg€ 18 o' 18