HomeMy WebLinkAboutInspection Report 2024 April 9.s.\Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Cottage Drive
Owner
information is
required for every
page
MA 02673 04t09t2024
City/Town State
lnspection results must be submitted on this form, lnspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector lnformation
Armando Pantoja
lmportant: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
Name of lnspector
Joe Martins dba Accu Sepcheck LLC
Company Name
17 Northside Drive
Company Address
Souih Dennis MA 02660
Cityfown
508-385-5891
State
sr 14296
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 abovei the information reported below is true, accurate and complete as 0fthe 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:
L X Passes
2. E Conditionally Passes t) t"Ct)
APR 2 5 2024
HEALTH DEPT
3. E Needs Furlher Evalualion by the Local Approving Authority
+. E raits
arr"-**lo,&,
@ Date
The system inspector shall submit a copy of this inspedion report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. lfthe 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 snoud be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of anspection and underthe
conditions of use at that time. This inspection doesnot addresshow the system will perform
ln the luture under the same or dfiIerent condltlons ol use.
tsinsp doc' ra 7/26/20T I Title 5 OflDia lnspclon Form: Subsurlace sMge Dispoelsysiem. tuge 1 o,18
Owner's Name
Wesl Yarmouth
Zip Code Date of lnspection
ffi
04t11t2024
i}' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth lVlA
Property Address
Helio Costa Jr 29 Cottage Drive
Owner
intormation is
required for every
page.
Owner's Name
West Yarmoulh
City/Town
MA
State
02673
Zip Code
04t09t2024
Date ol tnspection
C. lnspection Summary
Inspeclion Summary: Compleie 1, 2, 3, or 5 and all of 4 and 6
X I have not found any information which indicates that any ofthe failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
PUMPING RECOMMENDEO FOR SEPTIC TANK AS SOLIDS ARE AT 3O%O OF TANK LIOUID
VOLUME. PUMPING RECOMMENDEO AT 20%.
2) System Conditionally Passes:
E One or more system components as described in the "Conditional Pass" section need to be
replaced or reparred. The system, upon completion ofthe replacement or repair, as approved by
the Board of Health, will pass.
Check the box for'yes", 'no" or "not determined" (Y, N,D) for the following statements. lf .not
determined," please explain
The septic tank is metal and over 20 years old*the septic tank (whether metal or not) ls structurally
unsound, exhibils substanlial infiltration or e ion or tank failure is imminent. System will pass
inspeclion if the existing tank is replaced
Health.
a complying septic lank as approved by lhe Board of
* A metal septic tank will pass inspect
Compliance indicating that the tank is
if it is structurally sound, not leaking and if a Certificate of
lhan 20 years old is available
trY NN EN (Explain below)
t5 isp doc. re 7/26/2018 Tille 5 Ofibiai nsFcton Form: Sub6udace SeMg6 DsposalSysbn. Page 2o118
1) System Passes:
4,. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Owner
information is
required lor every
page.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Eq'9 qoJ!e_! r ?9_q9!CCC_q!'.y_9
Owner's Name
West Yarmouth
cit/r'own
----
IVIA
Stale
02673
zip cooe
o4109t2024
Date of nspection
C. lnspection Summary (cont.)
2) System Conditionally Passes (conl.):
n Pump Chamber pumps/alarms not operational. Syslem will pass with Board of Health approval if
pumps/alarms are repaired.
n
tr distribution box is leveled or re ced
n ND (Explain below)
E NO (exptain netow)
n ND (Explain below)
trY
nY
tr r.t
trN
n r.t
Y
! The system required pumping more then 4 times a year due to broken or obslrucled pipe(s). The
system will pass inspeclion if (with approval of the Board of Health):
tr broken pipe(s) are replaced tr Y tr N E ND (Explain below):
tr obstruclion is removed tr Y tr N n ND (Explain betow):
3) Further Evaluation is Required by the Board of Health:
n Conditions exist which require further evaluatio y the Board of Health in order to determine if
the system is failing to protect public health, s or the environment
a. System will pass unless Board of determines in accordance with 310 CMR
15.303(1 Xb) that the system is not fun oning in a manner which will protect public health,
tsinsp &c. rn 726t2O14
3afety and the environment:
E Observation ofsewage backup or break out or high static water level in the dtstribution box due
to broken or obstruc{ed 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
obstruction is removed
Thi. 5 Olri. al lnspecton Fo6 Sub6urface SeMge DEpoel Syst6m. Pdgs 3 or 18
€\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
Property Address
Helio Costa Jr 29 Cottage Drive
Owner
information is
required for every
pa9e.
Owneis Name
West Yarmouth MA 02673 04t09/2024
City/Town Zip Code Date of lnspection
C. lnspection Summary (cont.)
Cesspool 0r privy is within 50 feet of a surface water
tr Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b, System will fail unless the Board of Health (and Public Water supplier, if any)
determines that the system is funclioning in a manner that protects the public health,
safety and environment:
I The system has a septic tank a SO il absorption system (SAS) and the SAS is within
100 feet of a surface water supply tributary to a surface water supply
n The system has a septic tan nd SAS and the SAS is within a Zone 1 of a public water
supply.
E The system has a se nk and SAS and the SAS is within 50 feet of a privale water
ictank and SAS and the SAS is less than 100 feet but 50 feet or
r supply well-*.
Method used to d ine dislance
*t 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 cnteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All systems:
You must indicat o each of the following for 4l inspections:
Yes No
n x Backup of sewage into facilily or system component due to overloaded or
clogged SAS or cesspooltr x il'.'['f.'.T"ffi:'of3;l;flffi1$r,i'su;:in'n.,^ooraurfec€watere
tslnspdoc. r€v.7i26r2018 T ue 5 Ofiicial lnspe.l'oi Form subsurlac€ Sew?ge Disposal SFiem . ge4ol18
supply well.n The system has a
more from a privale w
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
State
(I.. CommonwealthofMassachusetts
Title 5 Official lnspection Form
Owner
information is
required for every
page.
Subsurface Sewage Oisposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Coftage Drive
Owner's Name
West Yarmoulh
C ty/Town
MA
State
02673
zip coae
04t09t2024
Date of lnspection
C. lnspection Summary (cont )
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
trX
trxnx
trx
NN
trx
trx
trx Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a privale water supply well with no acceptable water quality analysis. [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
and chain of custody must be attached to this fo.m.]
The system is a cesspool serving a facility with e design flow of2000 gpd'
10,000 g@.
The system E!lS. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the syslem fails. The
syslem owner should contact the Board of Heatth 10 determine what will be
necessary to correcl the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to '15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section C.4.
Yes No
ntr
trtr
trtr
the system is within 400 fe of a surface drinking water supply
the system is within 2 feet of a tributary to a surface drinking water supply
the system is locat in a nitrogen sensitive area (lnterim Wellhead Protection
Area - |V1/PA) or a mapped Zone ll oI a public water supply well
Tii€ 5 OftEial lnsp6cton Form: Sub€uftce SeMge DispoelSysbm. Page 5 oi 18
Static liquid level in the distribulion 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 irof 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 priw 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.
15 nsp.d@' re 7/26/2018
x
X
tr
n
.Cr. CommbnwealthofMassachusetts
Title 5 Official lnspection Form
Owner
Information is
required for every
page.City/Town
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Cosla Jr 29 Cottqge qrlye
Owner's Name
West Yarmoulh |J20t3 04t09t2024
Dale of lnspectionZip Code
6
C. lnspection Summary (cont.)
lf you have answered 'yes'to any question in Seclion C.5lhe system is considered a significanl
threat, or answered 'yes'10 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 Sedion C.5 or failed
under Section C.4 shall upgrade the system in accordance with 310 CMR 1 5.304. The system owner
should contact the appropriate regional office ofthe Department.
You must indicate "yes" or "no" for each of the following for a/ inspections:
Yes No
X tr Pumping information was provided by the owner, occupanl, or Board of Health
tr X Were any ofthe system components pumped out in the previous two weeks?
X tr Has the syslem received normal flows in the previous two week period?
T.t lll Have large volumes of water been introduced lo the system recenlly or as part ofu tzr'J this inspection?
M Tt Were as buitt plans ofthe system obtained and examined? (lfthey were not
available note as N/A)
X n Was the facility or dwelling inspected for signs of sewage back up?
X tr Was the site inspected for signs of break, ouf? . ^ /'ll- Af'-
X tr Were all system components, e$uding the SAS, located on site?
X tr Were the septic tank manholes uncovered, opened, and the interior ofthe lank
inspected for the condilion of the baffles or lees, material of conslruction,
dimensions, depth of liquid, depth of sludge and depth of scum?
tr Was the facility owner (and occupanls if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal syslems?
The size and location ofthe Soil Absorption System (SAS) on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR I 5.302(5)]
xtr
tsinsp doc . rd 71612018 Title 5 Oflicial lnspeclon Fo.m S! b6urlace SeMge Dsposal Sysism . Page 6 ol 1 I
State
nx
j*^ Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Cottage Drive
Owner
information is
required for every
page.
Owner's Name
West Yarmoulh 02673
City/Town State Zip Code
04t09t2024
Date of lnspection
D. System lnformation
1 . Residential Flow Conditions:
Number of bedrooms (design)6 Number of bedrooms (actual)6
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms)660 GPD
Description:
1000 GAL SEPTTC TANK, DBOX AND (6) 500 GAL LEACH CHAMBERS tN A 12'X54'X2'STONE
VOLUME.
Number of currenl residentsi
Does residence have a garbage grindef
Does residence have a water treatment unit?
lf yes, discherges to:
ls laundry on a separate sewage system? (lnclude laundry system inspection
information in this report.)
Laundry system inspecled?
Seasonal use?
Waler meter readings, if available (las1 2 years usage (gpd)):
nvesn uo
n Yes ! t,to
EYes! 1e
nvesE ruo
fl Yes n tlo
292 GPD
Sump pump?
Last date of occupancy
E Yes X tio
04t09t2024
Date
tsi.sp doc . ra 7/262018
Detail:
2023:111,000 G; 2o22. 102,000 G; PER YARMoUTH WATER DEPARTMENT.
Tnb 5 Ot aral lnsp.cto. Foim: Sirt6urlace SeMge Disposel SysEm. %ge 7 or 18
S:' CommonwealthofMassachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fo,m - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Cottage Drive
Owner
information is
required for every
page.
Owner's Name
West Yarmouth MA 02673 o4t09t2024
State Zip Code Date of lnspection
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/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 system?
Water meter readings, if available:
Last date of occupancy/use:
Other (describe below):
Gallons per day (gpd)
E ves E t,to
n vesE ruo
EYesn ruo
E yes I t'to
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:
PER YARMOUTH HEALTH: PUMPED lN 2014,2011,
2q08r 2005 2003 2002,2001,20 00,1 1998 19vb999
n Yes X tto
gallons
iSinsp doc . rev 226lm18 T 1le 5 Ofl cial l.specuor Form S! bsu.lace Serage D6poel Stslem . Page I ol 1 I
City/Town
5}' Commonwealth of Massachusetts
Owner
informetion is
required for every
page.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Helio Costa Jr 29 Cottage Drive
Owner's Name
Wesl Yarmouth UlOIJ 04/0912024
City/Town State Zip Code Date of lnspeclion
D. System lnformation (cont.)
4. Type of System:
X Septic tank, distribution box, soil absorption system
n Single cesspool
tr Overflow cesspool
n Privy
tr Shared system (yes or no) (if yes, attach previous inspection records, if any)
n Innovative/Ahernative technology. Atlach a copy ofthe current operation and
maintenance conlract (1o be obtained from syslem owner) and a copy of latest
inspection of the l/A system by system operator under contract
n Tight tank. Altach a copy ofthe DEP approval.
tr Other (describe):
Approximate age of all components, date installed (if known) and source of information:
AGE: DBOX AND SAS ARE 28 YEARS ; INSTALLED: 1996 ; SOURCE: PERYHD. PRE-
EXISTING SEPTIC TANK INSTALLED BEFORE 1996.
E Yes X tto
>10
feet
feet
t5hsp &c' re 7/2€l2O18 Tds5 Oniciallnsp@ton Fom Sub6uft@ Sonage OlsposalSFbrn. 9e9of18
Title 5 Official lnspection Form
33 & 35 Butler Ave West Yarmouth IvlA
Were sewage odors detected when arriving at the site?
5. Building Sewer (locate on site plan):
Depth below grade:
Material of construclion:
E cast iron n 40 PVC E other (explain):
Distance from private water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
NOTVIEWED IN WALL, FLUSH TESTED NO EVIDENCE OF LEAKS OR STAINING.
1f1' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Owner
information is
required for every
pa9e.
Owner's Name
West Yarmouth MA
State
02673
2ipcoae
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Cottage Drive
04t09t2024
Cily/Town Date of lnspection
D. System lnformation (cont.)
6. Septic Tank (locate on sile plan):
Depth below grade:
Material of construciion:
X concrete f] metal n fiberglass E polyethylene E other (explain)
1
feet
lf tank is melal, list age years
ls age confirmed by a Certificate of Compliance? (attach a copy of cerlificate)
Dimensions 8.5'X6'X5',
EYesE No
l OOO GAL
12"
Distance from top of sludge to bottom of outlet tee or baffle 22"
Scum thickness 4"
Distance from top of scum to top of outlel lee or bame 2
Dislance from boltom of scum lo bottom of outlel 1ee or baffle 10'
How were dimensions determined?
Commenls (on pumping recommendations, inlet and outlet tee or baffle condilion, slructural inlegrity,
liquid levels as related to outlel inverl, evidence of leakage, etc.):
PUMPING IS RECOMMENDED AS SOLIDS ARE AT 30% OF TANK VOLUME. PUMPING
RECOMMENDED AT 2OOIO. HAS A PVC INLET TEE AND A PVC OUTLET TEE. LIOUID LEVEL IS
48'AT OUTLET INVERT. NO EVIDENCE OF LEAKAGE.
lsinsp.doc. B 7/2612018 T0€ 5 Oificial lnspoclion Form Sub6una.s Sevase Drsposat Sysbm , page 1 O ol 1 8
Sludge depth:
CORETAKER
e. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Oisposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Cottage Drive
Owner
information is
required for every
page.
Owner's Name
West Yarmouth 02673 04t0912024
City/Town State Zip Code Date of lnspection
D. System lnformation (cont.)
7. Grease Trap (locate on sile plan):
Depth below grade:
Material of construdion:
n concrete E metal
NOT APPLICABLE- NO GREASE
TRAP
E fiberglass n polyethylene E other (explain):
Dimensions
Scum thickness
Distance from top of scum to top of o e or baffle
Distance from bollom ol scum to b of oullet tee or balfle
Date
Comments (on pumping recommendations, inlet and outlet tee or bame condition, structural integ
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locale on site plan)
Deplh below grade:
Material of construction:
E concrete ! metal
NOT APPLICABLE
! flberglass fl polyethylene n other (explain):
rity,
Dimensions:
Capacity:
Design Flow
gallons
gallons per day
T o 5 OflEral lnsp€clion Form: Su!6urhc6 S.{ag6 Oisposl Sy6bm . Pago 1 1 o, I 8
Date of last pumping:
t5 nsp do.. rd 7/26/2018
€\ Commonwealth of Massachusetts
Owner
information is
required for every
page.City/Town
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Cottage Drive
Owneis Name
West Yarmouth MA
State
02673 04t0912024
Zip Code Date of lnspection
D. System lnformation 1cont.1
8. Tight or Holding Tank (conl.)
Alarm present
Alarm level:
Date of last pumping:
Comments (condition of alarm and float
Alarm in working order:Yes E r'lo
Date
, etc.):
- Attach copy of currenl pumping contract (required). ls copy attached? E Yes !No
L Oistribution Box (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert AT INVERTS
tSrnsp do. . re 7/20,20T8
Title 5 Official lnspection Form
/ .res E tto
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.):
DBOX IS IN GOOD CONDITION WTH 1 PIPE IN AND 6 PIPES OUT. NO EVIDENCE OF SOLIDS
CARRYOVER. FLOW DISTRIBUTION IS EVEN.
Title 5 Otlrciar lnspeclion Form Slbourface Se@96 DsposatSlslem. pbge 12 otlB
i}' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System FoIm - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Cottage Drive
Owner
information is
required for every
page.
Owner's Name
West Yarmouth MA 02673 04t09t2024
City/Town State Zip Code Date of lnspection
D. System lnformation (cont.)
10. Pump Chamber (locate on site plan)l
Pumps in working order:
Alarms in working order:
Comments (note condition of pump chamber,
E Yes n No-
E yes E No'
ndition 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:
leaching pits
leaching chambers
leaching galleries
leaching trenches
leaching fields
overflow cesspool
innovative/altemative system
Typehame of lechnology:
number:
number:
number:
number, length:
number, dimensions
number:
6, 5OO GAL
CHAMBERS
6hsp .bc . 16, 7,26r0la TiUe 5 Ot aral nsFcton Foim Sub6u.tac6 Semg€ Dbpoet Sysiem . Flags 1 3 oi 18
Type:
!
x
!
n
tr
n
tr
fr Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Cottage Drive
Owner
information is
required for every
page.
Owner's Name
West Yarmouth MA
City/Town State Zip Code Date of lnspeclion
D. System lnformation (cont )
1 1 . Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS TYPE; (6) 500 GAL CHAMBERS.
LIOUID LEVEL: 0-1"
STAINLINE: 2-3"
CONDITION OF STONE: CLEANA/ISIBLE
GRADE TO SAS BOTTOM: 7.2'
'12. Cesspools (cesspool must be pumped as part of inspection) (locale on site plan)
Number and configuration
Depth - top of liquid 1o inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
lndication o
Comments
elc.):
f groundwaler infl
(note condition of
OW
il, signs of hydraulic failure, level of
nYes ENo
ponding, condition of vegetalion,
tsrnsp doc. rev 7/26/2018 Ttre 5 OrircEllnsp€cton Formr subsurface SeMge Dtsposal Slsbm. page 14 or iB
04!0912024
fl' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Cottage D TIVE
Owner
information is
required for every
Pe9e.
Owneis Name
West Yarmouth IV]A 02673 04t09t2024
City/Town Siate Zip Code Oate of lnspection
D. System lnformataon (cont )
13. Privy (locate on sile plan)
Materials of construction:
Dimensions
Depth of solids
NOT APPLICABLE
NOT APPLICA
NOT APP BLE
Comments (note condition of soil, signs of hydraulic ilure, level of ponding, condition of vegetation,
etc.):
NOT APPLICABLE
tSrnspdoc. B 7/26/m18 Tine 5 Otrc al lGFcljon Fom: Slbcufte SeMge Oisposat Sysbln. Paqe 15 ot i8
€\ Commonwealth of Massachusetts
Title 5 Official !nspection Form
Owner
information is
required for every
page.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Cottage Drive
Owner's Name
West Yarmouth
City/Town State
ulotS
Zip Code
04/0912024
Date of lnspection
D. System lnformation 1cont.;
14. Sketch Of Sewage Disposal System:
Provide a view ofthe sewage disposal system, including ties to at least two permanenl reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
hand-sketch in the area below
drawing attached separately
xtr
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tsiisp doc . @ 7/262018 Title 5 Ofticral lnspoclon Form Subsufaco Sevtag6 Disposal Systsm. paqe 16 oi 18
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N(t
1$,. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Owner
information is
requlred for every
page.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Cottage Drive
Owner's Name
West Yarmouth 02673
City/Town
MA
Staie Zip Code
04t09t2024
Date of lnspectron
D. System lnformation (cont.1
15. Site Exam:
X check Slope
X Surface water
X check cellar
X Shallow wells
Estimated depth to high ground water:>8.9
leet
Please indicale all methods used to determine the high ground water elevation:
X Obtained from system design plans on record
09/07/1996lf checked, date of design plan reviewed Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
FILE
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
FRIMPTER.
You must describe how you established the high ground waler elevalion:
DESIGN TEST HOLE ON 0812211996: NO GROUNDWATER AT 12.0'. M|W29B ADJUSTMENT
FOR O8/1996 IS 3.1'. GRADE TO SAS BOTTOM IS 7.3',
SEPARATION MATH : 12.0 - (7.3 + 3.1) = 1.6'.
Before filing this lnspection Report, please see Report Completeness Checklist on next page.
tsrnsp doc . €! 726,2018 lfte 5 Oficral nsp€cton Form:Sul6uda@ S6a?9e DisposalSysth. Pige 17of lE
x
€:r Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 & 35 Butler Ave West Yarmouth MA
Property Address
Helio Costa Jr 29 Cottaoe Drive
Owner
information is
required tor every
page.
Owner's Name
West Yarmouth 04t09t2024
City/Town State Zip Code Date of lnspection
E. Report Gompleteness Checklist
Complete all applicable sections of this form inclusive of:
X A- lnspector lnformalion: Complete all fields in this sedion.
X B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
XI C. lnspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
X D. System lnformalion:
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 d@. ra 7/26120i I Tille 5 Ofrbral lnspsctioi Form Sub6ldace S6Mg. Oisposat Sy6i6m , page I 8 ot 1 8