HomeMy WebLinkAboutInspection Report 2024 April 4A Commonweatth of Massachusetts
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 1 1 North Main St.
Property Address
Amy Adamaitis and Shawn Gartner
Owner
information is
rgquired for every
page.
Owne/s Name
S. Yarmouth,Ma 02664 4t4t?024
City/Town State Zip Code Date ol lnspeclion
lnspection rBults must b6 submitted on thb form. lnspection forms may not bo altered in any
way. Please see completenGs checklirt at the cnd of the tom.
A. lnspector lnformation
Darrell Stone
lmportant When
frlling out forms
on lhe computer,
use only the tab
key to move your
cursor - do not
use the return
key.
Name of lnspodor
Cape Cod Septic lnspection
Company Name
P.O. Box 1466
Company Address
Harwich Ma 02645
,*A City/Town
(508) 240-2500
State
s14995
Zip Code
Ielephone Number License Number
B. Certification
I certify that: lam a DEP approyed system inspector in full compliance with Section '15.340 of Tltle 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. E condition asses
AP( 2 5 2024
HEALTH DEPT
Need r Evalu th Local Approving Authority
41712024
Sign Date
The system inspector shall submit a copy of
of He;lth or DEP) within 30 days of completi
10,000 gpd or greater, the inspector and the
regional office of the DEP. The original form
the buyer, rf applicable, and the approving a
this inspection report to the Approving Authority (Bo-ard
ng this inspection. lf the system has a design flow of
s-vstem owner shall submit the report to the approprlate
siould be sent to the system owner and copies sent to
uthority.
Please note: This report only dEcribe3 conditions at the time of inspection and under.the
conditions of use at that tiril]ir,i" in"p""ti"n does not address how the system will perform
in the future undel the same or different conditions ol use'
Tnb 5 OfiiciallnsP6do' Fom Subsun@ S4ag6 D6posl svst6m P6g€ 1 oi 16
tsinsp doc. €v 7126r'2014
Title 5 Officia! lnspection Form
I
3tr
l.!
Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage DispGal System Form - Not for Voluntary Assessments
1'11 North Main St.
Property Address
Amy Adamaitis and Shawn GartnerOwnsr
information is
requircd for every
page
Owne/s Name
S. Yarmouth,Ma 02664 414t2024
City/Town State Zip Code Date of lnspeclion
C. lnspection Summary
lnspection Summary: Complete 1,2,3, or S and all of 4 and 6.
l) System Pas6es:
X I tr9v9 not found any information which indicates that any of the failure criteria described
in 310 cMR 15.303 or in 310 cMR 1s.304 exist. Any fairure criteria not evaruated areindicated below.
Comments:
2) Syctem Conditionally Passes:
! one or more system components as described in the "conditional pass'section need to bereplaced or repaired. The system, upon completion ot the replacement or repair, as approved bythe Board of Health, will pass.
check the box for "yes", "no" or'not determined" (y, N, ND) for the foflowing statements. rf ,,not
determined," please explain.
The septic tank is metal and over 2o.years old* or the septic tiank (whether metal or not) is structurallyunsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pissinspection if the existing tank is reptaced with a comptying septic tank as appi"riivlt
"
ii"5ro "rHealth.
' A metal septic tank will pass inspection if it is structurally sound, not leaking and if a certificate ofCompliance indicating that the tank is tess than 20 yearsbE is avaitable.
E Y tr rl El ND (Exptain betow):
tSi.sp.doc . ev 7l26Dafi Ttb 5 Ofidar t[3r€di.n F<rrn: Subscr.ce Sa^,age Oispos€t Sysisn . pa!6 2 of j8
1$. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 11 North Main St.
Property Address
Amy Adamaitis and Shawn Gartner
Owner
information is
required for every
page.
Owne/s Name
S. Yarmouth,Ma 02664 4t4t2024
City/Town Zip Code Date of lnspeclion
C. lnspection Summary (cont.)
2) System Conditionally Pa6sos (cont.):
! eump Chamber pumps/alarms not operational, System will pass with Board of Health approval if
pumpsi/alarms are repaired.
E Observation of sewage backup or break out or high static water level in the diskibution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
tr broken pipe(s) are replaced tr Y E N E ND (Exptain betow):
tr obstruction is removed tr Y tr N E ND (Exptain below):
n distribution box is teveled or replaced D Y n ru E ND (Explain below):
! The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
tr broken pipe(s) are replaced E Y ! N n ND (Exptain betow):
n obstruction is removed tr Y E N E ND (Exptain betow):
3) Further Evaluation is Required by the Board of Health:
n Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 3'10 CMR
t S.f Oflt 11t1 tnat the system is not functioning in a manner which will protect public health,
safety and the environment:
15 nsp.doc. .sv 7/26/2018 I 16 5 Ofrcisl l.sp€c1ion Fom Subsu.facs S*aoe OisPos Svsl'm'Page3 ot 13
State
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Sub6urface Sewage Dlsposal System Fom - Not br Voluntary Assessments
111 North Main St.
Property Address
Amy Adamaitis and Shawn Gartner
Owner
information is
required for every
page.
Owneis Name
S. Yarmouth,
City/Town
Ma 02664 4t4t2024
Zip Code Date of lnspedion
C. lnspection Summary (cont.)
tr Cesspool or 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 Supptier, if any)
detemines that the system is functioning in a manner that protects the public health,
satety and environment:
! 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.
! The system has a septic tank and SAS and the SAS is within a Zone 1 of a pubtic 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 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 ce(ified 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 Alt Systems:
You must indicate "Yes" or ,,No,, to each of the following for all inspections:
Yes
tr
tr
No
x
tr
Backup of sewage into facility or system component due to overloaded orclogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surfuce watersdue to an overloaded or c,ogged SAS or cesspool
Inb g Ofliciat tn6p€ctiofi Folm: Subsufa.e S€y/ag€ OEposal Systom . pa!€ { of 18
lsinsp doc. r6v 7p62018
State
5$, Commonwealth of MassachusetG
Title 5 Officia! lnspection Form
Subsurface Sewage Disposal SyEtem Form - Not for Voluntary Assessments
1 11 North Main St.
Property Address
Amy Adamaitis and Shawn Gartner
Owner
intormalion is
required for every
page.
Owne/s Name
S. Yarmouth Ma
Zip Code Date of lnspeclion
02664
City/Town
C. lnspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes Nonatratratrx
tra
na
tratra
x
Any portion of a cesspool or privy js less than 100 feet but greater than SO feet
from a private water supply well with no acceptable water quality analysis. fthissystem 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 form.l
The system is a cesspool serving a facility with a design flow of2000 gpd-
10,000 gpd.
The system !!Q. I have determined that one or more ofthe above failure
criteria exist as described jn 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.
tr
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, an addition to the
questions in Section C.4.
Yes No
tr the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a t.ibutary to a surface drinking water supply
the system is located in a nitrogen sensitive area (lnterim Wellhead Protection
Area - IVVPA) or a mapped Zone ll of a public water supply well
Tnb 5 Ofilcisl hspoction Fom Slbsurfa@ S€*a96 Disposl Svst€m ' Page S ol 18
!
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
than % day flow
Required pumping more than 4 times in the last year rVOf due to clogged or
obstructed pipe(s). Number of times pumped: _.
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy 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 ol a public water supply
well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
n
tr
D
tsinsp doc. rcv 72612018
tr
4t4t2024
St'dte
x
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'11 1 North Main St.
Property Address
Amy Adamaitis and Shawn Gartner
Owner
information is
required for every
page.
Owne/s Name
S. Yarmouth,Ma 02664 4t4t2024
City/Town Date of lnspedion
o
C. !nspection Summary (cont.)
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 f;ailed. The
owner or operator of any large system considered a significant threat under Section C.5 or fuiled
under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304- The system owner
should contact the appropriate regional oflice of the Department.
You must indicate "yes" or "no" for each of the following for a/ inspections:
Yes No
tr A Pumping information was provided by the owner, occupant, or Board of Health
n tr Were any of the system components pumped out in the previous two weeks?
X 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 ofr'J r'J this inspection?
M T-l Were as built plans of the system obtained and examined? (lf they were not
available note as N/A)
X tr Was the facility or dwelling inspected frcr 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, loceted on site?
X tr 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?
a 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 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) f310 CMR 15.302(5)l
x n
x
t5insp cto. . toy 71?6t2,1a Tnh 5 Offid, it3p€ctbn Form: Sub3ufaca S€u/ES€ Dilpa3alSyg€m , pag€ 6 of 18
St'ate Zip Code
n
A Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface sewage Disposal Systsm FoIIn - Not for Voluntary Assessments
1 1'l North Main St.
Property Address
Amy Adamaitis and Shawn Gartner
Owner
information is
required for every
page.
Ownels Name
S. Yarmouth,Ma 02664 4t412024
Zip Code Date of lnspeclion
D. System lnformation
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms):
Description:
2 bedroom house with detached garage and a 1 bedoom apartment
2+1
330
Number of current residents:
Does residence have a garbage grinden
Does residence have a water treatment unit?
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:
! ves I lto
! ves I trto
EYesE
IYesX
EYesE
No
No
No
Sump pump?
Last date of occupancy
EYesX No
Current
Oate
tsansp.doc. rev 726/2018 Ti06 5 Otrri.l lnspodion Form: Sub*,fa@ S6'a!' Disposal Stst6m ' Ptge 7 or 1a
City/Town State
lf yes, discharges to:
A Commonwealth of Massachusetts
Title 5 Official Inspection Form
Property Address
Amy Adamaitis and Shawn Gartner
Owner
information is
requi.ed for every
page
Ownefs Name
S. Yarmouth Ma 02664 414t2024
City/Town State Zip Code Date of lnspedion
D. System Information (cont.)
2. Commercial/lndustrial FlowConditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.)
Grease trap present?
Water treatment unit present?
lf yes, discharges toi
lndustrial \uaste 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)
nvesE ruo
EYesn ruo
f| Yes [] Ho
EvesE No
Dale
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:
Unknown
EYesE ruo
gallons
t5iru! do. . rev 7/26/2018 TiIl€ 5 Oticbl lnsp€dion Fomr Sublt face Sewag€ Oisposal Swtsm . pegs 8 or 18
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
111 North Main St.
5}. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Folm - Not for Voluntary Assessments
1 '1'l North Main St.
Property Address
Amy Adamaitis and Shawn Gartner
Owner
iniormation is
requi.ed for every
page.
Owne,'s Name
S. Yarmouth,
City/Town
Ma 02664 414t2024
Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
X Septic tank, distribution box, soil absorption system
tr Single cesspool
n Overflow cesspool
tr Privy
tr Shared system (yes or no) (ifyes, attach previous inspection records, if any)
tr lnnovative/Alternative technology- Attach a copy ofthe 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
tr Tight tank. Attach a copy of the DEp approvat.
tr Other (describe):
Approximate age of all components, date installed (if known) and source of information
2000 per BOH
Were se\ rage odors detected when aniving at the site?
5. Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
n cast iron El40 PVC E other (explain)
Distance from private water supply well or suction line:
E vesX No
14" + l-
feet
feei
Comments (on condition ofjoints, venting, evidence of leakage, etc.)
Apparent good condition
tsinsp.doc.rsv 7/262018 Titb 5 Ofiio.l lnsp€.ro Fom: SubGLn.@ S€u,ego oispolal Svstsm ' Pag€ I of 18
State
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 11 North Main St.
Property Address
Amy Adamaitis and Shawn Gartner
Ownels Name
S. Yarmouth,Ma 02664
City/Town Zip Code
D. System lnformation (cont.)
6. Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
X concrete ! metal
8"
! fiberglass ! polyethylene E other (explain)
feet
lf tank is metal, list age years
ls age confirmed by a Certificate of Compliance? (attach a copy of certificate) fl Ves I No
1500 gallon
Sludge depth:o
Distance from top of sludge to bottom of outlet tee or baffle 26"
Scum thickness 1t2"
Distance from top of scum to top of outlet tee or baffle 6"
Distance from bottom of scum to bottom of outlet tee or baffle 16"
How were dimensions determined?Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffie condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Normal liquid level No sign of leakage SCH 40 pVC ouflet tee
Recommended next maintenance pumping within 1.5 years
Recommended maintenance pumping every 2-3 years
l5iBp doc . Gv 726lmr6 Tille 5 Or'cial rrup€dion Fom: S!b!uf..a S€ryag. Dispo!€t Syridn . pag€ 10 ot I I
Owner
information is
required for every
page.State
4t4t2024
Date of lnspedion
Dimensionsl
5$' Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 11 North Main St.
Property Address
Amy Adamaitis and Shawn Gartner
Owner
information is
required ior every
page.
Owne/s Name
S. Yarmouth,
City/Town
Ma 02664 4t4t2024
Zip Code Oate of lnspeclion
D. System lnformation 1cont.)
7. Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
! concrete fJ metat ! fiberglass I pofethylene n other (explain)
feet
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of construction:
E concrete E metal ! fiberglass fl polyethylene n other (explain)
Dimensions:
Capacity:
Design Flow
gallons
gallons Per day
Itla 5 ofrrcial h.Pection Fom: Sublldsco 56 'ag6 DFrssl svstdn ' Pag€ 1 1 of 1 I
tsinsp d@ . r6v. 7,26/201 3
Title 5 Official lnspection Form
State
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurlace Sewage Disposal System Form - Not for Voluntary Assessments
1'l 'l North Main St.
Property Address
Amy Adamaitis and Shawn Gartner
Owner
information is
required for every
page.
Owne/s Name
S. Yarmouth
City/Town
Ma 02664 4t4t2024
D. System lnformation (cont.1
8. Tight or Holding Tank (cont.)
Alarm present:
Alarm level:
Date of last pumping
fl Yes E tto
Alarm in working order:
Date
Comments (condition of alarm and float switches, etc.)
* Attach copy of current pumping contract (required). ls copy attached? n Yes E ruo
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.):
OK condition
No scum
l outlet
No sign of leakage
t5i^6p.do., rcv t D6/2a1 O IiU€ 5 Oftciar lrupedion Fom: Subsldscs S€'rage Dbposal SFlam . p6g€ 12 or 1E
State Zip Code Date of lnspection
EYes EHo
Grade to box 16"
Normal Iiquid level
No sign of failure
5$. Commonweatth of Massachusetts
Title 5 Official lnspection Form
Property Address
Amy Adamaitis and Shawn Gartner
Owneds Name
S. Yarmouth,Ma 02664 4t4t2024
City/Town State Zip Code Date of Inspeclion
D. System lnformation (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: E Yes E lto'
Alarms in working order: ! Yes E Ho'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
" lf pumps or alarms are not in working order, system is a conditional pa$.
1 1 . Soil Abgorption System (SAS) (locate on site plan, excavation not required)
lf SAS not located, explain why:
Typel
tr
x
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:
4
tsinsp doc. rsv 7/26/2018 Tnb 5 Ofiiciel lnsr€ction Fom Slbsurf6€ Sry696 OisposalSysl6m ' Page 13 ol lA
Subsurface Sewsge Disposal System Form - Not for Voluntary Assessments
1 1'! North Main St.
Owner
information is
requirod for every
page.
A. Commonwealth of tlassachusetts
Title 5 Official lnspection Form
Subsurface Sewage Dbposal System Form - Not for Voluntary Assessments
1 'l'l North Main St.
Property Address
Amy Adamaitis and Shawn Gartner
Ownels Name
S. Yarmouth,Ma 02664 4t4t2024
City/Town State Zip Code Date of lnspection
D. System lnformation (cont.)
11. Soil Absorytion System (SAS) (cont.)
comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition ofvegetation, etc.):
4, Hi Cap H-20 Enviro Chambers with stone
Grade to SAS 22" lnspection port to grade Bottom 39,, Dry
No staining observed
No sign of hydraulic failure
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 f] Yes ! tlo
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
tsinsp doc. rev 7262018 Till€ 5 Official lns!€dion Fom: Subslda.s S€waq€ OBposar Swt6m . paoe 14 or 1a
Owner
information is
requi.ed for every
page.
5$, Gommonwealth of Massachueetts
Title 5 Officia! lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 1 1 North Main St.
Property Addrcss
Amy Adamaitis and Shan n Gartner
Owner
infomalion is
required for every
page.
Owne/s Name
S. Yarmouth,
City/Town
Ma 02664 4t412024
State zip Code Date of lnspeclion
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
tsinsp doc . .6! 726,2014 Tilb 5 OfF.ial hsp€<tion Fom: Su&r,f@ Saa!€ OisPosalSy3i€m ' Pag615 ot 1a
A, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System FoIm - Not for Voluntary Assessments
111 North Main St.
Property Address
Amy Adamaitis and Shawn Gartner
Owner
information is
required for every
page.
Owneis Name
S. Yarmouth,Ma 02664 4t4t2024
City/Town Zip Code Date of lnspedion
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
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 separately
te,r
,(n
,r,,I
6l'lro11
ti ?trP
?d(k
,l t b4
,?t
H
A B
I h 7-t nq-t,
2 53-o 3 6-z
3 lvt e 6-8
1 t{ 7-tt 5C -'
6
tsinso doc , @v 7l26l2o1a Titb 5 Oflicjal lrup€dim Fomr Subsrrtace S6rag€ Dilpo3€t SFt6.tr . pag6 16 ot 18
State
5
I
I
I
I
I
I
I
I
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'I 11 North Main St.
Property Address
Amy Ademaitis and Shawn Gartner
Owner
inlormation is
required for every
page.
Ownels Name
S. Yarmouth,
City/Town
Ma 02664 4t4t2024
Zip Code Date of lnspeclion
>5
feet
Please indicate all methods used to determine the high ground water elevation
X Obtained from system design plans on record
2000lf checked, date of design plan reviewed oate
! observed site (abufting propertyiobservation hole within 150 feet of SAS)
X Checked with local Board of Health - explain:
Plan on file
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
n
tr
You must describe how you established the high ground water elevation
Elevations from the design plan
Bottom of SAS ELV. 95.58
Bottom ofTest Hole ELV. 89.7
Separation >5'
Before filing this lnspoction Report, please see Repod Completeness checklist on next page.
t5nsp doc. @ 726P018 Irtls 5 ofdallnspoction Fm Sub$rfaca S€wa!€ Disposal Sysi.m ' Pa96 17 of 18
St'dtB
D. System lnformation (cont.)
15. Site Exam:
! check Slope
E Surface water
X Check cellar
E Shallow wells
Estimated depth to high ground water:
5s. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 11 North Main St
Property Address
Amy Adamaitis and Shawn Gartner
Oarner
information is
required for every
page.
Owne/s Name
S. Yarmouth,Ma 02664 41412024
City/Town State Zip Cod€Date of lnspedion
E. Report Completeness Checklist
Complete all applicablo sections of this form inclusiye of:
E A. lnspector lnformation: Complete all fields in this section.
E B. Certification: Signed & Dated and j, 2, 3, or 4 checked
X C. lnspection Summary:
1, 2, 3, or 5 completed as appropnate
4 (Failure Criteria) and 6 (Checktist) compteted
E 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 dG. Ev 7t26l2o18 Title s OfficiEt tnspacrion Fonn: Slbsudec€ 5€$?96 Oisposal Systgln . pao6 18 o,1s