HomeMy WebLinkAboutInspection Report 2024 April 235s. Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
p Road, South Yarmouth12 Pollock Ri M-98 P-74
Property Address
Edward Donovan
Owner
information is
required for every
page.
Ownels Name
12 Pollock Ri MA
siate
02664
Zlp Code
Road, South Yarmouth 4f].r2.,2024
Date of lnspection
lnspection results must be submitted on this form. lnspection forms may not be altered in any
way. Pleaae see completeness checklist at the end of the form.
A. lnspector lnformation
Ievlry!lliams
lmportant: When
filling out forms
on the computer,
use onlythe tab
key to move your
cursor - do not
use the retum
key.
Name of lnspector
T Wlliams Se tons
Company Name
19 Hummel Drive
Company Address
South Dennis MA
State
sr682
Zip Code
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); I have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. X Passes
2. E Conditionally Passes
3. n Needs Further Evaluation by the Local Approving Authority
APR 26 2024+. E Faits
June 27 . 2019
lnspecto 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 ofthe 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 describes conditions at the time of inepection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
lsnspdoc. rev 7262018 Iir 6 5 Ofi.El lnspsclLon Fom Subsud@ S€{age Drspo$lSystom' Pag€ 1 of 18
City/Tov,/n
02660ffiCity/Town
(508) 385 - 1300
REC
HEALTH DFP'
5fu. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Pollock Rip Road, South Yarmouth M-98 P-74
Property Address
Edward Donovan
Owner
inloamation is
required for every
page.
Owner's Name
12 Pollock Ri Road, South Yarmouth MA 02664 Aptll23, 2024
City/Town State Zip Code Date of lnspection
G.lnspection Summary
lnspection Summary: Complete 1 , 2, 3, ot 5 and all of 4 and 6
1) System Passes:
X 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:
System meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspectron is not a guarantee or warranty on the future working conditions of leaching, pipes,
components or the future structural integrity of said components and only represents conditions found
at the time of inspection only.
2) System Conditionally Passes:
' 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.
trY trN E ND (Explain below)
lsmsp .!oc. .6v 7/26/2018 T le 5 Onic€l lnspeclEn Fom SubsLrf@ S4ag€ Oisposl Syslom . Pag€ 2 ol 18
n One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. 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, ND) for the following statements. lf "not
determined," please explain.
The septic tank is metal and over 20 years old* o. the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exflltration 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.
5fu' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Pollock Rip Road,South Yarmouth M-98 P-74
Property Address
Edward Donovan
Owner
information is
required tor every
page.City/Town
Owner's Name
12 Pollock Rip Road, South Yarmouth 02664 Aptil23, 2024
State Zip Code Date of lnspeclion
C. lnspection 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, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
tr
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
E ND (Explain below)
E ND (Explain below)
E ND (Explain below)
trv
trY
trY
trN
trn
trN
! 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):
n broken pipe(s) are replaced ! Y tr N D ND (Exptain betow):
tr obstruction is removed trY trru E ND (Exptain betow)
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 system is not functioning in a manner which will protect public health,
safety and the environment:
tsinsp d@'rev 72612!18 TdE 5 Omoal lnspeclm Fom Subsurf@ S age Oi+osal Systd ' Pago 3 ol l8
Sr-\Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Owner
information is
required tor every
page.
12 Pollock Rip Road, South Yarmouth M-98 P-74
Property Address
Edward Donovan
Ownels Name
12 Pollock Rip Road, South Yarmouth 02664 Aptll23, 2024
City/Town State Zip Code Oate of lnspeclion
G. lnspection Summary (cont.)
tr Cesspool or privy is within 50 feet of a surface water
n 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)
dete;mines that the system is functioning in a manner that protects the 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.
! The system has a septic tank and SAS and the SAS is within a zone 1 of a public water
supply.
! The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
n The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
c. Other
.. This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform
-bacterra 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.
4) System Failure Criteria Applicable to All Systems:
You must indica or "No" to each of the following for all inspections:
Yes No
r-.r M Backup of sewage into facility or system component due to overloaded orLJ E)r clogged SAS or cesspool
r-.1 tvt Discharge or ponding of effluent to the surface of the ground or surface watersLJ rz)r due to an overloaded or clogged SAS or cesspool
15 nsp doc. r.v 7/26l2ola Till6 5 Offi.ial lnsp€.1ion Fom Subsurtac€ S€wage DsposalSyslem . Pag€ 4 ol18
more from a private water supply well**.
Method used to determine distance:
1fl\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Pollock Rip Road, South Yarmouth M - 98 P -74
Property Address
Edward Donovan
Owner
information is
required for every
page.
Owner's Name
12 Pollock Rip Road, South Yarmouth
City/Town State Zip Code Date of lnspeclion
02664 Apnl23,2024
C. lnspection Summary (cont.)
4) System Failure Criteria Applicabte to All Systems: (cont.)
Yes No
trx
trx
trtr
I]a
tra
trx
trx
trx 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. ffhissystem 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 analysls
and chain of custody must be attached to this form.l
The system is a cesspool servlng a facility with a design flow of 2000 gpd-
10,000 gpd.
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with adesign 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 thequestions in Section C.4.
Yes No
trtr the system is within 400 feet of a surface drinking water supply
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
Tilt€ 5 Officiat tnsp€cron Form Subsuda@ Sw.g€ DsposatSysrom. p€ge 5ol1a
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 I of a public water supply
well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
tr
x
isinspdoc. r6v. 7/2612018
trtr
x
tr
trtr
Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Pollock Rip Road, South Yarmouth M-98 P-74
Property Address
Edward Donovan
Owner
information is
required lor every
page.City/Town
Ownels Name
'12 Pollock Rip Road, South Yarmouth MA 02664 April23,2024
State Zip Code Date of lnspection
6
G. Inspection Summary (cont.)
lf you have answered "yes" to any question in Section C.5 the system is considered a significant
thieat, 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 tr Pumping information was provided by the owner, occupant, or Board of Health
tr X Were any of the system components pumped out in the previous two weeks?
X tr Has the system received normal flows in the previous two week period?
rsz Have large volumes of water been introduced to the system recently or as part ofLJ lal this inspection?
R-z Were as built plans of the system obtained and examined? (lf they were notlal l. available note as N/A)
E tr Was the facility or dwelling inspected for signs of sewage back up?
X tr Was the site inspected for signs of break out?
tr tr Were all system components, excluding the SAS, located on site?
X tr Were the septlc tank manholes uncovered, opened, and the interior ofthe tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
xtr 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) [310 CMR 1 5.302(5)]
tr
tsinsp do. ' rev 7/262018 Tirle 5 Ofiicial lnspeclion Fom Subsuriace S4ase Oisposai System ' Page 6 or 18
5\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
12 Pollock Rip Road, South Yarmouth M-98 P-74
Property Address
Edward Donovan
Owner
information is
required for every
pa9e.
Owner's Name
12 Pollo
City/Town
South Yarmouth MA 02664 Aptil23,2024
State Zip Code Date of lnspeclion
D. System lnformation
1. Residential Flow conditions:
2 Number of bedrooms (actual)
DESIGN flow based on 310 CMR 1 5.203 (for example: 1 10 gpd x # of bedrooms)
Description:
220 pet plan
2
220 g?d
1Number of current residents:
Does residence have a garbage grinde,
Does residence have a water treatment unit?
lf yes, discharges to N/A
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:
EYesX No
EvesX No
Sump pump?
Last date of occupancy
EyesXNo
occupied
lsnsp doc . rev 7/262014 Title 5 OffEEI lnspeclion Fom: Subslda@ Swage OisposalSyslom . Pag6 7 0118
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Number of bedrooms (design):
E Yes E tlo
XvesE Ho
EvesX No
23=26,000 gals.
??=4,oaq seE-
Date
(i\Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'12 Pollock Rip Road, South Yarmouth M-98 P-74
Property Address
Edward Oonovan
Otrrner
information is
required for every
page.
Owner's Name
12 Pollock Rip Road, South Yarmouth
City/Town
MA 02664 Aptil23, 2024
State Zip Code Date of lnspedion
D. System lnformation (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 to:
lndustrial waste holding tank present?
N/A
Non-sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use:
Other (describe below):
N/A
N/A
N/A
Gallons per day (gpd)
N/A
EvesE No
!vesE ruo
nvesE ruo
EvesE No
N/A
N/A
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:
No pumping info.
gallons
t5nsp do. ' rsv 72612018 Title 5 Otfroal lnspect@n Fm: Subsulacs Sef,a€€ DEposl Sy3iar1 . Psg€ 6 ot 1 8
E Yes X t',,to
5fu. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fo]m - Not for Voluntary Assessments
12 Pollock Rip Road, South Yarmouth M-98 P-74
Property Address
Edward Donovan
Owner
information is
required for every
page.
Owner's Name
12 Pollock Rip Road, South Yarmouth
City/Town
t\44 02664 Aptil23, 2024
State Zip Code Date of lnspeclion
D. System lnformation (cont.)
4, Type of System:
X Septic tank, distribution box, soil absorption system
tr Single cesspool
tr Overflow cesspool
tr Privy
tr Shared system (yes or no) (if yes, attach previous inspection records, if any)
lnnovative/Alternative 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
tr
tr
Tight tank. Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information
Tank,d-box and leaching were installed on 6/25187 per as-built
Were sewage odors detected when arriving at the site?
5. Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
I cast iron X +o pvC E other (exptain)
Distance from private water supply well or suction line:
18"
feet
feet
Comments (on condition ofjoints, venting, evidence of leakage, etc.)
Lines were found clear at the time of inspection.
l5msp doc. rev 7/26/2018 Tile5Ofi callnspeclonFom SubsurfEc€ SewageOisposalSystem.Page9of 18
Eves[ 1e
Efo. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Pollock Rip Road, South Yarmouth M-98 P-74
Property Address
Edward Donovan
Owner
information is
required for every
page.
owner's Name
12 Pollock Rip Road, South Yarmouth
City/Town
MA 02664 Aptil23,2024
State Zip Code Date of lnspeclion
D. System lnformation 1cont.1
6. Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
X concrete E metal
1'
feet
lf tank is metal, list age years
ls age confirmed by a Certificate of Compliance? (attach a copy of certificate) n yes ! ruo
Dimensions 1000 gallon
6"Sludge depth
Distance from top of sludge to bottom of outlet tee or baffle z', 6"
none
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 to
How were dimensions determined?probe/measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet !nvert, evidence of leakage, etc.):
Pvc inlet and outlet tees were found present and in worklng order. No evidence of leakage or damage
was found. Tank was not in need of pumping at this time.
tsiflsp doc . rev 7262016 T & 5 Ofl c a lnspetion Fornr: Subsurface Sewage Drsposal System ' Pag€ 1 0 ot 18
! fiberglass fl polyethylene E other (explain)
Scum thickness
$' Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Pollock Rip Road, South Yarmouth M - 98 P -74
Property Address
Edward Donovan
Owner's Name
12 Pollock Rip South Yarmouth
City/Town
MA 02664
Zip Code
Aptil23,2024
State Date of lnspection
D. System lnformation (cont.)
7. Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
E concrete ! metal
N/A
feet
! fiberglass E polyethylene ! other (explain)
N/A
N/A
N/A
N/A
N/A
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of construction:
E concrete ! metal
N/A
E flberglass ! potyethytene ! other (explain)
N/A
N/A
gallons
N/A
gallons per day
Tds 5 Otrciel l.sp€dion Form: Subsutaco S€wae€ Oisposl Syst€m . Pag6 I 1 ot 1 8ts,rsp doc ' r6v 7262018
Title 5 Official lnspection Form
Owner
information is
required for every
page.
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:
Dimensions:
Capacity:
Design Flow:
A Commonwealth of Massachusetts
Subsu ace Sewage Disposal System Form - Not for Voluntary Assessments
12 Pollock Rip Road, South Yarmouth M - 98 P -74
Property Address
Edward Donovan
Owner
information is
requared for every
page.
Owner's Name
12 Pollock Ri
Caty/Town
Road , South Yarmouth t\4A 02664 April23,2024
State Zip Code Date of lnspeclion
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present:
Alarm level:
Date of last pumping
N/A
E Yes Eto
Alarm in wo*ing order: ! Yes E ruo
N/A
Date
Comments (condition of alarm and float switches, etc.)
N/A
'Attach copy of current pumping contract (required). ls copy attached? E Yes n ruo
9. Distribution Box (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert level
t5msp dcc. rev 71612016 Till€ 5 Officrallnsp€clion Fom: Subsurlacs Ss*ag€ DEPoelSyslm . Pa9612 of 18
Title 5 Official lnspection Form
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 was found level and in working order.
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Pollock Rip Road, South Yarmouth M - 98 P -74
Property Address
Edward Oonovan
Owner
information is
required for every
page.
Ownels Name
12 Pollock Ri
City/Town
Road South Yarmouth 02664 tll23 2024
State Zip Code Date of lnspedion
D. System lnformation (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: E Yes E Ho'
Alarms in working order: E Yes ! ruo.
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
* 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:
Type
tr
tr
tr
tr
tr
tr
tr
leaching pits
leaching chambers
leaching galleries
leaching trenches
leaching fields
overflow cesspool
innovative/alternative system
Type/name of technology:
number:
number:
number:
number, length:
number, dimensions
number:
Itnsp doc . rcv 72612018 T(le 5 Otficial lnspeclion Fom su&ldac€ sswage olsposarsyslsm ' Psgs 13 ol 18
1 - 6'X6' pit with
2' of stone
g\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Pollock Rip Road, South Yarmouth M-98 P-74
Property Address
Edward Donovan
Owner
infomation is
required for every
page
Owner's Name
12 Pollock Rip Road, South Yarmouth MA 02664 April 23, 2024
Zip Code Date of lnspedion
D. System Information (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.):
Soil was sandy. Leach pit was found with 3.5' of water on inspection with a visible stain line approx.
18" below inlet invert. Pit was found structurally sound. No evidence of hydraulic failure or problems in
the past were found at the time of inspection.
Depth - top of liquid to inlet invert
N/ADepth of solids layer
Depth of scum layer N/A
N/ADimensions of cesspool
Materials of construction N/A
lndication of groundwater inflow ! Yes !ruo
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
lsinsp .,Dc. rov 72612018 Tnb 5 Onioallnsp€clim Fom Subsudace S€wag€ OGrosalSystm. P69€ 14 of18
City/Town State
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and conflguration N/A
N/A
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Pollock Rip Road, South Yarmouth M - 98 P -74
=--.-:
Property Address
Edward Donovan
Owner
information is
required for every
page.
Owner's Name
12 Pollock Ri Road South Yarmouth MA 02664 April 23 ,2024State Zip Code Date of lnspeclion
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
N/A
N/A
Comments (note condition of soil, signs of hydraulic fallure, level of ponding, condition of vegetation,etc.):
N/A
N/A
tsinso.doc . r6v. 7282018 Til€ 5 Officiitt hsprdion Fum: Subilrte g,s!mg6 Di.po65l Sy.tem . pag6 t 5 ot lO
City/Town
Commonwealth of Massachusetts
Title 5 Officiat lnspection FormSubsurface Sewage Disposal System F'orm - Not for Voluntaf Assessments
12 Pollock Rip Road, South Yarmouth M-98 P-74Property Address
Edward DonovanOwner
information is
required for every
pag€.
Owne/s NamE
12 Pollock Rip Road, South Yarmouth
City/Town 02664 April 23, 2024StateZip Code Date of lnspectionD.System Information (cont.)
14. Sketch Of Sewage Disposal System:Provide a view of the sewag. glip":lt system. including ties to at least two permanent referencetandmarks or benchmarks. Locate aI wels witnin roo rJ"i.-io"ate where prlri. *ri"i lr'piiv "i,t""the building. Check one of the boxes below:
El hand-sketch in the area betowLJ drawing attached separately
MA
3
I
u-L^- ti ," *_l
6'--L
0e.rc
nt.-?.f'3',
\' 20',1"
3' d3'
\t. 3t'
$ r " )o'7tr
4.t )Ltot
) t jgtLc
7. lu6.',
lsinsp doc . rcv.72ff2018 Trtlo 5 official lnspection Fom Subsuda€6 S61r,ag6 DispotalSyslom ' P.g€ 15 ol18
I
I
I I
l-*
---.1
s' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Pollock Rip Road, South Yarmouth M - 98 P -74
Property Address
Edward Donovan
Owner
information is
required for every
page
Owner's Name
12 Pollock Rip Road, South Yarmouth 02664 Ap(i\23, 2024
City/Town Zip Code Date of lnspeciion
D. System lnformation (cont.)
15. Site Exam:
X Check Slope
! Surface water
E Check cellar
n Shallow wells
Estimated depth to high ground water:11.5'+
feet
814186lf checked, date of design plan reviewed Date
X Observed site (abutting property/observation hole within 150 feet of SAS)
! Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
AIW 230 Zone C 25.5' 1.4' adjustment
Before filing this lnspection Report, please see Report completeness checklist on next page
You must describe how you established the high ground water elevation:
Test hole on plan showed no water found at 12.0'. Hand augered 4' below bottom of leaching with nowater found at a depth of 1 1.5'. Groundwater adjustment at the time of inspection was 1 .4'. Eottom ofleaching at 7.5'was found not to be located in the high groundwater elevation at the time ofinspection.
l5nsp doc ' rcv 726/2018
State
Please indicate all methods used to determine the high ground water elevation:
X Obtained from system design plans on record
tr
x
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5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Pollock Rip Road, South Yarmouth M-98 P-74
Property Address
Edward Donovan
Owner
intormation is
required for every
page.
Ownels Name
12 Pollock Rip Road South Yarmouth
City/Town State Zip Code Oate of lnspeclion
02664 Aptil23, 2024
E. Report Gompleteness Checklist
Complete all applicable sections of this form inclusive of:
I A. lnspector lnformation: Complete all fields in this section.
X B. Certification: Signed & Dated and '1, 2, 3, or 4 checked
X 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
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