HomeMy WebLinkAboutInspection Report 03_25_2025€i Commonwealth of Massachusetts
.: Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Ptr
HEALTI
40 Thacher Shore Road, Yarmouth
Property Address
John & Patricia Randall
Owners Name
40 Thacher Shore Road. Yarmouth
Crty/Town
Pqt
Port
M-121
Owner
anformation is
required lor every
page
IVIA
State
02675
Zip Cade
March 25. 2025
Date of lnspection
A. lnspector lnformation
tqy Wlllams
Name of lnspeclor
Troy Wlliams Septic lnspections
Company Name
19 Hummel Drive
compani nooress
South Dennis
aityrrown
{qq8) !q5 : 1300
Telephone Number
lmpodant: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
02660
Zip Cooe
License Number
*,4
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 tnspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this anspection I have determined
that the system:
1. I Passes
2. f] Conditionally Passes
3. fl Needs Further Evaluation by the Local Approving Authority
a fl rairs
1)z*;lnspector's SignatuF
March 75,2025
Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. lf the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer. if applacable, and the approving authoraty.
lsr.sp dft. r6v 7,26,i2018
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.
MA
State
sr682
Please note: This report only describes conditions at the time of inspection 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.
T l.5 OfiELal lnspeclion Fom Su$udsce S€wag€ Oisposal Syslem ' Pag€ r or la
C:,. CommonwealthofMassachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road, Yarmouth Port M - 121
Property Address
John & Patricia Randail
Owneis Name
P-6s
Owner
information is
required for every
pa9e.
40 Thacher Shore Road, Yarmouth Port MA
Stat;
02675 March 25,2025
City/Town Zip Code Date of lnspeolion
C. lnspection Summary
lnspection Summary: Complete 1, 2, 3, or 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 exlst. Any failure criteria not evaluated are
indicated below.
Comments:
System meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditons 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.
IY IN D ND (Explain below):
t5,nsp doc . rcv 7/26/2018 f(le 5 OfilcEI lrcpeciEn Fom Subsldaco S.*age DEposal Syster ' Page 2 ot 18
E One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. lf "not
determined," please explain.
The septic tank is metal and over 20 years old. or the septic tank (whether metal or not) is struclurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the exrsting tank is replaced with a complying septic tank as approved by the Board of
Health.
1s' Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road, Yarmouth Port
Propeny Address
John & Patricia Randall
P-65
Owner
inlormation is
requrred for every
page.City/Town
t\4A 02675
2ip Cooe
March 25, 2025
Date of lnspeclion
Ownels Name
40 Thacher Shore Road, Yarmouth Port
State
2) System Conditionally Passes (cont.):
n 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):
n broken pipe(s) are replaced n Y n N E ND (Explain below):
tl obstruction is removed n Y n N n ND (Explain below):
tr distribution box rs leveled or replaced I Y D N D ND (Explain below):
E 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):
! broken pipe(s) are replaced tr V n N I ND (Exptain betow):
n obstruction is removed f] V n N f] ND (Exptain betow):
3) Further Evaluation is Required by the Board of Health:
! Conditions exist which require further evaluation by the Board of Health in order to determtne 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:
Tnlo 5 Oltic a lnsp.cuon Fom Subsufsce Sewage Disposat Sysrem . Pag€ 3 ol 1 I
Title 5 Official lnspection Form
M:121
C. lnspection Summary (cont.)
!5 nsp doc. rev 7/2612018
€:\ CommonwealthofMassachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Owner
information is
required for every
page.C jty/Town
40 Thacher Shore Road. Yarmouth Port
Propedy Add.ess
John & Patricia Randall
Owner's Name
40 Thacher Shore Road, Yarmouth Port
M-121 P-65
MA 02675 MqIqlL25,2025
State Zip Code Date of lnspection
C. lnspection Summary (cont.)
n Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Watet Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety 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.
n The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
n The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
fl 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 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 ofthe analysis must
be attached to this form.
4) System Failure Criteria Applicable to All Systems:
You Eug! indicate "Yes" or "No" to each of the following for 3l! inspections:
Yes No
f, A Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waterstl lz:i due to an overloaded or clogged SAS or cesspool
I5nsp doc . rev 7/26|20l I Tille 5 Offr.El tnspecton Fom Slbsldace Sewage oEPosl Syslem ' Pag€ 4 ol 18
c. Other:
5}, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road, Yarmouth Port
Property Address
John & Patricia Randall
Owseis Name
40 Thacher Shore Road, Yarmouth Port
M-121 P-65
Owner
information is
required for every
page
MA
State
0267 5
Zip Code
March 25. 2025
Date of Ihspection
C. lnspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
trxnxnanx
tra
NX
NE
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. ffhis
system passes if the well water analysis, performed at a DEP certified
laboratory, for tecal 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 tailure 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 deslgn flow of 2000 gpd-
10,000 gpd.
The system lailg. I have determined that one or more ofthe 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 a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section C.4.
Yes No
n tr the system is within 400 feet of a surface drinking water supply
x
tr
tr
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
tha Y2day llow
Required pumping more than 4 times in the last year /VOf 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 wathin 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.
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 ol a public water supply well
T 1e 5 Oll c a lnspecl on Form Subsurlace Sewage Drsposal System ' Page 5 ot I I
nn
t5.sp do.. rev 7/26/2018
City,,rown
€\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form . Not for Voluntary Assessments
40 Thachel Shole Roadl Ya!:moulh Port
Property Address
John & Patricia Randall
Owner's Name
40 Thacher Shore Road, Yarmouth Port
City/Town
MA 0267 5 March 25 2025
State Zip Code Date of lnspection
M-121
Owner
information is
required for every
page.
6
C. lnspection Summary (cont.)
lf you have answered "yes" to any question in Sectuon C.5 the system is considered a significant
threat, or answered "yes" to any question in Section C.4 above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional offrce of the Department.
You must indicate "yes" or "no" for each of the following for a/ inspections:
Yes No
A n 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 t] Has the system received normal flows in the previous two week period?
T-t M Have large volumes of water been introduced to the system recently or as part ofLJ rzir this inspection?
M T-t Were as built plans of the system obtained and examined? (lf they were notu5r t'J available note as N/A)
B tr Was the facility or dwelling inspected for signs of sewage back up?
tr n Was the site inspected for signs of break out?
A n Were all system components, excluding the SAS, located on site?
X n Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
an 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 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 rs al issue
approximation of distance is unacceptable) [310 cMR 15.302(5)]
tra
x
r5Lnsp doc. re! 7/26l20j0 T e 5 Offrcral Inspection FormrSubs!.iace Sewage OcposalSyslem, Page6o118
P-65
tr
5},,. CommonwealthofMassachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road, Yarmouth Port M-121
Property Address
John & Patricia Randall
Owner
information is
requlred for every
page City/Town
Owner's Name
40 Thacher Shore Road, Yarmouth Port t\44 02675 March 25, 2025
State Zip Code Date of lnspection
D. System lnformation
'1. Residential Flow Conditions:
Number of bedrooms (design). 3 Number of bedrooms (actual)
DESIGN flow based on 310 CMR 1 5.203 (for example: 1 10 gpd x # of bedrooms):
Description:
Number of current residents:
Does residence have a garbage grinder?
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:
Sump pump?
Last date of occupancy
3
2
nvesX ruo
n ves X tto
n yes B r.ro
Sves[]no
nYesX No
25 = 1 '1 8,000 gal
24 = 109,000
fl ves El No
occup!ed
Date
tsinsp doc ' rev 7i26l2018 Tdle 5 Oflicial l4speclon Fom Subsurface Sewage DlsposalSvsl€m ' Page 7 of 1a
330 gpd
$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road, Yarmouth Port M - 121 P-65
Property Address
John & Patricia Randall
Owner
information is
required for every
page
Ownels Name
40 Thacher Shore Road Yarmouth Port
City/Town
0267 5 March 25, 2025
Slate Zip Code Date of lnspec{ion
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:
lnduskial waste holding tank present?
Non-sanitary waste drscharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use:
Other (describe below):
N/A
Gallons per day (gpd)
DvesI No
nvesE No
[]ves[ ruo
Evesn ruo
Date
3. Pumping Records:
source of information: P!:l[tpe! in fa
Was system pumped as part of the inspection?
lf yes, volume pumped: gitons
How was quantity pumped determined?
Reason for pumping:
ll 2024 per owner
nvesX ruo
rsnsp doc. rev 7/26/2018 Till6 5 Oftrcdi lnspeclon Forn Subsu.la@ S*age OrsposslSystgm. PagE 8oi l8
5f1. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road, Yarmouth Port M - 121
Property Address
John & Patricia Randall
P-65
Owner
informalion is
requred foa every
page.
Owner's Name
40 Thacher Shore Road, Yarmouth Port t\lA 02675 March 25, 2025
City/Town State Zip Cade Date of lnspection
D. System lnformation (cont.)
4. Type of System:
tr Septic tank, distribution box, soil absorption system
n Single cesspool
n Overflow cesspool
n Privy
tr Shared system (yes or no) (ifyes, attach previous inspection records, if any)
tr 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
n Tight tank. Attach a copy of the DEP approval.
X Other (describe):
mp chamber / no d-box
Approximate age of all components, date installed (if known) and source of information
Plmp ang lgeghlng-were installed to existing tank (712et87)on 716118 per as-built
il Yes X trtoWere sewage odors detected when arriving at the site?
5. Building Sewer (locate on site pian):
Depth below grade:
Material of construction:
E cast iron EI40 PVC n other (exptain)
18"
iaat
Distance from private water supply well or suction line: feer
Comments (on condition of joints, venting, evidence of leakage, etc.):
Lines were found clear at the time of inspection.
t5 nsp doc. rev 7/2612018 T,Ue 5 Ori c a lnspect or Fom Subsuriace Sewaqe Drsoosa System . Paqe I of I 8
ef Commonwealth of Massachusetts
Title 5 Official lnspection Form({
,r,1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road, Yarmouth Port
Owner
information is
required for every
page.
Property Address
John & Patricia Randall
Ownefs Name
40 Thacher Shore Road
City/Town
Yarmouth Port r\1A
State
0267 5
Zia Cade
M-121 P-65
March 25 2025
Date of lnspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
E] concrete n metat
H-20 Grade
lf tank is metal, list age
Sludge depth
18" with riser to grade
feel
[ fiberglass f] polyethylene D other (explain)
ls age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensrons: l ooo gallon
nvesn no
Distance from top of sludge to bottom of outlet tee or baffle
Scurn thickness thln layeJ
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]
be/measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pvc inlet and outlet tees were found present and in working order. Filter was clean on inspection. No
evidence of leakage or damage was found
2' 8"
6,nsp doc...v 7E€,/20r 8 T le 5 ofloal l.sp€dD. Fom Subsudace S€wage O,spoer Syst4 . Pa!€ 10 oi 1 8
Gi,s
How were dimensions determined?
5fl1' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Owner
intormation is
required for every
page
40 Thacher Shore Road, Yarmouth Port
properti Aoa,ess
John & Patricia Randall
Owner's Name
40 Thacher Shore Road. Yarmouth Port
City/Town
M-121 P-65
MA 0267 5 March 25, 2025
State Zip Code Date of lnspection
D. System lnformation (cont.)
7. Grease Trap (locate on site plan)
Depth below grade:
Material of construction:
n concrete n metal
N/A
n fiberglass n polyethylene n other (explain)
N/ADimensions:
Scum thickness
Distance from top of scum to lop of outlet tee or baffle
Distance from bottom of scum to boltom of outlet tee or baffle
Date of last pumping:
N/A
N/A
N/A
N/A
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
lrquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
8. Tight or Holding Tank (tank must be pumped at time of anspection) (tocate on site plan)
Date
Depth below grade:
Material of construction:
fl concrete I metal
N/A
[ fiberglass I po[ethylene n other (exptain)
Dimensions:
Capacity.
Design Flow:
NiA
N/A
Eailons
N/A
gallons per day
Tille 5 Official lnspection Form: Subsurfaco Sewage Oisposar Syslsm . Pag€ 1 1 ot 1 Ilslnsp doc. rev 7/262018
.(:. Commonwealth of MassachusetG
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road, Yarmouth Port M - 121 P-65
Property Add.ess
John & Patricia Randall
Owner
information is
req!ired for every
page.
Owner's Name
40 Thacher Shore Road, Yarmouth Port
City/Town
t\44 0267 5 March 25 2025
State Zip Code Date of lnspection
D. System lnformation (cont.)
8. Tight or Holding Tank (cont.)
Alarm present:
Alarm level N/A Alarm in working order: ! Yes E f.to
N/ADate of last pumping Date
Comments (condition of alarm and float switches, etc.):
N/A
- Attach copy of current pumping contract (required). ls copy attached? [ Yes I No
9. Distribution Box (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert
Comments (note if box is level and dishibution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No d-box
! Yes INo
ls,nsp doc . rev 7/2€r20i8 T{te 5 Ofi'oall.spedEn fom Subsu'rae Sesage O'sposarSysiom ' Pa9612 or 18
5\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road, Yarmouth Port M - 121
Property Address
John & Patricia Randall
Owners Name
P-65
Owner
infomation is
required for every
page.
40 Thacher Shore Road, Yarmouth Port
City/Town
0267 5 March 25,2025
State Zip Code Date of lnspection
D. System lnformation (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: E Yes n ruo-
Alarms in working order: fi Yes D No.
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump and alarm (on outside wall) were found in working order at the time of inspection. Cover to
grade.
- 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:
Type
n
x
n
n
il
n
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:
lsrnsp dcc. rev 7/262018 Tire 5 Otlioal lnspetion Fo.m Su&!da.e Sewaq€ DisposaiSystem. Page 13o118
20 Arc 36
Chambers
25'X 11 3',X 7'
(.:. CommonwealthofMassachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road, Yarmouth Port M - 121 P-65
Properiy Address
John & Patricia Randall
Owner
information is
required for every
page.
Owner's Name
40 Thacher Shore Road, Yarmouth Port MA 02675 March 25, 2025
City/Town Stale zip Code Date of lnspeclion
D. System lnformation (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of sorl, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil was sandy. Chambers were dry on inpection with no evidence of hydraulic failure or problems in
the past found at the time of inspection.
'i2. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration N/A
N/ADepth - top of liquid to inlet invert
N/ADepth of solids layer
N/ADepth of scum layer
N/A
Dimensions of cesspool
N/A
lndication of groundwater inflow n yes n llo
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
l5nsp doc' rev 7/26/2018 Trlle 5 Offclallnspecl oa Fom Subsurlaco S€wage D sposar Svstem ' Page 14 ot 18
Materials of construction
s' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sowage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road Yarmouth Port M-121 f,-b5
Property Address
John & Patricia Randalt
Owner
information is
required for every
pago.
Owneis Name
40 Thacher Shore Road
City/Town
, Yarmouth Port MA 02675 March 25 2025
State Zip Code Date of lnspeclion
D. System lnformation (cont.)
13. Privy (locate on site ptan)
Materials of construction:
Dimensions
Depth of solids
N/A
N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc. ):
N/A
lsitup d@, e. 71261018 T(rB 5 Onciar hspBction Form. subsulrc! s6w6g6 D6pos6l syslsm . pag6 15 o, 1g
(i- \Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurtace Sewage Disposal System F-orm - Not for Voluntary Assessments
40 Thacher Shore Road
Properiy AddA; -- --
John & Patricia Randatl
Yarmouth
Owner
information is
required for every
page.
Ownefs Name
40 Thacher Shore Road, Yarmouth Port March 25 2025City/Town State Zip Code Date of lnspeclion
D. System lnformation (cont.)
14. Sketch Of Sewage Disposat System:
Provide a view of the sewage disposal system, including ties to at least two permanent referencelandmarks or benchmarks. Locate all wells within 100 feet. Locate where pu'Uti" *iter irlfry entersthe building. Check one of the boxes below:
X hand-sketch an the area below! drawing attached separately
/"|-,,zl.u - t
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3
hr^ LL
IIT
t5nspdoc..ev 7/26/2016 TilLe 5 Ofiicral lnsp€clion Fori: Subsuri6ce S€wage Disposal System . PaS616 o, 18
M-121 P-65
MA 02675
_l
I
3)' CommonwealthofMassachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road, Yarmouth Port M - 12'1 P-65
Owner
information is
required for every
page City/Town
P.operty Address
John & Patricia Randall
Owneis Name
40 Thacher Shore Road, Yarmouth Port MA 0267 5 March 25. 2.025
State Zip C<rde Date of lnspection
D. System lnformation (cont.)
15. Site Exam:
X Check Slope
I Surface water
fl Check cellar
fl Shattow wetts
Estimated depth to high ground water:feet
tr
Please indicate all methods used to determine the high ground water elevation
X Obtained from system design plans on record
2t22t18lf checked, date of design plan reviewed Date
A Observed site (abutting property/observation hole within 150 feet of SAS)
tl Checked with local Board of Health - explain:
Checked with Iocal excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
System installed to plan in 2018 with a minlmum of 4.0' seperation from the established high
groundwater level.
Before filing this lnspection Report, please see Report Completeness Checklist on next page.
l5os0 doc . rev 712612018 Tdre 5 Olticiar lnspeclim Fom Subslrlace SewagB DisposalSFlem . Page r7 or la
see plan attached
n
€i Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Thacher Shore Road, Yarmouth Port M - 121 P-65
Property Address
John & Patricia Randall
Owner
information is
required for every
page.
Owner's Name
40 Thacher Shore Road, Yarmouth Port
City/Town
02675
Zip Code Date of lnspection
MA
State
March 25,2025
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
Xl A. lnspector lnformation: Complete all fields in this section.
I B. Certification: Signed & Dated and 1,2, 3, or4 checked
X C. lnspection Summary:
1 ,2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
Xl 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
l5r.sp Ce. rev 712612018 Tiue 5 Ottc,al lcpocrrc^ Fom: Subsudsco Saage O'spos! Syslem. Pag€ 18 ol18
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