HomeMy WebLinkAboutTitle 5 Inspection Form 860 RT 285s' Commonweatth of Massachusetts
Title 5 Official lnspection Form JAN 11 2023
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
860 Rt 28 Maytag Bldg
Property Address
HEALTH DEPT,
Owner
information is
required for every
pa9e
Owner's Name
South Yarmouth Ma 02664 1-O-2?
City/Town State Zip Code Date of lnspection
D. System lnformation (cont.)
'10. Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
Comments (note condition of pump
! Yes ! llo-
! Yes E ruo-
dition of pumps and appurtenances, etc.):
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- 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 whyi
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Type
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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:
3
15 nsp doc. rev 7/25/2013 TiUo 5 Ofliciai lnspo.tion Fofin Subsudacs Sewag€ DEposal Sysiem . Pag6 13 ol 18
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5fu, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
860 Rt 28 Maytag Bldg
Property Address
Owner
information is
required tor every
page
Owner's Name
South Yarmouth [,/]a 02664 1-9-23
City/Town Stale Zip Code Date of lnspection
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 is 3 Flow diffusers, flows are clean and dry with no sign of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuratton
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 E yes E ruo
comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc. ):
15nsp doc rev 726,2018 Till6 5 Otlcral lnspection Fom Slbslrfa@ S*age O6posalSystsm . PaOe 14 or 18
A' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fo;m - Not for Voluntary Assessments
860 Rt 28 Maytaq Bldq
Property Address
Owner
information is
required for every
page.
Owner's Name
South Yarmouth t\4 a 02664 1-9-23
City/Town State Zip Code Date of lnspection
D. System lnformation (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.):
t5.sp doc. rev 7/2612018 Title 5 Official lnspection FolY'n Subsud.co Sowaga 9lsposatSyslem . page 15 of 1E
5fu. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
860 Rt 28 Maytag Bldg
Property Address
Owner
information is
required for every
page.
Ownels Name
South Yarmouth Ma 02664 1-9-23
Crty/Town State Zip Code Date of lnspection
D. System !nformation (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:
hand-sketch in the area below
drawing attached separately
xtr
t5 nsp doc. rev 7/26/2018 T ne 5 Official lnsp6cl on Fom Subsudace Sewage Oisposa Syslem . Page 16 oi 1 I
$' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
860 Rt 28 Maytag Blds
Property Address
Owner
information is
required for every
page
Owner's Name
South Yarmouth Ma 02664 1-9-23
City/Town State Zip Code Date of lnspection
D. System Information 1cont.;
't 5. Site Exam:
El Check Slope
X Surface water
El Check cellar
X Shallow wells
Estimated depth to high ground water:8'
feet
X Observed site (abutting property/observation hote within 150 feet of SAS)
tr Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explarn:
tr
n
You must describe how you established the high ground water elevation.
Hand augered with ground water at 8' bottom of flow is 38"
Ad.lustment is 2.3, that puts ground water at 5.7 wilh 2' l" seperation
Before filing this lnspection Report, please see Report Completeness Checklist on next page.
lsinsp doc. rev 7/26/201E Titl6 5 Official lnspeclion Form: Subsurfac! S ag€ Disposal Syslsm ' Page 1 7 ot 1 8
Please indicate all methods used to determine the high ground water elevation:
! Obtained from system design plans on record
lf checked, date of design plan reviewed: oate
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
860 Rt 28 Maytag Bldg
Property Address
Owner
information is
required for every
page
Owneis Name
South Yarmouth
City/Town
Ma 02664 1-9-23
Stale Zip Code Dale of lnspection
E. Report Gompleteness Checklist
Complete all applicable sections of this form inclusive of:
X A. lnspector lnformation: Complete all fields in this section.
X 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
X D. System lnformation:
For 8: TighVHolding 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
tsi.spdoc..ev 7/2612018 Tille 5 Otliclal tnspeclion Fom: Subsudace Sewage Otsposatsyslsm . page 18 of 18
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HIGH GROUND.WATEB LEVEL COMPUTAT ION
,4vt <I ,rru )\Lol Nq
Address:
Conuactor:
Notes:
STEP 1
SYEP 2
STEP 3
STEP 4
STEP 5
t>/z>
month/Y€ar
Maasure dePth to watcr table
ro nearest I /10 tt. ..................
Using water'Level R ange Zone
and lndex Well MaP locate
site and determine:
Aoorooriale index v,/ell,',',.,, " "' '
Water.level range 2one ...... .,,. '
Uring monlhlY rcPort "Cu rrent
Water Resou.cei Condilions"
determin. curtent depth to
waler level fgr indcx well . ....
Using Table o{ Water'level Adiu3tmentt
lor ind€x well (STEP 2A), currenl deplh
ro watel levet fot index well {SIEP 3),
and water'level zone (STEP 2B)
dcrermino w:te, level adiuatrnenl .... ... .
E3timate depth lo high waler
by subt.ecting rhe water'
l€vel adiustment (STE P 4)
from measured depth to waler
l.vel at site (STEP 1) ...
.....0ate
monrh/daY/Y.ar
2rto/
Figure 13.-Reproducible compulation lo,m.
15
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