HomeMy WebLinkAboutTitle 5 Inspection 3 Duffy 20225fl' ' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Oisposal System Form - Not for Voluntary Assessmenls
3 Duffy Road
Property Address
June Carmel
Owner's Name
Yarmouth MA 02673 1119t2022
City/Town State Zip Code Date of lnspectaon
lnspection results must be submitted on this form. lnspectior forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. lnspector lnformation
Petri* Rutledge
Name of lnspector
Title Five Specialisls
lmportad: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.Company Name
22 Tafi
Cornpany Address
Dorchester MA 02125
City/Town
5082374628
State
st14198
Zip Code
Telephone Number License Number
B. Certification
2. E Conditionally Passes
3. E Needs Further Evalualion by the Local Approving Aulhority
+. E Faits
11t10t2022
lnspector's Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Boardof Health or DEP) within 30 days of completing this inspection. lf the system has a design flbw of10,000 gpd or greater, the inspeclor and the system owner shall submit the report to th; eppropriateregional ofnc€ ofthe DEP. The original form shoutd be sent to the system owner and copied sent tothe buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under theconditions of use at that time. This inspection does not address how tte system will perform
in the future under the same or ditrerent conditions of use.
tslnso doc' |!v 72612018 lde 5 ofrciallnsp€cto^ Fom subsud.ce s66?ge DEpoel sysEm . FEge 1 of 18
Owner
information is
required for every
page.
r',l
E_l
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 lrue, accurale and complete as of the time of my
inspection; and the inspection was performed based on my training and eperience in the proper fundion
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
i. E Passes
A.' Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Duffy Road
Property Address
June Carmel
Owner
inforrnation B
requir€d for every
page.
Owner's Name
Yarmouth
City/Town
MA 02673 11t9t2022
State Zip Code Dale of lr6pection
C.lnspection Summary
lnspeciion Summary: Comdete 1,2, 3, or5 and all of 4 and 6.
1) System Pass€s:
E 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.
Gomments
2) System Conditionally Passes:
E One or more system componenls 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 les', '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 nol) is struc*urally
unsound, exhibits substantial infiltration or exfiltration 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.
' A metal septic tank will pass inspecrion if it is structurally sound, not leaking and if a Certmcate of
Comdiance indicating that the tank is less than 20 years old is available.
trv EN I ND (Explain below):
6inspdo.. r* 7/2612018 'l'iUe 5 OrEid l.s!€1ih Fom Slbsrxrace Sarage Diepo6el SFlrn. Pag€ 2 of 16
jL,. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Duffy Road
Property Address
June Carmel
OrYner
inforrBtion b
requfed tor every
page.
Owner's Name
Yarmouth MA 02673 11t9t2022
City/Town State Zp Code Date of lnspection
c. lnspection summary (cont.)
2) System Conditionally Passes (cont.):
E Pump ChamDer pumps,/alarms not operational. Sy$em will pass with Board of Health approval if
pumpyalarms are repaired.
E ObseNation of sewage backup or break out or high sdatic water level in the distribution box due
lo broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspeclion if (with approval of Board of Heatth):
tr broken pipe(s) are replaced tr Y tr N E trtO (Exptain betow);
tr obstruction is removed ! Y tr N E ND Gxptain below):
A distribution box is leveled or redac€d trY trN E ND (Exdein betow):
D-box is ovemrown and damaged by rools, recommend replacement
fl Tne sysem required pumping morc than 4 times a year due to bmken or obstructed fipe(s). The
system will pass inspection if (with approval ofthe Board of Health):
tr broken pip€(s) are replaced tr Y tr N E ND (Explain betow):
tr obstruclion is removed tr Y tr N ! ND (Exptain betow):
3) Fur$er Evaluation is Required by the Board of Health:
I Conditions exist which require funher evaluation by the Board of Heatth in order to determine ifthe system is failing to protecl public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 3iO CMR
15.303(1Xb) that the system is not functioning in a manner which will protect public health,safety and the environment:
tsinsp d@. B 726l2ora f!d6 5 Or{rd tnsrerd Fojh:Sut6ur@ Ss.ag€ Dtrrogt Sysb.n. page 3 or 13
5s.' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fo]m - Not for Voluntary Assessments
3 Duffy Road
Property Address
June Carmel
Owner
inforrnation is
required for every
pa9e-
Owner's Name
Yarmouth MA 02673 11t9t2022
City/Town State Zip Code Oate ot lnsp€ction
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 satt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
detemines that the system is functioning in a manner that protects the public health,
safety and environment:
fl 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.
E The system has a septic tank and SAS and the SAS b within a Zone 1 of a public waler
supply.
E The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
E The sysem 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 bacleria indicates absenl and the presence of ammonia nilrogen and nitrate nitrogen is equal
to or less lhan 5 ppm, provijed that no other failure criteria are triggered. A copy of the analysis must
be aftached to this form.
c. Othen
4) System Failure Criteria Applicable to All Systems:
You @! indicate each of the following for 4! inspections:
Yes No
tv| Backup of sewage into facility or system component due lo overloaded orr'J r r clogged SAS or cesspool
tvl Discharge or ponding of effluent to the surface ofthe ground or surface watersIJ IAr due to an overloaded or clogged SAS or cesspool
tsinsp doc. B 7261118 Ir0e 5 OtrEid lnspeton Form: Sub6udace Seiage Disposal Sysgn . Page 4 of 18
g}. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Dasposal System Form - Not for Voluntary Assessmenls
3 Dufry Road
Propedy Address
June Carmel
Owner
infornration as
required tor every
page.
O,vner'S Name
Yarmouth
City/Town
02673
Zip Code Date of lnspection
c. lnspection summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
trtr
!a
trE
trtr
trtr
trtrntr
trtr
tr E
Any portion of a cesspool or privy is less than 100 feet but greaterthan 50 feet
from a private weter supply tivell with no acceptable water quality analysis. [Thissystem passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the prcsence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no otherfailure criteria are triggered. A copy ofthe analysis
and chain of custody must be attached to this form.]
The system is a cess@ol seMng a facility with a design flow of 2000 gpd-
10,000 gpd.
The system fails. lhave delermined that one or more ofthe above failure
criteria exist as described in 3'10 CMR'15.303, therefore the system fails. The
system owner should contact the Boerd of Heatth to detemine what will be
necessary to cor,bct the failure.
fl a
5) Large Systems: To bo conside.€d a large system thc system must serve a facility with a
design flow of i0,000 gpd to 15,000 gpd.
For large sysiems, you must indicate either }es" or "no' to each ofthe following, in addition to the
queslaons in Seclion c.4.
Yes No
n tr the system is within 4OO feet of a surface drinking water supply
Stetic liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cEsspool
Liquid depth in cesspool is less then 6" below invert or availaue volume is less
than % day flow
Required pumping more than 4limes in the last year rVOf due to clogged or
obstruded 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 of a public water supply
well.
Any portion of a cesspool or privy is within 50 feel of a privale water supply well.
the system is within 200 feet of a tributary to a surface drinking water supply
the system is localed in a nitrogen sensitive area (lnterim Wellhead proteclion
Area - |\A/PA) or a mapped Zone ll of a public water supply well
Trde 5 Oftc,at hsp€clon Fom Subslfae 56€9€ O6posat Srsre.n . page S ot i 8
trtr
tsnsp doc . .e 7€612014
trtr
11t9t2022MA
State
i}. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Nol for Volunlary Assessments
3 Duffy Road
Propedy Address
June Carmel
Owner
information is
required for every
page-
Owner's Nafile
Yarmouth MA 02673 1119t2022
City/Tovrn State Zip Code Date of lnsp€clion
o
C. Inspection Summary (cont.)
lf you have answered'yes" to any question in Seciion C.5 the syslem is considered a signmcant
threat, or answered "yes' to any queslion in Section C.4 above the large system has failed. The
owner or operator of any laEe syslem considered a signifcant threat under Sedion C.5 or failed
under Seciion C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Departmenl.
You must indicate 'yes" or "no" for each of the following for afl inspections:
Yes No
B tr Pumping information was provided bythe owner, occupant, or Board of Health
tr tr Were any of lhe system components pumped out in lhe previous two weeks?
tr E Hasthe syslem received normal flows in the previous two week period?
T-.t |vl Have large volumes of waler been intmduced to the svstem recenlly or as part of
this inspedion?
re Were as built plans of the sysitem obtained and examined? (lf they were notr r L-r available note as N/A)
A tr Was the facility or dwelling inspecied for signs of sewage back up?
E tr Was the site inspected for signs of break oul?
EI tr Were all system components, exduding the SAS, located on site?
tr tr Were the septic tank manholes uncovered, opened, and the interior of the tank
inspecied forthe condition ofthe baffles ortees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
trtr Wasthe facility owner (and occupants if different from owner) provided with
information on the prop€r maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Exisiing information. For example, a plan at the Board of Heatth.
Determined in lhe field (if any of the failure qiteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)l
E tr
a
tainsp do. . H 72612018 Ltle 5 O{6crd lnspeclio. FqB Sut6!'rae Sa*.se Disposd Syss, . tuse 6 ot 18
fI
5}i Commonweatth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Duffy Road
Property Address
June Carmel
Ownea
inforrEtion is
required lor every
page.
Owner's Name
Yarmouth MA 02673 11t9t2022
City/Tov{n State Zip Code Oate of lnspection
D. System lnformation
1. Residential Flow Conditions:
Number of bedrooms (deson): 2 Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms):
Description:
2
220
0Number of cunent residents:
Does residence have a garbage grinder?
Does residence have a water treatment unit?
lf yes, discharges to:
ls laundry on a separate sewage system? (lnclude laundry system inspeclion
information in this report.)
Laundry syslem inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
E yesX No
[3 ves ffi 16
Sump pump?
Lasl date of occupancy
EyesE No
NA
Date
tSnspdoc.B 7/26,2O1a Td.5 OFl6d lcp€cton Fdn1: Sub6urtac6 S6ia9€ Dispo€al SysEn. page 7 ot 18
IYesfi No
fl ves [ ruo
E ves E tto
; _,?.,
---.--_--'T_
5}. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Duffy Roacl
Property Addr6s
June Carmel
Owner
information is
required for every
page
Owner's Name
Yarmouth MA 02673 11t9t2022
City/Tovrn State Zip Code Date of lnsp€ction
D. System lnformation (cont.)
2. Commerciaulndustdal Flow Conditions:
Type of Eslablishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/personysq.fl., etc.):
Grease trap present?
Water treatment unit present?
lf yes, discharges lo:
lndustrial waste holding tank present?
Non-sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/us€:
Other (describe below) :
Gallons per day (gpd)
Evesn No
E vesE No
I vesn No
E Yes E tto
Date
3. Pumping Records:
Source of information:
Was system pumped as part ofthe inspeciion?
lf yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
EvesE Ho
gallons
t5nsp@.8 12612018 Tjde 5 oflicjal lnsFction Fom: Su!€sdace &,age Oispoel sFEn. F'age I ot 18
ft. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Duffy Road
Property Address
June Carmel
Owner
informtion -B
required for every
page.
Owner's Narne
Yarmouth
City/Town Zip Code Date of lnspection
D. System lnformation 1cont.;
4. Type of System:
tr Septictank, dislribution box, soil absorption system
tr Single cesspool
C Overflow cesspool
D Privy
tr Shared system (yes or no) (f yes, attach previous inspedion records, if any)
t] lnnovative./Altemative technology. Attach a copy ofthe cunent operation and
maintenance contraci Go be obtained from system orvner) end a copy of latest
inspeciion of the yA syslem by system operator under contract
tr Tight tank. Attach a copy ofthe DEP approval.
tr other (describe):
Approximate age of all components, date inslalled (f known) and source of information
2000
Were sewage odors detec{ed when afiiving at the site?
5. Building Scwer (locate on site plan):
Depth below grade:
Material of construc{ion :
E cast iron El40 PVc E other (exptain)
Distance from private water supply well or suction line:
E Yes [t tto
'1.5'
feet
feet
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
No Leakaoe noted
tsinsp doc. r* 712612018 I'de 5 Ofircial lnsp€.ron Fom: S!b6!.face SeEge Disposat Sysbm ' Page 9 ot l8
MA
Slate
02673 11t912022
Ai Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Duffy Road
Property Address
June Camel
Owner
information is
required for every
Pa9e.
11t9t2022
State Zp Code Oate of lnspectionCity/Town
D. System lnformation 1cont.1
6. Septic Tank (locate on site plan):
Depth belorv grade:
Material of construdion:
E concrete E metat E noerglass E polyethylene E other (explain)
1
feet
years
ls age confirmed by a Ceruncate of Compliance? (attaci a copy of certificate)
1500 Gal
n Yes E tlo
Dimensions:
Sludge depth:
Dislance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Dislance from top of scum to top of outlet tee or bame
Distancr fmm bottom of scum to bottom of outle{ tee or bafne
How were dimensions delermined?
4
JJ
8"
14"
Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to orrllet invelt, evidence of leakage, etc.):
Outlet in good shape, Liquid level with outlet, No evidence of leakage, Recommend pumdng now and
every two years
tsinsp.do.. rev 712642018 Irt€ 5 offcial lnspeciion Fo.m. Subcu.f.ce Saag€ Disposal sy*'n ' Fase 10 o, 18
Owner's NarE
Yarmouth MA 02673
lf tank is metal, list age:
1'.
5[. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Dufry Road
Propedy Address
June Carmel
Owner
infornBtion is
required for every
page.
Owner's Narne
Yarmouth
City/Town
MA 02673 11t9t2022
State Zip Code Date of lnspection
D. System lnformation 1cont.1
7. Grease Trap 0ocate on site plan):
Depth below grade:
Material of construdion:
E concrete E metal fl fiberglass fl polyethylene I olher (explain):
feet
Dimensions:
Scum tnickness
Distance from top of scum to top of outlet tee or baffle
Distance fmm bottom of scum to botlom of outlet tee or bame
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, struclurel integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (lank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of conslruction :
E concrete E metal E fiberglass E polyethylene E other (explain)
Date
Dimensions:
Capacity:
Design Flow:
gallons
gallons per day
,]i{i! 5 O{tcil lcpecton Fom: Sub6u*.ce Se*age epel Sysirn . ftg! 1 I oi 186insp (bc. lev 7/262018
1$. Gommonweatth of MassachusetG
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Duffy Road
Property Address
June Carmel
Ownet
information b
required for every
page.
Owner's Name
Yarmouth MA 02673 11t9t2022
City/Town State zip Code Date of lnsp€ction
D. System lnformation (cont.)
8. Tight or Holding Tank (cont.)
Alarm present:
Alarm level:
Date of last pumping:
n ves El tto
Alarm in working order fl Yes E ruo
Date
Commenls (condilion of alarm and noat switches, etc.)
'Attach copy of cunent pumdng contract (required). ls copy attachedZ I yes E t'lo
Depth of liquid level above outlet invert
Comments (nole if box is level and dislribution lo outlets equal, any evidence ofsolids carryover, any
evidence of leakage into or out of box, etc.):
Damaged Dbox,recommend replacement
t5hsp dr. B 7126rola Tide 5 Official lnspedion Fo.h: Sua6llfa@ S6^2ge O6!el SFbn . tuac 12 ol 1 8
9. Distribution Box (if present must be opened) (locate on site plan):
Level
5flf Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Duffy Road
Property Address
June Carmel
Owner
inforrEtaon is
required for every
page.
O!Yne{'s Name
Yarmouth 02673
City/Towl Zp Code
D. System lnformation 1cont.;
10. Pump Chamber (locate on site plan):
Pumps in working order: I Yes E tto-
Alarms in worting order: EI Yes E wo*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
" lf pumps or alarms are not in worting order, system is a conditional pass.
11. Soil Absorption System (SAS) (ocate on site plan, excavation not required):
lf SAS not located, explain why:
leaching pits
leaching chambers
Ieaching galleries
leaching trenches
leaching Relds
overflow cesspool
i nnovative/a[temative syslem
Typelname of technology:
5
isihsp.doc. td 7D6r2O1A ]-de 5 Oflicisl lnsp€ction Fom: Sub6ufa.e Serage Disp@l Slsbrn . PEge 13 of 1A
MA
Slate
't'U9t2022
EA;of tnspection
-
Type:
u
tr
tr
tr
tr
!
tr
number:
number:
number:
numb€r, length:
number, dimensions:
number:
j*'.. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Duffy Road
Property Address
June Carmel
Owner
infonnation is
required for every
page.
Owner's Name
Yarmouth MA 02673
City/Town State Zip Cde
D. System lnformation 1cont.;
1 1. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegelation, elc-):
Dry soil, No s(ln of failure, normal grass veg, some rools have grown into the leaching system-
Recommend removino the trees and veg itation sunoundinq the leaching system
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and conf,guration
Depth - top of liquid to inlet inved
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of conslruciion
Indication of groundwater inflow E yes !No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
ftnsr<k!. ra 7/'262018 Irt€ 5 Off.ial lnspecin Folm:Sut6ud.e Ser.g€ OEpcel SFbrn . PaS€ 14 of 16
11t9t2022
Date of lnsp€dion
fi. CommonwealthofMassachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fo]m - Not for Voluntary Assessments
3 Road
Property Address
June Carmel
Owner
inforrnation b
required for every
pa9e.
Owner's Name
Yarmoulh MA 02673 11t912022
City/Town State Zip Code Date of lnspection
D. System lnformation 1cont.1
13. Privy (locale on site plan):
Materials of construclion :
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
6lnspdoc.B 726f2018 Td6 5 Oficd lEp.ctoi Fom Slt6ufae S6ia9E Duposal SFErn . ElE t5 oa 18
5}, Commonweatth of Massachusetts
Title 5 Official lnspection Form
subsuface Sewage Disposal System Form - Not for Voluntary Assessments
3 Duffy Road
Property Address
June Carmel
OYfier
information is
required for every
page.City/Town
MA 02673 11t9t2022
State Zip Code Date of lnsp€clion
D. System lnformation 1cont.1
14. Sketch of sewage Disposal system:
Provide a view ofthe sewage disposal system, induding lies lo at leasl two permanenl reference
landmarks or benchmarks. Locate allwells within 100 feet. Locate where publicwater supply enters
the building. Check one ofthe boxes belor/:
trtr hand-sketch in the area below
drawing attached separately
6i.sp doc . B 7/26r'2o14 ftle 5 Official l.sp€to. Fom Sut6ufa@ Sgdage O6p@l SFte.n . Page 10 ol 1a
Owner's Name
Yarmodh
i[. Commonwealth of Massachusetts
Title 5 Official !nspection Form
Subsu,face Sewage Disposal System Form - Not for Voluntary Assessments
3 Duffy Road
Property Address
June Carmel
Owner
infomtion is
required for every
page.Crty/Town
MA 02673 11t912022
State Zip Code Date of Insp€ction
D. System lnformation 1cont.1
'15. Site Exam:
E check Slope
E Surface water
El Cnecr cellar
D Shallow wells
Estimated depth to high ground water:72"
feet
Please indicate all methods used to determine the hEh ground water elevation:
f] Obtained from system design plans on record
lf checked, date of design plan reviewed:Date
tr Observed site (abutting property/observation hole within 150 feet of SAS)
n Checked with local Board of Heanh - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
tr
tr
You must describe how you established the high ground water elevation:
Soil loo from olan
B€fo.€ filing this lnspection Report, pleas€ see Report completeness checklist on oert page.
tsrnsp .b. . lev 729m18 Iite 5 Omc1al lns!€.lion Fom:Sut6urface Saf,age Disposal Stsre.n . ttge 17 or 18
Owner's Name
Yarmouth
5}.' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposa, System Form - Not for Voluntary Assessments
3 Duffy Road
Property Address
June Carmel
Owner
information is
required for every
pa9e.
Owner's Name
Yarmouth
City/Tolvn
MA 02673 111912022
State Zip Code Oate ot lnspedion
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
El A. lnspeclor lnformation: Complete all felds in this section.
E B. Cenmcaion: Signed & Dated and 1, 2, 3, or 4 checked
X C. lnsp€clion Summary:
1, 2, 3, or 5 comdeted as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
E o. System lnformation:
For 8: TighuHolding Tank - Pumping contracl attached
Fo|l4: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of eslimated dedh to high goundwater included
6,nsp &c. B 7/2612018 Iile 5 Officrd lnspedio. Fom Sub6urfe Serale fr.pGalSysran . Page 16 of 18
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