HomeMy WebLinkAboutTITLE_5_INSPECTION_STAVE PATHCommonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessm ts
5 Stave Path
t ?o?i
DlProperty Address
Roland & Terry Hatch
Owner's Name
W Yarmouth,0267 5 7t31t2025CityllownStateZip Code Date of lnspection
lnspection results must be submitted on this form. Inspection forms may not be altered in anyway. Please see completeness checklist at the end of the form.
A. Inspector lnformation
Darrell Stone
lvla
lmpo.tant: V\,/hen
fllling out fo.ms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
Name of lnspector
Cape Cod Septic lnspection
Company Name
P.O. Box 1466
Company Address
Harwich Ma 02645
City/Town
(508) 240-2500
State
st4995
Zip Code
Telephone Number License Number
B. Certification
l-c9lti-i/ !!at I am a DEP approved system inspector in full compliance with Section ,15.340 of Tifle s(310 cMR 15.000); I have personally inspected the sewage disposil system at the property addresslisted above; the information reported below is true, accurate and comflete as of the time of myinspection; and the inspection was performed based on my training and experience in the prop'er functionand maintenance of on-site sewage disposal systems. After conduiting this inspection I have determined
that the system:
1. fi Passes
2. n Conditional
3. I Needs
4 F
luation by the g Authority
of Health or DEP) within 30 days of compteting this inspection. If 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 inspection and under theconditions 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.
8t2t2025
natu Date
e system inspector hall submit a copy of this inspection report to the Approving Authority (Board
Pass
er
tsinsp d@ ' rev 7262018 Title 5 Ofiicid l.specllo. Fom Subsurfae Seage D srosa Systen . Page 1 ot 18
Owner
information is
required for every
page.
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Di8posal System Fom - Not for Voluntary Assessments
5 Stave Path
Property Address
Roland &Jerry Hatch
Owner
information is
required for every
page.
Owner's Name
W. Yarmouth.7131t2025
City/Town State zip Code Date of lnspection
C. Inspection Summary
lnspection Summary: Complete 1 , 2, 3, or 5 and all of 4 and 6
1) System Passes:
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.
Comments
2) System Conditionally Passes:
! 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 structurally
unsound, exhibits substantial infiltration or exfilhation or tank failure is imminent. System wili 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 inspection if it is shucturally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
EY nN I ND (Exptain betow):
Irnsp doc. rev 7,26,2018 Ttle 5 Ofllclai lnsp€ction Fom Subsurfae Sewago Oispos€tSystem. pa96 2 of 18
Ma 02675
Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fbrm - Not for Voluntary Assessments
5 Stave Path
Property Address
Roland & Terry Hatch
Owner
informataon is
required for every
page.
Ownels Name
W Yarmouth Ma 02675 7 t31t2025City/Town Zip Code Date of lnspeclion
C. lnspection Summary (cont.)
2) System Conditionafly passes (cont.):
! eump Chamber pumps/alarms not operational. System will pass with Board of Health approval ifpumps/alarms are repaired.
fJ Observation of sewage backup or break out or high static water tevel in the distribution box dueto broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System wlttpass inspection if (with approval of Board of Health):
tr broken pipe(s) are reptaced tr V tr N n ND (Exptain betow):
tr obstruction is removed D V tr lf ! ND (Explain below):
tr distribution box is leveled or replaced E V E ru E ND (Explain below):
! The system required pumpin-g.more than 4 times a year due to broken or obstructed pipe(s). Thesystem will pass inspection if (with approvat of the Board of Health):
tr broken pipe(s) are reptaced E y E N ! ND (Exptain betow):
D obstruction is removed tr y ! N E 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 determine ifthe system is failing to protect public health, safety or the environment.
a. system will pass unress Board of Hearth determines in accordance with 310 cMR15:303(1Xb) that the system is not functioning in a manner which will protect public health,safety and the environment:
lsnsp d@. r6v 7/26/2018 Titl€ 5 Oni.€ lnspe<ton Fom: Subsurfa@ Swale Orspost Sysrom . p.oe 3 ot i 8
State
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fom - Not for Voluntary Assessments
5 Stave Path
Property Address
Roland & Terry Hatch
Owner
information is
required for every
page
Ownefs Name
W Yarmouth,Ma 02675 7 t31t2025
Cityfown State Zip Code Date of lnspec{ion
G. Inspection Summary (cont.)
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 Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
f] 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 septlc tank and SAS and the SAS is within a Zone 1 ol 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.
fl The system has a septic tank and SAS and the SAS is tess than 100 feet but 50 feet or
more from a private water supply well'..
lvlethod 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 nihate nikogen 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 Applicabte to A[ Systems:
You muat indicat o each of the following for 3l! inspections:'
Yes No
n X Backup of sewage into facility or system component due to overioaded or
clogged SAS or cesspool
tr X Discharge or ponding of effluent to the surface of the ground or surf;ace watersdue to an overloaded or clogged SAS o. cesspool
tsinsp doc ' rev 7261201a Tiil6 5 ofrici.t lrcp€dEn Fm: Subssrece saa!€ Dbrrosar system . peoo 4 c,r 1a
Commonweatth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System FLrm - Not for Voluntary Assessments
Property Address
Roland &Terry HatchOwner
information is
required for every
page.
Owneis Name
W. Yarmouth.Ma 0267 5 7t31t2025City/Town State Zip Code Date of lnspectionc.t nspection Summary (cont.)
4) System Failure Criteria Appticabte to A[ Systems: (cont.)
static Iiquid lever in the distribution box above ouflet invert due to an overroadedor clogged SAS or cesspool
Liquid depth in cesspool is less than 6,,below invert or avaitable votume is tesslhan /. day flow
Required pumping more than 4 times in the last year /VOIdue to clogged orobstructed pipe(s). Number of times pumped:
Any portion of the SAS, cesspool or privy is below high ground water elevation.
l,1l p-o_np" of cesspool or privy is within 1OO feet of a surface water suppty ortnbutary to a surface water supply.
Any portion of a cesspool orprivy iswithin aZonelof a public water supplywell
Any portion of a cesspool or privy is within 50 feet of a prjvate water supply well.
Any portion of a cesspool or privy is less than 1OO feet but greater than SO feetIrom a prrvate water supply well with no acceptable water quality analysis. ffhissystem passes if the well water analysis, performed at a DEp certifiedla-boratory, for fecal coliform bacteria indicates aOsent inOlhe presenceof ammonia nitrogen and nitrate. nitrogen is equal to orl"", ir,.n S ppr,provided that no other failure criteria ire triggered. A copy of tne anilysisand chain of custody must be attached to th-i; form.I
The system is a cesspool serving a facility with a design flow of 2000 gpd-10,000 spd.
The system fails. I have determlned that one or more of the above fajlurecriteria exist as described in 3iO CMR 15.303, therefore tnrsviiem fails. Thesystem owner should contact the Board of Health to determin; what will benecessary to correct the failure.
5) Large Systems: To be considered^a rarge system the system must serye a facirity with adesign flow of 10,000 gpd to 15,000 gpdi
For large systems, you must inoicate eitier..yes., or,,no,, to each of the foflowing, in addition to thequestions in Section C.4.
Yes No
nn
trtrtrn
Yes
tr
D
tr
tr
!
tr
tr
tr
No
x
x
tr
x
a
x
x
x
X!
the system is within 400 feet of a surface drinking water suppty
the system is within 2OO feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (lnterim Wellhead protection
nrea - l\rVPA) or a mapped Zone ll of a public water suppty we
Tiu6 5 OffEial lnspscrion Form: Subsudacg Sewage Disposa Systerrl . pag€ s or 1E
tsinsp do. ' r6v 7/261201 I
5 Stave Path
l \ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 Stave Path
Property Address
Roland & Terry Hatch
Ownea
information is
required for every
page.
Owner's Name
W. Yarmouth,Ma 0267 5 7 t31t2025
City/Town State Zip Code Date of lnspeclion
6
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 fail;d. Theowner or operator of any large system considered a signiflcant threat under section c.5 or failed
under section c.4 shall upgrade the system in accordance with 310 cMR 1s.304. The system ownershould contact the appropflate regional office of the Department.
You must indicate "yes" or "no" for each of the following for a/ inspections:
Yes No
tr tr Pumping information was provided by the owner, occupant, or Board of Health
! X Were any of the system components pumped out in the previous two weeks?
n ! Has the system received normal flows in the previous two week period?
T.l l'1 Have large volumes ofwater been introduced to the system recenfly or as part of
this inspection?
ly T-.1 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 for 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, located 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?
tr Was the facility owner (and occupants if different from owner) provided with
,nformation on the proper maintenance of subsurface se\Mage 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 lssue
approximation of distance is unacceptable) [310 CMR 15.302(5)]tr
15.sA do.. rc\ T/2612918 Titls 5 Ofiiciar l.sp€dion Fmr Subs!.f@ S*ege Dispolar Syslom. Pa!€ 6 ot 1a
C. lnspection Summary (cont.)
tr
x
A Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 Stave Path
Propedy Address
Roland & Terry Hatch
Owner
information is
required for every
page.
Ownels Name
W. Yarmouth,lvla 02675 7t31t2025
City/Town State Zip Code Date of lnspection
1. Residential Flow Conditions:
Number of bedrooms (design)nla Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15.203 (for example: 1'tOgpdx#of bedrooms)
Description:
3 bedroom residential dwelling
3
330
Number of current 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 inspection
information in this report. )
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
3
!vesfi No
!Yes[] No
!Yes[ ruo
!ves[ ruo
! ves I tto
E Yes X tto
Current
Date
tslnsp.doc..6v 72612014 Tnl6 5 Oftcial lnsp€clron Fom: Subsuda@ S€wage OsposatSystem. Pag6 7 or 18
D. System Information
Sump pump?
Last date of occupancy:
A. Gommonwealth of Massachusettg
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 Stave Path
Property Address
Roland & Terry Hatch
Owner
information is
required for every
page
t\ra 0267s 7 t31t2025
City/Town State Zip Code Date ol lnspection
D. System lnformation (cont.)
2. Commercial/lndustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seatsipersons/sq.ft., etc.):
Grease trap present?
Water treatmenl unit present?
lf yes, discharges to:
lndustrial waste 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)
Eyesn ruo
E vesn No
n Yes E t''to
E Yes E t'to
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:
Unknown
gallons
tsinsp doc . r€v 72612014 TiUe 5 Oticie lnspection Fom' Subs!,fa€ S€w.g€ Disposr System . Paq6 8 ot 1a
Ownels Name
W Yarmouth,
n Yes X tto
5s, Commonwealth of Massachusetts
Property Address
Roland & Terry Hatch
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Fo]m - Not for Voluntary Assessments
5 Stave Path
Owner
information is
.equired for every
page
Owner's Name
W. Yarmouth,l/a 0267 s 7 t31t2025
City/Town State Zip Code Date of lnspec,tion
D. System lnformation 1cont.)
4. Type of System:
X Septic tank, distribution box, soil absorption system
tr Single cesspool
n Overflow cesspool
tr
tr
tr
tr
Privy
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 latestinspection of the l/A system by system operator under contract
Tight tank. Attach a copy of the DEP approval.
Other (describe):
Approximate age of arr components, date installed (if known) and source of information
Cesspools pre 1978 , Leach pit 1989 per BOH
Were sewage odors detected when arriving at the site?
5. Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
! cast iron X 40 pVC I other (exptain)
Distance from private water supply well or suction line:
D YesI xq
24"-30"+t-
feet
Orangeburg
feet
Comments (on condition of joints, venting, evidence of leakage, etc.)
SCH 40 PVC line for the bathroom
Orangeburg line for the kitchen
Apparent good condition
lsins! doc. rev 712612014 Ttl€ 5 Officiai lnspGclon Fom: Subsldace SewaC€ Oisposat Sysrem . page 9 ot ta
5},, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Oisposal System Fo]m - Not for Voluntary Assessments
5 Stave Path
Property Address
Roland & Terry Hatch
Owner
information is
required for every
page.
Ownels Name
W. Yarmouth,Ma 0267 5 7 t31t2025
City/Town State Zip Code Date of lnspection
D. System lnformation (cont;
6. Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
! concrete I metal
feet
! fiberglass E polyethylene D other (explain)
lf tank is metal, list age years
ls age confirmed by a Certificate of Compliance? (attach a copy of certificate) ! yes ! No
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
ls'.sp doc. rev 7/2612018 Title 5 Ofiicial lnsp€ctlon Fom: Slbsurfa.€ S€^vage OafDsel Systom . Pa€e 10 of 18
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$. Gommonwealth of Massachusetts
5 Stave Path
Title 5 Official lnspection Form
Subsurtace Sewage Disposal Systom Form - Not for Voluntary Assessments
Property Address
Roland & Terry Hatch
Owner
information is
.equired for every
page.
Owner's Name
W. Yarmouth l\ila 0267 5 7 t31t2025
City/Town State Zip Code Date of lnspection
D. System lnformation (cont.)
7. Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
! concrete n metal
feet
! fiberglass E polyethytene n other (exptain)
Dimensions:
Scum thickness
Distance from top of scum to top of ouflet tee or baffle
Distance from bottom of scum to bottom of ouflet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,Iiquid levels as related to ouflet invert, evidence of leakage, etc.):
8' Tight or Holding Tank (tank must be pumped at time of inspection) (rocate on site pran):
Depth below grade.
Material of construction:
! concrete ! metal [ fiberglass ! potyethytene ! other (exptain)
Dimensions:
Capacity:
Design Flow
gailons
gallons per day
tslnso doc..sv 712612013 T.nle 5 Clfliciai tnspEcio. Foin Subsuda@ S€wag6 Disposat Syslem . page 1 1 ot 1 8
A Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 Stave Path
Property Address
Roland & Terry Hatch
Owner
information is
required for every
page
Owner's Name
W. Yarmouth.
City/Town
Ma 0267 5 7 /31t2025
State Zip Code Oate of lnspeclion
D. System lnformation (cont )
Alarm present:
Alarm level:
Date of last pumping
E Yes n r.to
Alarm in working order:! Yes E t'lo
Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). ls copy attached? ! Yes E 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 distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
15.sp.do.. rev 7262018 Title 5 Officia lnspeclion Fomr Subs!'1@ S€page Dlspoel SF16m . Pag. 12 of 1 I
8. Tight or Holding Tank (cont.)
5$, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 Stave Path
Property Address
Roland & Terry Hatch
Owner
information is
required for every
page.
Owneds Name
W. Yarmouth,
City/Town
Ma 02675 7t3112025
Zip Code Oate of lnspeclion
D. System lnformation (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: E yes E No.
Alarms in working order: E yes n ruo-
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 pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required)
lf SAS not located, explain why:
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:
Islnsp d@. rev 7262018 Tille 5 Ofiicial lnsp€cuon Fom Slbsrtae Seaoe Dispoe System . page 1 3 or 1 a
State
Type:
tr
tr
tr
tr
n
tr
n
I
1
A.. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsur{ace Sewage Dispoaal System Form - Not for Voluntary Assessments
5 Stave Path
Property Address
Roland & Terry Hatch
Owner
information is
required for every
page.
Ownels Name
W. Yarmouth,
City/Town
Ma 02675 7131t2025
State Zip Code Date of lnspeclion
D. System lnformation 1cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
1, H-20 (4x6') pit with stone
Grade to SAS 27" Cover 6" Bottom 85" Ponding 28"
Sidewall staining around 2" higher
No sign of hydraulic failure
'1, (5x4') Overflow Cesspool also handles the kitchen sink
Grade to CP 13" bottom 72" Ponding to outlet invert Structurally sound
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration 2 in series
Depth - top of liquid to inlet invert JO
Depth of solids layer 10"
Depth of scum layer 4"
Dimensions of cesspool (5xs')
Materaals of construction Cesspool Block
lndication of groundwater inflow ! Yes X lto
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Grade to Cesspool 25" Cover to grade Bottom 92" Structurally sound
Ponding to outlet invert
lsi.sp de. ev 7126D018 T e 5 Ofiicial lnspeclion Fom Subsu.rae Sewage Oisposel Syslom . P39614 ofla
1fu,, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 Stave Path
Property Address
Roland & Terry HatchOwner
informatioh is
required for every
page.
Owneis Name
W Yarmouth,lvla 02675 7131t2025
City/Town State Zip Code Date of lnspeclion
D. System lnformation 1cont.)
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.):
6rnsp de. rev 7t242018 Tnb 5 Oficial l.specl@. Fom SubsurleG Swage O s@sa Syslem . Page 1 5 ol 1 a
5\ Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 Stave Path
Property Address
Roland & Terry Hatch
Owner
information is
required for every
page.
Ownels Name
W. Yarmouth,t\4 a 0267 5
City/Town State Zip Code Date of lnspeclion
D. System lnformation (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage djsposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within lOO feet. Locate where public water supply entersthe building. Check one of the boxes below:
xx hand-sketch in the area below
drawing attached separately
K Qa/
n
k
C?\QL
3ot{togr kjlct,,a
A BIl2-L Vz-z-
2 2r-L .28 -8
3 L/1- €'?-0-6
4
5
5
15)..p do. . t6v T126/201A Tille 5 Oftcl6l lnspoclron Fom: Subsurfa@ S€w.86 Disposl Sy.lem . PaO6 16 of 1e
7 t31t2025
I
LP
6, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 Stave Path
Property Add.ess
Roland & Terry Hatch
Ownefs Name
W. Yarmouth,Ma 0267 5 7t31t2025
City/Town State Zip Code Date of lnspection
>0.1
feet
Please indicate all methods used to determine the hjgh ground water elevation
tr Obtained from system design plans on record
lf checked, date of design plan reviewed:
tr Observed site (abufting property/observation hote within 150 feet of SAS)
A Checked with local Board of Health - explain:
Test hole results from previous ins
n Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
See below
You must describe how you established the high ground water elevation
Elevations from USGS maps are approximate
Property ELV. 21.0
Bottom of CP1 ELV. 13.34
Bottom of CP2 ELV. 13.92
Boftom of LP ELV. 15.O
GW ELV. 8.0
Adjustment = 2.3' MIW-29 Zone B 7.99, June 2025
Separation >0.1'
Before filing this lnspection Report, please see Report completeness checklist on next page.
lsinsp doc . rev 72d2o1a Tiile 5 Ofiidallnspecllon Fom Subsudsce Sewags DisposatSystem. pag€ 17 or 18
Owner
information is
required for every
page.
D. System Information (cont.)
15. Site Exam:
! Check Slope
! Surface water
X Check cellar
E Shallow we s
Estimated depth to high ground water:
Date
x
A. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 Stave Path
Property Address
Roland & Terry Hatch
Owner
nformation is
required for every
page
Owner's Name
W. Yarmouth
City/Town
Irrla 0267 5 7131t2025
State Zip Code Date of lnspeclion
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
xI A. lnspector lnformation: Complete all fields in this section.
E B. Certiflcation: 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 (Checktist) completed
I 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
tsdsp doc. 161 7D6DA18 TirleS Ofiici.l hspection Fom Subsuda6 Sewag€ Dispo$tSystem. page lEoflE