HomeMy WebLinkAbout106 White Rock - T5 10.4.20255s, Commonwealth of illassachusetts
Title 5 Official lnspection Form
$ubcurfscs $ewaga Disporal Syat*m Form - Not frcr Voluntary Assessments
106 V$ite Rock Road
Property Addre*
Byyer - Rlck Tu
Orrner's Narne
RECEIVED
iul 1 4 ?026
HEALTH DEPT,
Owner
infumetion b
requittel for evcry
pes6.
lmPodant: Whon
filling out formc
on thc computer.
u8s only th€ lab
key to move your
cursor - do not
uso th6 rBtum
koy
Yq!ryr&Pst!.-_-
CltylTown Zip Code Dste of ldspectiofi
Ma
Staie
1At4t2025
lnapection reaults muct bs submittod on thie fom. lncpection formt mey not be altstod in eny
way. Fleaea aee comphtenets checkllat at the end of the form.
A. lnspector lnformation
Qha{ lfthaway
Narre of lnsgedor
Hathaway Septic Service LLC
Conrpany Name
P.O.Box 151
Forestdalq
City/Tryrn
Ma
silic
12866
02644
Zip Code
774 274 2581
Tebphone Number Licenss Numbor
B. Csrtification
I certify that I am a DEP approved eystem lnspoctor in full complianco wlth Sectlon 15.340 of Tith 5
(310 CtR t5.fitO); I haye personally inspected the sewage disposalsystem at the property address
listed above; the inbrmation reported belor is true, accurat8 and complete as of tho time of my
inspection; and ffre inspection was perbrmed based on my training and experience in the proper function
and rsintenance of on-site sewage disposal systems. After conducting tttis inspection I have determined
that the system.
1. Xl Passes
2. fl Conditionally Passes
3. n Needs Further Evaluation by the LocalApproving Authority
4. I Fails
lnqec;tor's Signature Date
The system inspector shall a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing thia inspection. lf the system has a tlesign 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 brm should be sent to the system owner and copbs sent to
the buyer, if applicable, and the approving authori$"
tgrtp.doc. r.v. 71g12fi8 T{b 5 Otrc8} lfirrd$fi Fcn. Sun6gllos g"r* DupolIl Srlian . p!9. 1 cf 18
I
10t4t2025
Plsaeo note: Thia rspofi only deecribee condltions at the time ol inrpection and under the
condltions of u*e at that time. This incpection dooo not addree* how tho *yatem wlll poriorm
in the future under the same or dlfferent conditiong of uee.
3fo, Comm*nwoelth of Maeeashuset&
Title 5 Official lnspection Form
$ubaurf*ca $crage Diepoeal Syatam Fonn - Not for Volufltary Asseserrpnts
106 S&ite Rock Road
Propery Address
Buyer - Rlck Tupper
{h*nor
in'foflration lr
requi&d fcr ov*ry
pags.
Ornsds Nsrp
Hi" ZrpcodeCitylToun Date of lnspeciion
C. lnepection $ummary
lnspection Summary: Complete 1, 2, 3, ar S and all of 4 and S
1| System Pas*ee:
ffi t trave not found any information whhh indicates that any of tha hilure crit*ria described
in 310 CMR 15.303 or in 310 CMR 1$.3CI4 exist. Any failure criteria not evaluated nre
indicated below.
Comments:
This inspection is not a guarantee and applies no warranty of the described septic components in this
report including but not limited to piping struc-tual intergrity of components and life exspectancy of
leaching and described components. Thi$ inspection is to describe conditions witnessed at tirne of
ins@tion only. Regular tank maintenanfe and rvater eonservation can prolong life of septie *ystems
. lnfsrmation on cars and du's and don't's can be found at town health dept ar rnsss.gov
,l $y*t*rn Gonditisn#ly Pnwes:
f] One or more tystem components as described in the "ConditionalPass's€ction nesd to be
re$aced or repaired. The systern, upon completion of the replaoernent or repair, as approved by
the Board of Health, will paas.
Check the box for "yes", *no'sr.not determined" (Y, l,l, ND) frrr tha following statBments. lf 'not
determined," please explain.
Th* septic tank is melal and over 20 yeam old" or the ssptic bnk {whether rnetal or not} i* etructurally
unsound, exhibits substantial infiltration or exfiltration or tank failure ie imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
' A nmtal septic txnk will pass inspection if it is Etructur*lly nound, not leaking and if a 0artificate of
Compliance indieating that the tank is less than 20 years old is available.
ilv trN xN0(Exprainberow):
lSrniF.doc. m 7/'J5r:O1E titla 5 OfrcOl bupeacn Fam; 3r.6errra Saage Oieo{d 3y&,n . pe.2 q, 18
1014t?:825
Commonwealth of MaseachusettB
Title S Official lnspection Form
$ubsuilaco Suwng* Oiapooal $yet*m Form - Not fCIr VCIluntary Assessm*nts
106 V\lhite Roclq Road
Property Addre*s
Buyer - Rlck Tupper
Orner
inlonnation b
rsqui$d fur s!,6ry
p8gc.
Oyrn6/s NamG
Yarylqut!'rpo-$.-
CifflTown
Ma 1AMnA25str6. i,pcii*e- -"Sst6 of lnspcttion
S. ln*pection Summary {nont.}
2l Syetcm Canditionelly Parea (cont.):
f] pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pump#-alarnts a re repaired.
f, Observation of sewage backup or break out or high static water level in the distribution box dueb broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. $yetem will
pa$$ inspection if (with approvalof Board of Health):
n broken pipe(s)are replaced f] V tr ft I Nn (Exptain betow]:
il obssuction is removed il V il N il fqn {Explain belowi:
n distribution box is leveled or replac*d il v il lt ff lrln {Explain belor):
D fne system required pumping more than 4 tines a year due to broken or obstructed pipe(s). The
system will pass inspeclion if (with approval of the Board of Health):
n brcken pipe(s) are reptaced tr V f] N I Xn (Exptain betowi:
n obstruction is rernoved fI V f] H fi zun {Exptain betow}:
3l Furthor Hvaluatlon is Requir*d by the Board of Health:
I Conditions exist which require further evaluation by the Eoard of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. Syatem will paee unlees Board of Heahh determinos ln accordance with 310 CnR
16.303{1Xb} thet th6 system ie not functi,oning in a mannor whlch urill protect publie hea}th,
aafoty and ths environment;
ls0sp.doc.ffi ?t6r?0'16 T(b 5 o'f*ral &trpacrro Fomr S'rb.{dm Sfl8lc ni{pG.l Sytlm . P.0r 3 d 18
S5, Commonrrealth of Maseachuaotts
Title 5 Official lnspection Form
$ubourface Sewaga Oiepoaal Syotnrn Form - Not for Valuntary Assessrnents
100 Vfiita Rock Road
Propcrt r\ddrEss -=.*--*-
Buyer - Rlck Tupper
Orner
information is
required for avery
p8ge,
Owne/* Name
Yarmouthport_
City/Toln
Ma 10t4pa25
Stste Zip Code Date of lrupoction
C. lnspection Summary {cont.)
Gesspool or privy is within 50 fuet of a surface water
n Cesspool or privy is within 50 het of a bordering vegetated wetland or a salt marsh
b. Syatem will fail unlees tho Boad of lloatth {and Publlc ltlater Supplier, lf any}
daterminos that tho system it functionlng in a rnannar thnt protectr tho public health,
calaty and envirnnmsnt:
il me $ystem hax a septic tank and **ilabcorption syatem {SAS) and the SAS is within
100 feet of a surface water supply or tribu&ry to a sudbca watar supply.
fJ The systom hax a septic tank snd $A$ nnd the $AS ie within a Zone 1 ol a public watar
$upply.
fJ The system has a neptie tank and $A$ and the $A$ is within $0 feet of a privale water
supply well.
fl fne system has a septic tank end $,4$ and the $A$ is less than 100 feet but 50 fuet or
mcre from a private water supply well'*-
Method used to deternnine distance:
*n This system passes if the well wat*r analysie, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of amrnonia nkogen 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.
c. Other:
{} $yctam Follum Criisrla *pplicabla ta A*l $yrtoms:
You tTuat indicato *Yso" or "No" tn oash of th* following $org!! lncpoctionr:
Yes l,lo
n M Backup of sewaga intn keili$ or systern cornponent due to ovarloeded ort-r clogged SAS or cesspool
Tt 191 Discharge or ponding of efffuent to the surface of the ground or eurf;ace watersr'J u, due to an oyerloaded or clogg*d 8A$ or cesspool
lsdris.doc"m lr281A1S T{le$Sttis*tln$(,is{rfomr Slhurtacossf,elpD@nslSyt rn.Pt {olf0
*n Commonwealth of Massachusettg
Title 5 Official lnspection Form
$ubeurfrct Saw*ge Oiepox*l $y*tom Fomt - hlot for Voluntary Assessments
106 White Rock Road
Property Addreus
Buyer - Rlck Tupper
Orner
intolmation i*
rquirad fnreirary
pags.
Chrne/s Nama
Yarrnouthport Ma fiw2425
Oala of lnopo**ionChy/Toun
C. ln*paction Summary (cont)
4) Syatem Failuro Criteria ABplicable to All $ptemr: (cont.|
Ye$ No
nmna
NBnmnm
ilanamx
ua
Any partion of a cesspa*lor privy is less than '!00 feet but Eraatsr than I0 feet
from a private water supply weltwith no acccptable water quality analysis. [Thbsyetem paasos if ths wall water analysic, performed at a DEP certlfled
lahoratory, for lscal coliform bacteria Indicatse aboent and tlrs pruacnce
of ammonia nitrogan rnd nitrate nitnrg*n i* oquel to or lara then S ppm,
provided that no athor failurr critsrie arc tdggorad. A copy of tha analyris
and cftain of curtody muat ba attsched to this form-l
The system is a cesspsol serving a facitity with a design flow of ?000 gN-
10,000 gpd.
The ry*em laila. I have determined that one or more of the above failure
criteria exisl as described in 310 CMR 15.303, therefore the system fails. The
sy$tsrn oyrner should contact the Board of Heallh to deterrnine what will be
neces$ary to correci th* failure^
n
5) Large $y*teme: To be cooeidored a lrrge systom tha ayetom muet eewe a facility with a
deeign flow of 10,000 $pd to 15,0ff) gpd.
For large systems, you rnust indicate either "yes" or "no" to each of the following, in addition to the
questians in $ection C.4.
Yen N0
n X the $ystem is within 400 fset of a surface drinking water supply
ntr the system is within 200 feet of a tributary to a surbce drinking water suppty
the system is loaated in a nitrogen sensitive area {lnterim t ftcllhead Protection
Area * l$rpA) or a mapp*d Zone ll of a publie waten supply wetl
TelA 5 S*icial kap{d*fi Fom; Sub3uir{* 86yt0|f, Ortp6*el $ydam . p.0a 5 d 18
Stati* liquid level in tha dbtribution box aboye outlet invert due to an oyerloaded
or clogged $AS or ces*pool
Liquid depth in cesspool is less than 6' below inveft or available volurne is less
than % day flow
Required pumping rnore than 4 times in the last year rTOf due to dogged or
obstructed pipe(s). Numbar of times pumped:
Any p*rtion of tha $A$, necspool or privy i* helow high ground watsr otovation.
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 cesspoolor privy is within aZone 1 of a public water zupply
well.
Any portion of a cesspool or privy is within $0 fset of a private waBr $upply w6ll.
a
t$iBp.doe. rsv. fffir2ot8
mn
4... Gommonwealth of iiaasachueettn
Title 5 Official lnspection Form
Sukurface Sewage Oispo*al Sy*tem Form - Not for Voluntary Assessments
10S l{&ite Flock Road
Fr$$sr*y AddrBss
$xyer- RlckTupper0rnar
inbrmetlon ig
requirud for evary
prye^
$r*nsfs Nartls
:grr9!{tttPgrtfi$lTorn
Ma 14t4t2025
Hrto - efrToA;**Date of lnsp€cfion
C. lnspection Summary {cont.)
lf you have answered 'y&s' to any question in Section C.5 the system is considered a significanl
threat, or answered "ys$. to any question in $ection 0.4 above tha large system has failed. The
fir.lHner or op6rat0r of any large *ystem considered a significant lhreat under Section C.$ or &iled
under $ection C.4 shall upgrade th* system in accordanc* with 310 CMR 15.304. The syet*m owner
should contact the approprriah regionaloffice of the S*partnen{.
S. You muet indicata'.y$tr" or n'no" for each of ths follwlng tor all lnspectionr:
Yes No
n A Pumping informalion was provided by the o\rner, occupant, or Boerd of Health
il m $&re any of the $ystem compon$nts pumped out in the previou* two wneks?
m n Has the rystem rsqsived normsl fl*ws ir the previoue tvro rrr*ek priod?
3 A Have laqe volumes of water been introduc€d to the system recently or as part of
this inspection?
A n Were as built plans of the system obtained and examined? (lf th€y were not
available note as N/A)
X n Was the tacilig or dwelling inspcted for signs of sewage back up?
m n Waa the site inspected frcr signs of break out?
m n !1&le *ll system oomponsnts, excluding the $A$, located on site?
ffi n Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected ficr the condition of the baffl*s or tees, material of corctruction,
dimensions, depth of liquid, depth of sludge and depth of scum?
a n Was the hcility owner (and occupants if different from owner) provided with
information on the proper maintenanee of subsurface sewage disposal systems?
The *ize and locetion of ths $oil Ahaorption System {SAS} on the site has
been determined based on-
Existing infurmation. For example, a plan at tha Board of Heslth.
satarmined ln the field (if any of th* failure criteria related to part c is at issue
approximation of distance is unasceptabte) [310 CMR 1f.30e{S}]
mn
n fxl
t$&ur,doc . iiy, frASrJo1 &fith S Ofli6{el h*psrtion fryrfi: $l.edlrfrca Sdtfls8G OrsFos8l Syrtom . fms6 cf r8
lfin Commonwealth of Maesachusetb
Title 5 Official lnspection Form
Subsudecs $ewege Dl*pocal Sys&m Fonn - tlot forVoluntary Assessmsnts
106 \ *|ite Rock Road
Own*r
informgIon ia
rsquirad lor ovary
Pogr6^
Prsporfy Addm*s
F*yst:*Blslrry*per _(hr*n*/x Xanp
Yarylquthport MaEidts 2ib Codi
10t4t2425
CitylTown Oate of lncp€{tbn
D. $ye&m lnfarmation
1. Reeidantial Flow Conditions:
Number of bedrooms {design):Number of bedrooms {actual):
DESIGN flow based on 31CI CMR 15.203 {for examp}e: 110 gpd x # of bedrooms}:
Description:
2 bedroom max Zone ll
I
220
Number of cunent residents:
Does residence harre a garbage grinder?
Does residence haye a water treatment unit?
lf yes, discharges to:
ls taundry on a separate sewage systern? (lnclude laundry system inspecfi*n
infonnation in this report.)
Laundry syetem inspectod?
$oagonal use?
Wbter meter readings, if available (last 2 years usage (gpd)):
Setail:
2023 12.000 ?024 8,000 galo
0
fl Ycs EI No
IYesB No
ilY*sg No
n Yes 8l No
f,Yesffi No
$ump purnp?
Lasl dat6 of occupancy.
fl Yes fi1 No
part time
seasonal
lSrr|lp doc . rBY. 7t2$l20tE Til,; 5 Qitrord ht4sctiel f m ${s*rrrca S}n5ga Ot'poa.l Syd'rn . PaC, 7 ed 18
Commonwealth of Massachu*etb
Title 5 Official ln*pection Form
$uhurface S*waga Dleposal Sya'tora Fonn - Not f*r Voluntary Assessrnsnts
106 White Rock Road
Proporty AddreBs
- Rlck
Orvner
inbnnstion ig
requlrad lcr evcry
pag€.
Ma
$t*ta Iip Code oatp qf lnspGclion
D. $y*tem Inforrnation (cont.)
7. CommorciaUlndurtrlal Flow Condltlonr:
Type of Establishment:
Deoign fl*w {ba*ed on 310 SMR 15.203):
Basis of design flow (seat#pers*ns/sq-ft., etc.):
Gallons per day {gpd)
Grease trap present?
\lVater treatrnsnt unit present?
lf yes, discharges to:
lndustrial waste holding tank present?
Non-saniiary waste discharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use:
other (descrihe below):
n Yes f1 No
IYesil No
lyosfJ No
fl Yes fl No
0ete
3. Pumping Recorde:
Source of information:
lAlhs syetem purnped as part of the inspec{ion?
lf yes, volurn* pumped:
How was quantity pumped determined?
Reason for pumping:
unknown
tvesXilo
gallofi$
tsrfrrp (h. feY. 712612018 Ttb 5 O{Rcal l'tlpsctix Fm: Sr.&cufeo Sorage Dispqal Syst n . P.Ca B of 18
Owne/s Nama
Yarmouthport 10t4{2425
6ElTown
3fl\ Commonwealth of itassachueetb
Title 5 Official Inspection Form
$ubaurfncs $ewago fli*pcaal $y$om Form - ilot frrrVoluntary Assessrnenh
t0* Wt'its Rock Road
Frop*dyAddrow
Buyer - Rlck Tupper
Ornor
inlormetion k
required for every
Bag€.
$*ner's Name
"}ggputhportCity/Torn
Ma 19t4t2025ststs Zip code Date of lnspodion
D, System lnforrnation (cont.)
4. Typoof$yatorn:
m $epti* tsnk" distribution box, *oil absorption syetem
n Single cesspool
t] Overficwcesspool
tr privy
n Sharsd $y$tem {yes or no} {if yam, atsch provioue inepec,{icn records, if any}
n lnnovativelAltemative hchnology. Attach a 6opy of tfie cunent operation and
maintenance contrac{ (tc b* obEined from sysEm orner} and a copy of lst*t
inepectbn of the l/A system by syetem operator under contract
tl Tight tank. Attach a copy of the BEP approval.
n Other {describe}:
Approxirnate ago of all components, date inshlled (if known) and source of informalion:
2W7
fJ ves I NolAhre sewage odor* *atected when aniving at tfie site?
S. Buildlng $suw {locat* on *iha plan):
Oep& beloirr grad*:
M gterial of constructicn:
I cast iron ffi *O pvC il other (explain)
Oietance from private weter $upply well or suctbn line:
2.5
feet
20+
foet
Comrnents (on conditlon of joints, venting, evid*nce of leakage, et*.):
gmd flow from hous* no signs of leaks or pcorventing
t$firs.{,oc. rsv. 7&0&s18 T** $ #tbisl lnf,F6dmo Foflrr Sub&I,nco $etr6# Sj,*pesl Syifran . Pefllo g d fa
*3' Commonwealth of illas*achusst&
Title 5 Official lnspection Form
$uhurfsce Sewrg* Diepooal $yrtem Fonn - Not for Voluntary Assessrnents
106 Whit6 Rock Road
(}nror
infonnaliiln is
nquircd lor $vory
ps{lo^Ctty/Town
Pmperty Addrass
Buyer - Rlck Tupper(Irnsr's l\larns
Yarmguthport 1Qt4nA25sato- Z6i}o,h-* -Date oI lnapetiion
Ma
D. System lnformation (cont.)
CI. $optic Tank (locate on site plan):
Depth helow grade:
Material of construction:
El eoncrete I rnetal
10SS gal tank
1.75
[ ftberglass f] polyethylene flother (expbin)
feet
lf tank is metal, list age:years
ls ag* confirmed by a Oertifrcate of Gnmpliance? {attach a sopy of certifieate) n Yes f} No
Dimensions:8'6"x5'
$ludqe depth:4"
Distance ftom top of sludge to bottom of outlet tee or baffle 30"
Scurrr thickness trace
DiEtance from tsp of scum to top of outlet tee or bafie 5"
Dislanre from hottom of scurn to bottom of outlet iee or baffle 14"
How,*ere dirrensions determined? trp9-"gl$" ![qg-eiu$sg - -
Commsnts {on pumping recommendatisn$, inlet and outlet tee or baffle condition, structural integn},
liquid l*vels as r*lated ts nutlet invert, evidence *f l*akage, etc.);
tees in place tank at norma* levels no signs of laaks, cracks or decay
*iis.doc . ror. ?fi6ff010 Tlb $ O{ncid heF.{iirJn f orm: &5tule $.r{c6 Oiryor.l $yttcn . F.0o l0 oa 18
1fr:. Commonwealth of Massachuset$
Title 5 Sfficial lnspection Form
$ubsuilaco Sewege Diepooal $yotem Form - Not for Voluntary Assessrnents
'106 Wfrit* Rock Soad
PrqortyAddruss
Buyer - Rlck Tupper
0vvnsr
infenfisti$n i9
requircd for overy
p8{to.
(lmsfa Heme
Y€rmouthport Ma 1fit4t2025
Stirte eip Cod€Dat€ of ]nspectionCity/Town
D. System lnformstlon {cont.}
7. Gransa Trap (locate on site plan):
Depth below grade:
Material of constructisn:
flconcrete flmetat [ fiberglass I pofefiylene flother (explain)
feet
0irnanroions;
Scum thickness
Distanco frorn top of ssum to top of ouffet tee or baffle
Si*tance kom bottom of scum to bottcm of outlot t6e or baffie
Dete of last pumping:Date
Comrnents {on purnping recornmendations, inlet and outlet tee or baffin eonditicn, structuml integri$,
liquid levels as related to outlet inved, evidence of leakage, etc"):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan);
Depth belcn*r grada:
Material of construc-tion :
t conrete flmetat [ fibergtass il poUethylene n ofier (exptain]:
Dimensions:
Capacity:
DeHgn Flow:
gallon$
gallooe pord*y
TOr 5 gscid h.po6irl Fom: &&artrc. S.r/.0a Oa$oca Steri . p.C. lt d 1ALii.rlp doc. .ov. 7l?sn01t
Gommonwealth of HassachucetB
Title 5 Official lnspection Form
$ubxurfaco Sewaga Diepoaal $yctam Fonn - Not lor Voluntary Assessments
10S Wftlte Rock Rsad
FrupefiyAddreo*
Ownar
inlormation is
reguircd for every
prga.
- Rlck
Yarmouthport Ma 10t4na25'Stso-" ap CoOc - -oate of lrcpeciionCity/Town
D, System lnforrnation (cont.)
S" Tight or Holding Tank {eont^}
Alsrrn present:
Alarrn level:
Date of last pumping:
LJ Yes il Nr
Alarm in worting order:f,ves nuo
Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of cur*nt purnping contract (r*guired). ls copy attached? [ Yes f] tto
S. Oi*tribution Box {if pre*ent must be opened} {locete on site plan]:
Depth of liquid level above autlet invert 0
Comments (note lf box is level and distribution to outlets equal, any evidence of solids canyover, any
evidence of leakage into or out of box, etc.):
OB3 h10 box with riser 1 inlet 2 outlets no decay or carry overs
tsh|p.doe . rev. ?i1&3018 Ti0* 5 S#iqrill k1*podon Fom: $ubsrfam $arago 0,sFGd syr*ffi . paoi 12 d ta
Commonwsa lth of ililassac huaeth
Title S Official lncpection Form
Subturfaca $ewage Bkpocal Systsm Form - Not forVoluntary A*eesments
106 \r6ite Rock Road
PropartyAddreas
Buyer * Rlck Tupper
Oqvner
ififomnelion iB
roquind hr overy
pa,ga-
0wnels f,lame
Ma \at4na25
Zip Code 0at6 of lnspeclroflStats
D. $yetem lnformation (cont.)
'10. Furnp Chemb*r{lomte on site plsn}:
Pumps in working order: n Ves tr No'
Alarme in working order: I Yes I No'
Cornmsnts (note c*ndition of pump chamber, canditian of pumpo *nd appurtananma, otc"):
' lf pumps or alarma er6 not in working order, systern is a conditional pass.
11. $sil Aheorptlon $y*tsrn {$AS} (hcate on sits plan, exsavation not r*qr.rirad)
lf SA$ not located, explain why"
Type:
m
m
n
n
il
T
il
leaehing pits
leaehing chambers
leaching galleries
leaehing Senche$
leaching fields
overfow cesspool
inn*vative#alternstive aystern
Typelname of techn*logy:
number:
numbar:
number:
numbsr, Nongth:
numb6r, dimensions:
number:
I
tsnrp.dm, ai!.. 7rt6r201 I Ttlo 5 Oiicisl kl*pactifi fornr Sdcufr6 Sd?.ep Dbpo.d 8yd3o . P.er 13 ot ft
Commonwsalth of illassachusetts
Title 5 Official lnspection Form
$ukurfaca Sowag* Olapocal Sy*tem Fonn - Not for Voluntary Assessrnents
10S \f$ite Rock Road
PmpcrtyAddr6s$
Buyer - Rlck Tupper
0rnor
ifltormetiso b
raquked for ercry
rego.Ci$/Tcnrn
MA
*iste
Orvrrcfs Name
Y*rmouthport 10t4t202szr"m--Date of lnspeciion
D. Sy*tem lnformation (cont")
11. Soil Akarptlon $yrlem ($AS) (cont.)
C*rnrnanta (nota condition of soil, signs ol hydraulic failure, level ol ponding, elamp soil, conditkrn of
vegetalion, etc.):
13'x25'x2'leaching with 2 500 galleach chambers dry with clean sandy bottom
12. Ceoepools (cesspool must be pumped as part of inspectron) (locate on site plan):
Number and configuration
Bepth - top of liguid to inlet invert
CIspth 0f solide layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
lndication of groundwater inflow f] yes n fUo
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
e&");
lsrBp doc. roY lf26/e0'ta T,(6 * Atfdal xqr{*ron For'!t; &Ssu!t$s S6r.gt6 Orrp6ot Syltsn , pi8! tl d {6
Csmmonwealth of illaesachusstts
Title 5 Offlcial lnspection Form
$uhourfaca $ervag* Dicpoml $ystem Fornn - Not for Voluntary As*essrnents
10$ VXhite Rock Road
Prs*e'E Addre*$
Buyer - Rlck Tupper&vrer
informetion is
rcqui&d fer svBry
p&gs.
Chrnsr's Name
Ma$tets Ulp Cods
fit4n025"i$t**fk#peiusn
D. System lnformation (cont.)
13. Frivy {lscate on eite plan}:
Materials of construction:
Dimens*ons
Depth of eolids
Comments (note conditiCIn of soil, signs of hydraulic failure, bvel of ponding, condition ol vogehlion,
etc.):
Sinrp.doc, rsv. ?fn8d0t8 Titls 5 ofic'al lr)rrrdian fErm: &drrutm Srrm0r Oieocat $yfrnr . Pa0c lS of 18
Yarmouthport
Sity/Town
Commonwealth uf iilassachucatG
Title 5 Official lnspection Form
$ubcurfac* $owego Otspocal Syatam Fnrm - Hot ficr Voluntary Assee-ernents
106 Wtrito Rock Road
Froperty Addre*e
Buyer - Rlck Tupper&rnor
ininrmat&rn b
rquind hrev*ry
pf,cs.
0!#nor'$ NasfiB
_]_9113911!hport Ma 1AM|28Z5
City/Tmn SiNts
*- zipffidr-Dats ot ln$poction
D. Sy*tem lnformation {cont.}
14. $kot*tr Of $cw*g* Di*po*al Syetam:
Provide a view of tfre eewage disposal system, including ties to at kast two pennanent refgrence
landmarks or benchmarks. Locate allwells urithin 100 feat. Locate where publicwater supply enters
the building. Check one of the boxes below:
mn hand-aketch in the area below
drawing attached separately
l{,
-?
3
\
lq
-22
* 31
-3y
)
LJ 8l* t3
2 -17
?q
*&t u,;I "j
n
I o
0
e-
ItsrsF.{toc . rev 7,26{?018 tffs 5 Otndn kl3pdiyl Fdrn: Subartaca 56.119. Oiqro(ol Sydlrn . P{r 1E oa 18
Com monwaalth of lllaosachuoetk
Title 5 Official lnspection Form
*ubaut*nco Swmg* Olapo*al Syxtom Fsnn - NetforVoluntary Asse**mont*
106 Vlhite Rock Road
Froperty ,&ddro*e
Orner
infonn*tion ie
rcquired for every
pa*e.
Ma 10t4t7025ffi* zr'ffi__D6te of lncpectron
D. Syetem lnformation (cont.)
13. $lta Hxarn:
EX *necx Slope
X Surkce water
Ex Check cellar
El $hallow wells
Estimelod depth to high ground watar:
Pleasa indicate all rnsthods used to deinrmine the high ground unatrpr elevation;
n Obtained frorl system deeign plans on record
lf checlred, date of design plan reviewed, P#
n Observed site (abuting prcpertylobservation hcle within 150 fuet of $A$)
n Cheeked with lccal Board nf Health - explain:
Checked with localexcavators, inetallers - {attach docurnentation}
Accessed U$GS database - explain:
l
D
You muat describe how you established the high ground water elevation
no GM/ at 120" per perc. bottom of SAS 60" below grade
Beforo flling this lnopection Rsport, pleace *eo Report Compl*lenesc Chscklist on nexl p.ge.
t$inqp.doc. w ?ngI?018 Tiys 5 Cfi,cial k!*S€*tron Fora: ${rtruho6 s.rn8q nilp6al gyd6n . p8gf, 17 oa f g
Yarmouthport
City/Tcn*n
greater then 10'
feet
Commonwealth of Ma*s*chu*ath
Title 5 Official lnspection Form
Sub*urfreo $owago Ditpo*al $ystorn Form - Not for Voluntary Asses$ments
106 Rosk Rsad
Property
- Rlck
Ma 1Al4t2A25
Stste ?ip Coda Date of Inspoction
Ou,n$r
intarrnetion is
rrquircd forevcry
pege.
E. Report Cornpletenss$ Checklist
Compl*ta ell appllcable sectlona of thir form lncluelve of:
ffi R. lnspector lnformation: Complete allfields in this section.
E e^ CertiRcation: Signed & Dated and 1, 2, 3, or 4 checked
m C. ln*pection $ummary:
1, 3, 3, or 5 cornpletod a* appropriat*
4 (Failure Criteria) and 0 (Checklist) compbted
El P. System lnformation:
For 8: TighfHolding Tank - Fumping contM attached
For {4: $ketch of $arage Disposal $ystem drEwn on pg. 16 or attached
For 1$: Explanation of e*timated depth to high groundwater includad
l$in p doc. ruv. m8n0l8 T[b 5 Ofi*]bl hrpcd]cn Fodni &S*Jt*o sa(f,qo OlrForal S]6hrr , Pa06 16 d 18