HomeMy WebLinkAboutInspection Report 2008 Nov 07 Commonwealth of Massachusetts
,, Title 5 Official Inspection Form
r. ' subsurface Sewage Disposal System Form-Not for Voluntary Assessments NOV 2 1 2008
HEALTH D T
��_,,,,;,+�^ 16 Widgeon Lane,West Yarmouth,fiAA �� �"=
Property AddressF �= , t., .
s-
Estate of George K.Garabedian -John Garabediani tlfid
_ _
Owner owners Nano .. .
,
iM a West Yarmouth MA 02673 11107/2008
every Pte
require for• civStatemown rip Code Date of inspection
inspection results must be subndtted on this form.Inspection forms may not be altered In any
way.
hoviroortam out A. General Information
kerns on the ) Kr,
1. inspector: t-i
only the�� 3to move your
do not Reid C.Elks
cursor-use the returnName of Inspector
key. Elks Brothers Const Co. di 310 7
Company Name
ri,Alli 23 Enterprise Road,P.O.Box 59, 0-'1
Company Address
MAII Yarmouth Port
CMA 02676
it rowel StZip Cods
508-382-6237 5121891
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true,accurate to and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage d',< ,.:= systems.Ian a DEP approved system Inspector pursuant to Section 15.340 of
Tltie S( - 1 CUR 15.000).The system:
[J Passes ❑ Conditionally Passes ❑ Fags
❑ Needs Further Evaluation by the Local Approving Authority
----e,l—
A�t nye ��``�,
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 ispection.If the system Is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the emendate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer,if applicable,and the ging authority.
"'*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 M the flatus under
the same or different conditions of use.
BJ.BROS INSPECTION OS 15%Wilson Iw.mc•OROS lig 5 QMi6d Inspodion east Subststsosessegp Olsposalliyalson•Paps 1 d 15
Commonwealth of Massachusetts
.t, -r Title 5 Official Inspection Form
r' - _+ Subsurface Sewage Disposal System Form-Not for Voluntary'''-:�, ,,-' 15 Widgeon Lane,West Yarmouth, MA
Properly Address
Estate
Name
a of George
K.Garabedian -John Garabedian]
Owner Owner's
infor
required
on a
West Yarmouth MA 02673 11/07/2008
e. Cityrro en State
Zip Cods Date of Inspection
D. System Information r
Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(kw example: 110 gpd x#of bedrooms):
G "
v
Number of current residents:
Does residence have a garbage grinder? 0 Yes 1:20;
Is laundry on a separate sewage system?[if yes separate inspection required] 0 Yes
Laundry system inspected? ❑ Yes6/P:
Seasonal use? 0 Yes i'! No
Water meter readings,if evadable(last 2 years usage(gpd)):
Sump pump? 0 Yes L'Ef No
Last date of occupancy: !tom 696.
Date
Commercial lndustrial Flow Conditions:
Type of Establishment
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.
Grease trap present? 0 Yes 0 No
Industrial waste holding tank present? ❑ Yes 0 No
Non-sanitary waste discharged ged to the Title 5 -tern? 0 Yes 0 No
Water meter readings,if available:
Last date of occupancy/use: Dare
Other(describe):
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Commonwealth of Massachusetts
*., , Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
<,. ,.,4 ''. 15 Widgeon Lane,West Yarmouth,MA
Property Address
Estate of George K.Garabedlan -John Garabedianl
Owner owners Name
ibis
required for West Yarmouth MA 02673 11/072008
every aese. citY/Tewe Stale Zip Code Dade of inspection
D. System Information (cont.) ,;
General infonnation _4 _._
$s "1
Pumping tom: -
Source of information: F �%v �t'` �t
Was system pumped as part of the inspection? f 0 Yes �No
If yes,volume pumped: MS^' T
yawns
1I
How was quantity pumped determined?
11
Reason for pumping:
T'Y o
Septic tank,distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes,attach previous inspection records,if any)
❑ Innovative/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 WA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
i����A�p�/ age of aN components,date-ins�ed(if known)and source1
of •�, �_, . :
,�� 8 A //-- gra— 't '''" --"*3
Were sewage odors detected when arriving at the site? 0 Yes al No
3 B C C nom-' J C4-1 per,j
Commonwealth of Massachusetts
- Title 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
*`
~
~ 15 Widgeon Lane,West Yarmouth,MA
Property Addams
Estate of George K.G -John Garabedanti .
Owner tion Ms owners Name
ktorm
required 6a West Yarmouth MA 02673 11107/2008
evely Page- Cityffavat State Zip gods Dale of tapeoSon
D. System Information (coni)
A(7.11:
1.61! Sketch Of Sewage Disposal System:Provide a sketch of the sewage disposal system including lies
to at least two permanent reference landmarks or benchmarks.Locate all wells wiles 100 feet.
Locate where public water apply enters the bultg.
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