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Commonwealth of Massachusetts
I; _, Title 5 Official Inspection Form
_? = 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•'V � 56 Main Street(Route 6A)
Property Address
Matthew Teague
Owner Owner's Name
information is Yarmouth ort
required for everyp MA 02675 3-25-20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (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
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
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TOWN OF'�
Subsurface Sewage Disposal System AS-BUILT Card �
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Street Number: ^� Sh�eet Nazne: �:� � �% �
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Owna's Name: I ��a � � - -= � G =
Date of Installation: `"� — �/ — /_t� Permit#: ( S — � �
Installer's Name: � ��f ;;� �,.t �r l- y��-
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Address: / :; i. � �rq �' /�i j� ,�� Town: }J ` h h i S
Installation of (Please CirCle): epric Tank D-Box SAS p Chamber J
Other(please list):
Certification of Installation
As the Disposal Works Installer, I certify the system has been constructed in compiiance with
310 CMR 15.000, the approved desigi pians, all local requirements and the following:
Y ✓ N NA_ 1.The septic system has been installed at the elevations shown on the approved design plan.
Y✓ N_NA_ 2. The septic system was installed in the locadon shown on the approved design plaa.
Y_N_NA'13.All nnsuitable material was removed and excavated five(5)feet laterally in all directions
beyond'the outer perimeter of the soil absorptian system to the depth of naturally occurring
�, pervious material and replaced with clean fill.
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Y�N NA_ 4.The septic system has been connected to the building.
Y�N_NA_ 5.The septic tank inlet and oatlet covers,distribution boa cover and leaclting facility cover(s)
have been brought to within 6"of fmished grade.
Y ✓�N NA_ 6.The pre-e�sting septic system was pamped,filled or collapsed.
Y�N_NA 7.Iynal grade over the septic system components does not exceed three(3)feet
Y_N_NA ✓ 8.The Design Engineer and Health Department were notitied of changes to the approved plan.
Y l N_NA_ 9.All other permits obtained and inspected as reqaired(electrical,plumbing).
Y_N_NA 10.All system components have been marked with magnetic tape.
Signed• ��'l.vz�i �L-1,��...-� Date: �j — � � � ��_
System Installer
SEE DIAGltAM ON 1�EVEIiSE SIDE
*P/ease show fu//foundation with front ofhouse and street/ocation/abe%d *
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