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. . Commonwealth of Massachusetts N%ED
_ ,p Title 5 Official Inspection Form
!^ d Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
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6 Olympia Drive Bass River Yarmouth MA
Property AddressAnita Kurland 210 Nahanton St Apt 504
Owner Owner's Name MA 02459 9;7/2011
information isNewton
required for every State Zip Code Date of Inspection
?age. City/Town
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information �/7
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usee the return Name of Inspector 2012
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Company Name 17 Northslde Dr.
A ti S. Dennis, MA 02660
l{l Company Address
I I +�G State Zip Code
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Telephone Number / License Number / /
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B. Certification /s c�rfrF1 cgfror �i�e -s'r-Persed s q/1 of yefr5
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate 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 disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
tielr,asses ❑ Conditiorally Passes ❑ Fails
E Needs Further Evaluation by the Local Approving Authority
.1 2- — Z V- 2— °( z—
nspectors Signature Date
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 inspection. 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 appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving 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 in the future under
the same or different conditions of use.
Title 5 cfl:r al Inspection Fore)Subsurface Sewage Disposal System•Page t o'17
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