HomeMy WebLinkAboutInspection Report 2014 Feb 04 � �
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W Title 5 Offi i ion orm -
; Su.bsurFace Sewage Disposal System Form - Not for Voluntary Assessments �EB 12 20 i�
�M 14 Arrowhead Drive
Property Address ,
Leslie W Millar (';� � �j�Q,(� _
Owner pwner's Name 4�� �:k,,._a t�.�.� .t;.�: ,�"�
information is Yarmouth ort Ma 02675 2-4-14
required for every p
page. CitylTown State Zip Code Date of Inspection
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
filling out forms
on the computer, �
' use only the tab 1. Inspector:
key to move your
cursor-do not RICky L.Wrlght
use the return ` Name of Inspector
key.
� B&B Excavation
!,y Company Name
14 Teaberry Lane
Company Address
� Sandwich Ma. 02644
City/Town State Zip Code
(508)477-0653 S14595
Telephone Number License Number
I
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 and complete as of the time of the inspection. Th ' specti n
was performed based on my training and experience in the proper function and maintenan of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Secti 15.340 of
Title 5(310 CMR 15.000). The system: � ��
❑ Passes � Conditionally Passes ❑ Fails 4' �
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❑ Needs Further Evaluation by the Local Approving Authority ��� � �
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2-4-14
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving thority(Bo
of Health or DEP)within 30 days of completing this inspection. If the system is a share 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.
t5ins•3/13 Title 5 Offidal InspecGon Form:Subsurface Sewage Disposal System•Page 1 of 17