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Home My WebLink AboutInspection Report 2013 Mar 29 �� a �� . M �5 �� :�� Commonwealth of Massachusetts �3?j � Title 5 Official Inspection Form ��i e zo� Subsurtace Sewage Disposai System Form-Not Yqlun� HEA�TH DEPT. � � _ �p�s �' ' � " � 54 Clifford Street � � ! � '` �-I r�+-lle /.ir-c � � ProPertYAddrese . . _ . . . - � 6��' V ('��cu//)lW-� Helen Lal s ��S � Owner � Owners Name � e int«mation is South Yarmouih � " Res�`�'`� required for every MA 02664 0329/13 Pe9e. �KYR� St� Zry�Cade-.. � of Ir�spedion � �-� �� 3 Inspection results must be wbmAted on this form.Inspection fom�may not be aleered in any way.Please sea comple�ness checklist at the end of fhe form. � � -� - �J�S ''"°°�"`:wh�, A. General Ir�formation ,�— " filling out forms on the camp�rter, � useonrythetab 1. InspecUor a f �'�"`-'l)_ key to move your � arsor-ao na Michael Kellett � � use the retun Name W Inspector key. Aardvark Environmer�l91 ' ns � �P�Y Nane � PO BOX 896 co��,y name� 1 S 1; � East Dennis MA 02641 �7 eC� �'�TOW^ �e ZiP Cotle 508-385-7608 S13742 ��o� , � TelepFwne Num6er ��N�p�y nt�^�1�� 1`�'A J B. Certification I certiry that I have personaAy inspected the sewage disposal system at U�is address and that the information repor�d below's true,accwate and complete as of the time of the i�pection.The i�pection was pertormed based on my training and e�erience in ihe proper function and maintenance of on site sewage disposal systems. I am a DEP a�►roved system inspector pursuant to Section 15.340 of ' TRIe 5(310 CMR 15.000�.The system: � � Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Lopl Approving Auttwrily ��e i.�/� �'f-�"�f.7� 03l30l13 IrspedoYs Signature p�e The system inspector shall submd a copy of this inspe��on report�o the Approving Authority(Board of Health or DEP)within 30 days of cwnpleting lliis inspection.If the system is a shaied system or has a desgn flow of 10,000 gpd or greater,ihe�specbor and tt�e system owner shall submitthe report to the appropriate regional o�ice of fhe DEP.The original should be sent to Uie system owner and copies sent to the twyer,'rf app6cah�,and the approving aulhordy. """*This report only describes condRans at the tene of inspection and underthe cond'Rions of use at that time.This inspecEion does rrot address how the system wip per(orm in the future under '" the same or different conditions of use. ��.,v,o Tm a olhm i�;,em,,,w�m:sewmm�wage�iepo��syeeem.aege t ot t7 � � Commonweatth of Massachusetts . Title 5 Official Inspection Form � subsurtace Sewage oisposal Sys�n Form-Not for vo�nlary Assessments 54 Clifforcl Street Property Addrees Helen Lalry Owner p�'s Name intonnation is South Yartnouth MA 0266t 0329/13 requred ta every P89e. Ciy/Town St�e Zy Code D�e d I�pection B. Certification (corrt.) Inspection Summary:Chedc A,B,C,D or E/aAvays canpleEe all of Section D A) System Passes: � 1 have not found any infortnation which a�dicaies that any of the fatlure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 e�asst.Any tailure criteria not evaluated are indicated below. Commenls: B) Sysffim Conditionaly Passes: ❑ One or more system componerds as described's�the"Conditional Pass"section need to be replaced or re�ired.The system,upon completion of tlie replacement or repair,as approved by �e Board of Heatth,wfll pass. Check ihe box for"yes", "no"or"not determned"(Y,N, ND)for the folbwing statements.If°not determined,"please explain. - The septic tank is metal and over 20 years old"or the septic hank(whether mefal or not)is structurally unsound,exhibits subslarrtial infiltration or euf'dtration ortank failure is �nminent System will pass inspecUon if the ebsting tank is replaced wilh a camptying sep6c tank as approved by ihe Boarci of HeaBh. •A metal septic tank will pass inspection iF it is structuraly sound,not leakmg and if a Certificate of Compliance indicating that the tank is less than 20 years oid is available. ❑ Y ❑ N ❑ ND(Explain bebw): t51m.11/10 Tib 50111cb1 N ryemon Fam:SWfurtxe Sewage D'apoaal Syabm•Pege 2 of tI I � Commonwealth of Massachusetts Title 5 Official Inspection Form SubsuAace Sewage DlspaBal System Form-Not for Voka�tary Assessmenls 54 Clifford Street Property Address Helen LaNy Owner qy�rs Name iMoimation is South YamrouTh MA 02664 0329/13 requred fw every P89e. City/Tavn St�e Zip Code D�e d Irspeetion B. Cert�cation (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high sta�water Ievel in the distribution box due to broken or obstruc�d p�e(s)or due to a brolcen,settled or uneven distribuGon box.System wil! pass inspection if(wilh approval of Board of HeafM): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(F�lain bebw): ❑ obshuction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replac� ❑ Y ❑ N ❑ ND(Explain bebw): ❑ The system required pumpirg more ttian 4 brt�s a year due to broken or obstructed pipe(s).The system will pass inspection'rf(with approval of tlie Board of Heallh): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain bebw): ❑ obshuction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluatan is Required by the Board of Heakh: ❑ Conditions e�asst which require further evaluation by the Board of HeaHh in order to detertnine if the system is failing to protect public heatth,safety or the ernironment. 1. System will pass unless Board of Heakh determines in accorda�e wilh 310 CMR 15.303(7xb)that the system is�pt functioning in a man�erwhich wal proted public heakh, safely and tl�e emrironmeM: O Cesspool or�ivy is wilhin 50 feel of a surf�e waler ❑ Cesspool or privy is within 50 feet of a bo�dering vegetated wetland or a salt marsh t5ins.1 V1C Tde E.'Y.,5e�i�ngpgtlipn F�m:�uY,g�a SBN9ge C"sp�dl S}�gfem.Pape 3 0117 r � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurtace Sewage Disposal Systern Fortn-Not tor Vohaitary Assessmenfs 54 Ciifford Street Aoperty Addresa Helen LaNy Owner pNr�,y�6 Name � information is South Yartnouih MA 0266b 0329/13 required fw every P89e. City/Town Sfate Zip Code DMe M I�pedion B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Warer Supplier,if any) determi�es that the system is functioning in a manner that protects the public F�alth, safety and environment ❑ The system has a septic tank and soil a6sorption system(SAS)and the SAS is within 100 feet of a surface water suppy or tribuhary to a surFace water su�ly. ❑ The system has a septic tank and SAS a�tlie SAS is within a 2one 1 of a public water suppy. ❑ The system has a septic tank and SAS and the SAS is within 50 fcet of a pmrate water suppry well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a pr'vate water suppy welM'. Method used to determine dis�ance: **This system passes if the well water anatysis,pertom�ed at a DEP certified laboiatory,for fecal coliform bacteria indicates absent and the presence of arranonia nrtrogen and nitrate nitrogen is equal to or less than 5 ppm,provided U�at no other failure cri[eria are triggered.A copy of the analysis must 6e attach�to this fortn. 3. Other. D) System Failure Criteria Applicabie to All Systems: You must indicate"Yes"or"No"to each of ihe foNowing for all inspections: Yes No � � Backup of sewage irrto faalily or system c�mpaieM due to overloaded or cbgged SAS w cesspool � � Disdiarge or ponding of eflluentto ihe surface of ihe ground or surtace waters d�to an overioaded or clo�ed SAS or cesspod � � S�tic Ipuid level in the d�ution box above outlet invert due to an ovedoaded or clogged SAS or cesspool � � L'q�ud depth in cesspool is less than 6"bebw invert or available volume is less than'r4 day flow �sme•�vio rne s omc'n�xnpemon wm:SLmnraee Sewa¢e pbpowi sywem.Page�or n I ' � Commonwealth of Massachusetts Title 5 Official inspection Form a Subsurtace Sewage Disposal System Form-Not tor VohmTary Assessmenis 54 Clifford Street Property Address Helen Lally �� Owner's Name � iMormation is South Yarmouth MA 02664 0329/13 required fw every Pa9e. City?own StaRz Zp Code DaRe d InaPeclion B. Cert�cation (cont) Yes No � � Required pumpng more ihan 4�nes in ihe last year NOT due to clogged or obstructed pipe(s).Nunber of times pumped:_ ❑ � Any portion of the SAS,cesspool or privy is bebw high grour�water elevation. � � Any portion of cesspool or privy is within 100 feet of a surface water su�ly or tributary to a surface watier supply- ❑ � Any por6on of a cesspool or privy is wilhin a Zone 1 of a public well. ❑ � Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ � Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet ftom a private water supply weN wilh no aa:epha6le water quality anatysis. [fhis system passes if tl�e weM wa�er anaysis,pertortned at a DEP certified laboratory,fw fecal colifo�m bec�ris i�Mice�s abx�R e�the presence of ammonia nitrogeo and ni6ate nitrogen is equal to or less than 5 ppm, provided that no otherfailure criteria are triggered.A copy of the analysis and chain of custody m�t be attached to this form.] � � The system is a cesspool serving a fadGty wilh a design flow of 2000gpd- t 0,000gpd• � � The system fails.I have de�erms�ed ihat one or more of the above failure criteria wacst as clescxibed in 310 CMR 15.303,therefore the system faik.The sysUem owner strould coniact the Board of Heatfh to determine what will be necessary to correctihe failure. E) Large Systems: To be considered a large system tl�e system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large sysfiams,you must indica4e eilher"yes"or'no"to each of the folbvving,in additbn M the questions in Section D. Yes No ❑ ❑ the system's within 400 feet of a surface driMdng water supply ❑ ❑ the system is wilh�200 feet of a tribuTary to a surface drinldng water su�iy � � the system is located in a nitrogen sensitive ar� (Interim Wellhead Protection Area—NVPA)or a rr�pped Zone II of a public water suppty well If you have answered"yes"to any quesiron�Section E Uie system is considered a signficant threat, or answered "yes"in Section D above tlie large system has��ed_'fhe ovmer or operaUor of any laige system considered a significantthreat under Section E or faied under Section D shall upgrade the system in ac�rdance with 370 CMR 15.304.TF�system owmer should contad ihe appropriate regional office of the Departr�eM. esms.,,no T9b 501fcql Inapetdon Form:SUEaurtxe$ey2ge Diepwel SYMem•Page 5 a 17 r i .. i . � Gammonwealth af MassachussHs Title 5 Official lnspection Farm � Subsurtace�ewege Olspasal3ystem Fo�n-Not for Vokmntary Assessments 54 Ciiftord Street _. _. _ _ — Property Addresa Helen Leliy __�. __—— qwner O�vner's Name iMonnetion irs SoUdt YamioUth MA 02664 03R9l13 re9uretl ta every CitylTavn S� 7�7 Code Cl�e d I�spection Pe9e� ...._. . . C. Checklist Check if the falbwing have been done.You must indicate'yes"ar"no"as to each of the following: Yes No � ❑ Purn�g infartnation was provided by the owner,oc;cuparrt,ar Board ut Heatth ❑ � iNere any of the system wmponenffi pumped out in Uie pre�us lwa weeks? � ❑ Fias the system recsived nom�i�aws in the previous iwo w�k Period? Have large volumes of water Geen�troduced to the sys�em recenily or as part af 0 � this inspecUon? � ❑ Were as bu�t p�ns of t!�system o6rtai�ad�d examir�d?{If they were nat available note as N/A) � ❑ Was the fadl�y or dwe�ng a�spec[ed for sgns af sewage baok up7 � ❑ Was the site inspec[ed for signs of break out? � ❑ Were all system comp�ents,excluding tlre SAS,located o�site? � ❑ Were the septic tank manhdes uncovered.opened,and the interior of the tank inspec�d for the condition of ihe ba11�s or fiees,material of construction, dimensions,depth of Bquid,deptfl of sludge ar�!dep�h of scum? � � Was the�aliky owner(and occupar�s if different from owner) provided with infomnatian on the prop�maa�terrance of subsurtace sewage di�posal systems7 The s¢e and locatrae at the Soi Absorption Sysnem(SaS)on ihe site has bsen dstem�'ned based on: � ❑ E�dsting information.Far e�rampie,a pian atthe Boarcl of Health. � � �temiined'ur the field(rF arry af the fs��ue cri�ria re�ta Part C�at issue approbmation ofdisFance is unacceplab�) [31Q CMR 15.302(5)j D. System Information i Residential Flaw Condl�ons: Number of bedroorr�s(design): � Num6er of bedrocxns{actuai}: 3 - OESIGN flow based on 314 CI+M2 i 5203{�exampie:110 gpd x�af bedraoms}: �� i3m-t ino rae sorttoi Napecnai Fam:suGwrcam sen-.sa okam.�"'rse.m.ca9e s m n � Commonwealth of Massachuset� Title 5 Official Inspection Form � Subsurtace Sewage Disposal System Form-Not for VoW�tary AssessmenLs 54 Clifford Street Roperty Address Helen Lalty O.vner pwner's Name infamation ia South YarmouU� MA 02664 0329/13 required for every P89e. C�h'/Town Sta[e Zip Code Date d Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grindeR ❑ Yes � No Is laundry on a separate sewage system?[rf yes separate inspection requ'red] ❑ Yes � No Laundry system inspected? ❑ Yes � No Seasonaluse? ❑ Yes � No Water meter readings,if available(las[2 years usage(gp�): Detail: Sump pump? ❑ Yes � No Last date of occupancy: Current Date CommereialAndustrial Flow Co�ilions; Type of Esiablishment: Design flow(based on 3t0 CMR 15203): ��g�� Basis of design flow(seats/persons/sq.R.,eic.): Grease trap presenY? ❑ Yes ❑ No Indusfial waste holding tank presenY? ❑ Yes ❑ No Non-sanitary waste discharged to the Tdte 5 sys[em? ❑ Yes ❑ No Water meter readings,if availaWe: t51n9.11/10 I lile 3011tu1 Inepetdm Fp�m:SNgy�y�g g�ye�p�gl SysEem•Page]of 17 � � Commonwealth af Massachusetis Title 5 C}fficial fnspection Form subsurtace Sewage D�posal SysGam Fosm-Not tor Vo�miary Assessments 54 C!i€forsf Street '�:. Property Addrees .....— ..�.... .� ._ Helen l.a�y pwner Owner's Name information ia �u�Y�� p�p p�q p3(�/13 ' required tor every Citylfown .�.—... ... State � ZIP Code pffie W Inspection i Pa9B� ...— , D. System Informa#ion (coM.) Last date of occupancy/use: � ---- Other{describe bebw): Generai information Pumping Records: Source of informatlan: --- - - Was system pumped as part of the inspedian? ❑ Yes � No If yes,volume pumped: �� - -- — How was quantity pumped determined? - - F2eason far pumping: 7ype of System: � Septic tank,distribution box,so�absarp6an system ❑ Singte cess(woi p Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes,attach previous inspection recqrds,'rf any) ❑ InnovativelAttemative lechnobgy.Attach a c�y of ihe current opsration and maintenance contract(ta be obtained from system awner)and a copy af iatest inspectiwn of the UA system by system aperatar under cootrad ❑ Tght taok.Atlash a copy of the DEP approvai. ❑ other(desuibe): tAFtte.tt7i� TPoe501felel In apeMbn Fwrtc SWe�lflace�a pfeponl Sys4em'Page 8 Of 1] f ' � Commonwealth of Massachusetts Title 5 Officiai Inspection Form � SubsuAace Sewage Disposai 5ystem Fo�n-Not(or Volunhary Assessmenis 54 CGfford Street Roperty Address Helen Lally �� Owner's Name inf«mation is South YartnaiCi MA 02664 0329M3 required for every Pa9e. CitYRaa� . Sh3e Zip Code D�e of Inspeaion D. System Information (cont.) Approbmate age of aN componenis,dabe�stalled(rf Imown)and source of information: oan ans Per aoH Were sewage odo�s detected when artiving at ttie sRe? ❑ Yes � Na Building Sewer pocate on site plan): 1.7 Depth belowgrade: � Material of construction: ❑cast iron �40 PVC ❑other(e�lam): Distance from private watersupply well or suction line: f� Commenis(on condiUon of joinis,veMing,evidence of leak�e,e�.): Septic Tank(locate on site plan): Depth belowgrade: 1'2 te� Material of construction: �concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(e�lain) If tank is meTal, list age: y�B Is age confirmed by a Certificate of CompSance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: ��9a� Sludge depih: 4� 151na•11/10 Ttlle 501fcb1l nepefdm Fwm'SWauRace Sexage OYposal9ysbm•Page 9 ot 17 r � Commonwealth of alassact3usetts Title 5 Official Inspection Form � SubsuAace Sewage Dispasal System Foms-Not fir Vol�x��ry AssessmenLs 54 CliffoM Street Property AtlCresa i - Helen La�Y —^.� � � Qwner Ownefs NBme .... intormation is South Yatm6utlt MA Q2664 03(19ti8 requred fa avery --.—.... � Zfp Code C1Ae d Irispediai p�9e. �YR� , D. System Information (cant.) Septic Tapk(cont.) Distance from top of sl�lge ta botkom af outlet tee or ba81e —`�8- `-� 3" Scum thickness _-- . —_ Ristance fr�n top of scum ta tap of outlei tee or batAe 6� Distance from battam of scum to bottan of ouGet tee�ha#fie 16� — Fiaw were d'm�siorrs detertrr�etl? measured Corrxnenis(on pumpv�g reeamnendations,i�iet a�xi ouGet tee or befite ca�Ilt�n,structurai�te9MY, liquid levels as rela�d to outlet inveR,evidence qf leakage,etc.): The tank was saind and tigM ardh tees�place ar��Guid at oufbt imrert. Gresse Trap{la:�te on site pian}: Depth beiowgrade: � Materiai of construction: ❑concrete ❑metal ❑fiberg�ss ❑ Pohrethylerre ❑ other(e�lain): Dimensions: — Scum ihickness _ D�nce from top of scum�top of ou�tee or baffle - -- C3�tance fran bottan of sc�n to bottam of out�t#ee or b�le - _ Date of Iast pumpng: p#e t51t�s.i iti6 Title 5 SMoai NapecEon Foim:SuM�lface SMvege DlYpoal 9/abm.Page 1p M i] � Commomnrealth of Massachusetts Title 5 Official inspection Form Subsurface Sevrage Disposai System Fom�-Not 1or VolunTary AssessmenLs 54 ClifFord Street Property Address Helen Lalry a+� Owner's Nane infwmation is South Yarmouth MA 02664 0329/13 required for every Pa9e� Citylfavn State Zip Code . D�e of Inspedion D. System I�formation (cont.) Commen�(on pumping recortsnendations,inlet and ouflet tee or beffle condition,sUuctural inte9MY, liquid levels as related to outlet invert,evidence of I�kage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)Qocate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberg�s ❑ poyethylene ❑other(e�lain): Dimensions: Capacity: �� Design Flow: �� Alarm present: ❑ Yes ❑ No Alarm level: Alarm in vworking order. ❑ Yes ❑ No Date of last pumping: �e Comments(condfion of alarm and float switches,etc.): 'Attach copy of current pumping c�ntract(requaed). Is copy attached? ❑ Yes ❑ No t5ms.�v�o rile s ar.�i e�ape�n Fo�m:9�bnurteo sewage o��syarom.aeAe��m n i i I • � Commonwealth of Massachusetts Title 5 Official Inspection Form � Su bsurface Sewage D�posal5ys[em Form-Not for Voqsiary Assessments 54 Clifford Street Property Address Helen Lalfy Owner � pW�$Name information is South Yartnouth MA 02664 0329/13 requred fa every P89e_ CityfToam St� Zip Code Date d IrspeUion D. System Information (cont.) Distribution Box(d present must be opened)(bcaUe on site plan): Depth of liquid level above outlet invert even Comments(note'rf box is level and d�ution to outlefs equal,any evidence of solids carryover,any evidence of leakage into or ou[of box,etc.): The box was level and tightwith no sign of carryover. Pump Chamber(locate on site plan): Pumps in wodcing order. ❑ Yes ❑ No Alarms in working oider. ❑ Yes ❑ No CommenLs(note condi6on of pump chamber,condition of p�rnps and appurBenances, ebe.): Soil Absorption System(SAS) Qocate on site plan,excavation not require�: If SAS not lopted,e�lain why: a�ne.,v,o ra:sa�mimapemmrvmcs�ewmoesew�eo�iaissm.yg.tzan . � Commonweakh of Massachusetts Title 5 Official Inspection Form � Subsurtace Sewage Disposal System Form-Not for Voluntary AssessrnenLs 54 Clifford Street Property Address Helen lally �'^'�� Owner'a Name � information is South Yartnouth MA 02664 0329/13 requred for ewery Pa98. City/Town SYate Zip Code Date d Inspection D. System Information (cont.) Type: � leaching pils number. � ❑ leachir�chambers number. ❑ leaching galleries number: ❑ leaching trenches number,IergTh: ❑ leaching fie�s number,dimensions: ❑ overfiow cesspod number. ❑ innovative/altemative system Typefiame oftechnology: Commenls(note condiiion of soil,signs of hydraufic failure, level of ponding,damp soil,condition of vegetation,etc.): This system has a 6�6'precast pit surrounded by a foot of stone.There was 28"between th inlet invert and the liquid with a s�in�ine U.S�above the aquid. Cesspools{cesspool must be pumped as part of inspection) Qocate on site plan): Number and configuration Depth—top of liquid ta inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construcGon Indication ofgroundwater inflow ❑ Yes ❑ No ts�ns•„no � . T�S OIfkM InaR��:SubuRaa�vnge Dbpoal 9/gtem.Page 13 of 1] � � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dlsposal5ystem Fo�m-Not for Voluniery Asse�menLs 54 Cliffo�d Street Roperty Address . Helen Laly �� Owner's Name i�f«mation is South Yartnouth MA 02664 0329/13 req�red for every P89e. CitY?own S[ate Zip Code Date of Irspeaion D. System Information (cont.) Commen�(no6e condi6ion of soil,signs of hydreuSc fatlure, level of ponding,condition of vegetetion, etc.): Privy(locate an site plan): Materials of construction: Dimensions Depth of solids Comments(note condi6on of soil,signs of hydrauic failure, level of porxiing,condfion of vegetation, etc.): n.1119��/10 T�!�J Q�YA� bWe�on Foim:SWruRace�wpe Dbpo�l 9fa[em.Page 11 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage D�posal System Fortn-Not for Voluniary Assessments 54 Clifforcl Street Property Addresa Helen Lally Owner Owner�s Nane iMortnation is South Yarmoutl7 MA 02664 0329/13 requred f�every P89e. Gh'/Towm Sta6e Zip Code Date af Irspea4ion D. System Information (cont.) SkeQd�Of S�age Disporal System:Provide a vi�v of 1he sewage disposal system,including fias to at least two pertnanent reference landrt��lcs or benchmarks.Locate aA wells within 100 feet.locate where public water supply enters the lwilding.Chedc one of the boxes beiow: � handaketch in the ar� below ❑ drawing attached separatey garege Yd 24 33 29 31 40 ❑ �z��s.��no iLe5Olftia�tif�ec6mFwm:SlbuRa4Six'ABe�YP�l3/�em.pgge150t1] .. � Commonwealth of Massachusetts Title 5 Official Inspection Form � SubsuRace Sewage Disposal5ystem Fomt-Not for Voluntary PssessmenLs 54 Clifforci Street PropeRy Addreas Helen Lally Owner Owner's Name information is South YaRnouth MA 02664 0329h3 required fw every Pa9e. �Y?own Stffie Zip Code D�e W Inepediai D. System Information (cont.) Site Exam: � Check Slope ❑ Surtace water � Check cellar ❑ Shalbwwells Estimated depth to high ground water. 8'S reet Please indicate all methods used to detertnne ffie high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: oMe � Observed site(abutling property/observation hole within 150 feet of SAS) ❑ Checked v�rith local Boa�d of H�tlh-e�lain: ❑ Checked with local e�acavators,instaNers-(attach dceumen�Uon) ❑ Accessed USGS database-e�lain: You must describe how you established the high ground water elevation: I augered to 11.0 feet and found rro water. I adjusted to 8.5 feet. Bottom of leaching is at 8.0 feet Before filing this Inspection Report,piease see Report Cw�leteness Checklist on next page. �ms.,,no �. . TLe 50rtICW1 NspecYm Fo�m_Subeurtace Sewpe DbP�I SyYem.PaBe 16�17 ' � Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Fortn-Not for Voluntary P�ssessmenLs a j 54 Clifford Street Property Addreas Helen Laly � Owner pwnyYs Name intormation ia South Yarmouth MA 02664 03/19l13 required for every � P89e. Citylfown SY�e Zip Code D�e of InspeGion E. Report Completeness Checkiist � Inspec6on Surmmry:A, B,C,D,or E chedced � Inspection Summary D(System Failure Criteria Applicable to All Systems)completed � System Information—Estirtrated depih to high groundwater � Skeb�h of Sewage Disposal System either dra�m on page 15 or atlached in separate file f5Me.11/10 T!e 30111m1 Yupectlon Fo�m:Su4uRa�x Saxpe D"aPoal 9/9Eem•page 1]W 11 . ' , �c�.�en.: o.�e._ . �ar-- i . ! N#GH$Ad1�lATfR IEVEt CCMiUTAT/0N r� .� �.lry�goKX WtNo, , e�r: Addnr� �- " Jlddwc I � - *�•. � i ; � g .....+�.......�� .�laq rt,v . 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