HomeMy WebLinkAbout2013 Apr 11 to May 15 - Info Re: Discrepancy of BedroomsC� L� Y'I. i''� • _
Like it never even happened.®
Fire & Water - Cleanup & Restoration'
i Tom &Lisa Balcom
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� Commonwealth of Massachusetts �33 �— �
Title 5 Official Inspection Form ��zo�3
Subsurface Sewage Disposal System Form-Not��,�fq�un� H •
, ,_ ti � , EALTH DEPT.
A� a
� 54 Clifford Street ""' k� ti t ;� ^ ' 1" ��-1 �-�le �lr-c�
He nLaedress � {��8� U l_^(w//�1o4�/
! ��S
� Owner � pwn�'$Name
imom,atirn is � ��I '� w Rcs��
required for every South Yarmouth MA 02664 0329l13 � ���
Pa9e. City?ovm State Zp Cede�c... � W Inepedion �-
�<-��,�
Inspection results must be submRted on this fortn.inspection forms may not be alEered in any
way.Please see comple�aness checklist at 1t�e end of fhe form. �
� /��IJ(S -Q
Important:When A. General Information � ,� "
filling out forms .
ontFicca�nPWer. . � r �i/G�+�-�l? �.
use oNy the tab �, Inspector. .
key to move your �-
°'r$°''d°^d Michael Kellett �
use the retun Nmne ot Inspeetar .
key.
��7� /�2ff�WdfiC EfIVIfOfNIIE(ld� fIS
�A�„� �� ComPanY Narne
��'V PO Box 8�
Camp�y Ad�eas
� East Dennis MA 02641 S ��' ';��
cAy�rown state vv� (e N � i�
508-385-7fi08 513742 ��
Telephone NwnEer Licer�se Number ^�.,�����
t`t�
B. Certification
I cerUfy that I have personally inspected the sewage disposal system at ihis address and that the
infomration reported below's true,acwrate and compkte as of the�ne of the i�pection.The i�pection
was pertortned based on my trai�ing and e�erience in ihe proper function and maintenance of on site
sewage disposal systems.l am a DEP appro�ned system inspector pursuant to Sectio�15.340 of
TRIe 5(310 CMR 15.000).The sysbem:
� Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by Uie Local Approving Aufhorily
�.� « ,� E�..�f.�1 03/30/13
Inspedors Signature Dffie
The system inspector shall submit a copy of ths insper�on report to the Approving Authority (Board
of Health or DEP)within 30 days of canpleting this�spection.If the system is a shaied system or
has a design flow of 10,000 gpd or gr�ter,ihe a�specUor arM the sys[em owner shall submit the
report to the appropriate regional office of the DEP.The original shouki be sent to tl�e system owner
and copies se�t Uo the twyer,'rf app6caWe,and the approving authorily.
"*"'This report only descriees conditions at the tane of insped'wn and under the cond'rtions of use
at that time.This inspQction do��wt address how the system wii perform in the future under
• the same or drffereM conditions of use.
L5ma.11l10 Tib 5011bW MapeNm Fam:&punc�e'Jewage�upoml Sys4m.Pape t M 11
r
� Commonwealth of Massachusetts
Title 5 ffi i I i
O c a nspection Form
SUDsurface Sewage O(sposel5ystem Form-Not for Vohmtary Assessmenl5
54 Clifford Street
Roperty Address
Helen Lally
Owner pwner's Name
inf«mation is South Yamwuih MA 02664 0329/13
requred fa every
Pe9e. CitYlTavn Sta� Z.q Cotle Oate d Inspection
C. Checklist
Check if ihe folbwing have been done.You must indicate'yes"ar"no"as to each of ihe following:
Yes No
� ❑ Pumping information was p�ovided by the owner,occupant,or Board of Health
❑ � Were any of the system componen�pumped out in the pre�rious iwo w�ks?
� ❑ Has the system received nomial Aows in ihe previous two week period?
� � Have large volumes of water been introduced to tl�e system recenUy or as part of
Uiis inspection?
� � Were as buiR p�ns of the system o6lained and eramined?(If ihey were not
available note as N/A)
� ❑ Was the faality or dwel6ng inspected for signs of sewage back up?
� ❑ Was the site inspected for signs of break out?
� ❑ Were all system compa��enls,excluding ihe SAS,located o�site?
� ❑ Were the septic tank manholes uncoveied,opened,and ihe interior of the tank
inspec�ed for the condition of the baftles or tees,material of construction,
dimensions,depth of Ipuid,deplh of sludge and depth of scum?
� � Was the�al�y owner(and occupanis'rf d'rfferent from owne�provided with
infortnafion on ihe proper mainterrance of subsurface sewage disposal systems?
The sae and locatia�of tl�e Soi Absorption Systiem(SAS)on the site has
bsen detertnined based on:
� ❑ Existing information. For e�mple,a plan at ihe Boarti of Healih.
� � Detertnir�ed in ihe field(rf arry of the failure criteria re�to Part C is at issue
apprmdmation ofdistance is unacceptable)[31U CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedroans(design): 3 Number of bedrooms(achial): 3
DESIGN flow based on 310 CMR 15203(for e�mple: 110 gpd x#of bedrooms): 330
L5Vre.1 t/10 lik 501fi[iai MaqWim Fpm:SiOgu�Iace 8avepe qspawl5ys[em•Page 6 oi 1]
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54 Clifford Street Zone II 04.11.13