Commonwealth of Massachusetts
Title 5 O f f i c i a l I n s p e c t i o n F o r m S u b s u r f a c e S e w a g e D i s p o s a l S y s t e m F o r m - Not f o r Voluntary A s s e s s m e n t s 1 Captain Towne Road Property Address
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Cervone paner j Information is required forevery page. tion
Owner's Name E a s City/Town
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CSM State
02537 Zip Code
M a r c h 1, 2 0 2 4 Date of Inspection
I n s p e c t i o n results m u s t be s u b m i t t e d on t h i s form. Inspection f o r m s m a y not b e altered in a n y w a y . Please see c o m p l e t e n e s s c h e c k l i s t at t h e e n d o f t h e f o r m .
f i n e catiome?? A . I n s p e c t o r I n f o r m a t i o n on t h e computer, use only the tab
E d w i n C . G i b b s Jr.
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N a m e o f Inspector
cursor - do not use the retum
G i b b s Septic Service
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C o m p a n y Name
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2 Oriole Lane Company Address
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Sandwich
MA
02563
City/Town (508) 888-5871
State 1750
Zip Code
Telephone Number
License Number
B. C e r t i f i c a t i o n |
c e r t i f y that: l a m a D E P a p p r o v e d s y s t e m i n s p e c t o r in f u l l c o m p l i a n c e w i t h S e c t i o n 1 5 . 3 4 0 o f T i t l e 6
(810 C M R 15.000); | have personally inspected the s e w a g e disposal system at the property address l i s t e d a b o v e ; t h e i n f o r m a t i o n r e p o r t e d b e l o w is t r u e , a c c u r a t e a n d c o m p l e t e a s o f t h e t i m e o f m y i n s p e c t i o n ; a n d t h e i n s p e c t i o n w a s p e r f o r m e d b a s e d o n m y t r a i n i n g a n d e x p e r i e n c e in t h e p r o p e r f u n c t i o n and m a i n t e n a n c e of on-site s e w a g e disposal systems. A f t e r conducting this inspection | h a v e determined that the system:
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Passes
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Conditionally Passes
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Needs Further Evaluation by the Local Approving Authority
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Fails
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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 has a design flow of 10,000 gpd o r greater, the inspector and the system owner shail submit the report to the appropriate regional office of the DEP. The original form should be sent to the system o w n e r and copies sent to the buyer, if applicable, and the approving authority. P l e a s e n o t e : T h i s r e p o r t o n l y d e s c r i b e s c o n d i t i o n s at t h e t i m e o f i n s p e c t i o n a n d u n d e r t h e c o n d i t i o n s of use at t h a t time. This i n s p e c t i o n d o e s n o t a d d r e s s h o w t h e s y s t e m w i l l p e r f o r m i n t h e f u t u r e u n d e r t h e s a m e o r d i f f e r e n t c o n d i t i o n s o f use. {Sinsp.doc
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rev. 7/28/2018
Thle 5 Official Inspection Form Subsurface Sewage Disposal System + Page 1 of 18