HomeMy WebLinkAbout0007 BABBLING BROOK ROAD - Health 7 Babbling Brook Road
Centerville
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Title 5 Official Inspection Form
<I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name /
information is Centerville I/ MA 02632 6/11/2020
required for every
page. City/Town 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 filling out forms A. Inspector Information s/0 lq:�&/
on the computer,
use only the tab James Ford
key to move your Name of Inspector
cursor-do not Ford Septic Services, LLC
use the return Company Name
key.
P.O. Box 49
� Company Address
Osterville MA 02655
City/Town State Zip Code
508-862-9400 S12482
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
6/23/2020
Insp c is Signature Date
The tem 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 or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable; and the approving authority.
r
Please note: 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
............c 7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 P Y rY
!% 7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
i
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd:
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c� Commonwealth of Massachusetts
itP Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
�< Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
cam !% 7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. CityTrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
unavailable
Sump pump? ❑ Yes ® No
Last date of occupancy: currently
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
n Title 5 Official Inspection Form
<I1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd.)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial w h i waste holding tank present. ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Unknown
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
r Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Date unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
c7 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 12"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 H-10
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle 20
Scum thickness 7
Distance from top of scum to top of outlet tee or baffle 5
Distance from bottom of scum to bottom of outlet tee or baffle 12
How were dimensions determined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The Tees were in place. There was no sign of leakage. The tank was pumped after the inspection.
Recommend removing bushes and over grown trees that have grown over the system.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0 7 Babbling Brook Road
v�
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
N/a
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/a
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
I
c Commonwealth of Massachusetts
,tip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Babbling Brook Road
u-
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
N/a
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Even
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The D-box was normal and no solids were present.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c Commonwealth of Massachusetts
I-P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1 - 1000 gal.
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
e Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 7 Babbling Brook Road
Property Address
Karen & Richard Mannel -
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The pit had 3' of water on the bottom. There was no sign of failure. A camera was used.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
n/a
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c � 7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. City/Town State Zip Code Date of Inspection.
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: N/a
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
'- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
: Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Babbling Brook Road
V
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 14 +/
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
Topo and water contours maps
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
per last inspection auger hole no water at 14'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Karen & Richard Mannel
Owner Owner's Name
information is required for every Centerville MA 02632 6/11/2020
page. CityTTown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
713abbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is required for every Centerville MA 02632 05/09/12
page. City/Town 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 filling out forms A. General Information
;
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael Kellett
use the return Name of Inspector
key.
Aardvark Environmental Inspections
Company Name
PO Box 896
Company Address
East Dennis MA 02641
Cityrrown State Zip Code
508-385-7608 SI 3742
Telephone Number License Number
B. Certification r�
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 lAspeott-" n
was performed based on my training and experience in the proper function and maintenance of-on site-,
sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 off
Title 5(310 CMR 15 000).The system:
® Passes q Q Conditionally Passes Q Fails :,:
❑ Needs Further Evaluation by the Local Approving Authority
/14/12
Inspector's 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.
t5ins-11/10 Tide 5Otrcial Inspection'Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is required for every Centerville MA 02632 05/09/12
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary:Check A,B,C,D or E/ahvays complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or-more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair,as approved by
the Board of Health,will pass.
Check the box for`yes","no"or"not determined"(Y,N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is.imminent.System will pass
inspection if the existing tank is replaced with a complying septic tank as approved.:by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•11t10 Title 501ficial Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is required for every Centerville MA 02632 05/09/12
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑. ND(Explain;below):
❑ obstruction is removed ❑ Y _ ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑.Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
4 C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment..
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering:vegetated-wetland or a salt marsh
t5ins•11f10 TiSi e 5 dial Inspector.Fonnr Subsulace Sewage Disposal Somm•Page 3 of W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is
required for every Centerville MA 02632 05/09/12
page. Cityrrown state Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment: F
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has aseptic tank and:SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analyse,performed at DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm,provided that no other failure criteria are triggered..A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"'to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet:invert due to an overloaded
or clogged SAS or cesspool
oLiquid depth in cesspool is less than 6"below invert or available volume is less
than day flow
t5ins-11110 Title 5 Official Inspedion Form:Subsurface Sewage Disposal Syst m-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is Centerville MA 02632 05/09/12.
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:.
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a.cesspool or privy is within 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
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliforrn bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain.of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails:I have determined that one or more of the above failure
criteria e)dst as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct.the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the following,in addition to the
questions in Section D.
Yes No
El ❑, the system is within 400 feet of a surface drinking water supply
}
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El El Area
system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E.the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5lns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is required for every Centerville MA 02632 05/09/12'
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate'yes"or"no"as to each,of the following:
Yes No
® ❑ Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS,located on site?
® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank
inspected for the condition of the baffles or tees,material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)1
D. System Information
Residential flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15203(for example: 1.10 gpd x#of bedrooms): 330
t5ins-11/10. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is required for every Centerville MA 02632 05/09/12
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings,if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
09/11
Last date of occupancy: Date
Commercial/lndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank.present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is required for every Centerville MA 02632 05/09/12
page. City[rown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes,attach previous inspection records,if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the VA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is required for every Centerville MA 02632 05/09/12
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont)
Approximate age of all components,date installed(if known)and source of information:
25 years
Were sewage odors detected when arriving at the site? ❑' Yes. ® No
Building Sewer(locate on site plan):
Depth below grade: 1.7
feet
Material of construction:
❑cast iron [Q 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage,etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.2
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain)
If tank is metal,list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1,000 gal
3" '
Sludge depth:
t5ins-11/10 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Officia[ Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is Centerville MA 02632. 05l09l12
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29"
Scum thickness 2'
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
The tank was sound and tight with tees in.place and liquid at outlet invert.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete 0 metal E fiberglass ❑polyethylene [:] other(explain):
Dimensions: ,
Scum thickness k
Distance from top of scum to top of outlettee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
.Date of last pumping: Date
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is required for every Centerville MA 02632 05/09/12
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm.in working order: ❑ Yes ❑ No
Date of last pumping:
Date:
Comments(condition of alarm and float switches,etc.):
*Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"( 7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is required for every Centerville MA 02632 05109/12
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc.):
The box was level and tight with no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located,explain why:
t5ins-11110 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is required for every Centerville MA 02632 05109/12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition,of soil,signs of hydraulic failure,level of ponding,damp soil, condition of
vegetation,etc.):
This system has a 6'x6'precast pit surrounded a foot of stone.There was no sign of ponding or
failure in the stones.
Cesspools(cesspool must be pumped as part ofinspection)(locate on site plan):
Number and configuration
Depth—top of liquid'to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System.Forme-Not for Voluntary Assessments
't 7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is required for every Centerville MA 02632 05/09/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(note condition-of soil,signs of hydraulic failure,level of'ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
t5ins-11/10 Title 5 Official Mspecton Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's flame
information is required for every Centerville MA 02632 05/09/12.
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system.,including ties to
at least two permanent reference landmarks or benchmarks.Locate all wells within.100 feet.Locate
where public water supply enters the building.Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
s hh
Y
s '
j S3 •
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
"s Subsurface Sewage Disposal System Fort-Not for Voluntary Assessments
' 7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is required for every Centerville MA 02632 05/09/12
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 11.7
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on.record
If checked,date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I angered to 14.0 feet and found no water.
I adjusted to 11.7 feet.
Bottom of leaching is at 9.6 feet.
Before filing this Inspection Report,please see.Report Completeness Checklist on next page.
151ns 1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official ,Inspection Form
_ Subsurface Sewage DisposatSystem Form-Not for Voluntary Assessments
7 Babbling Brook Road
Property Address
Stephen Leon
Owner Owner's Name
information is requited for every Centerville MA 02632 05/09/12
page. Cityfrown State Zip Code Date of Inspection
E. Deport Completeness Checklist
® Inspection Summary:A, B, C,D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•1 V10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
t
1 ,
j Date:
.? Permit:
Site Location:
Phone:
owner: Phone:
Contractor:
Notes:
STEP I Measure depth to water table
to nearest 1/10 ft-
Hate:
(depth is in feet below Land surfacz,) `mm/dd/YY feet below is
STEP a Using water-Level Range Zone and Index Well
Map locate site and determine: (�
p) Appropriate index well C
B) water-level range zone
STEP 3 Using monthly "Current Water Resources .
Conditions— determine current depth to water
levet for index well.
mm/YY
Rise for
STEP 4 Using Table of Potential Water Levelwater-
index well (STEP 2A), current depth
tD level for index well (STEP 3), and;water-level n.�
zone(STEP 2B) determine water-level J 0
adjustment.
STEP 5
Estimate depth to high water by subtracting the
water-level adjustment(STEP 4).from
measured depth to water levet at site( 1)-
9es 8-� -potential Water-
NOTE as worm tO thi:�Me*e.
Level Rise"are atc
f�0'i'lE'� Ya>i�
�/wells.htmt
Monthly index well data: www.capecodcomt�r►ission.o
��bblI'n &oo
No.. Fps.THE COMMONWEALTH OF MASSACHUSETTS
BOAR® Off' , HEALTH
y�
. : --------------OF.............!.: xC1 ..--..----•-------------------.
4 , ppliration for Bwvos al Works Toustrurtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
1 Location-Add ss No.
p��q ® `�rpy' ay , �`Qp[[\, (('`"�^` \�q
c...�.716:1�1.Z.... T... .......1aa�.�I�i .v-�.............. ..............} .... � ..... .....f/[._ :"TI. .v_
Owner Ad ress w f
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling No. of Bedrooms.._._..___ _._._Ex anion Attic g— --•----------- p (- ) Garbage Grinder
i a Other—Type of Building ...t,..?3x�_ ...._..... No. of persons........ ................ Showers
� (?�— Cafeteria (�)
d Other fixtures ..................................................•------•........._•--------------------------------------................................
---------
r w Design Flow......... ..............................gallons per person par day. Total daily flow..........2_3Q.....................gallons.
WSeptic Tank—Liquid capacity,l��.gallons Length................ Width._,.._.__.. Diameter._._._______---- Depth.....`__.._.__.
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water-___---____-_-__--__-__.
f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -----------------------------------------------------------•----------------------......-----------------
0 Description
tion of Soil...............................................
x �M ' --------. .--.--... ----------------------------------------- ---
U Nature of Repairs or Alterations--Answer when applicable:..............................................................................................
...-••••--•-------•--•-••-----•---------••-------------------•••-•---•--------••-••----------.....-------•----•-----•-•••------•-•-------•......---•--•-----•-•••-••-••--•----•---._......_._....------
Agreement:
The.undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i T'I.� 5 of.the State Sanitary Code—The undersigned further agrees not to place the system in
operation until..a Certificate of Compliance has been issued by the board of health.
Signed_.! ....................... •---•..........................
Date
Application Approved By.............
...... .............................. --••------k- - te -�
^-6- -
Da
Application Disapproved for the following reasons:--••---------•••••---------------------•••--•--------•-•------•••----------•-•-•----------------••--------....--
-•--------------•-•---------------------...•---------------------•-•----------•-----------•------....--------------------...--------••---------•-------------•------------------------•-------••-------
Date
Permit No.------. '.., fit----------------- Issued-...................................................
Date
t
THE COMMONWEALTH OF MASSACHUSETTS w
BOARD OF HEALTH
..........................................OF............................................................
Appliraiion for M-4p a al Works (foustrortion t1jornfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.................................. ..:-...... ,.......... �= � ....-- �'r --------------------------
t. Location-Ad ss ` o °fit No
C...... ...... .i.'+c�.d=-----•--`-------- ------•-------�•--- ` ......
i Owner Address
a ..........................Ito✓�.t ` `�.. .. ' ` ........ � L • - S ----.....,_ ..<. ..
Installer Address
Type of Building . Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms........... Expansion Attic ( ) Garbage Grinder (--)
p`4 Other—Type of Building ............... No. of persons....... ................. Showers Cafeteria ( )
P-1 Other fixtures --------................ •••---
W Design Flow.......�.�...............................gallons per person per day. Total daily flow..........3.39......................gallons.
WSeptic Tank—Liquid capacityAWQ..gailons Length... ....... Width.. ......... Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
Gz Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W -------••---....•--•-••••-•---•--•..................•-•------•-•....--------..........------------.........................................................
0 Description of Soil---------------------------------------------- ............ �.�'�s'...........� ----•------------------•----------•----------------
sv
U ..................................................•--------•-••--------------------••----.....-•---•...-•------•-•-----•----•--•-----•-•----••------•••••--•---•-•-----••---------•-----•--.....-•------
W
--------------------------------------------------------------------------------- -------------•------•--------------------------•--•--------•------------------------•-----------•---•-••-•------••-•
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
..----•-----------•--•----•-••••--...--•-----••----•---------••-•••---•--•--•---•-•---•------------------------•-•-•••-•••••••---••---•--------•-••--•------•---••-•---•-••-•-----••--•---------•--•--•
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of TITS; ;of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i sued by the board of health.
Signed_: �_..__.•-•--...... .
Date
Application Approved By............
Date
Application Disapproved for the following reasons:_________________________ ...
...............................................•--------------...........-•--•------
------------------
Date
PermitNo.---.... yf_2................. Issued--•------•--------------..............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... /^rr2: !!!ti .....OF.......... d .................................
fiff
Tntifirate of Tomplitaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ^<•) or Repaired ( }
by.................I........ A.... 3'c...............................................................................................................................................
hstaller (
1
at......... f�'__""--�--�-----•--'-"}-'---�'..�4e�:::an.__..__f�al:f.±e_a:---...-----...A----------�=4=-R-`-...0..'-=�=..=-'=-'-..`--
has been installed in accordance with the provisions of TILT s j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--------�_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------`. Al.................................... Inspector-----........
a
THE COMMONWEALTH OF MASSACHUSETTS
f
BOARD OF HEALTH
O J -µ 5�.........OF.. .:..'°*% ,�a�ll ......................................... `}............................ ---- /
r -.
Disposal Workii T-1000tr ivit rrm-
` -
Permission is hereby granted........................
-°'---------------------- ------
:...... ....
to Construct l� or Repair ( �) an Individ,ual Sewa'e Disposal System ff
at No.------...--�---✓. t_- dfJ'`b :-� .9i p_, r "•-""-'�-�-r� re
""-----�== = •--- -'-•---='=�'n i,c..A_1.. f
_ '� . ... - . Street__ .. ----•---•--•............•.............. f
as shown on the application for Disposal Works Construction Permit o. _�.�__. Dated..........................................
y�
...................... -�'_ef_1 �- j ..............._
................................
Board of Health
t
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
�l
20 FT. MIN.
TOP OF FOUND. SOIL T EST /
E L. _ ._.,L•`� 10 FT. MIN.
t DATE OF SOIL TEST
CONCRETE WITNESSED BY -7- 9-J
COVERS 4 SCH, 40 P,'C PIPE CLEAN SAND PERCOLATION RATE �- MIN. INCH
MIN. PITCH 1/8 PER FT. OBSERVATION HOLE I OBSERVATION HOLE 2
12
CONCRETE
COVERS 2" LAYER OF ELEV. = ?3 � ELEV.=
41' CAST IR N PIPE �
FOR EQUAL,) MIN. 1/8"- 1/2" WASHED
PITCH 1/4 PER FT. STONE " ' � o•9^�r
r.. ,uIc �g z.
JlUl�s O'L
FLOW LINE
EL = 170
EL.' f�6 2,0,
LEVEL
EL; EL- CL
L� _
DIST EL
} BOX o v o w WATER AT EL.= WATER AT /'-
a >-407� EL.
3/4"- I I/2" G �v° D o
GALLON WASHED STONE 4 ,1000 u o 00 •
,
DESIGN CALCULATIONS
SEPTIC TANK w 10 o _
a • -1 k:o _�
PRECAST LEACHING NUMBER
a EL.
NUMBER OF BEDROOMS
BASIN OR EQUIV. GARBAGE DISPOSAL UNIT
6 DIAM. r TOTAL ESTIMATED FLOW _
SEWAGE DISPOSAL SYSTEM PROFILE
GAL./BR./DAY x BR.) ��"� GAL. DAY
I NOT TO SCALE - REQUIRED SEPTIC TANK CAPACITY `� `� S GAL.
ACTUAL SIZE OF SEPTIC TANK l '' GAL.
BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE EL = LEACHING AREA REQUIREMENTS
OBSERVED WATER TABLET / / ) EL = SIDEWALL AREA '? S 6AL./S.F.
BOTTOM AREA GAL./S.F.
LEACHING CAPACITY ( BOTTOM t SIDEWALL) %`' GAL.
LaT 2 f LEGEND , RESERVE LEACHING CAPACITY GAL
EXISTING SPOT ELEVATION 0OX0
t EXISTING CONTOUR — —— -00— --—
FINAL SPOT ELEVATION
NOTES:
FINAL CONTOUR I. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.O,E.
�Vr SOIL TEST LOCATION
TITLE 5 AND THE TOWN RULES AND
t ) ° UTILITY POLE
TOWN WATER ---W -=W REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE,
,._� 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
1 a ? 31 _ CATCH BASIN
7 `® ) WITHIN 12 OF FINISHED GRADE .
_
L_ / f I EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE SAME.
? � � 4, ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE
OF WITHSTANDING H- 10 LOADING UNLESS THEY ARE UNDER OR
WITHIN 10 FT OF DRIVES OR PARKING AREAS. H-20 LOADING
to ' """ MIN FRONT SETBACK '� SHALL BE USED UNDER OR WITHIN 10 FT OF DRIVES OR PARKING.
MIN. REAR SETBACK l i 5. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE
MIN. SIDE SETBACK /O SHALL BE MORTARED IN PLACE.
6. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH
�12 DEEDED OR ZONING REGULATIONS. OWNER /APPLICANT IS TO
I y < OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
(� 1
r
APPROVED : BOARD OF HEALTH
ILI
•\ � •^ ,f,fir �.v �� � l I � iU 2 � � ` _.__.-�___ _...____..___
j
DATE AGENT
10�A 6K PROJECT LOCATION:
z' Ali
j: /J p � I � O a` {•'l � i' / j� .e1 f���,� � v � f.s�1a'�<:/'4..�!'..' f'`-^{.. ...� jf� �,/!�.
i
8 WAG/VER ASSOC. //VC
I-NGINFERS - LANDSCAPE ARCHITECTS
`LANNERS - LAND SURVEYORS
889 WEST MI-\IN STREET
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