HomeMy WebLinkAbout0055 BRALEY JENKINS ROAD - Health 55 Braley Jenkins Road
Centerville
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t THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
�J ��. .....OF.... -��. �" -•---------------•
Appliration for UiipnsFai Works Tonstrucrtion ramit
Application is herel die for a Permit to Construct ( Wor Repair ( ) an Individual Sewage Disposal
System at: 'gyp
- .
.Location-Ad re s or Lo
......_.. 1.31..�r r ?.�`�..........��.__
W n �ddress
.... ......�...�..`.
� Installer �� Address �
UType of Building Size Lot..1�_®-a c._..Sq. feet
Dwelling—No. of Bedrooms"'.
Attic�� Garbage Grinder
P4 Other—Type of Building .(__ 3< No. of persons.....�'.................. Showers (e — afeteria-(---T—
a' Other fixtures .._... _
---------------------------------------------- ------------------------- ....---------------.-.--------------
W Design Flow............................................gallons per person pf r day. Total daily flow........- .�...�..._....__._._..gallons
.��
WSeptic Tank—Liquid ca.pacityZ� gallons Length_T..A__. Width.___/!�__ Diameter................ Depth---S
x Disposal Trench—No..................... Width.................... Total Length............... Total leaching area_._.................sq. ft.
Seepage Pit No-----------,(------- Diameter... Z_1..... Depth below inlet..�:`�.._.. Total leaching area....c'.. q. ft.
Z Other Distribution box (?--r Dosing tank _�
aPercolation Test Results Performed by. ... ._. �. � ~1.�Date
„-.l Test Pit No. 1....:—_Z-minutes per inch Depth of Test Pit----2 ....... Depth to ground water_._ ...........
(Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ........------ ...................................---............. ...................................................................................
O Description of Soil
........................ ..�.. ....._—�-�.....�-_'�-
U ---•--•----•-----•----------•••-•--•-•---•---•-------------------------------------•-•---•---•----------------------------------------••------•-----------------------••------------•---•-•------•---••.
W
x •-----------•---------- -------•---•------------..._..•---•-----•--------------•---•-----------•---------•----•-----------•-----------------------•-•--•----...--------------------------------•-•------
U Nature of Repairs or Alterations—Answer when applicable..............................•____._..._........._........____.___........................_....
Agreement: �isv✓ �
The undersigne agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI.% 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.
Si .._---------- ------ � .......
....
y� D e
Application Approved BY .....-r/,.-`....--•-••-•-------------------•-••-•------•--•--- ..
Date
Application Disapproved for the following reasons:..............................................................................................................
--------------------------------------------------------------------------------------------------------.----•-•---•-------------•----------•-•----........................----.... ------.....
Date
Permit No... ....��....� .............. Date
Permit
Date
r
F.45;6...............
• THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................. OF..........................................................................................
Appliration for Uispwi al Works Tontrnrtion jhrmit
Application is,$ere�b IadeWr rmit to Construct ( �or Repair ( ) an Individual Sewage Disposal
System at:
��j }�, / [_ /
�-•-Cr��'C--- �ci��dFiu��� ........... 2---_._..._...��"Y�''��C�-�
F row i Address ............
Installer (L Address
P�1
Type of Building Size Lot............................Sq. feet
U _ __
Dwelling—:No. of Bedrooms._...._..................................Expansion Attic-("') Garbage Grinder ( )
aOther—Type
of Building _--_��-"-_-i No. of persons.._..�°.................. Showers (,—')'— Cafeteria)
d Other fixtures.....�-------------•-----.......----------------._.....---------------------------------------------F.. --=- -
J ..:
W Design Flow....••--•----------------------�- ...gallons per person per day. Total daily ll9w............................................g4l nsv,
WSeptic Tank—Liquid capacity.........._.gallons Length________________ Width. ......... Diameter................ Depth............
x Disposal Trench—No. .................... AAidth.................... Total Length.................-- Total leaching area.._....f._..-.sq. ft.
Seepage Pit No-----------/....... Diameter... ..... Depth below inlet._.-73............ Total leaching area..................sq. ft.
Z Other Distribution box ( � Dosing tank-•(")
'-' Percolation Test Results Performed by.r'`. :'`---.�'-_:.-.. ._.: /
W . Date-----•..........................
Test Pit No. 1_...�._Z-.minutes per inch Depth of Test Pit.... ............ Depth to ground water... `—'...........
(rq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Q+' --- --- - ----•--•------ - ------ ------•------------------•-------------••-----......---•-----•------•-•------------
ODescription of Soil...............--------•-----------------•------------•--•-----••-----•--•-•-----------------------....------------....---••----------------------------..............
x
U -•----------------------•----------•--....-----------•-------•--------------------...--•-••---------.....-----------------------...•----•---------------.....------.............---••------..__.....----
W
------------------------------------------------------•-------------------------------•--------------------------------------------------------------------•---------------.....-•------------•-•••----
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-------------------------• ------- - ---•-----------------------------
..................................................................................................
Agreement: ;; CA^
The undersignedagrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITITS 5 of the State Sanitary Code—The undersigned further agrees not to place the sy tem in
operation until a Certificate of Compliance has been is by the board oVhealth.
-----------•--•-••••-- ----------------------------------------------••-------•----
6
7ZS
Application Approved By.........................•---------•--- ........----------•--••-••---
1
Date
Application Disapproved for the following reasons:............................................................................•.-•--------•-------•--•••........
...............................................-.......................................................................................................................................................
V.. �J"
Permit No.................... ...............••• Issued Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
--/-�' BOARD,,QF HEA T'�
..........................................OF.....................................................................................
wrtifiratr of Tu pliFanrr ,�, — � Ci:—;
THIS IS O.eC�RTIFrY; T�iat;the,Individual Sewage Dis ck?r_ucted ( ) or Repaired ( )
by----------------- ............. ........ , •. .....................................................
,� Installer- ui/ ..
at.....-------•---....--- r r '? � ..... K./a S d ........ �...__!�/Lam_.....
has been installed in accordance with the provisions of T. �5 e State Sanitary C ,€ in the
4:7application for Disposal Works Construction Permit No......................................... dated------------- ... ..........
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH .
No.. .......... �'T'
........ FEE........................
Disposal !Tuunstrndioa� r , ,a / I
Permission is hereby ran urk ,_
to Construct (W�� �e_� (� )man Individual Sewage Disposal System �� ���
at No. L.?� --�--�.... ... 4L�'Y .. .<1 NS_.------�-�_'�------- 7�dfC.C.E
Street
as shown on the application for Disposal Works Construc 'ot> er,mit -............... ted.... (/........__..Ln(.r_►........
C7_
•................... -----------------------------------.......------.....------................._
DATE------ •- -- -.................................... Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
TQW�N�OF BARNSTABLE
LOCATION
VILLAGE — -
����,���'�- ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. V,, ,
t--SSEPTIC TANK CAPACITY
t,,,LEACHING FACILITY:(type) �', (size) (o
NO. OF BEDROOMS PRIVATE WELL OIftIBLIC WATEB�`
Q BUILDER OR OWNER
� J
DATE PERMIT ISSUED:
DATE COLiPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
1 �
14
11
I
WWN OF BARNSTABLE �J ,
LOCATION j�r�x-,,cwSEWAGE # (o -� � ' �i '-j /• ••
VILLAGE AS
$
SESSOR'S MAP & LOT ?
INSTALLER'S NAME PHONE NO.
LA
SEPTIC TANK CAPACITY U b<) a,cx�C , �
LEACHING FACILITY:(type) ', (size) Q �1
NO. OF BEDROOMS PRIVATE WELL O iIBLjC WATEB7
BUILDER OR OWNER
DATE PERMIT ISSUED: J-- )
DATE COMPLIANCE ISSUED: ✓ - �, ' 7 '
VARIANCE GRANTED: Yes No (�''
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
1. Property Information: I
p Y
55 Braley Jenkins Rd.
Property Address
Frank McDonald
Owner's Name
same
Owner's Address
Centerville MA 02632-2111
City/Town State Zip Code
Date of Inspection: 1/21/13
Date
2. Inspector:
Matthew L. Childs
Name of Inspector
same
Company Name,
4 Orchid Ln.
Company Address
W. Yarmouth MA 02673
CitylTown State Zip Code
508-989-1479
Telephone Number
Certification Statement:
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 inspection
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 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
.S/qfe(, 1/21/13
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.
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always 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:
passes
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.
Answer yes, no or not determined (Y, N, ND) in the ❑ 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.
ND Explain:
N/A
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
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
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
N/A
❑ 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
❑ obstruction is removed
ND Explain:
N/A
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
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
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:
❑ 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: N/A
** This system passes if the well water analysis, performed at a DEP certified laboratory, for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility 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:
N/A
MAC.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
` Commonwealth of Massachusetts
w Title 5 Official Inspection Form
- Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State ZipCode
Frank McDonald 1/21/13
Owner's Name Date of Inspection
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
❑ ® 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 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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.]
Yes No
❑ ® 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.
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
iG M
Subsurface Sewage Disposal System Form
A. Certification (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
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
❑ ❑ 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
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.
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
} S Not for Voluntary Assessments
c,M Subsurface Sewage Disposal System Form
B. Checklist
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
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 b the owner, occupant, or Board of Health
p 9
❑ ® 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(3)(b)]
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
CityFrown State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
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 gpd.
Number of current residents: 2
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d N/A
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
�
Last date of occupancy: currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): N/AGallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
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: N/A
Last date of occupancy/use: N/A
Date
Other(describe): N/A
/ Title 5 Official Inspection Form:Subsurface Sewage Disposal System MAC.doc•11 2004 p g p y
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'GSM
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
Cityrrown State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
Installation permit issued 5/22/87
Were sewage odors detected when arriving at the site? ❑ Yes ® No
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
aS Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville . MA 02632-2111
City/Town State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 2
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.):
All in good working order at time of inspection.
Septic Tank (locate on site plan):
Depth below grade: 1.5'
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 ❑ Yes ❑ No
certificate)
Dimensions:
8'x5'x5'outside 1000 gal.
Sludge depth:
0'
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness 0
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
1'
How were dimensions determined? sludge judge
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
< Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
J^M SVe e
Subsurface Sewage Disposal System Form
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank shows no signs of leakage and appears to hve been maintained properly at time of inspection.
Grease Trap (locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
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.):
N/A
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System e
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
iv^M
Subsurface Sewage Disposal System Form
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
Tight or Holding Tank(cont.)
Dimensions: N/A
Capacity: N/A
gallons
N/A
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ❑ Yes❑ No
Date of last pumping: N/A
Date
Comments (condition of alarm and float switches, etc.):
N/A
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0.0'
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.):
D-box is level with no leakage or solids carryover at time of inspection.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
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Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
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.):
1 6'x6' precast pit with 3' of stone had stain lines at 4.5'. No signs of backup were evident however
this report does not guarantee the performance of the system in the future under the same or
different conditions of use.
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
Cityrrown State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth —top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy (locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System.Form
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
Sketch Of Sewage Disposal System: Provide a sketch 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.
hand Oa O
MIT M-14,6
A2.33,6 12.26
A 34T U36.51
A
#55
/S
BrWey g .
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Page 15 of 16
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'GSM
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
Cityrrown State Zip Code
Frank McDonald 1/21/13
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
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
i i 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:
Observed site, shows no signs of high groundwater. Hand auger 12' below bottom of sas and did not
encounter groundwater.
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
I�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
";^M Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
1. Property Information:
55 Braley Jenkins Rd.
Property Address
Frank McDonald
Owner's Name
same
Owner's Address
Centerville MA 02632-2111
City/Town State Zip Code
Date of Inspection: 10/10/10
Date
2. Inspector:
Matthew L. Childs
Name of Inspector
same
Company Name '
4 Orchid Ln.
Company Address
W. Yarmouth MA C-1,02673
City/Town State -Vip Code
508-989-1479 }
Telephone Number, --+ C>
0- `p
Certification Statement:
I certify that I have personally inspected the sewage disposal system at this addres and that�,..hi' e
information reported below is true, accurate and complete as of the time of the ins pIction. Th*�inspo`�ion
was performed based on my training and experience in the proper function and maAtenancewfi on Pill
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluatior�by the Local Approving Authority
10/10/10
'rnnspector's Signature ~� 7 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.
MAC.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
A. Certification (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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:
passes
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.
Answer yes, no or not determined (Y, N, ND) in the ❑ 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.
ND Explain:
{
N/A
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Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'4M
A. Certification (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
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
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
N/A
❑ 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
❑ obstruction is removed
ND Explain:
N/A
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
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Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
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:
❑ 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: N/A
**This system passes if the well water analysis, performed at a DEP certified laboratory, for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility 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:
N/A
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
rG^M
Subsurface Sewage Disposal System Form
A. Certification (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
CityFrown State ZipCode
Frank McDonald 10/10/10
Owner's Name Date of Inspection
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
❑ ® 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 'h 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 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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.]
Yes No
❑ ® 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.
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Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
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
❑ ❑ 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
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.
MAC.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
4M
B. Checklist
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
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(3)(b)]
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
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 gpd.
Number of current residents: 2
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d N/A
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CM N/AR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.): N/A
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: N/A
Last date of occupancy/use: N/A
Date
Other(describe): N/A
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
iv^M
Subsurface Sewage Disposal System Form
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: owner pumped 2wks previous as maintainance
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Installation permit issued 5/22/87
Were sewage odors detected when arriving at the site? ❑ Yes ® No
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
2'
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.):
All in good working order at time of inspection.
Septic Tank(locate on site plan):
Depth below grade: 1.5'
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 ❑ Yes ❑ No
certificate)
Dimensions: 8'x5'x5' outside 1000 gal.
Sludge depth:
0
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness 0
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
1'
How were dimensions determined? sludge judge
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank shows no signs of leakage and was pumped 2 weeks previous as maintainance.
Grease Trap (locate on site plan):
N/A
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/ADate
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
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Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cost.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
Tight or Holding Tank(cont.)
Dimensions: N/A
Capacity: N/A
gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ❑ Yes❑ No
Date of last pumping: N/A
Date
Comments (condition of alarm and float switches, etc.):
N/A
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0.0'
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.):
D-box is level with no leakage or solids carryover at time of inspection.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
MAC.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
/GSM
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
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.):
1 6'x6' precast pit with 3' of stone had stain lines at 4.5'. No signs of backup were evident however
this report does not guarantee the performance of the system in the future under the same or
different conditions of use.
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy (locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
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Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
Sketch Of Sewage Disposal System: Provide a sketch 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.
hand O
3
1IR M-14,61
2IR 12.26
A-MT BUS
/S
Braley Jenkins Rd.
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Page 15 of 16
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• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
55 Braley Jenkins Rd.
Property Address
Centerville MA 02632-2111
City/Town State Zip Code
Frank McDonald 10/10/10
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
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:
Observed site, shows no signs of high groundwater. Hand auger 12' below bottom of sas and did not
encounter groundwater.
MAC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
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32t 1 MANHOLES AN.D COVER TO BE BUILT WITHIN
`psi P �^ �80 , s?' ELEV. TOP OF , .,.'" t2" OF ; FINISHED GRADE .
o;: FOUNDATION
t CS D£ -t�A 1 N. 2� SLOP E
:.n. FINISHED GRA 'f,
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F ' - :+'; t/6 12 PEASTON
PITCH C H li/r�/ E.,'
f 4-/�F T
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I INVERT GALLON INV DIST, tNVERT'
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D I A .RT Box "oim ,:.
SEPTICTANK INVERT WASHED STON
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t y f- INVERT ; ,.C3 ALL ARflUNb,
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SANITARY.! T RY D I S P O S:A L SYSTEM C7-16� , ,
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NOT O sC LE DE S .1C N DATA, y;
E B E D o M s R M.
CONSTR UCTCC) N OF, SAf*t iTARY DtS POSAL `
DESIGN F LOW
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SYSTEM SHALL CON F. O R. M ,T fl .M A SS.
LACH RATE
M t iV, INC H
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ENVI RONMENTAL CO ?E TITLE Sz REVISED 7- 1 1,
- =11cN .�.� i L PROP'OS'ED LEACH CAP.ACIT ,Y :
77
AND THE TOWN OF L3 ,
HEALTH R EG U LATI ON S.
• SEPTIC TANK, DISTR18UT10N BOX AND LEACHING a
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- PiTTO BE OF REINFORCED CONCRETE :- ,'
GAL DAY
MIN. CON'CRET.E STRENGTH 3`000 PSI
MIN. STEEL STRENGTH . 20,0 OOP Sl
H-10 DEStGN .LOADING
• DRIVEWAYS NOTTO BE , OCAT_ED OVER :SYSTEM , <
UNLESS H - 20 DESIGN ' ,LOADING IS USED.`,_
• ALL PIPES AND .F`iTT`I NGS TO BE ` WATERTIGHT AND
TO BE OF GA T IRON OR SCHED 40 P.V.C.
IJ I TIE P, L A N S_ HQW { NG PR ® POSED . CONSTR1CT. IONS H.?-O F'._l...SH S
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LE:GEND �
FOR : .� ., .> C C J2 r'"': A P P R O V E D 19
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scAL E. A." R D OE HEALTH
REGULATIONS PER __� _. ;
BUILDING SETBACK REGULA EXISTING CONTOUR 16 ,REFERENCE
BU LDI G NS ECTOR OR BUILDING
, .: PROPOSED CONTOUR DATE AGE N CO1AMi5StONER . ,A
TI N ,
I t T EVA O
20
EX ST NG 5PO EL t7, 6
- tN ,FRONT SETBACK _ . , f
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ASS. O2'641 ;
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