HomeMy WebLinkAbout0170 BUCKSKIN PATH - Health r 176 131..o SKIN Pt% /1, CCN7ERVILLE _
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Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
L�
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name/
information is Centerville Y Ma 02632 3-5-2021
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 � 9
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113747
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. N Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett Hicke Digitally signed by Bred Hickey
Y Date:2021.03.08 13:11:41-05'OV 3-5-2021
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 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.
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.
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
i
s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
page. City/Town 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:
The system was in working order at the time of inspection. System was originally
permitted for 3 bedrooms with a 4 bedroom design flow.
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, j 170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is required for every Centerville Ma 02632 3-5-2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
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
Commonwealth of Massachusetts
UP
_____� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
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 b 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
El El clogged
of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ a 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
St
page. City/Town ate Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ a 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 Y2 day flow
❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ El Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El 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.]
❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ D 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
t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
page. City/Town 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
❑ El Pumping information was provided by the owner, occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
El ❑ 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)
❑ [D Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
0 ❑ Were all system components,excluding the SAS, located on site?
0 ❑ 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?
❑ O 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:
0 ❑ 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
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
` fa
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, l� 170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 4
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440/GPD
Description:
Information taken from permit provided by Board of Health dated 10/16/1995
4
Number of current residents:
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 !I No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes R No
See below
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2020- 70,000gallons 2019- 67,000gallons
Sump pump? ❑ Yes ❑■ No
current
Last date of occupancy: Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
l
J
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owners Name
information is Centerville Ma 02632 3-5-2021
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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 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: Owner- date of last pump is unknown
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� 1
J 170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
0 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:
1995 per permit
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
21611
Depth below grade: feet
Material of construction:
❑cast iron M 40 PVC ❑other(explain):
Town water
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
wv
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is i Centerville Ma 02632 3-5-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'6"
Depth below grade: 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
1
Dimensions: 500gallons
10of
Sludge depth:
26"
Distance from top of sludge to bottom of outlet tee or baffle
2"
Scum thickness
611
Distance from top of scum to top of outlet tee or baffle
1411
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
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 in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
Commonwealth of Massachusetts
qTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: NAfeet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
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):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
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.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
0"
Depth of liquid level above outlet invert
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 in working order at the time of inspection.
t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
If Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
page. City/Town 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.):
NA
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:
(3)500 gallon chambers
El 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
i
Commonwealth of Massachusetts
---- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
page. City/Town Satet 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 SAS was in working order at the time of inspection. Leaching had 2" of standing
water when viewed.
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
NA
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: NA
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
Commonwealth of Massachusetts
�M1 Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
page. CitylTown State Zip Cade 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
E....,.. —,,.., .............. .. ...
:.. `..
1,19
'fr" �
I
R R
r
O
t51nsp.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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
page. City/Town 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: No GW @ 10'feet
Please indicate ail 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:
A hand hole was augured to determine high groundwater. No water was encountered
at 10'. Bottom of SAS is above high ground water.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Jonathan&Elaina Snyder
Owner Owner's Name
information is Centerville Ma 02632 3-5-2021
required for every
page. City/Town 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
No. 00 6 —34 ( Fee j
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
NpUtation for Vsposal �6pstpm Construction permit
Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑ X Complete System Individual Components
Location Address or Lot No. (170 OL),- f N Owner's Name,Address,and Tel.No.
G' L 00UQu45 to
tE2ij
Assessor's Map/Parcel (v]® 0 1/I(I 1 f
Installer's Name,Address,and Tel.No. S'O2 77—$87 7 Designer's Name,Address,and Tel.No.
CiAV OW L A 6 6 -1°s SAS C.C.< I\J1A
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) Al gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
CAS (,Vig r ST&) CAs-C MJ-1) i&&)e_
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board Heal
Signed Date
Application Approved by — Date
Application Disapproved by Date
for the following reasons
Permit No. V Date Issued �"
No. V "' �� y. ' Fee ./
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: g
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Disposal Opstent Construction Permit ,
Application for a Permit to Construct( ) Repair 0() Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. t3UG5K[NPok
'r�( Owner's Name,Address,and Tel.No.
G' VqLZ 00V6e--A5 131�2Yj
Assessor's Map/Parcel (t ram 2- 17o I>A,-rt4 U "
Installer's Name,Address,and Tel.No.5pg tt?-[-SS77 De�gner's Name,Address,and Tel.No. a
C.APEwto45 G,7 �v (st% L4S-r ,G 1Vli4
Type of Building:
Dwelling No.of Bedrooms Jr' Lot Size sq:ft. Garbage Grinder( );
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures Al
Design Flow(min.required) / gpd Design flow provided gpd ;
Plan Date i" Number of sheets Revision Date
Title
i
Size of Septic Tank Type of S.A.S.
Description of Soil _ �. 1
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: -
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board o Heart .
Signed _ Csef!:� � Date �, ''a1 0,42
Application Approved by „ Date q-,Lq - cc�
Application Disapproved by - Date
for the following reasons '
Permit No. 3 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of (Compliance
THIS'IS TOO'C� ERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired ) Upgraded( )
Abandoned.( )by(/,, A Pra(,,e,)m Ex)-Z-e"-t-j L<s s U-C
at I'l O CA00-e-s K I ti t A--r—t C VjttjC has been constructed in accordance
with the rovisio s of Title 5 and the for Disposal System Construction Permit No.261 b"*Xi1 t dated '�
Installer�A1'6 Lu[ &_ _ELY �Aj_- � U_(L Designer %
#bedrooms Approved design flow I r gpd
The issuance of this pe it all not be construed as a guarantee that the system wit,, nctiodas designed.
t Date �U Inspector r
_--_--_-- -'----r------------------------------------------------------------------------------------------------------- �---�-----------
No. t y Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair ) Upgrade( ) Abandon( )
System located at 1'7 0 19( 6z S4 W PA-7"
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title S and the following local provisions or special conditions.
f _,,.
Provided:Con i1'uction ust be completed within three years of the date of this permit"
Date Approved by
i
C� - d ��S 1 -7 � '�7No. � � Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,s MASSACHUSETTS
Yication for Mig ogar !Aem n5truction Vermtt
Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at:
Location Ad or Lot No. Owner's Name,A d ss'and Tel.No.
� 4 u 6rm Y1v` 5�\l
7
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 13 Garbage Grinder( )
Other Type of Building LA.,10"V> No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) LLO Q e *-Tb r cvg_"�t
`®0-�/ �
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been i su�bs _
Signed Date
Application Approved by l �(
Application Disapproved for the following reasons
Permit No. /'� 7�l0 Date Issued
———————————————————————————————————————
t7
0
V ' �
r '
No. v�� I � Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYication for Migpoga1*pgtem ngtruction Permit
r
F
Application is hereby made for a Eermit to Construct( )or Repair( an On-site Sewage Disposal System at:
LocationAd,m or Lot No. Owner's Name, ess and Tel.No.
170 uc �t t� l rc�
C , 7u 7Su�s�k (a2r
Installer's
Na ne,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of-Bedrooms Garbage Grinder(' )
Other Type of B lut ding it�lt3'� No.of Persons Showers( ) ,Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ��-
1`- `lam �30`�° �L2 0a4Q'�.1 t.��r(;-7ir�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title.5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been ' sued b�ts
Signed Date �Q (o Q'`J
Application Approved by
Application Disapproved for the following reasons
Permit No. 1 r'� ��(p Date Issued 4J,1,16
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance -
THIS IS TO CERTIFY,th On-site Sewage Dis sal System installed( )or repaired/replaced( /n
by \�--W `Pn.�� for
as ` has een constructed in accord ce�.....
with the provisions�of Title 5 and the for Disposal System Construction Permit No. /� dated e/
Use of this system is conditioned on compliance with the provisions set forth below:
No. V Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
dig oga16 gtem Congtruction Permit
Permission is hereby granted to
to construct( )repair(-U,<an On-si - wa e System located at ,
�gCrS�'^ YGr �y.�tF-vI
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All constructior//(
ust be completed within two years of the date below.Date: � Approved by "�'��
(50
I
-S�q.'
F .µ
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works '
construction permit signed by me dated d 1 (.0 concerning the
property located at meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are norprivate wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed. I
SIGNED : DATE: I
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
TOWN OF BARNSTABLE a
LOCATION, � SEWAGE# 95 I (D(O
VILLAGE QRXN:S \A .R, ASSESSOR'S MAP&LOT%Z6—6 7Z
INSTALLER'S NAME&PHONE NO. 'PQ\�QAXM O -'O 1 (02�
SEPTIC TANK CAPACITY ,
LEACHING FACILITY: (type)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE:I b�6\ 1 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Botton;of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wedand and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
i
A 1 441�
c
E8 -.
A
TOWN OF BARNSTABLE
LOCATION• 170 0UGkS x,-nJ Ra:7-A SEWAGE# q 5- /74?(p
VILLAGE ASSESSOR'S MAP&PARCEL /`70�0 7z
INSTALLERS NAME&PHONE NO. �,e t K 13 R O frh, -t/ 7 7/_tez 8 y
SEPTIC TANK CAPACITY /S !I D alb}[ �I
LEACHING FACILITY:(type) 3 (size) S-d O y 4-1
NO.OF BEDROOMS V
OWNER i AV/M .0-S ";-C hoel
PERMIT DATE: COMPLIANCE DATE: log/j-F/g {--
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of c m fa ci ' Feet
FURNISHED BY
r
Louse. c�
rl
o
F �
r \.
�.a:--t 06 i 2016 1,17:07 Jim The Inspector Man 5085349919 page 1
■ aI
sun 0 7-d
® � Commonwealth of Massachusetts
Title 5 Official Inspection Form f•
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
C'� t
- --t r
170 Buckskin Path
r
Property Address
Doug Bird - '
Owner Owner's Name
+/ s
information is Centerville MA 02632 10-5-16 00
required for every
page. GitylTown 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.
f
Important:When A. General Informationqp�
filling out forms �����` HtOFrMq
on the computer, "S `So i
use only the tab p `�`��;• I :
1. Ins ector: o?
key.to move your a�: JAMES •(P
cursor-do not James D.Sears '
use the return v:
Name of Inspector
key.
Capewide Enterprises, LLC q
Compan Name ��i CF Gk `` i
ray y �ii 5 1 N SPE ,v
153 Commercial Street "�f,�i,,,,,,,�t"',oi i
Company Address
Mashpee MA 02649 t
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
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 i
❑ Needs Further Evaluation by the Local Approving Authority
(2 10-5-16
spector's Signature Date
t
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd 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. s
tc,ins.doc•rev.6116 Title 5 Officia.Inspection Form:Subsurface Selvage Disposal System•Page 1 of 17
/ --
Oct 06 2016 17:07 Jim The Inspector Man 5085349919 page 2
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`F 170 Buckskin Path
Property Address
Doug Bird
Owner Owner's Name
information is i
required for every Centerville MA 02632 10-5-16.
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
t
Inspection Summary: Check A,B,C,D or E/always complete all of Section D i
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:
The system is a 1500 Gal Tank D Box and three chambers.
i
i
i
I
i
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.
I
The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally L
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):
k
15ins.doc•rev.6116 Title 5 Officia Inspection Form:Subsurface Sewage Disposal system•Page 2 of 17
,
1
1
I ,-
1
Oct 06, 2016 17:07 Jim The Inspector Man 5085349919 page 3
it
Commonwealth of Massachusetts
z
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3
170 Buckskin Path
Property Address
Doug Bird
Owner Owner's Name
information is Centerville MA 02632 10-5-16
required for every
page. CKy/Town State Zip Code Date of Inspection
f
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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
I
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
r
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
S
i
❑ 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):
i
t
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, I
t,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
I
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
l5ins.doc•rev.6116 Title 5 Official Inspecllon Form:Subskifeo9 Sewage Disposal System•Page 3 of 17
1,
Oct 06, 2016 17,07 Jim The Inspector Man 5085349919 page 4
[k
Vie\ Commonwealth of Massachusetts. I.
Title 5 Official Inspection Form r
f
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i
I
170 Buckskin Path '
e
Property Address
Doug Bird
Owner Owner's Name
information is Centerville MA 02632 10-5-16 t
required for every
page. Citylrown State Zip Code i
Dale of Inspection
1
B. Certification (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:
`* 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.
s.
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
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool i
❑ ® 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 is less than 6" below invert or available volume is less
than Y2 day flow .0 F4 e111A,,C
t51ns.doc•rev.6116- Title 5 Off ciat.nspedlon Form:Subsirface Sewage Disposal System•Page 4 of 17
Oct OQ 2016 17:07 Jim The Inspector Man 5085349919 page 5
Commonwealth of Massachusetts
i
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t
i
170 Buckskin Path
Property Address
Doug Bird i
Owner owner's Name
information is Centerville MA 02632 10-5-16-
required for every State Zip Code Date of Inspection
page. City/Town
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.
1
❑ ® 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 rust 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 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.
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. is
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
i
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
E
regional office of the Department.
15ins.doc-rev_6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Oct 06 2016 '17:07 Jim The Inspector Man 5085349919 page 6
Commonwealth of Massachusetts
Official Inspection Form
Title 5 O p
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
170 Buckskin Path
Property Address E
Doug Bird
Owner Owner's Name
information is Centerville MA 02632 _ 10-5-16
required for every State Zip Code Date of Jnspection
page. CityrTown
C. Checklist
Check if the following have been done.You must indicate''yes" or"no" as to each of the following:
Yes . No
E
❑ ® Pumping information was provided by the owner, occupant;or Board of Health r
El ® 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?
® El available
as built plans of the system obtained and examined? (if they were not t:
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
r:
❑ 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? f
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 r
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
i
El ® 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)]
i.
D. System Information
Residential Flow Conditions:
• 4 r
Number of bedrooms (design): NA Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
440
I
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 6 of 17 E
t
Oct 06 2016 17:07 Jim The Inspector Man 5085349919 page 7 i
. E
Commonwealth of Massachusetts j
Title 5 Official Inspection Form
f
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
« ES
�w r~ 170 Buckskin Path
Property Address lr
Doug Bird
Owner Owner's Name s
information is Centerville MA 02632 10-5-1.6
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
l
Description:
The system is a 1500 Gal. Tank D Box and three chamber's. E;
F'
i
NA
Number of current residents:
t
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No E
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
2014-41,000Gals
Water meter readings, if available (last 2 years usage (gpd)): 2015-66,000Gal's
Detail:
r
Sump pump? ❑ Yes ® NO
Present
Last date of occupancy: Date
Commercial/industrial Flow Conditions: i.
I
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? El Yes ❑ No
Industrial waste holding tank present? El Yes El No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No f
i?
Water meter readings, if available:
r
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
t5ins.doc-rev.6116
i
two
Oct 0,6 2016. 17:08 Jim The Inspector Man 5085349919 page 8 r
Commonwealth of Massachusetts
Title-5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
170 Buckskin Path
Property Address
Doug Bird
Owner Owner's Name
information is Centerville MA 02632 10-5-1.6
required for every
page Cityrrown State Zip Code Date of Inspection
D. System Information (cost.)
i,
Last date of occupancy/use: Date
Other(describe below):
n`
f
• i
a;
General Information
it
Pumping Records:
NA
Source of information: iL
I:.
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:
i
® Septic tank, distribution box, soil absorption system r
❑ Single cesspool
f
❑ Overflow cesspool
i.
❑ 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 I
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
it
❑ Other(describe):
t5ins.doc rev.6/16 - Title 5 officiai Inspection Form:Subsurface Sewage Dispose system•Page 6 of 17
i
Oct 06 2016- 17:08 Jim The Inspector Man 5085349919 page 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
170 Buckskin Path s
Property Address
Doug Bird
Owner Owners Name
information is required for every Centerville MA 02632 10-5-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) E
Approximate age of all components, date installed (if known) and source of information:
1996 -Permit # 95 - 1766
1
Were sewage odors detected when arriving at the site? ❑ Yes ® No
8
Building Sewer(locate on site plan):
30"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain): .
+r+f
1
Distance from private water supply well or suction line: feet :
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40.
i
e
r
Septic Tank(locate on site plan):
20"
Depth below grade: feet i
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene, ❑ other(explain) f
t.
Eta
3'
cti i
F,
If tank is metal, list age: years
e
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate). ❑ Yes ❑ No
1500 Gal. Precast H-10 F
Dimensions: j
lit
Sludge depth:
t5ns.doc rev.6It6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 01'17
Oct 0,6 2016, 17:08 Jim The Inspector Man 5085349919 page 10
i
Commonwealth of Massachusetts
tf
Title 5 Official Inspection Form
t.
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 41.
170 Buckskin Path
Property Address
Doug Bird
Owner Owner's Name
information is Centerville MA 02632
required for every 10-5-16
page. City(Town State Zip Code Date of Inspection
D. System Information (cont.)
i
Septic Tank (cont.)
29
Distance from top of sludge to bottom of outlet tee or baffle
1 -
Scur-h thickness
81, a
Distance from top of scum to top of outlet tee or baffle
17
Distance from bottom of scum to bottom of outlet tee or baffle
l..
Asbuilt -Tape
How were dimensions determined?
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, F`
liquid levels as related to outlet invert, evidence of leakage, etc,):
Tank at working level.Tank and covers at 20" below grade. In and outlet tee's. No sign of leakage
or over loading
t
• i_
C
f
i
Grease Trap (locate on site plan):
is
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions l
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
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
t
�.S
Oct 06 2016 17:08 Jim The Inspector Man 5085349919 page 11
t:
1.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i
F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
tf' 170 Buckskin Path
M
Property Address
Doug Bird _
Owner Owners Name
information is MA 02632 10-5-16 r
required for every Centerville
page. City[rown 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):
i,
Depth below grade:
s
Material of construction: E
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain),
t.
l
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order' ❑ Yes ❑ No t
11;
Date of last pumping: Dater
E
Comments (condition of alarm and float switches, etc.):
}
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ins.doe•rev.6116 Tills 5 Official lrspectlon Form:Subsuiace Sewage Disposal System-Page 11 of 17
s
Oct 06 2016 17:08 Jim The Inspector Man 5085349919 page 12
Commonwealth of Massachusetts
I
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
." 170 Buckskin Path
i
Property Address i
Doug Bird E
Owner Owner's Name
information is
required for every .Centerville MA 02632 10-5-16
page. City/Town State Zip Code Date of Inspection
r
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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 12"x16"-22" Below grade w/3 Lines out. Box is clean and solid. No sign of over loading !
or solid carry over.
i.
C
i
1
1
i
i-
Pump Chamber(locate on site plan):
r�
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Py
f
* If pumps or alarms are not in working order, system is a conditional pass.
ti=
Soil Absorption System (SAS) (locate on site plan, excavation not required):
F.
If SAS not located, explain why:
t5ins.doc rev.5/16 Tille 5 Officia:Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
l�
i
Oct 06 2016 17:08 Jim The Inspector Man 5085349919 page 13
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
170 Buckskin Path
r
Property Address
Doug Bird
Owner Owner's Name
information is Centerville MA 02632 10-5-16
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
I
Type:
❑ leaching pits number:
3
® leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
i
❑ 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.):
Leaching is three 500 Gal. dry chambers. Chambers are 26" below grade. 3".in chambers w/stain
line at 10"off bottom. Clean wall's. No sign of over loading or solid carry over. i
S
1
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): .
f
i
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
i
i
Indication of groundwater inflow ❑ Yes ❑ No s
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Uct Ob ZU1 b 1 W9 Jim I he Inspector Man 5Utb5349919 page 14
Commonwealth of Massachusetts =
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i
170 Buckskin Path
Property Address
Doug Bird.
Owner Owner's Name
information is required for every Centerville MA 02632 10-5-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): }
i
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.):
L
I:
i
{
t
• i
(e
15ins.doc.rev.6116 Tile 5 Official Inspecllon Form:Subsurface Sewage Disposal Syslem•Page 14 of 11
i"
l
3
r-a- -
i
t
.i
Commonwealth of Massachusefts
Title 5 Official Inspection Form
iS Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
170 Buckskin Path
Property Address
Doug Bird
Owner owner's Name
information is Centerville MA 02632 10-5-16
required for every i
page. CitylTown State Zip Code Date or 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 I
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:Mns.doct•rev.6116 Tive.5 orf,-da inspezron Form:SL'bSuftoe sewage Dispose?6yslm•Page 15 of 11
i
Oct 06 2016 17:09 Jim The Inspector Man 5085349919 page 16
Commonwealth of Massachusetts
Title. 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
>` 170 Buckskin Path
Property Address
Doug Bird
Owner Owner's Name
requiratifo is Centerville MA 02632 10-5-1.6
required for every '
page. City/Town State Zip Code Date of Inspection j
D. System Information (cont.) t
Site Exam:
i
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N0
Estimated depth t high ground water: 12,+
feet
Please indicate all methods used to determine the hlgh 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) I
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers -(attach documentation).
❑ Accessed USGS database- explain:
c
• t
You must describe how you established the high ground water elevation:
G.W. Depth on file at B.O.H. 12' no G.W.. r
� f
it
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6116 Title 5 Official Inspection Form Subsurface Sewage Disposal systen-Page 16 or 17
`W I
Oct *06 2016 17:09 Jim The Inspector Man 5085349919 page 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Doug Bird
Owner Owner's Name
information is Centerville MA 02632 10-5-16 `
required for every
page. Citylrown State Zip Code Date of Inspection i
i
E. Report 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
r,
I
i
i
i
i
15ins-doc rev.6116 Title 5 afficia:Inspection Fam:Subsurface Sewage Disposal System•Page 17 of 17
• lU�
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
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.
A. General Information
1. Inspector: v
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
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 y the Local Approving Authority
7-15-13
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.
t5ins•3l13 Title 5 Official Inspection Fo : bsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. Cdyrrown State Zip Code Date of Inspection
B. Certification (cont.)
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:
System is in good working order with no sign of failure.
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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):
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•3/13 Title 5 Official Ins ection Form:Subsurface Sewage Disposal p g System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. CityTTown State Zip Code Date of Inspection
B. Certification (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:
** 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.
3. Other:
I
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 Y2 day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to dogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ N. 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 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 2000gpd-
10,000gpd.
❑ ® 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.
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.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface SLwage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. City/Town 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)]
D. System Information
Residential Flow Conditions: `
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
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
Sump pump? ❑ Yes ® No
Last date of occupancy: 6-2013
Date
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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 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
M 170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. Cityfrown 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: N/A
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 I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 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
170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
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:
1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"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.):
Good condition.
Septic Tank(locate on site plan):
18"
Depth below grade: 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: 1500 gal
Sludge depth:
12"
t5ins•3/13 .,. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. City/Town 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
20"
Scum thickness
1"
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
15"
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
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
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
v. Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. CityFrown 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.):
i
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. City/Town 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 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.):
Good condition with water at working level and no sign of back-up from field.
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.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
JIN Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3-500's
❑ 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.):
Leach chambers in good condition and empty at inspection with stain line at 8"off bottom of chamber.
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M °p 170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information i e
required for every Centerville MA 02632 7-15-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. City/Town 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
R.
C
Lee
7? t/
r 6 �
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. City/Town 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: 12'
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:
i
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 170 Buckskin Path
Property Address
Kevin Supka
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-13
page. Cityrrown State Zip Code Date of Inspection
E. Report 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
I
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOW 01;13ARNSTT
LOCATION �GtG Sf� SEWAGE#
VILLAGE C y I�G A,SSESSOICS`1#AP 3t LOT
INSTALL
ER'S NA2vIE&PHO1+dEi€).
SE�FLC 'T'A�IK CAPACITY
S 3. SQd S
LEAC�IING.FACII.. :(tYP"} �G�.�'r` '
(size)
NO.OFBEDR.()OMS
c�
Al
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S��aI'dtltln AJiStanCe$etWBeYI EhC
Maximum AdjustedGroandwaterTa IetotheBottotn of,Lt;achtngFatt[tty Feet
Private tatez Supply VdeI a W Leac ung acBtty { any r77
sexist
an s�Eee,v+ritttiti 2t�feeto€Feaehtt►g faci}tcy} Feest
Lea
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Edge W etlan anc!' ching Facility{If any wetiattds exist
wtttun 3 feet Q hind facilfitY} /� Feet
F-rtttshed
tiD.
2- 73 578,
..........U
..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA' -r"
_��........OF.L
Appliration -for 11opotial Works Tonfitrurtban Vrruift
Application is hereby-made for a Permit to Construct or Repair )Individual Sewage Disposal
System at,
........................ ....... ..... ...... ----
.................. ......... ------- ----------------------------------------
A cation-A ess or Lot No.
........... ........................................... . . ... ........................ .................................................................................................
Owner Address
I.. ... . .. ........ . .. . . .. ................................... ........................................................I........................................
I aller Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic Garbage Grinder
Other—Type of Building _------------------------- No. of persons.._____-------------.-_._-__ Showers Cafeteria
Other fixtures ....................................----------
----------------------------------------------------------------------- ------------------------------
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank—Liquid capacity------------gallons Length................ Width.........--.._. Diameter_-__..........._ Depth..-.----__--.
x Disposal Trench—No. .................... Width-_-.___-_---_------_ Total Length................_... Total leaching area--------------------sq. f t.
Seepage Pit No..................... Diameter-.-_.___------__---_ Depth below inlet_..._..._........... Total leaching area----------- ......sq. f t.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------- ..................................................... Date----------------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit.--____-.___--___--- Depth to ground water---.---..-.--._---._.--.
(i, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-..-.--.----_-------....
Ix ................ ---%......................................................................................................................................
0 Description of Soil........................................................................................................................-----------------------------------------------
x
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ...........
U
----------------------------------------------------------------------------------------------------------- - -----/------------------INi- -- ---------------
U Nat of Repairs or Al ratio 61 C)
U s—Answer when a ble_e --------- --------e)----IT-W.,------------
4CV----------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b . ssue b the board oyh aylt .
Sign ... ......... �t ----
-_01-X& 42
--------------------- ------------------ -------
. Date
Application Approved By.......... Date
7-
Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
r r.
l
THE COMMONWEALTH OF MASSACHUSETTS
BOA RD , F HE T
74{'"�' .......O F. .......................
Appliratiun -for JUWV vial Workii Tomitrnrtinn Verntit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
------------------------------------------
' bFb cation-A s. or Lot No.
•. ---
Owner •, ----Address
W .......... ..............................
I alley Address
UType of Building r Mc Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------_-----------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
VZ
Q' Other fixtures _
W Design Flow...............................................gallons per pet§on per day. Total daily flow ---------------- _._ .gallons.
WSeptic Tank—Liquid capacity 3yl' g lions 4 Length................ Width-------- ------- Diarieter -. Depth -_____ _._..
x Disposal Trench—No_ ___________ _______ Width___ ____________- Total Length________._.....___.. Total teaching;arez_.-_ _ ._._____sq. ft.
ti.: ry
Seepage Pit No_____________________ Diameter __-_. Depth below inlet____•_______-._.-__- Total'leacliiiig tre l,------------------sq. ft.
Z Other Distribution box ( ) Dosingta}zk (
a Percolation Test Results Perform°ed by ,4; `;';. Date............. ..._.._:
Test Pit No. 1----------------minutes per inch Depth of Test Pit k,________.. Depth to ground,water..-_____._ -
w Test Pit No. 2----------------minutes per inch '`Depth of Test Pit------------ Depth to ground water._._,.._______-_____---
-------•-•------ -•---- 3,
.,_
O Description of - --------------
Description
V -------------------------------------------------------------------------•------••-------------------<---------------;,------------------------------------------------- ---••_--------------------------
W •• -•---•------- ------------ -- -----------------------------•-•------------------•--
-----
UNat e of Pepair o - 1 ratio .,Answer when aftile..- _ � _ -CJ___ __ ,._.._-._
Get j or
yF
greement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b sue b the board,o4palt C�
.. --•-----
Application Approved By______ t _ %���'���A t>e/' toe'
Application Disapproved for the°following reasons:------------•-..--..__-.- ---____-- ______....._....__._. :.:_._...._._.__ .nate .._.._____
w.
Date ,,. r
PermitNo--------------------------------------=--. Issued...................... ..................................
Date
THE COMMONWEALTH OF MASSACHUSETT5
BOARD W HEALTH
...............1.........................O F.......... ..... ...............................................................
-..
01ertifirate of Tontphaure w L
THIS T9 CE " IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired V I'll ( )
y --------� ---- ----
xller
0.
at. +' -� -------------• ------ y # r �
v
has been installed in accordance with the provisions of Article XI of The State Sanitary-Code as .......described in the
application for Disposal Works Construction Permit No_________________________________________ dated....0 ""_ .:.._r
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM., WILL FUNCTION SATISFACTORY.
DATE................................................................................. Inspector......................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH401, y
... ... ......OF.......... 1Y*2 7 " E--......
No.......••.... FEE.....----...............
Binpli,ittl k n nitrnrtinn rrntit
Permissio ereby granted___ ____________
to Cons�t�ruc L r Repair ( an Irfdivtd ewage/Disposal ,SIstem t
at N o. �"f ' �'' �'y j d O,! ------
at Street .-
as shown on the application for Disposal Works Construction . Dated____Lerl __��
i Board of Health
DATE---- --------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
n
, LO+CAT 1AN S f EWAGE PERMIT NO..
i C3 1 Geld ►�� I,> l t"'��'� 7� �.
VILLAGE
INSTAA L fR'S NAME & ADDRESS
B U It D E R OR O W N R
DATE PERMIT• ISSUED
DATE COMPLIANCE ISSUvED �- � �
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