HomeMy WebLinkAbout0018 CHEQUAQUET WAY - Health 18 Chequaquet Way, Centerville
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
p Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
10
18 Chequaquet Way t ;
Property Address
Ryann Hibbart
Owner Owner's Name %j,"
information is ✓ '
required for every Centerville Ma. 02632 3-16-19 c:s
page. Cityrrown State Zip Code Date of Inspection NJ
rat
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 A. General Information �j
filling out forms `'' (3(P W9
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not DayidJ. Burnie
use the return Name of Inspector
key.
High Tide Septic Solutions
ma Company Name
3 Perry's Way
Company Address
few
E. Harwich MA 02645
Citylrown State Zip Code
774-216-1440 S1386
Telephone Number License Number
B. Certification
I certify that l 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:
��p►►►I I►I If rrnr���
® Passes ❑ C f$t'ha6y�R��s � ❑ Fails
❑ Needs Further Evaluation by the Ldc ;Approving AutWity
J.
co
pector Si t e ...
The system inspector shall submit a copy of t'�i'r'swftpt`ion 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-16-19
page. Cityrrown 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:
The system passes, septic tank and distribution box at normal levels. leaching stone dry.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
µ 18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-16-19
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-16-19
page. Cityfrown 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:
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 '/2 day flow
t5ins-11/10 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
18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-16-19
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 clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal 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
0 ❑ 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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-16-19
page. Citylrown 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 CM 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-16-19
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1500 gallon septic tank, distribution box and 4 infiltrators in a straight line.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): yes
Detail:
2018= 31.000 gallons=85gpd...2017= 26.000gallons=72gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: current
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,.•y 18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-16-19
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: year round
Date
Other(describe below):
Current and year round
General Information
Pumping Records:
Source of information: none per owner
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-16-19
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
built 12-31-96 per prior report
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Normal as to what we could view
Septic Tank(locate on site plan):
12"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Inlet and outlet tee in place, tank at normal level.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•11/10 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
18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-16-19
page. Cityrrown 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 24"
Scum thickness 4 to 6"
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
8"
How were dimensions determined? Tape and estimated
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 needs pumping. should then be pumped every 2 years.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Chequaquet Way
Property Address
Ryann Hibbart
Owner
Owners Name
information is required for every Centerville Ma. 02632 3-16-19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is
required for every Centerville Ma. 02632 3-16-19
page. Cityrrown 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 d box at normal level.
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.):
Normal level, not leaking
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
i
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located,explain why:
Leaching located and probed stone and found dry at the top and moist at the bottom.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-16-19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 4 infiltrators
❑ 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.):
None, no backup at distribution box and the stone was dry.
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-11/10 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
18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owners Name
information is required for every Centerville Ma. 02632 3-16-19
page. Citylrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is
required for every Centerville Ma. 02632 3-16-19
page. Cityrrown 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments
18 Chequaquet Way
Property Address
Owner Owners Name
information is
requiredfor every Centerville MA 02632- Qf
page. Cityrrown 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
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t5ins•11I1Q Title 5 OMdal Inspection Form-Subsurface Sewage Disposal System—Page 15 of 17
n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is
required for every Centerville Ma. 02632 3-16-19
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: plus
fee
t
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:
No plan on file. prior report and 12-2-96 form signed by the contractor certified the
ground water being 14' or greater below the leaching
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Prior report dated 4-6-2013
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 18 Chequaquet Way
Property Address
Ryann Hibbart
Owner Owner's Name
information is
required for every Centerville Ma. 02632 3-16-19
page. City[Town 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
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is Centerville MA 02632 Aril 6, 2013
required for every P
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
-
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Cou hanowr, R.S.
use the return Name of Inspector
key.
Eco-Tech Environmental
� Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364-0894 1328
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:
Cw7 � O
® Passes ❑ Conditionally Passes ❑ Falb
=' ..�.
❑ Needs Further Evaluation by the Local Approving Authority
Qw�4--ki . f�-s
April 6, 2013 ii a
Inspector's Signature Date
t„rr
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.
UlU
t5ins-11/10 Title 5 Official InspectionFo :Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is Centerville MA 02632 Aril 6 2013
required for every p
page. City/Town 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:
Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer
Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The
scope of this inspection is limited to health and environmental compliance and the septic system has
been evaluated according to the conditions observed on the day it was inspected. No estimate or
guarantee of system longevity is made or implied by a passing determination.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is Centerville MA 02632 Aril 6, 2013
required for every p
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is Centerville MA 02632 April 6 2013
required for every p
page. CityTrown 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is Centerville MA 02632 Aril 6 2013
required for every _P
page. City(rown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal 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 11 of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is required for every Centerville MA 02632 April 6, 2013
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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is Centerville MA 02632 Aril 6, 2013
required for every P
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 156 gpd
9 ( Y 9 (gpd)):
Detail:
2011, 2012
Sump pump? ❑ Yes ® No
current
Last date.:of occupancy:=q. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is required for every Centerville MA 02632 April 6, 2013
page. CityrTown 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: occupant
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 18 Chequaguet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is Centerville MA 02632 April 6 2013
required for every p
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 16+ years. Certificate of Compliance for new system issued 12/31/1996. (permit#96-634).
Were sewage odors detected when-arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
�
Depth below grade: 2feet
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.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
10.5 x 5 x 6- 1500 gallon tank
Sludge depth: 6 in
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 18 Chequaquet Way
Property Address
P Y
Mary J. McInerney
Owner Owner's Name
information is Centerville MA 02632 April 6, 2013
required for every
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 28 In
Scum thickness 6 in
Distance from top of scum to top of outlet tee or baffle 7 in
Distance from bottom of scum to bottom of outlet tee or baffle 11 in
How were dimensions determined? Permit application
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Maintenance pumping is recommended at this time and every 2-4 years thereafter. Tank and tees
appear structurally sound and functioning as intended. No evidence of leakage in or out was
observed.
Grease Trap (locate on site plan):
Der1th 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is required for every Centerville MA 02632 April 6, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working:°order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 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
18 Chequaquet Way
4�M SV y0
Property Address
P Y
Mary J. McInerney
Owner Owner's Name
information is Centerville MA 02632 Aril 6 2013
required for every p
page. Cityfrown 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 at 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.):
D-Box appears structurally sound and functioning as intended. No evidence of leakage in or out was
observed. Some solids in sump. A bucket of water was poured into the distribution box and was
observed to pass through in a rapid and unobstructed manner.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is Centerville MA 02632 Aril 6, 2013
required for every p
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
}® leaching galleries number: 1
❑ 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.):
Soils above leaching gallery appear unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into
the distribution box and was observed to pass through in a rapid and unobstructed manner, and could
be heard splashing down into the infiltrator unit.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is required for every Centerville MA 02632 Aril 6, 2013
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of:;Massachusetts q' .
. Title 5 0 icia'I linsp+e�ct ion- Form-
Subsurface:Sewage Disposal:-System Form Notl Voltantary,Assessrnerits,
18 Chequaquet Way;
Property Address.
Mary"J. McInerney
Owner= Owner's Name
_.
e m o ereqared fory ery' Centerville M . 20k. A riy6,'213:
page City'Ffown State; ZIp Code Date of;lnspedtion
D. System 1"nformation �(eont.)
Sketch,Of Sewage Disposal"System -Provide a,,view of'the sewage disposal-:system.including ties#o,
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
El drawing attached.separately
O
T/+.N K
V
vV
Cu:EcuAaur� T WA;Y
951ns•11110" TiIIe 5 Oiricial Inspection Form;Subsurface Sewage Disposal System Pap 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is Centerville MA 02632 Aril 6, 2013
required for every p
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 14+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Certification form
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Certification form of 12/2/1996 signed by Robert J. Bortolotti on file with the Board of Health attests
that"The observed groundwater table is 14 feet or greater below the bottom of the leaching facility". A
Disposal System Construction Permit was issued on the basis of this certification form.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Chequaquet Way
Property Address
Mary J. McInerney
Owner Owner's Name
information is Centerville MA 02632 Aril 6, 2013
required for every p
page. City/Town 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 i
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
a
t5ins•11h0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
K
No. e �
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYtcatton for ni000l *raem Conotructton 3pertntt
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. v G e y�Ulj� l(/� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder
Other Type of Building ie No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow J3�_l gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations Answer when applicable) y6���//SD7/' ¢D'�f?Iex SOX
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 issued by B He
Signed Date / /L e�
Application Approved by Date /.-L-
Application Disapproved for theYollowQ reasons
Permit No. A �{;� �/ Date Issued
6 No.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
application for Migpool *pgterd Congtruction Permit
Application is hereby made fora Permit to Construct( )or Repair( V<an On-site Sewage Disposal System at:
Location Address or Lot No. $ P L(/q Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ti
Type of Building:
Dwelling No.of Bedrooms-- Garbage Grinder(_Oa
Other Type of Building le fk?� 01_ef 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
ti
i j,i,•�t.,,i#
Nature of Repairs or Alterations(Answer when applicable) '22—
y� �r'�/
Date last inspected:
Agreement:
The undersigned agrees to ensure'the construction and maintenance of the afore detsertbed on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmehtal Code and.not to'.place the,systei `in.r�operation until a Certifi-
cate of Compliance has been issued by Board,of H ih. ,w /
A
Signed Date /77
Application Approved by r 4 y Date /a. 2 —,'L
w
Application Disapproved for the olowin reasons _
wway
Permit No. !ne r,S N Date5ssued
Air
__ r ------ - ----
—— r
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY that the On-site Sewage Disposal System installed( )or repaired/replaced(--<on
by D.i'ST/''u2'j/,*Installer
at / �� e!' Lf y (PSI v7-1,V//e, has been constructed in accordance
with the provisions of Title 5 and the for Disposal System ConstrucPermit No, FZ-4,3-
�.l dated
Date Inspector
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.
No. 9�A _--------------------------- Fee,
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Migpool 6p/gtet,,tnc Congtruction permit
Permission is hereby grant Ito �d l�/�G-l�// / Cz2%57I'vC�J 4W
to construct( )repair( ✓4an On-site Sewage System located at No.# Ghe Z! 6, Gva
Street
and as described in the above Application for Disposal System Construction Permit.
No. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
Date: �- - c1 — /�i� Approved by
Board of Health
TOWN OF BARNSTABLE �f 7
4; `rr J
L0C-8,TIONZ 414, 1 SEWAGE #
VILLAGE C eil}�L°�'�/��� ASSESSOR'S MAP & LOT Old
INSTALLER'S NAME&PHONE NO. A0122bll) C'o't 7 ZZ
SEPTIC TANK CAPACrrY 5-4o Cr-L
LEACHING FACILrrY: (type) (size) //X 33 0A-A o
NO.OF BEDROO 3
BUILDER O OWNER pes"
PERMI TDATE: fZ 'Z—1 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �f Feet
Private Water Supply Well and Leaching Facility (If any wells exist �I
on site or within 200 feet of leaching facility)
'l! Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I,,ekrl'7, 401)VC0�fj' , hereby certify that the application for disposal works
construction permit signed by me dated l2 Z!�� , concerning the
property located at �� G �c/ ldBj`j�a% Cel� '/"Ui�li� meets all of the
following criteria:
/There are no wetlands within 300 feet of the proposed septic system
V! There are no private wells within 150 feet of the proposed septic system
Y The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
Y There is no increase in flow and/or change in use proposed
V
There are no variances requested or needed.
SIGNED: DATE:
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].
q:health folder:cert
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TOWN OF BARNSINII3LE.
LOCATION C` 4& A1a I SEWAGE #
VILLAGE G�h �/ L� ASSESSOR'S MAP Bc LOT l���
INSTALLER'S NAME dt PHONE NO. ,�o�'�d�e, � 77/
SEPTIC TANK CAPACITY Sob L r
LEACHING FACILITY: (type) L :`(size)
NO.OF BEDROO
...' BUILDER O OWNER Q�A" '
PERMTIDATE: IZ 'Z—` COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �f Feet
Private Water Supply Well and Leaching Facility (If any wells exist �/ /� Feet
on site or within 200 feet of leaching facility) ;
Edge of Wetland and Leaching Facility(If any wetlands exist
tV Lb
within 300 feet of leaching facility) Feet
: Furnished by
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LOCATION IlS �eq GtGc. q Lf P�' lCu/ SEWAGE #
VILLAGE ASSE OR'S MAP& LOT/1b
1.PP4-?t) S NAME&PHONE N ( diCe�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS_ -3
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 le 'n cili ) Feet
Furnished by �f
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BORTOLOT 1'I CONSTIM( '1'1( N INC.
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765 WAKEBY ROAD, MARSTONS MILLS, MBA 02648
508-771-9399 508-428-8926 FAX: 508-428-9399 r
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CFRTIFICATION
Property Address: , I (,{ C_ G
Date of Inspection:- /-/ -9(o Inspector's Naioc:_ I c7,
(Pvyner's Name aqd Address:��
�'70t0rUl //P — (A3 a
CERTIFICATION STATEMENT:
I certify that I have personally inspected lhe.sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewn e
disposal systems. The System:
Passes C?6
Conditionally Passes )`
Needs FurtheAEvuation By the Local Aproving Authority
Fails
Inspector's Signature: Dale:
The System Inspector shall submit copy of this inspection report to the Approving authority within thir-
ty(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 Department of Environmental Protection. 'fhe original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
A)SYSTEM PASSES:
I have not found any information which indicates lhat the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system, upon comple-.
tion of the replacement or repair, passes inspection.
Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
not determined",explain wiry not.
The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or
exfnitration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if.(with approval of The Board of Health):
- 1 -
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of"I'1►e Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
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 the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND TIIE 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.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT TILE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has aseptic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)S TEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in'310 CMR 15.303. The basis for this determination is identified below. The Board of Health
shoe contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or systein component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of eIIuent 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 clog-
ged SAS or cesspool
✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year hLOl due to clogged or obstructed
pipe(s). Number of times pumped
-2-
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (coi►tinucd)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a 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 I 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. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large sysic►n in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safely and the environment because one or more of the following .
conditions exist:
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 11 of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 MR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CIIECKLIST
Check if the following have been done:
✓Pumping information was requested of the owner, occupant,and Board of Health.
y None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
�As-built plans have been obtained and examined. Note if they are not available with N/A.
y The facility or dwelling was inspected for signs of sewage back-up.
`The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
___j,LA11 system components,excluding the Soil Absorption System, have been located on site.
_ The septic tank manholes were uncovered,opened, and the interior of the septic tank was in-
spected for condition of baffles or tees, material of construction,dimensions;depth of liquid,
depth of sludge,depth of scum.
The size and location of the Soil Absorption System o❑ the site has been determined based on
existing information or approximated by non-intrusive methods.
-3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 13
CIIECKLIS'I'("continued)
✓ �r with information on
The facility owner(and occupants, if diITerent from owner)were provided w
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RF.SIDENTLA,Lo✓
Design Flow: gallons Numbcr of Bcdiooms: Number of Current Residents:
Garbage Grinder: Laundry Connected To Systcm:� Seasonal Use:
Water Meter Readings, if ilable:�
Last Date of Occupancy:
COMMERCLAI ANDU STRIAL'
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings, If Available: _ Last Date of Occupancy:
OTHER: Describe) _
Last Date of Occupancy: _
GENERAL INFORMATION
PUMPING RECORDS and source of informat'on:�� ,v�J
System Pumped as part of inspection: / t) If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
hared System(If es,attach pr vious inspection recor s, if any
Other(explain): J S ���
O
APP OXIMATE AGE of all components, date installed(if known)and source of information:
Sewage odors detected when arriving at the site: (/L)
-4-
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK: /Y U
Depth below grade: Material of Construclion: concrete metal FRP_Other
(explain)
Dimisions: Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:_
Distance from bottom of scum to bottom of ouifet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert, structural integrity,evidence of leakage,etc.)
GREASE TRAP:
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain) -- — — —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert, structural integrity,evidence of leakage, etc.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction:__concrcte_rnetal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level: _
Comments:(condition of inlet tee,condition of alanu and float switches,ctc.) '
DISTRIBUTION BOX:
Depth of liquid level above outlet invert: _
Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into
or out of box,etc.)
PUMP CHAMBER•
A/d
Pump is in working order:
Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.)
-5-
SUBSURFACE SEWAGE VISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive
methods) If not determined to be present,explain'
Type:
Leaching pits, number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches, number, length:_
Leaching fields,number,dimensions:
Overflow cesspool,.number:
Comments: (note condition of soil, signs of hydraulic failure level of ponding,condition of vegetation,
etc.) --- -- - ----
CESSPOOLS: -
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: " 8 Indication of grotmdwalcr:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note c idition of soilk, signs of hydrae ' faJII ire, level of ponMI' conditi it of vegetation,
etc.)
---
PRIVY:
Materials of construction: Dimensions:
Depth of Solids: _
Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.) ---- — ----
-6 -
I _ i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
ce-
r
11 _
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DEPTH TO GROUNDWATER:
Depth to groundwater: Feet /►
Method of Deter mi ation r Approxima(ion: AlY✓ /1 1`/'c`�/. G� ✓�
�1ady �
- 7-