HomeMy WebLinkAbout0050 ENSIGN ROAD - Health 5 D Ensign Road
Centerville
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SMEAD*
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Ensign Rd
Property Address
McBride
Owner's Name
Barnstable MA 02632 9/29/11
Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information
1. Inspector:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433
Telephone 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:
LU ® Passes ❑ Conditionally Passes ❑ Fails
P
6-± Ell, Needs Further Evaluation by the Local Approving Authority
is
ce:i
r� ` ' 9/29/11
u--• Inspect Signatur Date
C:) a
Thesystem inspector shall submit a copy of this inspection report to the Approving Authority(Board
e , of iH:ealth 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.
14 1,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 50 Ensign Rd
Property Address
McBride
Owners Name
Barnstable MA 02632 9/29/11
Citylrown 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:
Pumping suggested every 3 yrs to prolong the life of the system
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
n/a
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
Commonwealth of Massachusetts
Title 5 Official Inspection . Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 50 Ensign Rd
Property Address
McBride
Owner's Name
Barnstable MA 02632 9/29/11
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
n/a
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
n/a
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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.
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM 50 Ensign Rd
Property Address
McBride
Owner's Name
Barnstable MA 02632 9/29/11
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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:
n/a
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
❑ ® 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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Ensign Rd
Property Address
McBride
Owner's Name
Barnstable MA 02632 9/29/11
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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.
i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Ensign Rd
Property Address
McBride
Owner's Name
Barnstable MA 02632 9/29/11
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)]
Commonwealth of Massachusetts
Title- 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Ensign Rd
Property Address
McBride
Owner's Name
Barnstable MA 02632 9/29/11
CityrFown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
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)):
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: n/a
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:
Last date of occupancy/use: Date
Other(describe): n/a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Ensign Rd
Property Address
McBride
Owners Name
Barnstable MA 02632 9/29/11
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Annual pumping 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):
Approximate age of all components, date installed (if known) and source of information:
1982 per age of home
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 50 Ensign Rd
Property Address
McBride
Owner's Name
Barnstable MA 02632 9/29/11
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
1'
Depth below grade: 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.):
Septic Tank(locate on site plan):
3"
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: 1000g
Sludge depth: trace
Distance from top of sludge to bottom of outlet tee or baffle >12
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle >211
Distance from bottom of scum to bottom of outlet tee or baffle >2^
How were dimensions determined? measured
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 50 Ensign Rd
Property Address
McBride
Owner's Name
Barnstable MA 02632 9/29/11
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.):
Pumping suggested every 3 yrs to prolong the life of the system
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
n/a
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
n/a -
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
,r
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
n/a
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Ensign Rd
Property Address
McBride
Owner's Name
Barnstable MA 02632 9/29/11
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
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.):
n/a
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert level w/the bottom of the pipe
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 6" below grade. Average condition for its age
Pump Chamber(locate on site plan): /
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Ensign Rd
Property Address
McBride
Owner's Name
Barnstable MA 02632 9/29/11
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Top of pit is 18" below grade. 6"of effluent in it at this time. Stain line 18"from bottom of pit. Clean
sidewalls. No indication of backup
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�N 50 Ensign Rd
Property Address
McBride
Owner's Name
Barnstable MA 02632 9/29/11
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
n/a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Ensign Rd
Property Address
McBride
Owners Name
Barnstable MA 02632 9/29/11
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 50 Ensign Rd
Property Address
McBride
Owner's Name
Barnstable MA 02632 9/29/11
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: >12
feet
Please indicate all methods used to determine the high ground water elevation:
F
❑ 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:
Augered hole to 12'4" in 1996 per past inspection report in file
Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
see above
v
do
Commonwealth of Massachusetts
Executive of Environmental Affairs OC
DIEP 5 1996
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Z"o
Property Address: So -�,� Qd , C.Nt\.v�11-e, t-1 i�- .
Address of Owner: rd�,a�� µ, tAO),;—\ L f kckj pC:�
(if different)
Date of Inspection: Fo A, , v `t30
Name of Inspector: Mrchaaf C�eDecko
Company Name, Address and Telephone number: Atlantic Environmental
P.o B ox 2384 - M ashpee M a 02649. Tel : (508) 4771420
CERTIFICATION STATEMENT
I certify that I have personally inspected the.sewage disposal system at this address and
that the information reported below is true, accurate and complete as of the time of
inspection . The inspection was performed based on my training and experience in the
proper function and maintenance of on site sewage disposal systems. The system
..K Passes
---- Conditionally Passes
---- Needs further evaluation by the local Approving Authority
-- Fails .
Inspector 's Signature: Date:
-2L) S�
The system Inspector shall submit a copy of this inspection report to the Approving
Authority within thirty (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 or the Department
of Environmental Protection.
The original should be sent to the system owner and copy sent to the buyer, if applicable
and the approving authority.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: So 2,,asjV,, V0
Owners : t kc"Hz hno y Q6
Date of Inspection : Q*01
INSPECTION SUMMARY:
Check A,B, C, or D
A) SYSTEM PASSES:
-A I have not found any information which indicates that the system violates any of the
failure criteria as defined in 310 CM 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
completion of the replacement or repair, passes inspection.
Indicate yes, no, or not determinate (Y,N, or ND). Describe basis of determination in all
instances. If "not determinated", explain why not.
--•• The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or
exfiltration ,or tank failure is imminent. The system will pass inspection if the existing
septic tank is replaced with a conforming septic tank as approved by the Board of
Health.
-•- Sewage backup 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).
•-- broken pipe(s) are 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 the Board of Health):
----- broken pipe(s) are replaced
----- obstruction is removed
C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A
CERTIFICATION (continued)
Property Address : Sc)
0 wner : Nor� w�aq ti,c�
Date of Inspection :
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
---- Conditions exist which require further evaluation by the Board of Health in order to de-
termine if the system is failing to protect the public health , safety and the environ-
ment.
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 THE ENVIRONMENT:
---- Cesspool or privy is within 50 feet of a surface of water
---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small
marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC-
TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT.
---- The system has a septic 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 within 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 analy-
sis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and
nitrate notrogen is equal to or less than 5 ppm.
D)SYSTEM FAILS:
-- I have determined that the system violates one or more of the following failure criteria
as defined in 310 CM 15.303. The basis for this determination is identified below.
The Board of Health should be contacted to determine what will be necessary to cor-
rect the failure.
Backup of sewage into facility or system component due to an overloaded or
or clogged SAS or cesspool.
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: So
Owner:
Date of Inspection: C �
D) SYSTEM FAILS (continued)
-- 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 over-
loaded or clogged 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 NOT due to clogged
or obstructed pipe(s).
number of times pumped
--- Any portion of the Soil Absorption System, cesspool or privy is below the high
groundwater elevation.
--- Any portion of cesspool or privy is within 100 feet of a surface water supply
ortributary 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 ana-
lysis. 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.
i
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: SB %r,�Ncp, Qjok
Owner: VA 0�_cWj0,)
Date of Inspection : C1 1 a415 b
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above
The design flow of system is 10,000 gpd or greater Large System and the system
is a significant threat to public health and safety 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 I I of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compli-
ance with the groundwater treatment program requirements of 314 CMR 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
CHECKLIST
Property Address: Sc� 9—t<�,%A Q�
Owner: �Z�v �
Date of Inspection:
Check if the following have been done :
-x Pumping information was requested of the owner , occupant and Board of
Health.
--x None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during the period. Large
volumes of water have not been introduced into the system recently or as part
of this inspection.
--x As built plans have been obtained and examined. Note if they are not available
with N/A.
--x The facility or dwelling was inspected for signs of sewage back-up.
--x The system does not receive non-sanitary or industrial waste flow.
--x The site was inspected for signs of breakout.
--x All system components,excluding the Soil Absorption System, have been
located on the site.
---x The septic tank manholes were uncovered, opened and the interior of the sep-
tic tank was inspected for conditions of baffles or tees,material of construc-
tion, dimensions, depth of liquid, depth of sludge, depth of scum.
•--x The size and location of the Soil Absorption System on the site has been deter-
mined based on existing information or approximated by non-intrusive methods
---x The facility owners and occupants if different from owner were provided with
information on the proper maintenance of Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: SC S*JskC �
Owner:
Date of Inspection: ��y\
RESIDENTIAL:
Design flow : 33C� gallons
Number of bedrooms : o3
Number of current residents: C�s
Garbage grinder (yes or no) : K (z)
Laundry connected to system (yes or no): `S<-__tS
Seasonal use (yes or no) : %.�
Water meter readings, if available: 1,3`P*
Last date of occupancy : tc�4
COMMERCIALIINDUSTRIAL :
Type of establishment:
Design flow : gallons/day
Grease trap present: (yes or no)
Industrial waste holding tank present(yes or no) :
Non-sanitary waste discharged to the Title 5 system (yes or no) :
Water meter readings,if available :
Last date of occupancy :
Other: (Describe) ............................................................................................................
Last date of occupancy:
GENERAL INFORMATION
P MPING RECORDS and source f informa i
Sys m pumped as park of inspection[yes or no):.....P.. .......
if yes, volume pomped: .................... gallons
Reasonfor pumping :............................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: SO
Owner:
Date of inspection:
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)
--- Other (explain)...........................................................................................
APPROXIMATE AGE of all components, date installed (if known) and source of information
R�� x.... .... .....�5 ?.S....................................................................................
................................................................................................................................................
................................
Sewage odors detected when arriving at the site : (yes or no)...tad...
SEPTIC TANK :
(locate on site plan)
Depth below grade:
Material of construction: . 7S,concrete ......... metal ........ FRP........ other (explain)
.................................................................................................................................................
Dimensions:'Sx X:5..
Sludge depth :...0 ......
Distance from top of sludge to bottom of outlet tee or baffle:........�.�► .............
Scum thickness :....Q.".......... ,
Distance from top of scum to top of outlet tee or baffle: .............�p........
Distance from bottom of scum to bottom of outlet tee or baffle :......1.b.(...........
Comments:
(recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid
level in el io too I t rt,strut I ' e ity,evi of�eakage,etc. ........... ....
� .!hJ.. . VY! - .... ..!4�. . . .
. . ... .. ...
Ti c, .►. -z,�... a. .!�. �... e........ ..... _....
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAR T C
SYSTEM INFORMATION (continued)
Property Address: SC3
Owner: t`�eNT� ��Ne7
Date of inspection:
GREASE TRAP : ......K.)C-)....
(locate on site plan)
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:.......................................
Distance from bottom scum to bottom 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.)........................
................................................................................................................................................
..................................................................................................................6.............................
TIGHT OR HOLDING TANKS:.A3.�j.
(locate on site plan)
Depth below grade:...............
Material of construction:........concrete........metal.........FRP..........other (explain)..........
................................................................................................................................................
Dimensions:............................
Capacity:....................gallons
Design flow:...............gallons/day
Alarm level:.............................
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
................................................................................................................................................
.................................................................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of inspection:
DISTRIBUTION BOX:..�trS
(locate on site plan)
Depth of liquid level above outlet invert:.. y.� .wl
Comment:
(note if level and dstribution equal evidence o s�i _ carr over, evi ence of leaks a i�Q
or out of box,etc.) -.�k... .. ... ...;.�`l� .'
.......................................................................................................
PUMP CHAMBER:.....,
(locate on the site)
Pumps in working order: (yes or no)...............
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)....................
................................................................................................................................................
................................................................................................................................................
SOIL ABSORPTION SYSTEM (SAS):.......�.. �....
(locate on site plan, if possible; excavation not required, but may be approximated b non-
e q y PP y
intrusive methods)
if not determined to be present, explain:
.................................................................................................................................................
.................................................... ...........................................................................................
Type: -----_.
leaching pits,number: ..
leaching chambers, numb r:........
leaching galleries, number:...........
leaching trenches, number ,length:.....................
leaching fields,number,dimensions:...................
overflow cesspool, number:..........
Comments:
(note n&ipn of soil, sig of hydraulic failure, level of ondi condition ife tion,
fw`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property address: `6—
Owner: Nt w��g tv0
Date of inspection:
CESSPOOLS:.....
(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: .....................
Indicator of ground water: ....................
inflow (cesspool must be pumped as part of inspection)
.................................................................................................
..................................................................................................
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
................................................................................................................................................
................................................................................................................................................
PRIVY : .....
(locate on the site)
Material of construction: ...................................
Dimensions: ......................
Depth of solids: ..............
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
................................................................................................................................................
................................................................................................................................................
e
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address :
c
Owner:
Date of inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'
i
DEPTH TO GROUNDWATER:
Depth to groundwater: �. .�Z.! .feet
Method of determination or approximative:
Alm .� ,...�`4nt��- :......
...........P-5..:........ ..........��. ................................................................................
................................................................................................................................................
:LOT NO-: �L ADDRESS: CMG
OWNERS NAME: CSS�
SEWAGE PERMIT NO. :' NEW: REPAIR:
�-oJ �rJ
DATE T- U :_a DATE INSTALLED:
IMMEWS NAME
INSTALLATION OF: S T IoMm p
WATER TABLE:Al,, LFINA.L INSPECTION BY:
DRAWING OF INSTALLATION ON REVERSE SIDE:
41 -3z
63-3yG
a �
' 3
LOCATION & SEWAGE PERM T NO.
- �
VI I LACE
1 lt�-S lER'S N E i ADDRESS
iUILDEIt OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED //�/ �
00
No-& ..............
............
THE COMMONWEALTH OF MASSACHUSETTS •
BOARD OF HEALTH
..............OF............. -.e...........
Allpfiration for Dispoiial Works (foustrurtion rantit
Application is hereby made for a Permit to Construct �r Repair an Individual Sewage Disposal
System at:
.............................L.
..df..........�.. .... a .P. CA .. . . .
Lo io- Address ()LDt N
......
.... f j . . . . . .. . .... ..Owner. Add
ress
.......................... ......................T ........ .................................... . .. ..... .....................................
Installer Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms.........3------------------------------Expansion Attic Garbage Grinder V-.1b
�4
PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
P4Other fixtures ......................................................................... ............................................................................
Design Flow....................5-5..................gallons per person per day. Total daily flow............. .__®.............gallons.
1:4 Septic Tank—Liquid'capacity.1 bD.O.gallons Length................ Width--.............. Diameter................ Depth................
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.
Z Other Distribution box (L,-)"*' � Dosing tank ( - -Percolation Test Results Performed by...................... ..... Date.........
14 Test Pit No. ...minutesperinch Depth of Test Pit- Depth to ground water_._ .....Q......
P-4 ----- Depth to ground water.-��
04 Test Pit No. 2W-4¢— minutes per inch Depth of Test Pit
--,Z:�----- - --------------
1:4 ........................ ..............................................................................................
0 t--------- li-�Description of Soil..........................0..i.i= .. I. ....
T---------------------7 -- ---------------------------------------------------------------------------------
...........:.T. - I I�t'.L...........................................................................
---------------------------------------------------- -Z- /,Z ............... ..............................................................
MI ..............................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of heajth,,
Signed............... ........ .... .......................... ....
Date
Application Approved By.............--- .- -&............ Z..........
---- ---------------------------- -----
Date
Application Disapproved for the following reasons:................................................................................................................
........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
No................-....... Fps.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ApplirFation for Bhipooal Workii Tottfitrurtion thrutit
Application is hereby made for a Permit to Construct .(A--or Repair ( } an Individual Sewage Disposal
System at -^^ r f
..... ..... .......................... .................................................. ......
Location Address a _ /�y j{ rosy Lot No:� tts
Y T ds
Owner Address
...t�.... r.°, k�f r S C �',� r...-..�.,. �. 7 _. .............
Installer Addres Ss
� Type of Building Size Lot___________________________ q. feet
Dwelling—No. of Bedrooms.........3_____________________________Expansion Attie (O,j 0 Garbage Grinder Q/o
'4 Other—Type T e of Building ______________ No. of ersons__.___.__.____.________._.__ Showers —
a yp g ______________ p ( ) Cafeteria ( )
Q' Other fixtures ------------------------------------------•--
Design Flow----------_----- ��.______R.--____.gallons per person per day. Total.daily flow............ f �______..____gallons.
1:4 Septic Tank—Liquid capacity_t bOV.gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No_.................... Width.................... Total Length............ Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (L.� Dosing tank ( ) _ v _ c
Percolation Test Results Performed by............................�'t--.._...�...._._�wC__.._.. Date....... ��..C-r _._
Test Pit No 1 X ....minutes per inch Depth of Test Pit rr_�w___ Depth to ground water.-'
ater ! � r
(s, Test Pit No. Z'� __:_minutes per.inch .Depth of Test Pit __.. Depth to ground water...........C..........;...�+
04 ........^_-_----•--•--- -----•-- ..-•-3=i..........'......__......-•-------------
• "............
...............
...........
•--------------
•-••••--•-•-----
® Description of Soil........................... -• j.:_....4!..__i..••-•-4•-• "�----•
U --•----
UNature of Repairs or Alterations—Answer when applicable................................................................................................
----------------------------•-....-•--------------------•--•-------------------------•••--•---------------•----------------=--------•------------------•---------..-.--•--------•---......_..-•--•----•.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1:; y g g p y
5 of the State Sanitary Code—The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the o;-Ird of health.
Date
ApplicationApproved By..................................................................................................
Date
Application Disapproved for the following reasons:...............................................................................................................
-•-----•------------•--_------------------------------------------------•-----------------.....---•------..__.....__...-•----•-------•------...---•-•---------------------••-----•-.••---•--•-•-•••••-•-•-
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
,. BOARD OF HEALTH
...... .....!w�'' ..........OF...............:.... .s!. .. .�?... ....................
Tbrrtifiratr of Tontplianrr
THIS IS TO CERTIFY, That the I.kidividual Sewage Disposal System constructed ,,or Repaired ( )
by.................................. ............. ................................. .+ .........................
Y yg �, -
Installer
at................... •----.--.-•---_.. 4._r:..............................FF --• 1••�_N*_- E+
has been installed in accordance with the provisions of TIT- j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
, THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.........................3._'_l _:�............................... Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
•- `� BOARD OF HEALTH
.... ��� 4...............OF..................12 • ...........- --..................................
No......................... FEE........................
Dispoml Vorkv Sono r than �rarti�
Permission is herebyranted_.._.___ F' _ l_. _�........... _ _. .1. __..� . _
g •••. .,...-..
to Construct�(." `or Repair ( ),�an Individual Sewage Disposal Systemg /,, '`
at No. lr =- ...- .t� f. -' -` -t---L., ° .....................
treet
as shown on the application for Disposal Works Cgnstructlo eH b..____._- ed..........................................
/ t Board of Health
DATE....................................✓...........................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS \
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�FSSfONA �
LEGEND �SNOFM 'eR CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION OxO
EXISTING CONTOUR --- 0 ——— t_a-r- ¢ - EWSI6_,,.1 2vAD
FINISHED SPOT ELEVATION s H C�1.1-r�R•l/i L�
FINISHED CONTOUR 0 ft=74 0
IN
APPROVED s BOARD OF HEALTH �STE�`�o�`
No suR�� A IM S TA S L gj III ASS*
DATE AGENT SCALEt Pf'-GO' DATE of .14.82
'-DREDGE E"'NEERN9 Co' IN CLIENT 2bAR12- I CERTIFY. THAT THE PROPOSED
eliREGISTER REGISTUYR
JOB NO. '?KMZ BUILDING SHOWN ON THIS PLAN
CIVIL LAN CONFORMS TO THE Z ING LAWS
ENGINEER SURVE DR.BY= Q OF ,BARNSTAB ro, M S.
712 MAIN STREET CH. BY Q•g •
HYANN I S, MASS. of.14TE ,
SHEET! OF �' DATE LAND SURVEYOR