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Centerville
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form n
- ; Subsurface Sewage Disposal System Form -Not for Voluntary Assessmente
50 Fuller Road Ili
u Property Address
Aaron&Kate Dunigan-Atlee +
-r,
Owner Owner's Name
information is
required for every Centerville Ma 02632 4-10-,19
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer, Brett Hickey l
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
0-11
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑■ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
-.opnmh.'grea ey BrenH��
Brett Hickey ��m= � w•a� � � � 4-10-19
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
u
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑■ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. P
System will ass
Y
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):
l5insp.doc-rev.7/26/2018 Title 5 Offclal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 16
c Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
50 Fuller Road
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
P 9 9 q
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ a Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City[Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ Q Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
❑ Q Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0 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.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ O The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 5 of 18
c Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under.Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
El ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ 0 Were an of the system components pumped out in the previous two weeks?
Y Y P P P
El ❑ Has the system received normal flows in the previous two week period?
❑ ❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
0 ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ E] Was the facility or dwelling inspected for signs of sewage back up?
0 ❑ Was the site inspected for signs of break out?
ID ❑ Were all system components, excluding the SAS, located on site?
El ❑ 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?
❑ El Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
0 ❑ Existing information. For example, a plan at the Board of Health.
❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 3
Number of bedrooms(design): Number of bedrooms(actual):
330/GPD
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
4
Number of current residents:
Does residence have a garbage grinder? ❑ Yes El No
Does residence have a water treatment unit? ❑ Yes 0 No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes 0 No
Seasonaluse? ❑ Yes [E No
See below
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2018- 50,000gallons 2017- 46,000gallons
Sump pump? ❑ Yes ❑■ No
current
Last date of occupancy: Date
l5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
. 50 Fuller Road
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner- last pumped 2 years ago
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
~ jai Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
V
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El 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:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
v, Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1
Dimensions: 500gallons
411
Sludge depth:
3211
Distance from top of sludge to bottom of outlet tee or baffle
2"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
1411
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
v
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
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
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
on
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box was in working order at the time of inspection.
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
�s ,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
"If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
(2)500.gallon chambers
El leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7l26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
i Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
v
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Chambers were dry when viewed
with no high staining.
12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�a
50 Fuller Road
V
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
NA
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑■ hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
t
C Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
V
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
M Check Slope
❑■ Surface water
❑■ Check cellar
❑■ Shallow wells
Estimated depth to high ground water: No GW @ 134"
feet
Please indicate all methods used to determine the high ground water elevation:
R Obtained from system design plans on record
10-28-04
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
A plan on file at the local Board of Health was used to determine high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
V
Property Address
Aaron&Kate Dunigan-Atlee
Owner Owner's Name
information is Centerville Ma 02632 4-10-19
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
❑■ A. Inspector Information: Complete all fields in this section.
❑■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
❑■ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
❑■ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the computer, use 1. Inspector: IB
only the tab key
to move your David D. Coughanowr
cursor-do not Name of Inspector
use the return
key. Eco-Tech Environmental
Company Name
r� 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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
October 9 2009
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use. j
r'I
t5ins•09/08 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
wM 50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9 2009
every 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==> A septic system is deemed to pass this Real Estate Transfer Inspection if the
inspector cannot answer Yes to any of the failure criteria listed in Section D on pages 4-5 of this
report. 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-09/08 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
wM 50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 M 50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. Cityrrown 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 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
GSM 50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. CitylTown 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
l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9 2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 89 gpd
9 ( Y 9 (gpd))
Detail:
2007-2008
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-09/08 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
50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. Citylrown 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: 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4'M 50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is Centerville MA 02632 October 9 2009
required for ,
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 4+ years. Certificate of Compliance issued 1/8/2005 (Permit#2004-670)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
No evidence of leakage or backup into dwelling was observed.
Septic Tank (locate on site plan):
Depth below grade: 1
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 ft x 5 ft x 5 ft(1500 gallon)
Sludge depth: 6 in
t5ins-09/08 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
w 50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
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 4 in
Distance from top of scum to top of outlet tee or baffle 8 In
Distance from bottom of scum to bottom of outlet tee or baffle 12 in
How were dimensions determined? Design Plan
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 not required at this time but maintenance pumping is recommended within and every two
years. 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):
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
l5ins•09/08 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 , 50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9 2009
every 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:
t
❑ 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
l5ins-09/08 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
50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9 2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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 with no evidence of leakage in or out.
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•09/0, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
2 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ 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.):
Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching gallery stone and no standing effluent or effluent contact staining was observed in the stone
or overlying soils
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•09/08 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
50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is Centerville MA 02632 October 9 2009
required for ,
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
w
3.2
4/ 31
3
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 50 Fuller Road
Property Address
Susan M. Griffin et al
Owner Owner's Name
information is required for Centerville MA 02632 October 9 2009
every 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: 20+
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. 12/21/04
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
El Checked with local excavators installers- attach documentation
® Accessed USGS database -explain:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Approved design plan on file with the Board of Health shows bottom of system to be 5.4 feet above
the bottom of a witnessed test pit in which no water was encountered. Town of Barnstable GIS
Department records indicate that the property is over 20 feet above groundwater table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 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 50 Fuller Road
Property Address
Susan M. Griffin et al +
Owner Owner's Name
information is Centerville MA 02632 October 9 2009
required for ,
every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
01/31/2005 11:00 5087751594 MSPCA PAGE 01
JHIY.cam.�k�It1� llrrh tt-WIt i r & OREILI-Y 1,40.77e
NOENNETt TO'REILI.*XInC.
Engineering, Environmental & Surveying Services 1571 Main street
S,nicavy 218/sita RAMWWian pmpsrty Lee � PO Box 1667
Site Devolapmont HydmZwIogiC Survey Subdivislem Brewster,MA 02651
Waim WwAr Tmawwt w&*Qu&atyl anWdRS LAudcour, 608-896.6630
WaGor Supply I.tWWW Site Pwbssionai TAII Cautt Witness 508.896.46B7 Fax
January 19,2005 S004 4112
Tom Mo]Kcan
Town of Barnstable
Health Department
200 fain Street
Hyannis,MA 02601
Ro: 50 Fuller Road
Assessor's Map 188,Parcel 029
Centervil3e, MA
Susan Griffin -Owner
Dear Mr.McKean:
As par the requirement of the Mescachusetts State Sanitary Code 310 CMR 15.021(3),
BEMETT&O'REILLY,INC,has conducted an on-site inspection of the newly installed
sewage disposal system at the above referenced property.
At the time of our inapeetien en 1/19/05,the system installation had been completed with the
exception of backfilling and final grading, Our observations were Limited to the top of the Soil
Absorption System(S.A.S),the observation mAnholes for both the septic tank and d-box and the
Broil oonditions above the S.A.S. Soil condition around and be]Dw the S.A.S.were not observed.
Based on our observations,the sewage system was installed wit'.iin substantial oompliance with
the approved plat; dated 10/29/04 as filed in your office.
This letter repraeents BENNET°T&O'RMLY'a inspection priar to backfill. No wanent,ies or
guarsmee we expressed or implied for the future operation of Cilia system.
Picase ccuataet my office dlrcctly with any questions,commaats or for any additional information
you may seed,
'fiery Truly Yours,
B'ENNETT&V REILLY,INC
I, nds J,Pinto,EIT
Civil Engineer
cc:Client
John M. O'Roiia%P.E
L IPAri
r i-IM u:L.=N= 11 L4MI'l =MMI17 I FWL- Z)vMrVI VI'
Town of Aarnstabie ,
Regulatory Services.
# # Thous F.Geiter,Direetor '
Public Health Divhion ,
TjtoMae'Mckeak Director
?A41Katn Street,W nnb,MA 02401
ofaes 508-862.4644 �aa: sas�9o-6�0�
7a aller&DeManir GW=RUQR
Date: 3 i oS
p STa� �kG U�7
Designer: nne4 1�
Addrms: �� 73 - IL 2�� Address:
ews 01631
on 7A�`r � Cx ��-ri 6' ,a®issued a pst to in�all a
Rite 7 ' 3aeta1ler ,
iep at 50 �lltr 2j Cen4vev 111� nZb 32,based e a desip drawn by.
9B)
O6 �� � Wad. �0
Y certify that-the peptic,system mfesenoed above was JuRtallied substsntielly am to
' the de rich may mlolude minor approved cbor ps suoh as lateral relacat GM ome
distdbu=box andlor sgdo tom.
x oaft that th® sq#o s at= re&=ced abov®was,installed wi&rd4or chmUm 0A
gtireater than 10' }ateral rooeation of SAS or any vertical relocation of any�om>>ouent
o the arc era)but in accadmsee with SWO&Local Aegulafio3, Plsn ravia11oa or
ectifted is built by deeiper to know.10 '
OF
O°p d®I,tLY M.
_ J CIVIL
No.362fl ,.� 3 6 4®O
10
RJOT BE
r
Q;�ee�/8eplk/Dos�Ce�flodt3en Fbffi
T'd 068'ON A-I-1 I3dO '8 113NN39 Wd2.S:T S002'ti8'Ndf
TOWN OF BARNSTABLE
LOCATION . P y�rL��t. /L SEWAGE # 0`I " 400
VILLAGE= t?= `" ��= C_VVAEI 1 Ll SSESSOR'S MAP & LOT drf'P— /9
INSTALLrR'S NAME&PHONE NO. AV.$
SEPT7 ." TANK CAPACITY �-
LF.,ACHING FACELI TY: (type) 60 4-41t;ei (size) rl i -V 13
NO.OF BEDROOMS 3
BUILDER OR OWNER li��`4-..l� �?�
PERMTTDATE: /2 COMPLIANCE DATE:
E
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 of leaching facility) Feet
Furnished by
r FA,
r
f� 33.2
3
No.v0 dy ; ,y s . - Fee V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
Yes
PUBLIC HEALTH DIVISION--TOWN OF BARNSTABLE, MASSACHUSETTS
2pprication for Migool OpWm Com6truction 3permit
Application for a Permit to Construct( . )Repair( )Upgrade( Abandon 0 Complete System 0 Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel La d
Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. 1
/ 4gf-0EC-C VC)Q(/)ITlulUSd)C g6AJAJL--TT
<B go/i )?( Syq,�,Owlc) 15-73
4�d4rtit sT C3 =�s���
Type of Building:
Dwelling No.of Bedrooms 2; Lot Size l(!' sq.ft. Garbage Grinder( )
Other Type of Building,5i/U&-L6 Fes,WNo.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ?J V gallons per day. Calculated daily flow 34� el gallons.
Plan Date 9b -1a -�y Number of sheets Revision Date
Title
Size of Septic Tank �S ���� Type of S.A.S. )(o75
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
e ku�vu be,5
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 Enyironment 1 Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued ifi's`Bo flea
Signed Date
Application Approved by 2 f Date 0-2 i-"
Application Disapproved for the following reasons
Permit No. ZU d`{ -6 7V Date Issued /.1-9 1 - '�
No. 0 vLI z 1 Fee v v
�� �.., ( _
_ NEOfv'iMONWEALTH OF MA S CHUSETTS Entered in computer:
t, •,i PUBLIC HEALTH.DIVISId-k-TOWN OF BARNSTABLE., MASSACHUSETTS Yes
U .
Yication for )Dig o5al *p ztem Cow5tructiou Permt
Application for a Permit to Construct( . )Repair( ).Upgrade(I Abandon( ) ❑Complete System 0 Individual Components
Location Address or Lot No.� Owner's Name,Address and Tel.No.
SuSW r�7 �Vi �iCi�.J
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
p?Si"aQl- < vc Pv)gT&tuSd)c 9&Vlv1_--rr
�yoda✓tfl� y )7l S�tiv�ulc/ fkiv9e4U S7" 6f,�Ewr-f6
Type of Building:
Dwelling No.of Bedrooms 2-; Lot Size sq.ft. Garbage Grinder( )
Other 'Type of Building5ia) -L( �No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design.Flow �,�� U gallons per day. Calculated daily flow 3� q --gallons.
Plan Date h) - Number of sheets Revision Date
Title
Size of Septic Tank ISOO cl G 1/6` Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ) / � ti 4��� y ��/�' 0? e
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certif-
Cate of Compliance has been issued by this Bo -of IH - -----..
Signed Date/a
Application Approved by ,11" Date
Application Disapproved for the following reasons
4
f�+
Permit No. 2 U 70 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CE TIFI', that the On-site Sewage Disposal System Constructed( )Repaired.( )Upgraded(�
Abandoned( )by I U_3 41V/
at =-'v r_o- I r,.'11a has been constructed in accordance
with the pro v' 'ons of Title 5 and the for Disposal System Construction Permit No. .7Uu L/-b 7 U dated l?- 2 1-0 y '
Installer m�-rti.P Designe _ o r, ,.o J--Q- Aso.' [
The issuance oftt 's e t shall not be construed as a guarantee that the sy tem(will function as designed' d
Date 1 S Inspector.�5. \ ` _J�-- -'"
- ---------------------------------------
No. ;�U U t�'6 7o Fee 1),/
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mi$po$al *pgtem Con5tructiou Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at Q.) ed, Cvn�✓� �/�
_t
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this-perrmiit) n
Date:
l
/ r) q Approved by
GENERAL NOTES: 501L TE5T LOG5: 5Y5TEM DE51GN CALCULATIONS: BarnstaMA '
A.)NETTMER DRIVEWAYS NOR PARKING AREAS ARE ALLOWED OVER SEPTIC SYSTEM HAND BORING 1: EL=49.4± _ SEWAGE DESIGN FLOW:DWEWNG RR
\\
UNLESS H-20 COMPONENT5 ARE USED. �LOR SUNG OTHER ® I 10 GPD = 330 GPD
LEACHNG CAPACITY REQUIRED:
B.)THE DESIGNER WILL NOT BE RE5FONSIBLE FOR THE SYSTEM AS DESIGNED UN- ONCHEB) OJ9DA)
LESS CONSTRUCTED AS SHOWN. ANY CHANCES SHALL BE APPROVED IN WRITING. A I E - 330 GPD REQUIRED FuNer Rd
3f -- B _ �LQm -and ---- I
NONE 10'b Graved SEPTIC TANK CAPACITY REQUIRED: 28 �i
C.)CONTRACTOR SHALL BE VMFON515LE FOR VERIFYING THE LOCATION OF ALL 30-1 1 Cr C I I NONE Gravel. Loose _ DAILY f9V- - 66o GAL. REQUIRED
UNDERGROUND AND OVERHEAD LMLM15 PRIOR TO COMMENCEMENT OF WORK
SEPTIC TANK CAPACITY PROVIDED:1500 GALLON SEPTIC TANK
CONSTRUCTION NOTES: - _ - _-- . , )
ING CHAMBER CAN LEACH: LN�CUS
HAND FROM�EL49.3��=qqtLL-- ------------ --- _L SOIL OTHER - V�„1NG 0�2.83) +ACITY�(25.O�X.2.0)2 + (12.83 X 2.0)2)0.74 GPD/SF=349.28 GPD
1.)ALL CONSTRUCTION SHALL CONFORM TO THE STATE ENVIRONMENTAL.CODE. �A9) HORIZON��RE � MOTTIJNG� 349 GPD>330 Gi'D REQUIRED
TITLE 5.AND THE REQUIREMENT5 OF THE LOCAL BOARD OF HEALTH.
NOTE: A GARBAGE DISPOSAL 15 NOT PERMITTED WTTTi THIS DESIGN.
A __ , �garry Sand I CMt 2/I NONE
2.)5EPTIC TANK(5).GREASE TRAP(5). DOSING CHAMBERf5)AND DISTRIBUTION -- - _ -- - ---- ---- INSTALL.
BOXES)SHALL BE SET ON A LEVEL STABLE BASE WHICH HAS BEEN MECHANICALLY . I '__ _� Coaax Sand _ I OYR 6J6 NONMejIumE---- 30'16 Gravel. Looms - 1500 GALLON SEPTIC TANK I
COMPACTED.OR ON A 6 INCH CRUSHED STONE BASE. -33 - ONE(1) -3 OUTLET DISTRIBUTION BOX(H-20 Rated) W
F 2 I QYR W4 NONE _-Loose-_----- TWO(2)- 500 GALLON LEACH CHAMBERS WITH 4'OF STONE ALL AROUND
3.)SEPTIC TANKS)SHALL MEET A5TM STANDARD C 1 127-93 AND SHALL HAVE _ ----_
AT LEAST THREE 20'DIAMETER MANHOLES. THE MINIMUM DEPTH FROM THE BOT- -- ---- t_ _ _�. _ _ _-_ __---_----
NOT TO SCALE
TOM OF THE SEPTIC TANK TO THE FLOW LINE SHALL BE 48'. DATE OF TESTING: 10/21/04 EP
4.)SCHEDULE 40 PVC INLET AND OUTLET TEES SHALL EXTEND A MINIMUM OF 6' PERCOLAT`ION RATE: tE55 THAN 2 MIN/INCH IN V LAYERS. (V --
ABOVE THE FLOW LINE OF THE SEFTTC TANK AND SHALL BE INSTALLED ON THE WITNESSED BY: LINDA J. CRONIN, EIT, BENNETT♦OREILLY. INC. n_
CQJTERUNE OF THE TANK DIRECTLY UNDER THE CLEANOLrT MANHOLE. NOT REQUIRED TO BE WITNESSED BY BARNSTABLE BOARD OF HEALTH v LAND COURT PLAN 246 14-E
NO WATER ENCOUNTERED CERTIFICATE #27396
5.)RAISE COVERS OF THE SEPTIC TANK AND DISTRIBUTION BOX WITH PRECAST USE A LOADING RATE OF 0.74 GPD/5F FOR SIZING OF SOIL ABSORPTION 5Y5TEM, A55E55OR5' MAP 158 PARCEL 029
CONCRETE WATER TIGHT RISERS OVER INLET AND OUTLET TEES TO WITHIN G'OF
FINISH GRADE.
G.)PIPING SHALL CONSIST OF 4'SCHEDULE 40 PVC OR EQUIVALENT. PIPE 5HALL
LEGEND
BE LAID ON A MINIMUM CONTINUOUS GRADE OF NOT LESS THAN I%.
7J DISTRIBUTION LINES FOR SOIL ABSORPTION SYSTEM (A5 REQUIRED)SHALL BE Lot 14
32 EX15TING CONTOUR
4'DIAMETER SCHEDULE 40 PVC LAID AT 0.005 PT/FT. LINE 511ALL BE CAPPED Town Water
32 PROPOSED CONTOUR
AT END OR AS NOTED.
�a EXISTING SPOT GRADE
8.)OUTLET PIPES FROM DISTRIBUTION BOX SHALL REMAIN LEVEL FOR AT LEAST 24x5 PROP05ED SPOT GRADE
2'BEFORE PITCHING TO SOIL ABSORPTION 5Y5TEM. WATER TEST D15MBLmON -W-- WATER 5ERVICE LINE
BOX TO ASSURE EVEN DISTRIBUTION, Bdrm
9.) D1STRIBUTION BOX SHALL HAVE A MINIMUM SUMP OF 6' MEASURED BELOW Bdrtn p _ -OH OVERHEAD UTILITY UTILITY
5ERVICE
THE OUTLET INVERT. t/�//' -u-- -- UNDERGROUND UTILITY SERVICE
Approximate location
10.)BASE AGGREGATE FOR THE LEACHING FACILITY SHALL CONSIST OF 314'TO �� of Utility Pole 50 --G-- GAS 5ERVICE LINE
1-112'DOUBLE WASHED STONE FREE OF IRON, FINES AND DUST AND SHALL BE of p a TE5T HOLE/ BORING LOCATION
INSTALLED BELOW THE CROWN OF THE DISTRIBUTION UNE TO THE BOTTOM OF THE t 5T 5EPTIC TANK
SOIL ABSORPTION SYSTEM. BASE AGGREGATE SHALL BE COVERED WITH A 2' L,v,rl Kitchen Zoj•32 DB D15TRJBLMON BOX
LAYER OF 1/8'TO I/2'DOUBLE WASHED STONE FREE OF IRON, FINE5 AND DUST. g �/`/Q
1 1.)VENT SOIL ABSORPTION SYSTEM WHEN Df5TRIBUTiON LINES EXCEED 50 FEET; � 4 14"Oak 1 Y 5 501L AB50RFTION 5Y5TEM
WHEN LOCATED EITHER IN WHOLE OR IN PART UNDER DRIVEWAYS, PARKING AREAS, Dining !�l / RGxrve R.E5ERVED FOR FUTURE
TURNING AREAS OR OTHER IMPERVIOUS MATERIAL; OR WHEN PRESSURE D05ED. !/! 5.0 Z.IZ 7.93
12.)SOIL A850RPTTON SYSTEM 5t1ALL BE COVERED WITH A MINIMUM OP 9'OF 12'Oak ws� UTILITY POLE
CLEW MEDIUM SAND tTXCWDING TOPSOIU. � � �� � w �a '. •�•M '�i CATr:H BA51N
FLOOR PLAN 0LOT 1 5 ., FIRE riYDR ANT
13.) FINISH GRADE 5HA',1 BE A MAXIMUM OF 30 OVER THE TOP OF ALL SYSTEM NOT TO SCALE Area- 10, 195 5F-r �� ! WELL
COMPONENTS, INCLUDING THE 5EPTIC TANK, DISTRIBUTION BOX, DOSING CHAMBER
AND 501E ABSORPTION SYSTEM. SEPTIC TANKS SHALL HAVE A MINIMUM COVER a .50.18 EMti S N DRAINAGE MANHOLE
OF 9'. 95 \ ` t .,aW 48 ■ CONCRITE BOUND. F�7Uh'�g,.�
t 4.)FROM THE DATE OF INSTALLATION OF THE SOIL ABSORPTION SYSTEM UNTIL ./ry \ 99-3"�J drve / j i vt vi bAk4=,.
RECEIPT OF A CERTIFICATE OF COMPLIANCE, THE PERIMETER OF THE 501L AB.SORP- t0
TION SYSTEM SHALL BE STAKED AND FLAGGED TO PREVENT THE USE OF SUCH ""A? K cry PICKET FENCE
AREA FOR ALL ACTIVME5 THAT MIGHT DAMAGE THE SYSTEM. ^^ EDGE OF CLEARING
15.)THE BOARD OF H151TH 5Hr,U REQUIRE INSPECTION OF ALL CONSTRUCTION i .5047 ---- ------
BY Ai4 AGENT OF THE BOARD OF HEALTH (OR THE DESIGNER IF THI5 SYSTEM RE- / e �
QUIRES A VARIANCE)AND MAY REQUIRE SUCH PERSON TO/,-ERTIFY IN WRITING
THAT ALL WORK HAS BEEN COMPLETED IN ACCORDANCE WITH THE TERMS OF THE
PERMIT AND APPROVED PLANS. 48 HOURS ADVANCE NOTICE 15 REQUESTED. �� I /� % 'W
ZANY SEPTIC INSTALLER
5HALL VERIFY INVERT
COMPONENTS ELEVATIONS PRIOR TO INSTALLATION OF w �nq w �* Sq:,r " � w G
�.�q p\ ory .03 +
17.)EXISTING CE55POOL(5)TO 15E PUMPED DRY, FILLED WTII I CLEAN SAND. ` 49Y n 48 4' '
I AND ABANDONED IN PLACE. /S 9 I 48 ^�
18.) INSTALLER TO CONFIRM LOCATION OF ALL UNDERGROUND AND OVERHEAD /
UTILITIES PRIOR TO START OF CONSTRUCTION. T `$�r �\as O �'
Lot 24
19.) INSTALLER TO CONTACT DESIGN ENGINEER AFTER PUMPING CESSPOOL#1 48.3s P s i Exlstartg Town Water D-Box h
TO DETERMINE OWNERSHIP OF CE55FOOL#2. IF THE TWO ARE CONNECTED, SEE �Cexpool
NOTE#17. OTHERWISE fT MAY BE THE SYSTEM FOR THE ADJACENT PROPERTY. #2ry�
BENCHMARK: 50" (see note#19)�+
crete m,e
Top of Con Bound 50 .,e 3� a, ,
EL-50.28(Asdxned daGirn)i
FLOW PROFILE: - Eat 16 /00 00'
NOT TO SCALE Town Water
. • ,�,� PLAN VIEW
48 °z 5CALE 1'=20
_-_ _-- 24' DIAMETER CONCRI�COVERS
TOP OF FOUNDATION RAISED TO WIMIN !'OF FINISH
-- EL-5 I.O± GRADE(OR A5 NOTED)
- E*stin EL-49.5± 6astinc� EL=49.5+ a.-49.0± PLAN
--
- -
� scAL>= 1 20
4827'Propo5M TH 15 AREA 15 SERVED - - - - ------------------ ---- - --
46.3± (9'Min-36'Max)
BY TOWN WATER. 51J5an M o Griffin
2'LAYER OF 1/8' - 112'STONE 50 Fuller Road, Centerville, MA 02632
48.1± 47.C>D 1O, 14' 46.75 - b •_
mash* 3/4 1-I12 STONE y�"` '�� SEWAGE DISPOSAL SYSTEM
3'� ( T � 45.83_-
4� I �c � L �� 50 fuller Road, Centerv111e, MA
2' DROP -- - - � ---- - - O C2'r'.c1L Y } ,°
GAS BAFFLE 43.50 CIUTI
USE TWO SHOREY PRECAST U
t�
500 GALLON REACH CHAMBERS 5.4'+ Q^ -,:, ?;. ° �`'ti B E N N E T T 0'R E I LLY, Inc.
Longest Run WITH 4'OF STONE AROUND Engineering, Environmental and Surveying- vi 7 Serces
6' 1500 GALLON 23 DB 3 _ L I, -- --- (ENE)VIEM -
SEPTIC TANK -V q L.EAChING ChAMDER ' - -- EL-38.I± Bottom of Hand Bonng#2 0 20 40 GO
OX 25.0 x 1 2.83'x 2.0' 1573 Main Street - Route 6A
H 20 -- P.O. Boa 1667
SCALE 1.=20 (508)896-6630 Office Brewster, MA 02631 (508)896-4687 Fax
�D�A - - -j5C�1J`: -Y A1EClC: JOB NUMBER
DRAWING:CADRAWING__AGnfhn. %41 12sds.d" 10/28/04 As Noted LJP/I JMO 11 8004--4 1 12