HomeMy WebLinkAbout0030 GUILDFORD ROAD - Health 71/-7
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VILLAGE O-P q�r al Ili? ASSE R'S MAP/&LOT
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AME&PHONE NO. �.c
SEPTIC TANK CAPACITY /660 qal, /Gn A—
LEACHING FACILITY: (type) �4�4 �/ (size) /�h
NO.OF BEDROOMS 3
BUILDER OR OWNER 4e-(P-rn S f(-CLz4f LC)
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching fa ' 'ty) Feet
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VILLAGE .CC`1?'Cr U `IC ASSESSOR'S MAP&LOT
INSTAL!-ER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
TTY
LEACFIING FACILLTI'Y:(type-) _'�' 7 ma` s (size)
No.OF'BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE-
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility _-- Feet
Private Water Supply Well and Leaching Facility (If any yells exist
on site or within 2tm feet of leamhing facility? ]poet
Edge of Wetland and Leadiing Facility(If any wetlands exist
within 300 feet off'leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts `� � 'L,
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is required for every Centerville V Ma. 02632 November 6 2018
page. Cityrrown 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 Sly 3�1�
on the computer,
use only the tab Thomas Roux
key to move your Name of Inspector
cursor-do not
use the return Company Name
key.
89 Mayflower Lane
r� Company Address
East Wareham Ma. 02538
City/Town State Zip Code
774-678-9066 S14531
Telephone Number License Number
i
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty 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:
a
1: -E Passes ---..-
2. ❑. Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
a
�L , C)
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is Centerville Ma. 02632 November 6, 2018
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�a
30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is Centerville Ma. 02632 November 6, 2018
required for every
page. CitylTown 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 El ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
— --- - system will pass inspection if(with approval of the Board of Health): =---- -- _ --- -- -
❑ broken pipe(s)are replaced ❑Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Y 30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is required for every Centerville Ma. 02632 November 6, 2018
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
[]The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 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
❑ ® 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.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Guilford Rd.
Property Address,
WinWin Capitals and Investments
Owner Owner's Name
information is Centerville Ma. 02632 November 6, 2018
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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.
El ® 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.
❑ ® 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.]
T ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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 Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owners Name
information is Centerville Ma. 02632 November 6, 2018
required for every
page. Cityrrown 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
❑ ® 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?
® ❑ Wasthe 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'n a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owners Name
information is required for every Centerville Ma. 02632 November 6, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 331.8 gpd
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
h 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Guilford Rd.
Property Address
_WinWin Capitals and Investments
Owner Owners Name
information is required for every Centerville Ma. 02632 November 6, 2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
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: No information
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is Centerville Ma. 02632 November 6, 2018
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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:
14 years Design plan dated Dec. 3, 2004.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2.5'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.):
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
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is Centerville Ma. 02632 November 6, 2018
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1.51
Depth belowgrade: 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: 8'L x 5.67'W x 5.67'H
Sludge depth:
1"
Distance from top of sludge to bottom of outlet tee or baffle
31"
<1"
Scum thickness
Distance from top of scum to top of outlet tee or baffle 6„
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
!n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is required for every Centerville Ma. 02632 November 6, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
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):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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 ,
�n ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is required for every Centerville Ma. -02632 November 6, 2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes [:]'No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
0,.
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.): . .
D-Box was corroded and was replaced with a new D-Box. A riser was installed so as to bring the
cover to within 6"of finished grade. The D-Box was installed by Condon Excavating.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is required for every Centerville Ma. 02632 November 6, 2018
page. Cityrrown 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.):
*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:
The septic tank and D-Box are functioning correctly. Therefore, the SAS is draining properly.
e
Type.
❑ leaching pits number:
® leaching chambers number:
5
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is required for every Centerville Ma. 02632 November 6, 2018
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.):
No evidence of hydraulic failure.
12. 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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. �� 30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is required for every Centerville Ma. 02632 November 6 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is required for every Centerville Ma. 02632 November 6, 2018
page. Cityrrown 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
W(A 4i r /Vr TS
i
ec (�
C
A
0+1e f = y.
s �
SAS I
t5insp.doc°rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is required for every Centerville Ma. 02632 November 6, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: below 12'
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Dec. 3, 2004.
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:
From the design plan on file.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Guilford Rd.
Property Address
WinWin Capitals and Investments
Owner Owner's Name
information is
required for every Centerville Ma. 02632 November 6, 2018
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria) and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
I _
Commonwealth of Massachusetts
F Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. CitylTown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information —�N
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
CO ® Passes ❑ Conditionally Passes ❑ Fails
ct. d
t1:1 El Needs Further Evaluation by the Local Approving Authority
G
• r�
2-13-12
- Inspector's Signature Date
C' The system inspector shall submit a copy of this inspection report to the Approving Authority Board
CD ;E of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has i 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. al 2) �311 �)
t5ins•11/10 Title 5 Official Inspection Form:S�k surface Sewage Disposal System-Page 1 of 17
T
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
bM 30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upowcompletion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M y 30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. CitylTown 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):
I
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El ® 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-
1 0,000g pd.
❑ ® 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.
❑ El Area
system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 TMe 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
t
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. Cityrrown 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?
El ® 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 (f 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
t5ins-1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 30 Guildford Rd
Property Address
Alfred Bole
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [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)):
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: 2-2012
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Titie 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. City/Town 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: Not since new in 2007
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) (f 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 1/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (f known) and source of information:
2007
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 18
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: 1000 gal
Sludge depth:
12"
t5ins•11/10 Title 6 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
�M 30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 20
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of.current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from field.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is
required for every Centerville MA 02632 2-13-12
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 5-infiltrators
❑ 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.):
Infiltrator leach field in good condition with no sign of back-up into d-box or surrounding stone.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids.layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. Cityfrown 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
Brack ) $
O
d
�D
t5ins•11/10 Title 5 Official Inspection Form'Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 30 Guildford Rd
Property Address
Alfred Boe
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-12
page. City(rown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 30 GUILDFORD RD �� �O6
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is required for CENTERVILLE MA 02632 3/29/07
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.
Important: A. General Information
When filling out
forms on the
computer, use 1. Inspector:
only the tab key
to move your MICHAEL DEDECKO -
cursor-do not Name of Inspector
use the return
key. COMPASS REALTY DEV CORP
Company Name
P.O. BOX 2384 - -
Company Address
MASHPEE MA 02649
City/Town State Zip Code--_
508-221-5003
Telephone Number License Number 1,
I
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:
BK'Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
s"0. 0r-1 1 3/29107
CiOrrs ature 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.
n
281OLD MEETINGHOUSE-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is required for CENTERVILLE MA 02632 3/29/07
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
VI ve 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:
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:
❑ 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
281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is required for CENTERVILLE MA 02632 3/29/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is'leveled or replaced
ND Explain:
❑ 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:
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.
281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is CENTERVILLE MA 02632 3/29/07
required for
every page. City/Town 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ 2 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
ElDischarge 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
❑ LSD Liquid depth in cesspool is less than 6 below invert or available volume is less
than Y day flow
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed Pi e 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
El tributary to a surface water supply.
281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 15
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is CENTERVILLE MA 02632 3/29/07
required for
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No.
❑ I/ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ 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 1000 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.
261 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is required for CENTERVILLE MA 02632 3/29/07
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ Egl"� Pumping information was provided by the owner, occupant, or Board of Health
❑ Lid 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?
❑ y Have large volumes of water been introduced to the system recently or as part of
/ this inspection?
L21- ❑ 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?
[gle"'e ❑ 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?
-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:
❑ 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)]
281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is CENTERVILLE MA 02632 3/29/07
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):.
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder? ❑ Yes E- No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 0?-Ilo
Laundry system inspected? ❑ Yes R-INo
Seasonal use? ❑ Yes P_No
Water meter readings, if available last 2 ears usage d �
9 ( Y 9 (gP ))�
Sump pump? ❑ Yes E<No
Last date of occupancy: 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? f ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe): -
281OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877.
Owner Owner's Name
information is required for CENTERVILLE MA 02632 3/29/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes 5�, oo
281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,M 30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is required for CENTERVILLE MA 02632 3/29/07
every page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 'feet
Material of construction:
cast iron 2e40 PVC ❑ other(explain):
Distance from private water supply well or suction line: .feetw cL;�
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
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: 1000
r�
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle I ,�
C7 [�
Scum thickness
Distance from top of scum to top of outlet tee or baffle Z,'
Distance from bottom of scum to bottom of outlet tee or baffle rl
How were dimensions determined? v�I
281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
. 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is required for CENTERVILLE MA 02632 3/29/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
�� I ' V
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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
• 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is required for CENTERVILLE MA 02632 3/29/07
every page. 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.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
wt OUR am! T-NI,ktr a -
Depth of liquid level above outlet invert I —V
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.):
X lot f' (S 12?1bi) dt,.i , n f � � S' t (d..
tQ 'LCa°
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM , 30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is CENTERVILLE MA 02632` 3/29/07
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information.(cont.)
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:
Type:
❑ leaching pits number:
leaching chambers number: S
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
t � 1
/-I� A 011 A L— ,
LLJ C
l-
-i L�itla'17QKJ WV�Mo,
281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is required for CENTERVILLE MA 02632 3/29/07
every page. City/Town 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.):
281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is CENTERVILLE MA 02632 3/29/07
required for
every page. City/Town 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..
r
6
a
.J
+32-
� - 53
2810LD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 30 GUILDFORD RD
Property Address
JAIRO&BARBARA CONTRERAS 238 BARRACK HILL RD RIDGEFIELD CT 06877
Owner Owner's Name
information is required for CENTERVILLE MA 02632 3/29/07
every page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
Site Exam:
dheck Slope
Surface water
❑ Check cellar
Shallow wells
Estimated depth to ground water:
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
{�-
(d11�1 �'��du oi- �3rfirtn;s�r,� w�r�� S6tow�s �(e��•.�'ioiu �$ �`�
You must describe how you established the high ground water elevation:
1� j OrOS CLiI
281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
V
M FAILED INSPECTION ,AP
DARCEL. -
�O�
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: A 1 L, Ln %;
=y
rw,
Owner's Name: ( -`
Owner's Address: j }
A-
Date of Inspection:
Name of Inspecto please pri t) J �� `j
Company Name:
Mailing Address:
Telephone Number: _ `2-7
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DIEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fail
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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
5� 'T
Page of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2 4/.� ; `�T"' d✓e' �c r.cr.tU
A
Owner:
Date of In e on: 0y/
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:
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:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with..
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is.leveled or replaced
ND explain:
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:
2
Page 3 of I']
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Q
er:1�?111-/ 'PA Pn
Date of 1 pe ion. Q
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.
_ 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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal'to or less than 5 ppm,provided that no other
failure criteria are triggered..A•copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL,INSPEC.TION FORM-NOT FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. 'FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date.of 1 p ion: 00
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each.of the.following for all inspections:
Yes No
d Backup of sewage into facility or.system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution.box above outlet invert due to an overloaded.or clogged SAS or
cesspool
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ -7 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool orprivy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality.analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the.well is.free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than ppm, provided that no other failure criteria.
are triggered. A copy of the analysis must be attached.to this form.]
}
(Yes/No)The system fails: I have determined that one or more of the above failure criteria exist.as
described in 310 CMR 15.303,therefore.the system fails. The system owner should contact the Board of
Health to determine what will be necessary to'correct the failure.
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•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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—I WPA)or a mapped
Zone I1 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.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
<PART B
CHECKLIST
Property ddress:
Owner:
Date of I p ion.
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes o
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 ?
1/ 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)
V _ Was the facility or dwelling inspected for signs of sewage back up
_ Was the site inspected for signs of breakout?
_ 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:
Yes no
Existing information. For example,a plan.at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page G of 11
OFFICIAL I.NSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS
ENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: _
Date of I pec on: " 11)00
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310.CMR 15.203 (for example: 11.0 gpd x#of bedrooms):
Number of current residents:
Does residence.have,a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no): if yes separate inspection required]
Laundry system inspected(yes or no):/
Seasonal use: (yes or no): �..
Water.meter readings, if av ilable(last 2 years usage(gpd)): Z-.J A3'_ 10'0'0
Sump pump(yes or no): O B
Last date of occupancy: �C'�
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR.15.203): glid
Basis of design flow('seats/persons/sgft,etic
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as cart o them ection(yes or no): y_ _
If yes, volume pumped: gallon's--How was quang ty pumped determined? j
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)
�/Totgjl'er(describe):
' t tank —Attach a copy of the DEP.approval
l
_ �� J
proximate age of all comp ent ,date installed 4if known)and source of information:
Were sewage odors<detected when arriving.at the site(yes or no !�
6
Paae 7 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: /
Date of Ins ect' n: �jC✓
BUILDING SEWER(locate on site plan)
Depth below grade:
Materiais of construction:_cast iron 40 PVC_other(explain):
Distance from private water supply well or suction line.
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate'on s Ian)
N/;
Depth below grade:
Material of construction: oncrzte_metal_fiberglass polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate) /
Dimensions: X S
Sludge depth:
Distance frTn top of sludge to bottom of outlet tee or baffle: /
Scum thickness: / I/ q
Distance from top of scum to top of outlet tee or baffle:
Distance from bottomof scum to bott m f outlet tee or baffle:
How were dimensions determined:
Comments (on pumping recomme dations, nlet and outlet tee or baffle condition, structural integrity, liquid levels
s related to outlet invert,evi ence of leakage, etc.):
/, 1710
GREASE TRAP,:.Alocate on.site plan)
Depth below grade:_
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL:INSPECTION,FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property dress:
Owner:. A
Date of In a n:
TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan) .
Depth below grade:
Material of construction: concrete metal f berglass.__polyethylene other(explain):•
Dimensions-
Capacity: gallons
Design Flow- gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments (condition of alarm and float switches,etc.):
DLSTRIBUTION BOX / 1 (if present must be opened)(locate on site plan) „
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.):
PUMP CHAMBE$rl�(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no): --
Comments (note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
AJAA
�Q
Owner: . .
Date of I n:
spe o
SOIL ABSORPTION SYSTEM (SAS):Zoocate on site plan, excavation not required)
If SAS not located explain why:
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,
O 6L , . /i
Aw
rx� V.Ail >r01 A - ,
CESSPOOLVkj� (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 or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY��(]ocate 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.):
9
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION,(continued)
Property Address:
Owner: �a
Date.of In pe ion: �,000
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.
�a
cam® c�llon
Ito
i0
Page 11 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ("Gt'
Owner:
Date of In a on:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water g feet
Please indicate(check)all methods used to determine the high.ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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: 7
<s
11
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: O� � ®� r Lot No.
Owner: CYG Address:
Contractor: ®� Ll.'9l � Address: / ✓� ���r� //�
Notes:
.STEP 1 Measure depth to water table j
tonearest 1/10 ft. .............................................................................. .Date II <
month/daY/Y ar
i
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OAppropriate index well..............................; Y.1/rl Z
CWater-level range zone ..................................................... �.
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ........................... month/year yl ( ffii
t
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B)
determine water-level adjustment ...........................................................................................
STEP 5 Estimate.depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) ............................................................................................................. !7
Figure 13.--Reproducible computation form.
15
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`9 '896.
BORTOLOTTI CONSTRUCTION, INC.
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648
508-771-9399 508-428-8926 FAX: 508428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: Qd
Date of Inspection: - Inspector's
99wner's Name and Address: -Zea
z22z4 C1/ �&,Z
CERTIFICATION STATEMENT•
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true, accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal stems. The System:
Passes
Conditionally Passes
Needs Further E luation By he Local Aproving Authority
Fails /
Inspector's Signature: r Date:
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10.000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
A)SYSTF PASSES:
I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system, upon comple-
tion of the replacement or repair, passes.inspection.
Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
"not determined", explain 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 sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
- 1 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
r f Health in order to determine if
' which require further evaluation b The Board o
Conditions exist q Y
the system is failing to protect the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING 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 with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have.determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
w
V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool.or.privy js�within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and 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 II of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 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
Check if the following have been done:
✓Pumping information was requested of the owner, occupant, and Board of Health.
_'None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
✓ As-built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
,/The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on site.
./The septic tank manholes were uncovered,opened, and the interior of the septic tank was in-
spected for condition of baffles or tees, material of construction,dimensions,depth of liquid,
depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
G 4
` gam::• . / `'`
R:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
►,XThe facility owner(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
FLOW CONDITIONS
RESIDENTIAL:
Design Flow: gallons Number of Bedrooms:__Ll Number of Current Residents:
Garbage Grinder: S Laundry Connected To System: Y'S Seasonal Use: / n�
Water Meter Readings, if vailable:
Last Date of Occupancyi -'/-ei�
COMMERCIALAND USTRIAL•
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings, If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
Al
PUMPING RECORDS and source of information: h
System Pumped as part of inspection: If.yes,volur6e.pp_ ed gallons
Reason for pumping:
TYPE OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes, attach previous inspection records, if any)
_Other(explain):, ��;C `7ipl� i�C1 -r -
AP$ROXIMATE AGE of all components, date installed(if known)and source of information:
/ `� riS �' ,/`,'C • '� BSc. ,f '
Sewage odors dete ted when arriving at the'—site: A/)
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK: /
Depth below grade:: Material of Construction: f/ concrete metal FRP Other
(explain)
Dimisions: , `�.�` 5 ' Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle: 3-5- H
Distance from bottom of scum to bottom of outlet tee or baffle: Nelh tf
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation t outlet invert, structural integrity evidence of leaks e,etc.)T,LS
00
67,
GREASE TRAP:
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other
(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert, structural integrity,evidence of leakage, etc.)
TIGHT OR HOLDING TANK:n1
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:) " +
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into
or out of box,etc.)
PUMP CHAMBER:
Pump is in working order:
Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SOIL ABSORPTION SYSTEM (SAS)::
(Locate on site plan, if possible; excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present, explain:
Type:
Leaching pits, number:_Leaching chambers, number: Leaching galleries,number:
Leaching trenches, number, length:
Leaching fields, number, dimensions:
Overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failu a level of ponding, conditio of vegetation,
etc.) �S /S i? ~��7 "� / ./- G_:; f
CESSPOOLS::
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY::
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
I
I
C
Cxr\�
7✓
DEPTH TO GROUNDWATER:
Depth to groundwater: 2 Q Feet 7
Meth of etermin�tion or Appjoximatiop:
i
-7-
r i
No. l.. J)L4-- V Fee
THE COMMONWEALTH OF MASSACHUSETTS y' Entered in computer:
Yes
PUBLIC HEALTH DMOSION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZIppYfcation for ;h6pozal Opotem Construction Vertu
Application for a Permit to Construct( . )Repair X Upgrade( )Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. 3C) (2)U t 1(ft(qtrC� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel cen eCU i 0-e t
2l ® 0'1 M E
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
15 — _'g(o(41
Type of Building:
Dwelling No.of Bedrooms Lot Size 1 s%aS 4 sq.ft. Garbage Grinder(tj/A-
Other Type of Building iJ0 fl2 No.of Persons Showers( N'Cafeteria( V
Other Fixtures L��a^ars�d Ic�TC►1El� �fr.D� LAunIDR�
Design Flow 1 gallons per day. Calculated daily flow ?)al n Po gallons.
Plan Date , D N MID4 Number of sheets I Revision Date --
Title t- S Lh SAP_f jY,
Size of Septic Tank i i, Type of S.A.S. rAIFt t_� ToQS
Description of Soil �o {AQA
l n' X 3--`mp_wc q
Nature of Repairs or Alterations(Answer when applicable) ��ies �icn
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 provision of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss d by t is Board f ealth. /
Signed Date �Cl/
Application Approved by Date Iv d
Application Disapproved for the following.reasons
Permit No.
d dL4 Date Issued —c1
i•-r. ram. � t, ._ _ .�
No~ v U o L Fee I J '
THE COMMONWEALTH OF MASSACHUSETTS r. ?Fptered in computer:
Yes
PUBLIC HEAL-iH DIVISION - TOWN OF BARNSTABLE, MASSACHUrSETTS
01pplitatioT for dig o ar i tent Construction Permit
Application for a Permit to Construct( )Repair)Upgrade( )Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. 30 (2)U j j d(C 0r(4, —t;Za Owner's Name,Address and Tel.No.
Assessor's Map/Parcel I
a ot0a SAME
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Gqe - Sato S3ci- _~9(0(cl
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size ),S 4 sq.ft. Garbage Grinder
Other Type of Building IJO C1Q No.of Persons. 4 Showers Cafeteria( ✓)
Other Fixtures L-A jA-rna Y lc,TC N F,J S 1.3 : L A u N)1)
Design Flow .,-1)?)C) gallons per day. Calculated daily,flow 1• O gallons.
Plan Date �' -,7-)NP Ar Number of sheets Revision Date
Title ° �-.`z� c>SUC)�i C S U SUM'.V 'iJ CC�.Q
Size of Septic Tank i S'k . 1. Type of S.A.S. S hJ t t T-P r4'tyR S
Description of Soil yo - P�C.n io X �1"T"2tAjC t-(
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with.the provision's of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board'of Health. /y�
Signed MIf/k _ Date-
Application Approved by l r -Uin.i .L Date
Application Disapproved for the following reasons
Permit No. Do o L� y Date Issued /;? _ 5
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded(A
Abandoned( )by
at ( �i !/1 id& CA-,_/f f kqlj, e has been constructed in accordance
with the pro\\visii�ons of Title and the for Disposal System Construction Permit No. U dated 13, -6 -U
Installer � Y°V f) Jl� Designer /
The issuance of7�7
s ped4 it shall not be construed as a guarantee that the system ill function as de ignedDate / N Inspector
t ,
No. e��)dt.�— �`7X _ _ - ._.. .._.._..__ .. ..- ... .._. _.. Fee
— e
1 THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mi.5po.5al *p$tem Con!5trurtion Permit
Permission is hereby granted to Construct( )Repair air )Upgrade( )Abandon( )
System located at )yr l \
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:Const ctio must be completed within three years of the date of thi"pe it.
/ r
Date: `'''7 Approved by
r ,
Town of Barnstable
�tHE ip�� Regulatory Services
Thomas F. Geiler, Director
WtNSPASL6.
A •``g. Public Health Division
TEu na+ Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
• t
Office: 508-8624644 Fax: 508-790-6304
Installer & Designer Certification Form
Date:
Designer: h sq Installer: 2k!?=C- cs 5ED�►r SJCS-
Address: ,l`� 12)6X Address: 15 TCoc��(1 S
Y
On Q Dom,, � 1L was issued a permit to install a
(date)' (installer)
septic system at 10. C \'V- based on a design drawn by
(address)
v. C dated l a Z
K!ysigner)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
t
,1
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or '
certified as-built by designer to follow.
�H DF Ikq
(Installer's Signature) CARR W y�N
u. S'AY N
NG. 1181
'tDesigner's Signature) (Affix De e�.^` ere) Fit
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVIS N. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. ='•
THANK YOU.
Q:Health/Septic/Designer Certification Form
h
r
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TOWN O BARNSTABLE �
'3� ,L SEWAGE #
LOCATION �—_ ASSESSOR'S MAP &LOT
VILLAGE tl`1T�1��1�i�
INSTALLER'S NAME&PHONE NO oil �.. .
SEPTIC TANK CAPACITY
(size)
LEACHING FACILITY: (type) 1 t�
NO.OF BEDROOMS � `
BUILDER OR OWNER
PERMITDATE: I�—6 COMPLIANCE DATE:
Separation Distance Between the: Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
l
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+i V ourab
LA
;VST me
r
TOWN OX BARNSTABLE
LOCATION "30 C����( `�U SEWAGE # ��
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.'--:D �
aSEPTIC TANK CAPACITY IE�1 S 1j='\
L
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: I Z—6 C9� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to.the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist,
within 300 feet of leaching facility) Feet
Furnished by
1
i
1
1
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No....UT.60. "..X Finz...I'd...................
THE COMMONWEALTH OF MASSACHUSETTS
�
BOARD
- ,g.4 1,1151L-Irlrovar 1 *- -------OF.......
Appliration -for Diapwial Works Tiatuitrurtion Vrrmft
Application is hereby made for a Permit to Construct (X ) or Repair an Individual Sewage Disposal
System at: 117P
(9 LL"/ Ate'd d L4 et,4-�q,
.............................................. ................................................ .........Q:'.................................................................................
Location-Address or Lot
..No jd ..............
....................... ........
0#0 Owner Address
................. ..L_.................................................... ..................................................................................................
Installer Address
Type of Building Size Lot....14'4kn........Sq. feet
U
Dwelling*No. of Bedroom, b_t.4 n4-------Expansion Attic Garbage Grinder
Other—Type of Building ---Zc6--------- No. of persons--_.___-a................ Showers ( I ) — Cafeteria
dn
Other fixtures ------------------------------------------- ............ ...... ------------------------------
-------------------------------------------
Design Flow............. ......................gallons per person per day. Total daily flow...... i -_-----____---_-.._.gallons.
9 Septic Tank 4l,iquid capacity,/.Q#Pgallons Length________________ Width..___..._...._.. Diameter_--.---._.-_____------ Depth.--.._.__..-_..
Disposal Trench—No. .................... Width...._.._._._.._____ Total Length-------------------- Total leaching area------------
--------Sq. ft.
Seepage Pit No.._.._.I------------ Diameter---1_0aj0.J00FeP96ffe ow inlet Total leaching area-_--------------sq. f t.
Other Distribution box Dosing tank X j(— -7
Percolation Test Results Performed by........................................................................... Date----.------------------- ----------
Test Pit No. I----------------minutes per inch Depth of Test Pit.__..__...........__ Depth to ground water.-..__--_____-_--_._....
L� Test Pit No. 2................minutes per inch Depth of Test Pit-___-___--_-_______- Depth to ground water-_._--..__--__-_____---.
0 -----4 •I
Ci ..........I----------------------_--
DescriptionofSoil - .E--- 44�
.... ... -j .......
----r- -------2---.---.-.-.-.-.-.-.-.-----------------------------
----
--------------- -- _U ------------- ----------------------------------------------------....................-------------------------------------------------------------------------------------------------------------
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 Article XI of the State Sanitar .Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ee issued by the b ohealth.Sig d- --------- ......jr—- . _W�i 4 e - 1349, P;
......................... -----------*-------
Date
Application Approved By----- - ------ Ao(noo 42��
.................
-"Dat'e
Application Disapproved for the following reasons:------------------------- ...............................................................................
.................................................................................................................................................................. ------------------------........
D............
Permit No.............----------................................. Issued--------------------i---- . .......
ate
—----------- ------------------------------------------NN�----------- -------------------------------
NO. FES.... �!`........°....Y........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HEA TH
OF....... � ....... . .. -
Applirtt#ion -for Dio oottl or P. owitrurtion Permit
Application is hereby made for a Permit to Construct (V)for Repair ( ) an Individual Sewage Disposal
System at "
U�A r"Ra ..---- � ��r ....----•- ................................... -------------•----••-------............................
Location Address / or Lot Nor,,
t' a l tc-- ----�----- - ------------------- - ��'`= l '� ......................................................H r., f
Owner Address
Installer Address
d Type of Building Size Lot---.rS"Do�._._.._.Sq. feet
Dwelling�No. of Bedrooms__ _ ..__ !"°U ^ _____Expansion Attic ( ) Garbage Grinder ( )
r!
pa, Other—Type of Building __ 4r! ........ No. of persons_______---------------------------- Showers ( 1) — Cafeteria ( )
0.i Other fires
ASS ---....
-------------------------------------------------------------------------------------------
W Design Flow....:.......................................gallons per person Rer day. Total daily flow__..._.....'.' :�.�...___...__..___...gallons.
PW Septic Tank--t Liquid capacity-/ allons Length...... ___.. Width......---------- Diameter---------------- Depth________...--.
Disposal Trench-No_____________________ Widtli___-________ 4ngth-------------------- Total leaching area--------------.-----Sq. ft.
_________ Diameter______ ____________ e t Blow 'nlet Total leaching area __ .________.sc it.
Seepage Pit No.: /e7100 S g 1.
z Other Distribution box ( ) Dosing tank ( ) t:L A �
'-, Percolation Test Results Performed by--------i`----------------- .............................................. Date.......----------------------------------
a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water.._-____._____-____-___-
(i Test Pit-,No. 2......_---------minutes per inch Depth of Test Pit.................... Depth:to ground water...-...______________-
` t ` f
Description of So- ------ Q 4'y -
,(
U ! 'nt'!* a � --------------------------- -----
W
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 Article XI of the State Sanitary.- Code The undersigned further agrees not'to.place the system in
operation until a Certificate of Compliance has en ssued by the b r of ealth
�. 1 Y
I t lei
jsi .
-- ------Application Approved By-------- - - ------------------
Date
Application Disapproved for.the following reasons:........................ -----------I ---------------------------------•-•--•---••-------------------------
--------------•------•------•------.....------------------............---•----•--------------•-•---........-•--•-------•----...........----••--•---•-•-•--•----------------------..........---------.--•-
Date
PermitNo......................................................... Issued.................................:.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
HEA. ..L.._
..................... oF.......
Trtifirtt#r of �ompIittnr `
T TO F That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...... . � I---t- . ---a-e-
.-.-e
. .......................................................
....
- `at - �------ - .................-.....................................
has been installed in accordance with the provisions of Article The St to Sanitary as dvc��ell in-Ov
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.......................................................------------------------ Inspector............................................. ..................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
li-
.......OF...... .......'-t--------------------------------............ f
No... FEE....1 -...........
nrtion Permit
'Permission is.hereby granted....... -------------------. -- ............................ ......................
to Co st t pr tr ) In t a1- wage i o.
O �j '
atNo V� _ -•----- -- -- - -------------------............................
Street
as shown on the application for Disposal Works Construction P�itN Dated _ ................................
-
-------------
Board of Health
DATE...................................................-----------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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LOCATION : SEW 64E PERMIT UO.
r v►LLpGE - - -=e- - - / 2 0
'►1�1STALLERS ' ADDRESS
E5UILDER 5 AWl 4t, ADDRESS
DIa-TE PERNA T 155UED
D A.TE COMPLI &&ICE ISSUED :
4,
�'�
\��`�� ..
,' `�'
II, �. i
_- _ .�
*NOTE: ALL PIPES ARE TO 8E 4" SCHEDULE 40 P.V.C. VENT PIPE (O Least 24 inches tan) SECTION A -A ohm
Schedule 40 PVC w/Chorcoal Odor Filter 1
10' min. from ALL OUTLET PIPES FROM THE a
Existing Foundation [house to septic tank PROFILE VIEW OF ADDITION TO LEACHING SYSTEM DISTRyBUTION Boot!HALL BE ""•..,_
Septic to covers must be D-80X cover must be SET LEVEL FOR AT LEAST 2 FT. 12" CONCRETE 0014R �^
TOP OF FOUNDATION ELEV. 100.00 (Assumed) within 6 in. of finished de withtn 6 In. of finished grade 3" of 1/8" - 1/2• Washed
Peaston y �
` Grade over Septic Tank - 99.00 Grade over D-Box - 99.00 ode over SAS - 99.00 3/4' to 1 1/2 " Washed shed Stone 'r 3 - 8•OUTLET M. •�.� e�
KNOCKOUTS
4' PVC(CAPPED) INSPECTION PORT To BE - 6.5" + ' 1Z INS
S • 0.02 INSTALLED AND TO BE WITHW 6" OF O1tADE ` OUTLET •.,z "'/ {•'S .
3 HOLE Box
Tap Load - Elev. -95.70 �. r. a• 4
g 11.5 EXIST. 5-0.01 a Greater S7. 80X J' Mmdmum Cover Top OF System- Elev. -95.20 :�: "• `�4 J �, /` r
FROM EXIST.FDlNIDAT1pN 4 n RML � 1,000 GAL. p 27' s- 0.01• per foot ♦ I 16.5• •' 4" - SCH. 40 T r~
Os SE TIC ANK .9 0" Effect ve Depth t,73
000�ww-��� N H-10 `0". ° 2 5 ur''ts a &25' = 30' PLAN SECTION CROSS-SECTION ,
CONCRETE FULL FOUNIDAT1 c u �i 3'
i 0.83' 3'
`�
$ u i � � y c i
SYSTEM PROFILE 6 ti•of 3/4"-1 1/2" -4 11 t u 3725' 3 HOLE H--10 DISTRIBUTION BOX �` ' °` `r ''
compacted stone v $ >
Not to Scab - c $ �' q �_ Effective Length NOT TO SCALE 421 4' -�I 4 p SOIL ABSORPTION SYSTEM (SAS) 8=41p� �4,
GENERAL NOTES
6 in.of 3/4"-1 1/2' INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN
compacted stone Effective V h th (OR EQUIVALENT) Not to Scale
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6* BELOW GRADE 0 1. Contractor is responsible for Di safe notification
Bottom of Test Hole 1 Elsv.-87.00 DO 1. Dig
safe
Gro_u_n_dw_ate_r__o_b_served O_ 144' NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10' and protection of all underground utilities and pipes.
- _ ~-- ------� 2. The septic tank once distri Dion box shall be set
level on 6 of 3/4 -1 1�2 stone.
3. Backfill should be clean sand or gravel with no
stones over 3" in size.
4. This'system is subject to inspection during installation
by Carmen E. Shay - Environmental Services, Inc.
LOT #146 5. The contractor shall install this system in accordance
P E R C 0 LAT I O N TEST with Title V of the Massachusetts state code, the approved plan
LOT #145 and Local Regulations.
LOT #147 6. If, duringinstallation the contractor encounters an
Date Percolation Test: NOVEMBER 26, 2004 soil conditions or site conditions that are different
Test Pea rformed By. CARMEN E. SHAY, R.S., C.S.E.
Results Witnessed By. WAIVER (per BARNSTABLE B.O.H.) 100.00' from those shown on the soil log or in our design
EXCAVATOR: SHAY ENVIRONMENTAL SERVICES, INC.
installation must halt do immediate notification be
Percolation Rate: Less Than 2 MPI 0 24" made to Carmen E. Shay - Environmental Services, Inc.
7. No vehicle or heavy machinery shall drive over the
1 septic system unless noted as H-20 septic components.
33.5' 37.25' 29.5' 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends.
9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
Test Hole
No. 1 1 s1, e e "•� �� 10. All solid piping, tees & fittings shall be 4" diameter
d k v,. .r� };t Schedule 40 NSF PVC pipes with water tight joints.
DEPTH SOILS ELEV. �I Ivr "�1a` 1 ,, �w1' ' VENT
11. Municipal Water is Connected to ALL OF The Residence and Abutting
0 S 99.00 Properties Within 150 Feet.
andy
Loam D-Box
TEST HOLE #1 THE PROPERTY LINES ARE APPROXIMATE AND
to vR 3/2 O ELEV.= 99.00 COMPILED FROM THE SURVEY PLAN
o"-�" A, sa.4o ENTITLED " SUBDIVISION PLAN OF LAND, CENTERVILLE, MA
Failed FOR PETER SCHAEFFER, BY BARNSTABLE SURVEY CONSULTANS
Sandy DATED MAY 28, 1971, PLAN BOOK 247 PAGE 84
Loom PROJECT BENCH MARK Leach Plt AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
10 r1R S/6 TOP OF FOUNDATION 4 '
7"-42" Be 95.5o IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
Medium ELEV. = 100.00 (Assumed) THE SEPTIC SYSTEM INSTALLATION.
29oYdB/4 Q EXIST. 1000 gad
Septic Tank EXISTING LEACH PITS TO BE PUMPED OUT AND FILLED IN PLACE OR
42 -144 C, 87.00 O LOT #179 REMOVED TO FACILITATE NEW SEPTIC SYSTEM INSTALLATION
DECK NOTE: ANY STRIPPED OUT SOiL CONTAINING LEACtiAiE
FROM THE EXISTING LEACH PITS TO BE DISPOSED
h
OF AS PER BOARD OF HEALTH SPECIFICATIONS.
h7�7 NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY
EXISTING
i I LOT #181 3 9EDROOM ASSESSORS MAP 172 PARCEL 062
�`- HOUSE LEGEND
Perc #130 DECK _---98
Depth to Perc: 42" to 60" DENOTES PROPOSED
Perc Rate= Less Than 2 MPI r------����(� 104X 1 SPOT GRADE
Groundwater Not Observed
No Observed ESHWT II II DENOTES EXISTING
ADJUSTED H2O Elev. = None X 104.46 SPOT GRADE
PL PROPERTY LINE
_ I
ASPHALT ; �96P PROPOSED CONTOUR
I
LOT #180 i DRIVEWAY ; - - - - - -97 EXISTING CONTOUR
15,254 Square Feet +/-
` DEEP TEST HOLE &
2-18" DIAM. ACCESS MANHOLES I I
6 I PERCOLATION TEST LOCATION
I
�', , ;.,-:;::: 96---- ----------------------------- ---- ' •--- 6 FOOT STOCKADE FENCE
100.00,
INLET j / 1 --96 �
LOT PLAN
• �•� THE ACCESS COVERS FOR THE SEPTIC TANK, / \
OF PROPOSED SEPTIC SYSTEM UPGRADE
DISTRIBUTION BOX AND LEACHING COMPONENT
�'•� '� t:'�• -•-`''• I SET DEEPER THAN 6 INCHES BELOW FINISHED
GRADE SHALL BE RAISED TO WITHIN 6" OF
STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. D PREPARED FOR
PLAN VIEW INSTALL TUF-TITE GAS BAFFLES OR EQUALS G UIL ID F 0�D 1�r 0-A -ZZ ) R 0 Y F• LEAF
3-24" REMOVABLE COVERS
(40 FOOT RIGHT )F WAY) AT
'4 • ''� • 4" y ^ - #30 GUIL_DFORD ROAD
3 min. clearance 13' INLET•T"••
INLET 8" min.;-12_ min. Inlet to outlet e. mM
14" min.
�� Liquid level„ OUTLET
- C E N T E R V I L L E, MA
5' -7• ---- s -7• Design Calculations
r: Ev '� 4'-0" min. LTHO PREPARED BY:
b Liquid depth Number of Bedrooms:3 Equivalent to 330 Gal./Day (330 Gal./Day I+in. per Title V) I
Garbage Grinder: No RM
1 Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V; O E N c m 1� 1►l j N ,L� a Sllu
A Y
Septic Tank : - 2 x 330 Gal./Day = 660 USE EXIST. 1,000 GAL. �!ptic Tank. ENVIRONMENTAL SERVICES, INC.
8'-0• 4• -10" SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch 0 20 40 No,
CROSS SECTION END-SECTION Bottom Area: 0.74 gol/sq. ft. x 370 sq. ft. - 273.8 gallons \ F a P.O. BOX 627
Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. - 58 gallons ` ISTER�
s EAST FALMOUTH, MA 02536
Providing: 331.80 gallons gNITARIPN
TYPICAL 1000 GALLON SEPTIC TANK SCALE: r"=2o' TEL FAX : 508-548-0796
NOT TO SCALE Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83 (10 INCHES) EFFECTIVE DEPTH, SCALE: 1 "=20' DRAWN BY: OES DATE. DEC. 3, 2004
TO BE USED WITH 4.0' OF VASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE
__ _ 0N THE ENDS. NO STONE UNDER. PROJECT#SD666 FILENAME: SD666PP.DWG SHEET 1 OF 1