HomeMy WebLinkAbout0089 ROSEMARY LANE - Health 89 Rosemary Lane
Centerville,MA
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UPC 12534
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
It
ll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
v
Property Address
Scott&Patricia Lutch
Owner Owner's Name /
information is Centerville Ma 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 6/ M �441
on the computer, Daniel Hawkins
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
QCompany Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S114324
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑■ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
DanHawk in. Digitally signed by Dan Hawkins
fl k :'Date:2020.08.1311:20:32-oa'0a 8-12-2020
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.
. I
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
A
' Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
is
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
L�
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma 02632 8-12-2020
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:
0 I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
I
Commonwealth of Massachusetts
�9 Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level.in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced [I,Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
�M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
u Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 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
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l;
89 Rosemary Lane
V�
Property Address ,
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ El Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/day flow
❑ El Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ Q Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ El The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 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
El ❑ 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
�T Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/ I
89 Rosemary Lane
u
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is required for every Centerville Ma 02632 8-12-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ ❑ 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?
❑ El Has the system received normal flows in the previous two week period?
❑ a Have large volumes of water been introduced to the system recently or as part of
this inspection?
El ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ 0 Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
El ❑ Were all system components, excluding the SAS, located on site?
0 ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ 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:
El ❑ Existing information. For example, a plan at the Board of Health.
❑ Q 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
�T ,, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 �
Number of bedrooms(design): Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 490/GPD
Description:
Number of current residents: weekends only
Does residence have a garbage grinder? ❑ Yes F] No
Does residence have a water treatment unit? ❑ Yes [E No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes R] No
Seasonaluse? ❑ Yes No
Water meter readings, if available(last 2 years usage (gpd)): See below
Detail: 1
2018- 89,000gallons 2019- 112,000gallons
Sump pump? ❑ Yes ❑■ No
' Last date of occupancy: off/on
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
�= ,1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
V�
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.).-
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner- last pumped 2015
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
�a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
........... 89 Rosemary Lane
v
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
0 Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes,,attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1985 per plans
Were sewage odors detected when arriving at the site? ❑ Yes K No
5. Building Sewer(locate on site plan):
3'
Depth below grade: feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑ other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
'= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
u=
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
2'
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:
1000gallons
3"
Sludge depth:
3311
Distance from top of sludge to bottom of outlet tee or baffle
6"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
11"
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form '
b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
u—
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: NAfeet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Offdal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
�l; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
V�
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is required for every Centerville Ma 02632 8-12-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
offDepth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box was in working order at the time of inspection.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
v—
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is required for every Centerville Ma 02632 8-12-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
k '
Type:
El leaching pits number: (1 ) 6'x4' pit
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is required for every Centerville Ma 02632 8-12-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Pit was 1/4 full when viewed
with no high staining.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
NA
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.):
s
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failurejevel of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
V�
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma. 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
1
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
�= 15Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,Itz
89 Rosemary Lane
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
■❑ Check Slope
❑■ Surface water
❑■ Check cellar
Shallow wells
Estimated depth to high ground water: No GW @ 150"
+ feet
Please indicate all methods used to determine the high ground water elevation:
0 Obtained from system design plans on record
12-12-1985
If checked, date of design plan reviewed: pate
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
A plan on file at the local Board of Health was used to determine high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
�^ Title 5 Official Inspection Form
m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane
V�
Property Address
Scott&Patricia Lutch
Owner Owner's Name
information is Centerville Ma 02632 8-12-2020
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
�■ A. Inspector Information: Complete all fields in this section.
❑■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
t
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
Title 5 Official Inspection Form
e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane, Centerville
Property Address
William Glover
Owner Owner's Name
information is required for every Centerville MA, 02632 2/12/2009
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.
Important:When A. General Information
filling out forms 1
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Patrick K. McDowell
use the return Name of Inspector
key.
PKM Contractors, Inc
r� Company Name
P.O. Box 775
Company Address
East Dennis MA 02641
City/Town State Zip Code
508-385-5993 S1 13023
Telephone Number I License Number .
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and th@t the
information reported below is true, accurate and complete as of the time of the inspection.Tte inspection
was performed based on my training and experience in the proper function and maiptenand4f orb ite
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 340rof
Title 5(310 CMR 15.000).The,system:
® Passes ❑ Conditionally Passes ❑ Fad
t
-a f.
eeds Further Evaluation by t Local Approving Authority ;
J
In pector's Signature k 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.
L 2/ Dq
T-5-89 Rosemary Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
L
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 89 Rosemary Lane, Centerville
Property Address
William Glover
Owner Owner's Name
information is required for every Centerville MA 02632 2/12/2009
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) i
Inspection Summary: Check A,B,C,D or E/ always complete all of Section D
A) System Passes: i
® 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 i
❑ obstruction is removed I
T-5.89 Rosemary Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Rosemary Lane, Centerville
Property Address
William Glover
Owner Owner's Name
information is required for every Centerville MA ' 02632 2/12/2009
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;3.10CMR:
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:
I
❑ 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.
T-5-89 Rosemary Lane•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 89 Rosemary Lane, Centerville
Property Address
William Glover
Owner Owner's Name
information is required for every Centerville MA 02632 2/12/2009
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
I
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"*.
t
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:
.. r
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each-of the following for.all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool-
❑ ® 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.
T-5-89 Rosemary Lane•03/08 Title 8 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM ,.•~''p 89 Rosemary Lane, Centerville
Property Address
William Glover
Owner Owner's Name
information is required for every Centerville MA 02632 2/12/2009
page. City/Town State Zip Code Date of Inspection
e
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private.water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than:5 ppm,
provided that no other failure criteria are triggered. A copy.of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The .
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems,you must indicate either"yes" or"no"to each of the following in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department. }
T-5-89 Rosemary Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.•Page 5 of 15
Commonwealth of Massachusetts
Kam
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane, Centerville
Property Address
William Glover
Owner Owner's Name
information is Centerville
required for every MA 02632 2/12/2009
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?.
® ❑ Has the system,received normal flows in the previous two week period?'
E ® 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)
El ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
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?.
® ❑ 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)]
T-5-89 Rosemary Lane•03108 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
� _ i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
c�M 89 Rosemary Lane, Centerville
Property Address
William Glover
Owner Owner's Name
information is Centerville for every
MA ' 02632 2/12/2009
page. Cityfrown State, Zip Code Date of Inspection
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
Number of current residents: t 1
Does residence have a garbage grinder?. ❑` Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ :Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use?
❑ Yes ® No
Water:meter readings,.if available (last 2 years usage (gpd)): 2007-266 gpd
2008-288 gpd
Sump pump?
❑ Yes ® No
Last date of occupancy: . m current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft.,etc.):'
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t
T-5.89 Rosemary Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 89 Rosemary Lane, Centerville
Property Address
William Glover
Owner Owner's Name
information is required for every Centerville MA 02632 2/12/2009
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
f
Source of information: No records per BOH
Was system•pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
i
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 operatiomand
maintenance contract(to be obtained from system owner) and a copy of latest t
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
I
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
Installed 9/26/88 per BOH records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
T-5-89 Rosemary Lane•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
89 Rosemary Lane, Centerville I
Property Address
William Glover ,
Owner Owner's Name
information is required for every Centerville MA 02632 2/12/2009
page. Cityrrown 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 ❑ 40 PVC- ❑ other (explain):_ :
Distance from private water supply well or suction line: feet
Comments'(on condition of joints, venting;_evidenceiof leakage-, etc.):.:
Septic Tank (locate on site.plan)`. :. ...
' �1 29
Depth below grade: 29
feet
Material of construction
concrete ❑ metal ❑ fiberglass ❑ polyethylene El-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 gallons
Sludge depth:
3"
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
2"
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
10"
How were dimensions determined? Probe
T-5.89 Rosemary Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 89 Rosemary Lane, Centerville
Property Address
William Glover
Owner Owner's Name
information is required for every Centerville MA 02632 2/12/2009
page. CitylTown 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.):
Baffles in place. No sign of leaking into or out of tank. Recommend additin of risers. Tank should be
pumped every three yers per DEP recommendations.
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):
T-5-89 Rosemary Lane•03/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
__ I
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane, Centerville
Property Address r
William Glover
Owner Owner's Name
information is required for every Centerville MA 02632 2/12/2009
page. City/Town State Zip Code Date of Inspection
1
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.):
AttacWcopy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan): „
. Depth of liquid level above outlet invert
Liquid at outlet invert.
Comments(note if box is level and distribution to outlets equal, any evidence of solids,carryover, any.
evidence of leakage into or out of box, etc.):
No evidence of backup or solids carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
l
T-5-89 Rosemary Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane, Centerville
Property Address
William Glover
Owner Owner's Name
information is C
required for every enterville MA 02632 2/12/2009
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.):
I
Soil Absorption System (SAS) (locate on site plan, excavation not required):
I
If SAS not located, explain why:
I
Type: ..
® leaching pits number: 1 X 6-600
gallll ons)
El leaching chambers number:
❑ leaching galleries - number:
❑., leaching trenches number, length:
El fields number, dimensions:.
❑ overflow cesspool number:
❑ innovative/alternative system I
Type/name of technology:
i
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No signs of hydraulic failure. Pit contained 8"of liquid at bottom at time of inspection. Stain line
showed liquid at about 1' at some previous date.
{
t
{
T-5-89 Rosemary Lane•03/08 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
89 Rosemary Lane, Centerville
Property Address
William Glover ,
Owner Owner's Name
information is required for every Centerville MA 02632 2/12/2009
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
t
Depth of scum layer —
I I
Dimensions of cesspool
Materials of construction —
s Indication of groundwater inflow 0 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.):
i
T-5.89 Rosemary Lane•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Rosemary Lane, Centerville
Property Address
William Glover
Owner Owner's Name
information is Centerville MA 02632 2/12/2009
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.
� u ;
A .- i
3= a3 '
H : 'fo' f
I
3 - 3s i
y = to7 '
T-5-89 Rosemary Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
y
Commonwealth of Massachusetts '
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Rosemary Lane, Centerville
Property Address
William Glover
Owner Owner's Name
information is required for every Centerville MA 02632 2/12/2009
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar +
❑ Shallow wells
I
Estimated depth to high 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:
You must describe how you established the high ground water elevation:
Per Barnstable BOH, plan (1986)shows test hole found groundwater at 150" below grade=12.5'
below grade(approx 26"ASL). GIS spot elevation map(Town of Barnstable)shows site elevation at
approximately 39'ASL Bottom of pit is about 7 feet below grade, leaving 5.5 feet of separation.
between bottom of test hole and bottom of leaching. '
t
T-5-89 Rosemary Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
JM
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 89 Rosemary Lane
Centerville, MA 02632
Owner's Name: John Vickery ���
Owner's Address:
Date of Inspection: July 5. 2005
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49 `
Osterville.MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT cfi
I certify that I have personally inspected the sewage disposal system at this address and that the in onnatioUepo
below is true, accurate and complete as of the time of the inspection. The inspection was perform d based�o myao
training and experience in the proper function and maintenance of on site sewage disposal system . I am.a DEPi-
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sys em:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
j
Inspector's Signature: � Date: July 10, 2005
The system inspector shall sub 't a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of comple ng 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
L
Page 2 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 89 Rosemary Lane
Centerville, MA
Owner: John Vickery
Date of Inspection: July 5, 2005
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:
i
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 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 89 Rosemary Lane
Centerville, MA
Owner: John Vickery
Date of Inspection: July 5, 2005
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 1 I
R VOLUNTARY ASSESSMENTS
OFFICIAL INSPECTION FORM-NOT FOR
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'A
CERTIFICATION (continued)
Property Address: 89 Rosemary Lane
Centerville, M.4
Owner: John Vickery
Date of Inspection: July 5, 2005
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/z 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.
_ ✓ 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 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.]
No (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 System:
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-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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 89 Rosemary Lane
Centerville, MA
Owner: John Vickery
Date of Inspection: July 5, 2005
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner, occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components, excluding the SAS, located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the.baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS)on the site has been detennined 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)].
I
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 89 Rosemary Lane
Centerville, MA
Owner: John Vickery
Date of Inspection: July 5, 2005
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: I
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
C OMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
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:_ Pumped in 2004-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped detennined?
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:
Installed on 9126188-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
i
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 89 Rosemary Lane
Centerville, MA
Owner: John Vickery
Date of Inspection: July 5, 2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials 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 site plan)
Depth below grade: 30"
Material of construction: ✓ concrete _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: 1000 Qal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
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: 10"
How were dimensions determined: Measuring stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Cement tees were present. The liquid level was even with the outlet invert There did not appear to be any si ns of leakaze.
Recommend installing risers on the tank.
GREASE TRAP: None (locate 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 reconunendations, 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 Address: _ 89 Roseinary Lane
Centerville, MA
Owner: John Vickery
Date of Inspection: July 5, 2005
TIGHT or HOLDING TANK: None (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/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.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Commnents (note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.):
The D-box was level and clean.
PUMP CHAMBER: None (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 I l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _ 89 Rosemary Lane
Centerville, MA
Owner: John Vickery
Date of Inspection: July 5, 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -4'x 6'(600 gal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Continents(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
There leach vit had 6"ofliauid on the bottom The scum line was approximately P up from the bottom There did not appear
to be any signs offailure. The bottom to grade was 7'
t
CESSPOOLS: None (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):
Continents. (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
PRIVY: None (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.):
9
f
f• Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 89 Rosemary Lane
'Centerville, MA
Owner: John Vickery
Date of Inspection: July 5, 2005
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.
(Ar4 L
to
� 18 31
3 a3 3
y yv c,-7
10
I
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 89 Roseniary Lane
Centerville, MA
Owner: John Vickery
Date of Inspection: July 5, 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 17+/- feet
Please indicate(check)all methods used to detennine 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: topographic and water contours neaps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours ina s. the naps were showing approximately 17'+/-
to groundwater at this
site.
i
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report.
11
I
TOWN OF BARNSTABLE
TION S /A� SEWAGE #
'VRLLAGE C1!/1 �N� ASSESSOR'S MAP & LOT I
_CAINSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I Club _
LEACHING FACILITY: (type) X 6 P, (size) G
NO.OF BEDROOMS 3
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 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 leas ung facility) J Feet
Furnished by T11 S t tr, J FD�G'
i i I
;L-7�
3 a3 3
y
yv ��
_ Fk
hot
t� TOWN OF BARNSTABvE
CCATION / �� SEWAGE #
VILLAGE��`��i��t? ASSESSOR'S MAP & LOT -(�--_
INSTALLER'S NAME & PHONE NO. / Orss�f C'a TKC
` SEPTIC TANK CAPACITY /000 Cry l
LEACHING FACILITY:(tppe) Prr Ca.s (si�.e)�() '
NO. OF BEDROOMS PRIVATE WE11LL' OR PUBLIC WATER
BUILDER OR OWNER_��`chL4 cS S
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED_
VARIANCE GRANTED: Yes No '`�
�Lf ces
<z
�,b
No.... ................. Fizz
. ...... ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD "OF HEALTH
�Qkt��Y) V:��CXr
... ioC
................. ....................OF.............................. ....................................................
Appliratiou for Dispasal Nforks Tonstrurtion jJermit
Application is hereby.made for a Permit to Construct or Repair an Individual Sewage Disposal.
S stem at
ose-YY\
.......................................... ....... ....................................................................................
Location-Address
. -.. ,1 0...........I.............................. ......... . /L t1t/I'�o�...... *1
Owner Address
....................
_.V
............46........ ......C'(2!V57" _V.vj�?............. i.AL ....................7
. ... .................
Installer Address
Type of Building Size Lot..\_75.4-020.....Sq. feet
U
Dwelling—. No. of Bedrooms..... :...:.....................:.....Expansion Attic Garbage Grinder
04 Other—Type of Building ............................. No., of persons.... ........ Showers Cafeteria
------------
Otherfixtures ......................................................................................................*'*.= . . .............................
Design F! '5S :5
ow............... ....gallons per person
......................... gT Jay. Total da4
Q0W............................... --- 10
Septic Tank—Liquid capacityV�qa.gallons. Length........3�--- Width;.A.1
p Diameter................
Disposal Trench—No..................... Width Total Length....... Total leaching area-. sq ft
.......... ' * G�6
90. 1 sq-
Seepage Pit No... r-li', .... Diameter... Depth below,inlet..4. Total leaching area....... .......... .ft-
Z Other Distribution boi Dosin tank
Percolation Test Results
Performed by . .................................................................. Date..............................
Test Pit No. L. ..Minutes per inch Depth of Test Pit... Depth to ground water.... ...........
Test Pit No. 2................minutes per inch.. Depth of Test Pit....................... Depth to ground water....................._..
..........Y., ........... -----------11...... ........ ---;ii�
D ------- ........ ...........
escriptigp of Soil. 0. ..-27A..... ............ ...............
1* - — ...............
-IS, - 0-c"V-1
S ....21....................................d.......................... ......................... ........
............................................... . ................................................................
................w ......C ... .... ....
.0 Nature of Repairs or Alterations-Answer,when applicable................................................................................................
------------------- ................................................*"**............................:...............................................................................
Agreement:
-1 - The undersigned agrees to install the aforedescribed Individual Se ge isposal'System in-accordance with A. L
the provisions of A. A. 5.of the,State Sanitary Code — T e unders'i fu e rees not to place the system in
I'L
operation until a Certificate of Compliance has be n issu
Sign ...... ............. ............... .. ........................................ .... ..
Application Approved By..........►...i........... . ........
............................:.......................... ...... .......
Date
Application Disapproved for the jollo.wing r ons:................................................................................................................
............................................................................................................................................................................................
Date
PermitNo....................................................... Issue&....................................................
Data
•H ,FE NO...::j�'. ,. . s.� -�.�..Sb
THE COMMONWEALTH-OF MASSACHUSETTS
BOARD OF HEALTH,
`` F
�OW1�............. .....OF...!....? `r115Tb12
................................................
Appliration for Disposal Works Tonotrurtion Permit
Application is hereby.made for a°Permit to Construct 06 or Repair ( ) an Individual Sewage Disposal
S stern at 1 f
vi11e... _,. .b ...0 .. - -...: ..:....
....... F ... .. ... ..
-Location Address or Lot No.
........./1'.... �1,�'n.."z:!z! ............... 1 .... - . .. '9 / C` �.tJ . 1�l 1' /s✓ �'....40_'�%� /C
Owner
fan ST?can t`..w�_u_ l G� y 5
.a ....r :... -- 4.......... . ....... 1 f--./'V/71 C .................. . ..............
Installer' %, — Address t-
Cq
V
Type of Building g ..3 ( . -�, Size Lot.. 5.,.�oo_--Sq: feet
.r Dwelling—No. of Bedrooms..................:.........................Expansion Attic ( )'• Garbage Grinder ( )
a'4 Other—T e of Buildiil
YP g..........-.................. No. of persons............................ Showers ( ) — Cafeteria
Q Other fixtures ...:............................_........................................................................
._.. .._......_..:.........................
Design Flow............................................gallons per person er Oay. Total daily tlow......................................... ..g�llo
Septic Tank—Liquid capacity)SR9..gallons Length.��? .._. Width:..4._ _: Diameter__:............. Depth..... e
x Disposal Trench—No. .................... Width s:.�..r....:.......Total Length.......t--.. -,-- Total leaching area----•-.•--------:--_sq. ft.
3 Seepage Pit No...gn!eI...... Diameter. 12-. T :. Depth below inletA.e _:.. Total leaching area.:!!�9 ..)..sq-fe-•G,
Z Other Distribution box ) Dosin tank
� Percolation Test Results Performed by.......:...... ..................•---.---...--.-r�........... ....... Date..............................rr........
Test Pit No. L 2...minutes per-inch Depth of Test Pit... $....:_. Depth to ground water...1s�...........
L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
w ......
O 2 T� C10.vr��• UbSo1 " Or;-•---• t ..«...... n
Descriptio of Soil. O- ..... S 2�}- C�2a1� v�n2 c� San.... o -18
U rr_ ...... ear, r„e�. Sae 1�32."
.
.... s......\. ......... ........................................... ............................:.S�1
w ::.............:..............................--------- ................. :.......- ------- See. ...............
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 AI:U 5 of the State Sanitary Code—The undersi�- ed further�a''grees not to place the system in
operation until a Certificate of Compliance has been issueby,Rtthenboar2l'`oftlialfh.
./'
Signed,em-.` ieL, �:.:. ............................................................. -� X.:6.:..:...:7
i ate`
Application Approved By.......... .. ` -' ...._... � � _.: ......:
1
f r Date
Application Disapproved for the following reasons:..............................:...................•----•----••..................__:_....--•-•--••---.........._
-......................................................... --• .• •-- •--•-••--.......... ---• •--......................................................... :......: .
r Date
Permit No................... ...... Issued.. -
---••--• •-----. Date ........ ... •....
_:LTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f_�.i l �� Trrtt f iratr of Tomplianrr -'
THIS IS TO 'CERTIFY; That the Individual Sewage Disposal System constructed (x, or-Repaired ( )
Gtt� s.
.............•--• -•---•------ ----
Installer
at........... .12................... .................................:........... .. ttti..:...:...... ......_...:..:.---•--••---..... ............. '
has been installed in accordance with, the provisions of TITLE 5 of The State Sanitary Code asp described in the
application for Disposal Works Construction Permit No..: �;. ..: _ ........... dated......-1.j..... .1."_c?1.. ........
U
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE. '
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................... .. �:. ..... .............. Inspector................. ----• ..--•--- .....--• . -- .
n
.---_�.«,.....-„_»=-e-�•-"�'""" ~�c_TH�-COMMONWEAL:THeOF+MASSACHUSETTSY)���r�A��� --��•�--�
BOARD .OF HEALTH
No............t...l..�- {.. .... ....... FEE..... -------------
Disposal Yorks Tonstrudiun Permit
Permission is hereby granted.............. a;. .0 vu 1^-k,-•------.6.-.`...:1�\.:v-••-----
to Construct (Y) or Repair ( ) an Individual Sewage Disposal System
at No....�-*� ........... � ............ ''"1 �=�-- 6.41..4
,: ...,..... ..•... :-•-•- --.'. .... ....
Street _ �7
as shown on the application for Disposal Works Construction Permit No.&..::.'_.L.Z Dated....... `"_...... .................
...................... \ Cif...__ :�`l
.................................
t� — BS and of Health
,DATE------••--•--•• ----••................•--------•.......----- .---. ..,....:. t
.t
A
SECTION - SEWAGE -
--
'. Ct. 42 .g.s{ `
3.
` -SEPTIC TANK - S I - D"BOX - � ! - LEACH
PIT _
TOP F FDN
=�•(MSL)tt "2"OF i/STO 4z" - -
WASHED STONE
LA N
t
M1 .:
7,
IN•
OUT• IN•
Q d OUT• IN• �sigO�p 1 b
39.10 -SEPTIC /�{ 6 °• 7L �- 1 E�.' JS.S
3?85 TANK � 3 ":ZP
ELEV. ELEV. ELEV. ELEV. �'S 4-, '• I I C "2
-s-1 �;.O oe -
, , '
ELEV: ELEV. b ��(•
�I WASHED STONE
33
TEST HOLE LOG _P t 4040 o ,
IEVEL 2c•Z \ 5 0
�° o \a(
TEST BY R*AtRBANK 1-S. ?. CON LON c
WITNESS
TEST DATE le 1 0 DESIGN BEDROOM HOUSE \
\
T.H. # 1 T.H. # 2
ELEV. ELEV.
5� w ,29u 3�85� PERC RATE �2 MIN/IN: DISPOSER DISPOSER :
SoC� s -
cLe FLOW RATE (GAL./DAY) 33
Mee ; �.
s�Np SEPTIC TANK j�O K ((•51= S 30 �. �• \...
SILT '! 32.o R I N l000 �EO'D SEPTIC TANK SIZE
_ CLEAN _
LEACH FACILITY
SAWD 29.2 � SIDE WALL :12�i�4=15a,S sf (2.51 3117.� G/D. —
,�. BOTTOM IeWA = 1::A3•I I. ( 1.0 ) s VISA G/D. ,*- 100 . 00 � -
132.,Z7 S - S'1
SILTY �� ;�:� - - TOTAL 2,63.-q' S. _ .4.: o,�, G�D• t r•, �31.
w4k�r Igo
kI
USE: ONE. LEACHING -P(T
Yes 121 e�� d'a x 'e; �e�rh I �Cill� '�AG/,, �
J WATER ENCOU RED
�l�GA1ZJD - tol
-
NOTES: (UNLESS OTHERWISE NOTED)
1.DATUM(MSL)+TAKEN FROM.- �I�..N I S__---- QUADRANGLE MAP OVA OF _
2.MUNICIPAL WATER�_____15 -____ AVAILABLE -
3.PIPE PITCH:V4"PER FOOT -
4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASFO- 1 67 - --' - -44 ARNE�# t1/ ' _`9�
�'�' O - y "_DISTANCE AS-CERTIFI-ED ---- -- -- - C r
5.MIN.GROUND COVER OVER.ALL SEWAGE FACILITIES:(1)_PT. �A(� : ARNE G *J v _ - SEWAGE A�j G
6.PIPE JOINTS SHALL BE MADE WATER TIGHT O H -•_
7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS.
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STATE ENVIRONMENTAL CODE TITLE 5_ _ NO.� '` +"• ' - _ .
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