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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16
366 White Oak Trail f.,
Property Address q
Penta
Owner
formation is Owner's Name
required for every Centerville '� MA 02632 6/14/19 ',
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.
A. Inspector Information
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Cityrrown State Zip Code
508.272.6433 13010
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
6/14/19
Insp,00s I atu 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
�I
ti
Commonwealth of Massachusetts
Title 5 Official Inspection Form
~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owner's Name
information is
required for every Centerville MA 02632 6/14/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
�a
366 White Oak Trail
Property Address
Penta
Owner Owner's Name
information is
required for every Centerville MA 02632 6/14/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owner's Name
information is
required for every Centerville MA 02632 6/14/19
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 asses if the well water analysis, performed at a DEP certified laboratory, for fecal
Y p Y . p rY�
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
El ® clogged,SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 118
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
15 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
366 White Oak Trail
i�vw I
Property Address
Penta
Owner Owner's Name
information is
required for every Centerville MA 02632 6/14/19
page. City/Town 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.
❑ ® 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.]
❑ ® 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 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc.rev.7/26/2018 Title 5 Official Inspection 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
366 White Oak Trail
Property Address
Penta
Owner Owner's Name
information is
required for every Centerville MA 02632 6/14/19
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?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
6g Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owner's Name
information is
required for every Centerville MA 02632 6/14/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: 5
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
Date
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Ig Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owner's Name
information is
required for every Centerville MA 02632 6/14/19
page. Cityrrown 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: Pumped March 2019 per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
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
f" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owners Name
information is
required for every Centerville MA 02632 6/14/19
page. City/Town 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:
Existing septic tank, new d-box and infiltrators 2000 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 18"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 Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owner s Name
information is
required for every Centerville MA 02632 6/14/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 10"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound, outlet end has steel cover to grade, outlet T has filter
which should be cleaned periodically
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000g
Sludge depth: trace
Distance from top of sludge to bottom of outlet tee or baffle >12
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle
>2"
Distance from bottom of scum to bottom of outlet tee or baffle ,211
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.):
Pumping suggested every 3yrs to prolong the life of the system
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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owner's Name
information is
required for every Centerville MA 02632 6/14/19
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 ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owners Name
information is
required for every Centerville MA 02632 6/14/19
page. CityrFown 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):
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.):
D-box is 18" below grade, no adverse conditions
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
r� (o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owner's Name
information is
required for every Centerville MA 02632 6/14/19
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:
Type:
❑ leaching pits number:
® leaching chambers number: 5
❑ 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Z Commonwealth of Massachusetts
rP Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owners Name
information is
required for every Centerville MA 02632 6/14/19
page. Citylrown 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.):
Infiltrators were video inspected and are damp at this time, no indication of past hydraulic failure,
bottom os SAS approximately 4'6" below grade
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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owner s Name
information is
required for every Centerville MA 02632 6/14/19
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
!~ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owner's Name
information is
required for every Centerville MA 02632 6/14/19
page. Cityfrown 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
TOWN OF BARNSTABLE L`
LOCATION ��� f ) `A MQI �i("— SEWAGE It.
VUA.AGE— l_ v�``�- ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. � p—C(As��3�PceL
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 4A% Crap"ca'>R . (size)
NO.OF BEDROOMS
�_
BUII.DER 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 leaching facility) Feet
Furnished by
• s
R1. ill�
1 3t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-� 366 White Oak Trail
Property Address
Penta
Owner Owner's Name
information is
required for every Centerville MA 02632 6/14/19
page. City Fown 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: >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: Per permit GW>34'msl
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
2000 compliance on file
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping, site is at 70'msl and nearby surface water is at 30'msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
366 White Oak Trail
Property Address
Penta
Owner Owner's Name
information is
required for every Centerville MA 02632 6/14/19
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 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
1
Commonwealth of Massachusetts
v Title 5 Official; Inspection Form
Subsurface Sewage Dispossii System Form- Not for Voluntary Assessments
366 White Oak Trail
Property Address
Mike Murphy
Owner Owners Name
information is required for every Centerville MA 02632 12/18/2013
page. City/Town State Zip Code Date of Inspection
f
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not ,James Ford Vv"� I I
use the return Name of Inspector
key.
rab Company Name ;
P.O. Box 49 I
Company Address
Osterville MA 02655
City/Town } . ' State Zip Code
508-862-9400 S12482
Telephone Number ;I License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
'r
❑ Needs Further Eva !ion by the Local Approving Authority
�M NNW 12/18/13
Inspe 's Signature Date
The ys em inspector shall submit a copy of this inspection report to the Approving Authority(Board
of He 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 conditibns of use.
, 1�3
t5ins-3/13 ( Title 5 official?Peciojolu bsurface Sewage Disposal System•Page 1 of 17
i
t ;
t
Commonwealth of Massachusetts
Title 5 Official' Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y ' a 366 White Oak Trail
Property Address
Mike Murphy
Owner Owner's Name
information is required for every Centerville 0 MA 02632 12/18/2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check. A,B,C,D or E/always complete all of Section D
A) System Passes: I
® 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:
t
1
B) System Conditionally Passes:
❑ One or more system cor.pponents as described in the"Conditional Pass" section need to be
replaced or repaired.1 he 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.
2 .
❑ Y ❑ N ❑ ND(Explain below):
i
l
r<• t.
s'
t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
1
Commonwealth of Mas!gkhusetts
Title 5 Officially Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 366 White Oak Trail
Property Address
Mike Murphy 4
Owner Owners Name t
information is required for every Centerville MA 02632 12/18/2013
page. City/Town State Zip Code Date of Inspection
B. Certification (contj;)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
11
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):
i
i{ I
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s�are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which'require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass'Unless Board of Health determines in accordance with 310 CMR
.15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 OfficiaA Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
366 White Oak Trail
Property Address
Mike Murphy
Owner Owners Name
isrequired for every
very Centerville MA 02632 12/18/2013
page. City/Town 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 al;'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 Wseptic tank and SAS and the SAS is within 50 feet of a private water
supply well. ;I
❑ 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:
F
**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: S;;
i
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes' or"No"to each of the following for all inspections:
e .
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(o 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
tl,
commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal P"ystem Form -Not for Voluntary Assessments
°M 366 White Oak Traili 3
Property Address
Mike Murphy
Owner Owners Name
information is
required for every Centerville MA 02632 12/18/2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
11'
El ® Any potion of the SAS, cesspool or privy is below high ground water elevation.
El ® Any 0ortion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
1 1 `
❑ ® Any Rqi tion 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-
10,00.0gpd.
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
nece$sary 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 io 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. I
Yes No
I;
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the Sys Item is within 200 feet of a tributary to a surface drinking water supply
El E] 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"Vo any question in Section E the system is considered a significant threat,
or answered "yes" in Sectio,;n 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 $10 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i`
{I
;i
Commonwealth of Massachusetts
Title 5 Officizl' Inspection Form
Subsurface Sewage Disposol System Form -Not for Voluntary Assessments
i .;
�M a 366 White Oak Trail `
Property Address
Mike Murphy ;' .4
Owner Owner's Name
information is
required for every Centerville MA 02632 12/18/2013
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
y
9
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 tl system received normal flows in the previous two week period?
I
❑ ® 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
availa416,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 sizeand location of the Soil Absorption System (SAS) on the site has
been Itermined 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
approxienation of distance is unacceptable) [310 CMR 15.302(5)]
b
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 4
n
( g: ) Number of bedrooms (actual):
DESIGN flow based on 310i p.CMR 15.203(for example: 110 gpd x#of bedrooms): 440
,
f,
C
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
1
:R
f
Commonwealth of Mastachusetts
W Title 5 Officif, Inspection Form
Subsurface Sewage Dispos4i,System Form - Not for Voluntary Assessments
366 White Oak Trail
Property Address l
' a .
Mike Murphy
Owner Owners Name
information is
required for every Centerville MA 02632 12/18/2013
page. City/Town ;! `; State Zi Code
P Date of Inspection
D. System Information
Description:
F
y
t
4
Number of current residents; ` 1
C .
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected'? ❑ Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail: a
unavailable
i,
Sump pump?
❑ Yes ® No
Last date of occupancy: current)
i, Date
Commercial/Industrial FI wConditions:
Type of Establishment: .i.
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? El Yes ❑ No
Industrial waste holding tank.present? ❑ Yes ❑ No
Non-sanitary waste discharg'ed to the Title 5 system? El Yes ❑ No
Water meter readings, if available:
t5ins•3113 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
r
{I
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage DisposeI System Form -Not for Voluntary Assessments
°�M ,••'�t 366 White Oak Trail
Property Address g'
Mike Murphy
Owner Owner's Name
information is I
required for every Centerville MA 02632 12/18/2013
page. CitylTown State Zip Code Date of Inspection
D. System Informaticir" (cont.)
Last date of occupancy/use:, summer use
Date
Other(describe below):
ti
l I
t,
General Information
Pumping Records:
Source of information:
summer of 2013
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 tanks, distribution box, soil absorption system
❑ Single cesspool
J
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/�,'Iternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection a;E the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
� .j
i
Commonwealth of Massachusetts
m Tale 5 Official;,: Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
h `I
°M •'- 366 White Oak Trail
Property Address
Mike Murphy
Owner Owner's Name
information is
required for every Centerville MA 02632 12/18/2013
page. City/Town State Zip Code Date of Inspection
D. System Informati6n (cont.)
Approximate age of all components, date installed (if known)and source of information:
installed -new leach field gk;9' 9/7/2000
Were sewage odors detected when arriving at the site?
_ ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
i
feet
Material of construction:
❑ cast iron ® 4l),PVC ❑ other(explain):
Distance from private wate' .s'upply well or suction line:
feet
Comments (on condition ofjjoints, venting, evidence of leakage, etc.):
li
Septic Tank(locate on site lan):
Depth below grade:
13'
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain)
t
is
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gals.
Sludge depth: 211
t5ins,•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
6
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal system Form -Not for Voluntary Assessments
c�M 366 White Oak Trail
Property Address
Mike Murphy
Owner Owner's Name
information is
required for every Centerville L MA 02632 12/18/2013
page. City/Town State Zip Code Date of Inspection
D. System Informati6n (cont.)
Septic Tank (cont.) i
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness 1"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
12"
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.):
There were no signs of Ieakage.The outlet cover was to grade.
,
Grease Trap(locate on site plan):
I.,
Depth below grade:
feet
Material of construction:
❑ concrete ❑ l meta ❑fiberglass ❑ polyethylene
,. ❑ other(explain):
N/a .
Dimensions:
f .'
t: , •
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•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
d
`tl
Commonwealth of Massachusetts
Title 5 Official:. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
366 White Oak Trail
M
Property Address ;
Mike Murphy
Owner Owner's Name
information is
required for every Centerville H MA 02632 12/18/2013
page. City/Town State -ZipCode
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.):
s:
1 ,
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
r ;
Material of construction: 1,
❑ concrete i 3
❑ metal El fiberglass ❑ polyethylene ❑ other(explain):
N/a
Dimensions:
�i
Capacity:
gallons
Design Flow: ;
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: El Yes
El No
Date of last pumping:
Date
Comme
nts of alar •(condition m and float switches etc.).
r,
t
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
366 White Oak Trail
Property Address
Mike Murphy
Owner Owner's Name
information is
required for every Centerville MA 02632 12/18/2013
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 even
I,
Comments (note if box is IeVel and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The D-box was normal. Thy;cover was 18" below
I ,
li
{
Pump Chamber(locate onr site plan):
Pumps in working order: El Yes
❑ No*
Alarms in working order: ` El Yes ❑ No*
F
Comments (note condition Qf pump chamber, condition of pumps and appurtenances, etc.):
N/a
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 �
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
t-
Commonwealth of Mas,aa'chusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
366 White Oak Trail
Property Address i
Mike Murphyi
Owner Owner's Name
information is
required for every Centerville MA 02632 12/18/2013
page. CitylTown State Zi Code
P Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pith " number:
® leaching chambers number: 5- High-cap.
infiltrators
❑ leaching gJeries number:
,.
❑ leaching trenches number, length:
t,
❑ 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.):
There was no signs of failure Used a camera to inspect.
t
t...
Cesspools (cesspool must'be pumped as part of inspection)(locate on site plan):
Number and configuration
N/a
Depth—top of liquid to inlet inert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
(Sins•3/13 CI Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
t '
� S
Commonwealth of Massachusetts
• W Title 5 Official, inspection Form
o L
Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments
366 White Oak Trail
Property Address
Mike Murphy
Owner Owners Name
information is
required for every Centerville i '; MA 02632 12/18/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): ' ?
Privy(locate on site plan): i
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/a
ii
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
u
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments
366 White Oak Trail .. .
Property Address
Mike Murphy
Owner Owner's Name
information is required for every Centerville MA 02632 12/18/2013
page. City/Town State Zip Code Date of Inspection
D. System Informatip' R (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
;I
O O d
3
f
F
b
i
as
33aaa
t5ins•3/13 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official';, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a,•'�• 366 White Oak Trail i
Property Address F
Mike Murphy
Owner Owner's Name
information is
required for every Centerville MA 02632 12/18/2013
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
I
Site Exam:
❑ Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 40+/-to groundwater
feet
Please indicate all methods used to determine the high ground water elevation:
a
t
❑ Obtained.from system design plans on record
If checked, date of design plan reviewed:
Date
❑ Observed site Iabuttin( g property/observation hole within 150 feet of SAS)
li
® Checked with local Board of Health - explain:
Using topo and water contours maps
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
a
i '
You must describe how you established the high ground water elevation:
see above p
; t
;I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3l13 + Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r
4
s '
Commonwealth of Massachusetts
W Thle 5 W ic'W: Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
366 White Oak Trail
Property Address
Mike Murphy .
Owner Owner's Name
information is required for every Centerville MA 02632 12/18/2013
page. City/Town s State Zip Code Date of Inspection
E. Deport Completenes's Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Si
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i
, I
I
f t
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
I TOWN OF BARNSTABLE
LOCATION
�,L)�?� �0�- ✓41L. SEWAGE # �U�
VILLAGE l iti�Y�y�``—� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY-'`2% s t t1 t c)
- Aw�-���o�
LEACHING FACILITY: (type) -VA '&aitiu ci• otFF (size) �v
NO. OF BEDROOM, .
BUILDER OR OWNERu
PERMTTDATE: 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
j Furnished by
IC
2D•C'
LOCATION SEWAGE ►ERMIT NO.
VILLAGE
INSTALLER'S NAME t ADDRESS
A�-1i111/c Arl 107 '
Am/
I V I'L O E R 02 OWNER
DATE PERMIT ISSUED79
GATE COMPLIANCE ISSUED
Q� Twd
No. O 1,1+1 Fee
_X/THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for Digpogar *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair(V)Upgrad4 Bandon( ) ❑Complete System (;Individual Components
Location Address or Lot No. T.GO Trh, Owner's Name,Address and Tel.No.
Assessor's Map/Parcel G 11�_-)_40
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
MJj9_CPdIk S���C f
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow q qc7 gallons per day. Calculated daily flow `j q�_) gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank _Type of S.A.S. .t[ CG
Description of Soil CU41Z,C S �34 cJ
Nature of Repairs or Alterations(Answer when applicable) Five-1
l�l
r C77 1-C-L iv rs o ' � r
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has bee of
Signed Date r L vV
Application Approved by Date
Application Disapproved for theYollowiA reasons
Permit No. �( a u 'rz2 Date Issued
'. d(��/ �+� Fee
No c
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pplicatton for Mtge of *pztem Con6truction Permit
— '
Application for a Permit to Construct( )Repair( )Upgrade'('�f Abandon( ) O Complete System Individual Components
Location Address or Lot No. J �f Owner's Name,Address and Tel.No.
Assessor's Map/Parcel t-1,? 4 D %I
Installer' Name,Add and Tel. .o.. Designer's Name,Address and Tel.No.
�t l� CvgXs' s `��'C
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures [J (
Design Flow gallons per day. Calculated daily flow ` �1 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank F r t IGcv, v, �, Type of S.A.S. t Cc�aa,'t° `l
vA/Z
De cription of.Soil.
Nature of repairs or Alterations(Answer when applicable)
C_`4 1 G :T �t�c C j i�atfS C.� L ! S T u p, o A , iv-,- r 7' /Cl q
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been-issu' e�by thls o alth.
Signed , _' Date CW
Application Approved by Date
Application Disapproved for the following reasons-
Permit No. ACC 0 Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(tertif icate of Compliance
THIS IS TO CERTIF tat e .n- it JSewagc_D* os 1 System Constructed( )Repaired ( )Upgraded
Abandoned( by /Y► l r ✓�Y
at ' / <<'" F�T�r�r has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.-1CW" dated
Installer Designer
The issuance of this-perm�it shall o construed as a guarantee that the system will,functio as designed r r I/~Date � / Inspector !1 / Vr <,(_�
_�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mtgpogar *potem (ton6tructton Permit
Permission-is hereby granted to Construct( Repair( )Upgrade �)Aandon( )
System located at / /' lG 7
Gov�s
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: $ 'a 7 - D Approved by `�J
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
11 2 �• ��!�S hereby certify that the applicatio
n for disposal works
construction permit signed by me dated , concerning the
property located at '3-pr' fi i69%� �`� C Q� meets all of the
following criteria:
C�This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
v
E---Tlrere is no increase in flow and/or change in use proposed
There are no variances requested or needed.
—�The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
applicable]
• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
,groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W.Elevation 7' �`O+the MAX. High.G.W.Adjustment. ' 7
DIFFERENCE BETWEEN A and B
SIGNED : DATE:
[Please Sketch proposed p an of system on back].
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
i ,1 �.
+. ,��:
O
J
,,.. .
n�� ��, _ r.-.,.. - .
� �J
Q TOWN OF BARNSTABLE C
LW ATION �A ) ,,� SEWAGE #
VILLAGE r -e ji, ` �V��`'�`—� ASSESSOR'S MAP & LOT
y�-�1 INSTALLER'S NAME&PHONE NO. V
SEPTIC TANK CAPACITY
�
LEACHING FACILITY: (type) � __� (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMUDATE: COMPLIANCE DATE: CSC
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
t
fan �a �
-gal.
13 0 3` ��
03-25-1998 11:58AM CENT DST FIREDEPT 5087902385 P.02
iviaxe appucation to iocai rire ueparmerm
Fire Department retains original application and issues dupGmte as Permit.
d� :.,
CZUIr9 V�/X�11LCeb — 4QYI�L O/�'G�✓ x� /vt
APPLICATION and PERMIT I Fee: 10.0E .
for storage tank remcvs] and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chapter 148-Section 38A, 527 CMR 9.00, application is hereby mare by:
Tank Owner Name(pleaw print) Micheal Murphy X
signature epuymprorpermr
Address 366 White Oak Trail, Centerville
Strew Crry slam ZIP
Removal • u • • - Z
Company Name Advanced Environmental Co.or Individual Advanced Environmental
Print Print
Address P.O. Boa 472, S. Dennis, MA Address
Print print
Signature(if ap I 'ng fcr-ermit) Signature(if applyinc fer permit)
,,,,,//
IF 1 ertifi Other IFCI Certified = LSP x Other
Mt V
Tank Location 366 White Oak Trail, Centerville
Steel Address r
Tank Capacity(gailcrrs. 250/500? Substance Last Storea #2 Fuel Oil
Tank Dimensions(die r; mr x length)
Remarks:
7Firmtramporing waste Advanced Environmental State Lic. # MV5083856100
aste mar. E.P.A.#
Approved tank disposal yard J.G. Grant Tank yard# 03501
Type of inert Readville, MA
yp gas Tank yard address
City or Town Centerville FDID# 01920 Permit#
Date of issue March 25, 1998 Date of expiration April 8, 1998
Dig safe approval nun-tw. 981205965 1 g Safe 11 oil�- T u er•FOO-3:22-4844
Signature/Title of Otficsr zranting permit tAq,��-Yu
After removal(s)send F=-,T ?•290R signed by Local Fire Dept,to UST Regulatory Compliarxa Jnit, One Ashburton Place,
Room 1310, Boston,MA :2-08-1618.
FP-292(revised 9/961
TOTAL P.02
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at: q
Address
Installer Address
Type of Building Size Lot.Aioo..0K.....Sq. feet
Z Other Distribution box Dosin tank
Test Pit No. 1p!-----9k.minutes per inch Depth of Test Pit........... iTlak
-'--'--'--'---' --'--'—''--'---'-------
' g -_-_-.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System ir accordance with
the provisions ofTI IT,ILE 5of the State Sanitary
,as
operation until a Certificate of Compliance I _ued by thirtamTi-4 lie4ith.
----''-'---' -----------'----
�JD,31 ��
� Application Approved Dy'-... ..-..^..0 ...'��&�. ^_----------- -���'����--��.-�.�----
� Da e
Application Disapproved for the following reasons:................................................................................................................
........................................................................................................................................................................................................
Date
| '
' rPermit .
[ ^"
Date
No......... 7.. Fxs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TO
]V4 OF '
ApplirFation for Uiiplaii al Works Tatuarn.rtinn tirruat
I
Application is hereby made for a Permit to Construct ( ) or Repair„( -)wan Individual Sewage Disposal
System at• _ '
........... ,�' �. ..Owt . .,nd, ................. .........................................................
ygcatnAddres s L!',, No..
yq?. l.1._.... ... .....:....... ..
O
Address 't
..........................
Installer Address f
UType of Building Size Lot-.-.V...._._9._._.......Sq. feet
,., Dwelling—No. of Bedrooms............. ......................_......Expansion Attic ( ) Garbage Grinder (/V P
'4 Other—T e of Building No. of persons.....--..... ---------- Showers . — Cafeteria
Q' Other fixtures ............................ .
W Design Flow..... / ...........................gallons per person per day. .Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity.100..gallons Length....... ....... Width:i: `:. ..... Diameter................ Depth..._............
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...-..--------------- Diameter.................... Depth below inlo� ---,Total leaching area sq ft.
z Other Distribution box ( ) Dosin nk ) //
�" Percolation Test Results Performed b : [± ................................................... Date.. ..� .. !_
Y
aTest Pit No. 11.."....A-Minutes per inch Depth of Test Pit.................... Depth to ground water...�0.. ✓/ +
(z Test Pit No. 2................minutes per inch Depth of Test Pit..........._........ D.epth:to ground water---------...............
' Description of Soi1..C�' .:� ! ? _. i
1
CxWj ------------------•--------•-•-- ' IJ F
i
�~'� 1 ` a `=
-------------------
VNature 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 TIT?.;,,. 5 of the State Sanitary Cooke— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been-Assued byx lie kith.
S �f - - - - -- ----------------- --- -------
,
'._ c ia-Z;Z
Application Approved By.... f ......... .
Date
Application Disapproved for the following reasons:............... .....................................................-...........................................
------------------------••--•--------••••.....--•-------•-•--•-•-•-----•-•• ...............:...................................................=--------------------•--------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�....c. w.i+;l........oF..... .�}...?.T1.........................................
Trtifiratr of Tlantplianrr
THIS IS TO CERTIFY, T at the,Individua�ewage Disposal System constructed ( ) or Repaired ( )
by.....-- �. �LJ... T .w .t►S .......... �1 h stall d$ ----•-------•--......
__.._ 51..1 � :c .1�....._.. -- t.!__. -1 # +C'`A / t djl. - ------- ------------
at
has been installed in accordance with the provisions of e State Sanitary C as.xlewui1Ain the
application for Disposal Works Construction Permit No.._.._.-.. ------ --------- dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT:BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................................................................•--..---- Inspector......................................................................-•-••-----------
THE COMMONWEALTH OF MASSACHUSETTS
7 BOARD OF HEALTH
�� ............ .. ..l.+t,): ...OF,... .�.. ... .., .. .. ............ s �..�
No......................... Fp .... ...........
Uan , .ranii .
Permission is hereby granted...1 4_ ..�_�.t741._!wf_-----_C o'.�!'.._:-. �?.. ..._._ 1 ...............................
.................
to Construct ) or Re air ) an India��dual Sa e Disposal Sy em
at No. §tJ... .. a.. r..:............ t if .
----------••--------•-----•--------------•--------------
e t - ..•�.i�` 7
as shown on the application for Disposal Works Construction t N Dated
------- ` -''--.....-----
Board of Healt
DATE...................................... ------- ------------•----•------------
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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