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c Commonwealth of Massachusetts 0709�
�� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c !% 48 Wilton Dr. <
u� Property Address
Thomas Quinn
Owner Owner's Name /
information is required for every Centerville ✓ Ma. 02630 3-18-20
page. City/Town State Zip Code Date of Inspection
y
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.
filling
A. Inspector Information C°/� Iycvy(p
filling out forms
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
key.
363 Whites Path
Company Address
South Yarmouth Ma. 02664
Citylrown State Zip Code
508-477-8877 S114430
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
```````� �\N OF'►
2. ❑ Conditionally Passes 41
F MICHAEL9yN'
3. ❑ Needs Further Evaluation by the Local Approving Authority =o SEARS .�
* No.SI14430 °
4. ❑ Failsc�FRr)F��`�'
3-18-20
Inspector's SignatYLDate
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.
System•Page 1 of 18
t6insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage DisposalSy g ��
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 48 Wilton Dr.
Property Address
Thomas Quinn
Owner Owner's Name
information is required for every Centerville Ma. 02630 3-18-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.!% 48 Wilton Dr.
u—
Property Address
Thomas Quinn
Owner Owner's Name
information is Centerville Ma. 02630 3-18-20
required for every
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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ I, Subsurface Sewage Disposal System Form Not for Voluntary Assessments
V � 48 Wilton Dr.
Property Address
Thomas Quinn
Owner Owner's Name
information is Ma. 02630 3-18-20
required for every Centerville
page. Citylrown 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 aseptic 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
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c , Commonwealth of Massachusetts
�- p Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Wilton Dr.
Property Address
Thomas Quinn
Owner Owner's Name
information is Centerville Ma. 02630 3-18-20
required for every
page. City(rown 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 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l;
48 Wilton Dr.
Property Address
Thomas Quinn
Owner Owner's Name
information is required for every Centerville Ma. 02630 3-18-20
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
�n Title 5 Official Inspection Form
iI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 48 Wilton Dr.
u—
Property Address
Thomas Quinn
Owner Owner's Name
information is required for every Centerville Ma. 02630 3-18-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. 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
Description:
0
Number of current residents:
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)): 2018- 135000ga12019- 30000 gal
Detail:
Sump pump? ❑ Yes ® No
NA
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Wilton Dr.
Property Address
Thomas Quinn
Owner Owner's Name
information is required for every Centerville Ma. 02630 3-18-20
page. City/Town 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: NA
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
lI p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u—
48 Wilton Dr.
Property Address
Thomas Quinn
Owner Owner's Name
information is Centerville Ma. 02630 3-18-20
required for every
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 PEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
37"
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, evidence of leakage, etc.):
t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
,tip Title 5 Official Inspection Form
�. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�G !% 48 Wilton Dr.
Property Address
Thomas Quinn
Owner Owner's Name
information is required for every Centerville Ma. 02630 3-18-20
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
27"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500 gal
If tank is metal, list age: years
s
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
4"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
24"
2"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? sludge gudge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500 gal tank at 27" below grade Inlet cover at 11"with tee outlet cover at 25"with tee
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Wilton Dr.
Property Address
Thomas Quinn
Owner Owner's Name
information is required for every Centerville Ma. 02630 3-18-20
page. City/Town 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
cam, Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Wilton Dr.
u
Property Address
Thomas Quinn
Owner Owner's Name
information is Centerville Ma. 02630 3-18-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
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 16x21 with 3 outlets, cover at 23" with box at 41" below grade
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
I,; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 48 Wilton Dr.
Property Address
Thomas Quinn
Owner Owner's Name
information is required for every Centerville Ma. 02630 3-18-20
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.):
* 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:
3-500 gal
❑ 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
!% 48 Wilton Dr.
Property Address
Thomas Quinn
Owner Owner's Name
information is required for every Centerville Ma. 02630 3-18-20
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.):
SAS is 3-500 gal dry wells.
Wells are 50" below grade with cover on center well at 12" below grade
Wells are dry and clean no sign of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Wilton Dr.
V
Property Address
Thomas Quinn
Owner Owner's Name
information is Centerville Ma. 02630 3-18-20
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:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Wilton Dr.
Property Address
Thomas Quinn --
Owner Owner's Name
information is Centerville -__ Ma. 02630 3-18-20
required for every State Zip Code Date of Inspection
page. Cityrrown
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
C
A
O
33
E�� o
a �
3N
3-11
y_'33
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
t5insp.doc•rev.712612018
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
<lI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
e 48 Wilton Dr.
Property Address
Thomas Quinn
Owner Owner's Name
information is Centerville Ma. 02630 3-18-20
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: 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:
Where SAS is located it is visible 20' over roadway
No water issue at 7' (bottom of SAS)
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
+ � 48 Wilton Dr.
Property Address
Thomas Quinn
Owner Owner's Name
information is required for every Centerville Ma. 02630 3-18-20
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
. . For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
Gde
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Q
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
:1
No. Fee top
r
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplitation for Dig;poe;al *pgtem Construction Permit
Application is hereby made for a Permit to Construct(t.)or Repair(J/�an On-site Sewage Disposal System at:
Location Address or Lot No. la aLj_v,Cho vj Owner's Name,Address and Tel.No. &t.41
Assessor's Map/Parcel ! -7 7 Ll 8 W -`, 31, l
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
11Brvct�l mo cr
8'l a— Si;
dSTer� ,� 1-{aF�-�sa9
Type of Building:
Dwelling V- No.of Bedrooms�_ Garbage Grinder(A/P
Other Type of Building ' No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date /�®� 1 �'i Siq Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 4Y GMr-/J C 6s Pe_ 4eqt
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 issued by this]3oard of bleaj&
Signed /ua e Date t o2a�
Application Approved by Date :L
Application Disapproved for the following reasons
Permit No. Date Issued
E7 Fee C7
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BpARNSTABLE., MASSACHUSETTS
Migpogat *potent Com5truttion J)ermtt
Permission is hereby granted to -3r� �c o
1l
to construct(k-Trepair( )an On-site Sewage System located at No.#
Sheet
and as described in the above Application for Disposal System Construction Permit.
No. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
Date: Approved by
Board of Health
t. t No 0L. ;. Fee
. _r aw
y
- HE`CONJMONWEALTH OF Mk6SACHUWE-T�FS° A
`PUBLIC-HEA1+T DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Ztppficotibn for igogal *p!5tem Cow6tructibn Permit
Application is hereby made for a Permit to Construct(,t )or Repair(dsan On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Add r ss and Tel.No.
Assessor's Map/Parcel / ( J ', r. Ce
Installer's Name,Address,and Tel.No. , Designer's Name,Address and Tel.No.
LA416'S5a9
OsTe��.11t
Type of Building:
Dwelling p ' No.of Bedrooms .91 Garbage Grinder(grip
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Dated u - j Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when appjlica6le) Ly 6rri-/J`P.
/ _ r.t t • /r l
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 issued by this oard of Health.
,u >' _
Signed, P // ' Date f ,3 1za000
Application Approved by 1 s, .., 1_SD «, Date, P- •-;'- 5
Application Disapproved for the following reasons
Permit No. c./Y.1^ — ��lo Date Issued
----------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed(k_)or repaired/replaced( )on
by Installer .1S ru(e �1G CcJ( ",3 1 c
at has been constructed in accordance
with the pzczv sions of Title 5 and the for Disposal System Construuci6n P rmit No — 1 dated
Date' 2, "' InspectorM�_Z � z
y'
r
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.
No.
TOWN OF BARNSTABLE
r
L'.�^''..,rvTInN S' i +'CAI �i/'L;: — SEWAGE #
VILLAGE Ui I IL ASSESSOR'S MAP & LOTg"
INSTALLER'S NAME PHONE NO.
/ 00 GAI
SEPi7C TANK CAPACITY -
�vNc2t r� -
�
LEACHING FACILITY: (type) !�?b l�4j �/1ei�/ (size)
NO. OF BEDROOMS
BUILDER OR OWNER � �6'✓1 C Cam°I i°1d `'• r
' PERMIT DATE: '2 � COMPLIANCE DATE: _
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching'facility) �j Feet
Furnished by. "
t
r _
t. a � � �
+ � �s � '.
_ .} N ,
• .o`�
a r
sl � �
32 � 2� ' �
�,�,� 3 �
-- � 3 �
��� , � 3
� �� 3�.5
TOWN OF BARNSTABLE
LOCATION SEWAGE # 0 /J 60
V1LI:AGEC�r 1. / ASSESSOR'S MAP & LOT �T d
INSTALLER'S NAME PHONE NO.
O?moo(S-✓
j SEPTIC TANK CAPACITY
LEACHING FAC Z<7 �2 Fri
IL ITY: (type) S U v 14� /��
S Mvi; (size) X 3 %
i NO. OF BEDROO,MS �_ T `- S
BUILDER OR OWNER "�"�s✓)
L1/ AoA
PERMITDATE: �00
—Vu--
COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of beaching Facility Feet
Private Water Supply Well and LeachingFacility ty (If any wells exist
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by- /1 s �� . ` < ? reef . .. . . ..
y t
Zl � i
fir\
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION f 191
Property Address: 48 WILTON DR. CENTERVILLE MAP 290 PAR 077 L 3
Name of Owner ELAINE CRAVEN
Address of Owner: 168 HART ST.UNIT 71 TAUNTON MA.02780
Date of Inspection: 6/16/99 ` UAf
Name of Inspector:(Please Print)JOHN GRACI Ig99
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) � 0f N
Company Name: n/a
Mailing Address: n/a r 1
Telephone Number: n/a
s Z
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection Is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
Needs Further Eva ua on By the Local Approving Authority performing at the time of the Inspection.My inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:6117/99
The System Inspector shall#thesystem
copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.I is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S
USEFULL LIFE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 48 WILTON DR.CENTERVILLE MAP 290 PAR 077 L 3
Owner: ELAINE CRAVEN
Date of Inspection:6/16199
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
Wa 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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
_ distribution box is levelled or replaced
Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_ broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 48 WILTON DR.CENTERVILLE MAP 290 PAR 077 L 3
Owner: ELAINE CRAVEN
Date of Inspection:6/16/99
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 the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nt&(approximation not valid).
3) OTHER
n[a
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 48 WILTON DR.CENTERVILLE MAP 290 PAR 077 L 3
Owner: ELAINE CRAVEN
Date of Inspection:6/16199
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone li of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 48 WILTON DR.CENTERVILLE MAP 290 PAR 077 L 3
Owner: ELAINE CRAVEN
Date of Inspection:6/16/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
Subsurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 48 WILTON DR.CENTERVILLE MAP 290 PAR 077 L 3
Owner: ELAINE CRAVEN
Date of Inspection:6/16/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-M g.p.d./bedroom
Number of bedrooms(design): 2 Number of bedrooms(actual):2
Total DESIGN flow: UR
Number of current residents:Il
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): MQ If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):DLO
Water meter readings,if available(last two year's usage(gpd): nLa
Sump Pump(yes or no): NO
Last date of occupancy: 9/1/98
COMMERCIAL/INDUSTRIAL
Type of establishment: nLa
Design flow: n&gpd(Based on 15.203)
Basis of design flow: Wa
Grease trap present:(yes or no):�LQ
Industrial Waste Holding Tank present:(yes or no): Na
Non-sanitary waste discharged to the Title 5 system:(yes or no):MO
Water meter readings.if available:n&
Last date of occupancy: n&
OTHER: (Describe)
D&
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
DIA
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped nLa. gallons
Reason for pumping: n&
TYPE OF SYSTEM
X 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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
35+YEARS OLD.
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2198 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 48 WILTON DR.CENTERVILLE MAP 290 PAR 077 L 3
Owner: ELAINE CRAVEN
Date of Inspection:6/16/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: ZLE
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nta
Comments: (condition of joints,venting,evidence of leakage,etc.)
Wa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: Z'
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
Wit
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ
nLa
Dimensions: 6'X5'BLOCK CESSPOOL-NOT TIGHT
Sludge depth: EMPTY
Distance from top of sludge to bottom of outlet tee or baffle: Wit
Scum thickness: EMPTY
Distance from top of scum to top of outlet tee or baffle: EMPTY
Distance from bottom of scum to bottom of outlet tee or baffle:n(a
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
MAIN CESSPOOL AND ALL COMPONENT ARE STRUCTURALLY SOUND,RECOMMEND PUMPING SYSTEM EVERY YEAR.
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nLa
Dimensions: nLa
Scum thickness: n&
Distance from top of scum to top of outlet tee or baffle:iVa
Distance from bottom of scum to bottom of outlet tee or baffle n&
Date of last pumping: n&
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
Wa
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 48 WILTON DR.CENTERVILLE MAP 290 PAR 077 L 3
Owner: ELAINE CRAVEN
Date of Inspection:6/16/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nta
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nLa
Dimensions: nta
Capacity: n& gallons
Design flow: n& gallons/day
Alarm present: NQ
Alarm level:jiLa- Alarm in working order:Yes—No—: MQ
Date of previous pumping: Wa
Comments:
(condition of inlet tee,condition of alarm and Float switches,etc.)
13&
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:nta
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP CHAMBER: NO
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nta
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 48 WILTON DR.CENTERVILLE MAP 290 PAR 077 L 3
Owner: ELAINE CRAVEN
Date of Inspection:6/16/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number: n&
leaching chambers,number: -nLa
leaching galleries,number: ji&
leaching trenches,number,length: n&
leaching fields,number,dimensions: nLa
overflow cesspool,number: 625'BLOCK CESSPOOL
Alternative system: n&
Name of Technology: jVa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE OVERFLOW CESSPOOL IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY,THE PIT HAS NOT BEEN MORE THAN 1/2 FULL.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n&
Depth-top of liquid to inlet invert: n&
Depth of solids layer: Wa
Depth of scum layer. n&
Dimensions of cesspool: n&
Materials of construction: n&
Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection)nla
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nla
PRIVY: _
(locate on site plan)
Materials of construction:n& Dimensions:n(a
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 48 WILTON DR.CENTERVILLE MAP 290 PAR 077 L 3
Owner: ELAINE CRAVEN
Date of Inspection:6/16/99 '
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
�g yY
all
tp l�
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 48 WILTON DR.CENTERVILLE MAP 290 PAR 077 L 3
Owner: ELAINE CRAVEN
Date of Inspection:6/16/99
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: Wa
Observation Wells checked: NQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
X Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS AND VISUAL-12+FEET
revised 9/2/98 Page 11 of 11
GENERAL NOTES:' v0P o =ou>-,bt�,r}o,J i.�g� rL� r�
-I'LLrL TEST PIT Or-i T,=1
J. THIS PLAN IS FOR THE DESIGN A,4'D e V, ti t�0.0 0 ir.P. -1 T.P. -2
CONSTRUCTION OF THE SEWAGE DISPO.�;A� LUV�f�T ELEVA TIDrUS." � -/ � • 10 GR;;D.
' �i S Sll��F� � G.1J. EL��/� --" G. W. ELE/.
FACILITY ONLY. IVbt/IT AT &VILDING — •1 `
2. ALL CONSTRUCTION METH00S, VATE,�IIALS AAD Ii✓ltt;T IN AT SEPTIC TAMK aq ,� O —
��Ci
MAINTENANCE FOR THE SEPTIC SYSTEM SHALL •_ �CC�SS COVERS ,MUST BE
CONFORM TO MASS. D.E. O.E. TITLE 5 AND LOCAL INVERT OJT A T SEPTIC T4AY
BOARD OF HEAL TH REGULA TIONS. INVERT IN A T DIST. - BOX __� �17• t'I 0 V � •A'. S r'ErIC. TEST
INVERT OUT AT DIST. Box
3. ALL SEPTIC SYSTEM COMPONENTS SUB.ECT TO
VEHICL E L OADING U.E. UNDER DRI VEWA YSr ETC.) •�7 — �41IN. 2' 0,=
SHALL BE DESIGNED TO WITHSTAND H-20 L OAOIhG. INVERT IN A T S.A. S.BOTTOM OF S.A.$ 5�- , INDICA TES I
0 4' �fIN. ' /B'-1/2' DI,;.
LIQUID hASfIED ST✓,r - E
4. ALL SEWER PIPE SHALL SE SCHE,�OLE 40 OR OBSERVED GROUNDWATER o €'= ® 0�l� RVED kJ
APPROVED EQUAL. i S
DEPTH Gr';oUi^JD;✓A Tc"R �- S � -L
.ADJUSTED GROUNDhA TER --�'"� 10 DIST. -1 1i?
ml i 0 BOX �u�' hAS,IEJ STUJ,'�
S. BEFORE STARTING CONSTRUCTION CAL L DID 5,, —�� GN L. Q i
1-800-322-4844 FOR LOCATION of SEPTIC TAM% � t� ��� . �O ;'.JIC,A
UNDERGROUND UTIL I TIES. 11-1 0
SEPTIC TA" 6 D-BOX ToBE S6TDNA
6. DATUM IS A55vt--1i�,*- V 6" BUJ' OF CagPAOTED CRVV4F9 S7UE.
MVCTa9 70 W TFA T6W D--BOf; TO PROP. S. A. S.
7. NO DETSWINA TION HAS BEEN MADE .;S TO COMPL IAIvCE K-W?
YI TH DEED RESTRICTIONS OR MVItiG REGUL A TIOPJS.
IT SHALL REMAIN THE OWiVER 'S R SPO�'JSIBII_I TY TO
OBTAIN ALL REOUIRED PER,Y1 TS, SPECIAL Pc�2�ll TS, ----— - , ---
i)LLI 01351'I2VA'!'fON BULL LOG ifc)!c # i�
VARIANCES, ETC, FOR THIS PPO-ECT. ucpw rror,i sail)mri7on So texture sou color —
Swlace(in) ((JSOA) (Munscl)) A,(u(ti I(Stn cluic,tinuit[, I I,n,IJcrcS % ✓ ti!Y' �y���_ �� 1� G is V����4
B. IT SHALL REMAIN THE 0MVER'S RESPONSIBILITY I� �f
TO HAVE THE PROPOSED DWEL L INS FOUNDA TION
DESIGNED TO ACCOUNT FOR THE EkYSTING GRADEAND SOIL CONDITIONS AT THE L OCA TION OF THE , ! - - # -� 4 _ ----- — -- - 5
PROPOSED DWELLING. - -s- ---��--- - t5- - '—..�4. i� -= - - - - 3 rE, ,'C. RATS- ,tlli�✓./ IV, I�
dox , IV
�>AAVIIs-sG C .$,SP DL$ v 14*PYLL
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l PROJECT