HomeMy WebLinkAbout0078 MIDWAY DRIVE - Health FF
8 Midway Drive
Hyannis
A = 252 — 068
v
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
lI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
h � 78 Midway Dr
Property Address
Volha Liauchuk r
Owner Owner's Name f
information is Centerville ��
required for every ar)(1 Ma. 02632 8-17-20
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 4F
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.
�--.h 363 Whites Path _
IC—V Company Address
South Yarmouth Ma. 02664
tof City/Town 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
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OF M4,9�4,,,
2. ❑ Conditionally Passes �.�`ya`�• ' sq�,''%��
MICHAEL '.N
3. ❑ Needs Further Evaluation by the Local Approving Authority ?o SEARS
*: No.SI14430
4. ❑ Fails
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8-17-20
Inspector's 5 ature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
ISubsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
78 Midway Dr
Property Address
Volha Liauchuk
` Owner Owner's Name
information is
required for every Centerville Ma. 02632 8-17-20
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
r
c Commonwealth of Massachusetts
92 _. Title 5 Official Inspection Form
11.2 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
78 Midway Dr
Property Address
Volha Liauchuk
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-17-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
f
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
11; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
«!% 78 Midway Dr
v�
Property Address
Volha Liauchuk
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-17-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
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
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
78 Midway Dr
Property Address
Volha Liauchuk
Owner Owner's Name
information is Centerville Ma. 02632 8-17-20
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/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.
An portion of cesspool or privy is within 100 feet of a surface water supply or
Y p P P Y pP Y
❑ ® 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
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
78 Midway Dr
Property Address
Volha Liauchuk
Owner Owner's Name
information is Centerville Ma. 02632 8-17-20
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® 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?
11 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)]
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
c Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
��!% 78 Midway Dr
Property Address
Volha Liauchuk
Owner Owner's Name
information is
required for every Centerville Ma. 02632 8-17-20
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:
1
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 NA2019- 20196 gal
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Dateent
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c / 78 Midway Dr
V
Property Address
Volha Liauchuk
Owner Owner's Name
information is
required for every Centerville Ma. 02632 8-17-20
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: 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
AIX, Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
78 Midway Dr
Property Address
Volha Liauchuk
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-17-20
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:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
24"
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
78 Midway Dr
Property Address
Volha Liauchuk
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-17-20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 14"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000 gal
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
1"
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness 0
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 18
How were dimensions determined? Sludge judge, 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.):
1000 gal tank with tee in baffle out both covers at 14" below grade
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
« � 78 Midway Dr
v—
Property Address
Volha Liauchuk
Owner Owner's Name
information is Centerville Ma. 02632 8-17-20
required for every
Y page.
Cit /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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
78 Midway Dr
Property Address
Volha Lia_uchuk
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-17-20
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 16x16 with 1 outlet pipe cover at 36" below grade
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
II? Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4,
78 Midway Dr
Property Address
Volha Liauchuk
Owner Owner's Name
information is Centerville Ma. 02632 8-17-20
required for every —
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:
4
❑ 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
f
cam, Commonwealth of Massachusetts
1p Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
78 Midway Dr
Property Address
Volha Liauchuk
Owner Owner's Name
information is Centerville Ma. 02632 8-17-20
required for every ---_
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is 4 bio diffusers, clean and dry with 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
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
78 Midway Dr
Property Address
Volha Liauchuk
Owner Owner's Name
information is
required for every Centerville _ Ma. 02632 8-17-20
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
78 Midway Dr
v� Property Address
Volha_Liauchuk
Owner Owner's Name
information is Ma. 02632 8- 7-20
required for every Centerville
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A
1
A l -
� L/g - �-q
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sew ge Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I,
« � 78 Midway Dr
V
Property Address
Volha Liauchuk
Owner Owner's Name
information is
required for every Centerville_ Ma. 02632 8-17-20
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: 12
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Hand augered 12' no ground water
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i. Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen s
78 MidwayDr
Property Address
Volha L_iauchuk
Owner Owner's Name
information is required for every Centerville _Ma. 02632 8- 7-20
--- -------- --
page. City/Town State Zip Code Dale 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 atta&ed
For 15: Explanation of estimated depth to high groundwater included
7'
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewag Disposal System-Page 18 of 18
TOWN OF BARNSTABLE / \
LOCATION*79 SEWAGE # ZM-Z�
VILLAGE ^AAr ASSESSOR'S MAP& LOT Z1.Z-06�
INSTALLER'S NAME&PHONE NO. LELC,tis
.SEPTIC TANK CAPACITY
F
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS 7�1 i
BUII.DE :R: OWNER � � fu p � ��
PERMIT DATE:- —/I—O.f COMPLIANCE DATE: `��u ' Uy
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by 6Z-(.cd -+
4
I
J
• 1
No. �f✓�" � a Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t-
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppfication for Mioogal *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location�DAdd��i I���. !�„`� � � �f,¢� Owner's Name,Address and Tel.No. Jei ]-_ v
Assessor's Map/P col /V
41A4
Installer's Name,Address,and Tel.No. Designer's Name,Address Ld Tel.No.
-To WW
Type of Building: QQ
Dwelling No.of Bedrooms y Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow .3 gallons per day. Calculated daily flow .3�� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ! �y'' Type of S.A.S.
Description of Soil q C, oW
Nature of Re ai or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the cons on and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 ofAfeltivironmental Code and not o place the system in operation until a Certifi-
cate of Compliance has been issued by this d o Health. OF
Signed " Date
Application Approved by. Date ��'4��
Application Disapproved for the following reasons
Permit No. Date Issued
Fee 6 r---
Entered in computer: v
THE COMMONWEALTH OF MASSACHUSETTS Yes
PUBLIC HEALTH D ISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0[pprication for Digonl *p!tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon('' ) El Complete System ❑Individual Components
Location Address %o. ✓f� tl/ - Owner's Name,Address and Tel.No./A >v
Assessor's Ma /P el ,y� �j
p .-r 2 2 Gl d /�'
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building: f
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 7 gallons.
Plan Date ;Number of sheets Revision Date
Title
Size of Septic Tank G J ' Type of S.A.S. ' ` f°!� //j�4, �&l
i _
Description of Soil Q' '� C
f �
Nature of Repairs or Alterations(Answer when applicable) 1..3 l� 1 'A
Date last inspected:
Agreement:
The undersigned agrees to ensure the cons tion and'maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 o Environmental Code and no to place the system in operation until a Certifi-
cate of Compliance has been issued by th' " o d o ealth
1 �J
Signed � � '�" Date
Application Approved,b � - Date tot�
Application Disapproved for the following reasons
Permit No. 02r/— 4 Date Issued
-------------------,r -------------------
THE COMMONWEALTH OF MASSA ,�``f1S'ffTS
BARNSTABLE AnS16AC— TTS
Certificate. of,q ont�Yfiance
THIS IS TO CER3TFY, hat the On-site Sewage'Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by
at / �"r `"� l �r r�i '= >'�- r' has been constructed in accordance
with the provisions o ide 5 a9tthe for Disposal System Construction Petin> /lft dated5 -' -_;;-a' Installer '�` � � ''�'""` � Designer
The issuance of this pet sh 1 not be construed as a guarantee that the s will Xolas_de&igne�,Dateg Inspector y /
Fee�( ✓�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mi!6pont *p$tem Construction Permit
Permission is hereby granted to Construct,( )Repair( )Upgrade( ).Abandon L f /�
System located at /° Y , / y� t� `��, /.._
s
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of t 's ermit.
Date: G$ Approve, 9
r /'
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)
L hereby certify that the application for disposal works
construction permit signed by me dated ,�j -���/ , concerning the
property located at / D�-� ���`�'Omeets all of the
iVe
wing criteria:
is failed system is connected to a residential dwelling only. There are no commercial or businessses associated with the dwelling.he soil is classified as CLASS I and the percolation rate is less than or equ to 5 minutes per inchhere are no wetlands within 100 feet of the pr
oposed oposed septic system
/oW• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed V
AV • There are no variances requested or needed. V
$he bottom of the proposed leaching facility will not be located less than five feet above the maximum
ho 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-1/
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 +the MAX.High G.W.Adjustment. _
DIFFERENCLBEEN A and B /
SIGNED: DATE:
(Please Sketch proposed plan 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:¢etc
}
Y,
1
11
F v a4g'u K.� is7'-i
j•^"t.,:.r �x' :Ls i.� fi •�.�,-nth, t'-.,u, __ m` 2� �� �'{ :,:�,.r Y�r.�° � s',�.-��� �..T'�._
} Ji
TOWN OF BARNSTABLE .
OCATIO 7 . M,
SWAGE
WAGE # �
I VILLAGE . ASSESSOR'S MAP & LOT ZS Z
1 INSTALLER'S NAME&PHONE NO: �l-ChS �(cZ 'G��
j SEPTIC TANK CAPACITY , I
I LEACHING FACILITY: (type) (size) (� �C 3Z
size
NO.OF BEDROOMS
BU nE G►v( v 011—IN 4.,5
PERMTTDATE: /I—O 1 COMPLIANCE DATE.: Z.ry I
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) A�1,w
'Feet
•
Furnished by 6Z-i.o4
:
z
-
t
a
.. _ "C,ID
- -
�J
Commonwealth of Massachusetts
..i_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address c
Owner yy/
Owners Name
r /�s
� llP
information is ��f 9 required for every __ N ►'(/r
page: CltylTown State Zip Code Date of FrIspection
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. i'l
key to move your f
cursor-do not a �0 l
use the return
key. Name of Inspector_
Company Name
/'�10 QoX /o �8
Company Address
osAawl
Cityrrowr, 11VA
State Zip Code
Telephone Nu er 0
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 0 Fails
❑ Needs Further Evaluation by the Local Approving Authority
Insqsyv
Signature Date
Thm inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10.000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
(-Ito 5 Cflicial 1m;P�(yion Firm:Subsurface Sea age sposal Sys7.nn•Page I of 17
Commonwealth of Massachusetts
r : = Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner
information is Owner's Name//` ,� / /
required for every t i��-'�'C✓yt! A D
page. City/Town State Zip Code Date of nspe ion
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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):
IsnS•I u10
Rio 5 Official Inspad_F,_.Seb,-fac-e Sev�ge Ois0ci l SVslem•Page 2 nl 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
...
Property Address
Owner _ GY'
Owner s Name
information is
required for every t1-1 g k�_
page. Ctylrown State Zip Code Date of Insp
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N
❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
System will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y
❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N
❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
I. 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
,Sins•11/10
GIh 5 Official Inwedion Form:Sutrsuiface Sevsge Oisposel Sysfern•Page 3 04 17
Commonwealth of Massachusetts
_= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�zf
Property Address /C/S --
,Or--
information Owner Owner's Name / Al /
information is �e Ile Od Oa 9 02, 1
required for every � �^ ✓��
page. City/Town State Zip Code Date o Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning In a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
'•This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You must Indicate "Yes" or"No" to each of the following for all Inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool -
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
Sins•11!10
Tile 5 OMdal Inspecion Form SlltI urrace Sewage Cisposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is
required for every eo�C✓li! �� / S y�
page. Citylrown State Zip Code Date41p�ehori
B. Certification (cunt.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed'pipe(s). Number of times pumped:
❑ L�J Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ L!� Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ (E 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 collform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10'000gpd.
❑ The system falls. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
!Sins•i mo
TIte 5 Official Inspection Form:Subsurface Seyage Disposal System-Page 5 of 17
. Commonwealth of Massachusetts
r=- Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name /
information is (fe _ l.,rv/
required for every 7C / /
page. City/Town State Zip Code Date 6f Ins ection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes o
❑ umping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
❑ Q/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?
Q ❑ Were all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
—/ been determined based on:
Existing information. For example, a plan at the Board of Health.
❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
` DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
!Sins•i mo 01e 5 Olfwal Insp lion Form:S-,bs,,rlus Seerag a Di.
sposal Sybem•Page d o!17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is /� p
required for every � //
page. City/Town State Zip Code Date of nspedion
D. System Information
Description: / 16 0
lC Gipsy
Number of current residents: O
Does residence have a garbage grinder? ❑ Yes
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 3--No
Laundry system inspected? ❑ Yes Q o
Seasonal use?
❑ Yes No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump?
❑ Yes No
Last date of occupancy:
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Gallons per day(gpd)
j Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Sins.I V to
rik:5 Official:nspe,xion F,)rm:Subsurlace Sevmge Disposal System.Page 7 0l 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is �✓l�6
required for every /e✓t
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records: Fyn f
Source of information: '
Was system pumped as part of the inspection?
❑ Yes No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of S ern:
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):
15i.s. 1 1110
T'ila 5 Official Intpzl]ion Fnrm SiFxur/ac,S.—ge Disposal System•Pqe 8,1 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface
/Sewage Disposal
ll Sy tem Form - Not for Voluntary Assessments
Property Address /' J
Owner Owner's Name /// / `/'/• /
information is
required for every
page. Cityrrown State Zip Code Date df Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes NO
Building Sewer(locate on site plan): c2
0
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.):
Septic Tank(locate on site plan): /Z/
Depth below grade: feet
Material of construction:
❑ concrete ❑metal ❑fiberglass ❑polyethylene
❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: ,SX g _
Sludge depth' -- --- --- ----- -------
15ins•Ili 10
File 5 Offirial insperlion Fovn:Sutxur/ace Sewage Disposal System•Page 9 0(17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface /Sewage Disposal System Form - Not for Voluntary Assessments
Property Address —
Owner Owner's Name
information is
required for every e n �
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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 ^/
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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:
Oate
t5ins•I 1/10 File 5 Offinal Inspection Form Subsurface Sews a Dis
g posal Syaiem Page 10 0l 17
Commonwealth of Massachusetts
= :- Title 5 Official Inspection Form
` _ -- Subsurface Sew
age Disposal
1.._Disposal System Form - Not for Voluntary Assessments
,4 � W N Property Address
a, S
Owner Owner's Name
—
information is
required for every � ✓lil !( �_�l. 7
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ins•11/10
Tille 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
Property Address
Owner Owner's Name
information is p.
required for every l� y�d/>; �a-6. - / �h/
page. City/Town State Zip Code Date of In pection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan).-
Depth of liquid level above outlet invert
��-e4�
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.):
7-
At
Pump Chamber(locate on site plan):
Pumps in working order.. ❑ Yes ❑ No
Alarms in working order. ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.).-
Soil Absorption System (SAS) (locate on site plan, excavation not required).-
If SAS not located, explain why:
t5ms•i vio
❑Ik 5 Off-al 1n peaion Form:Subsurface Sege Oisposal Syslem•Page 12 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is /lam / 0 1
required for every �' ✓��// ff- o�
page. Cltyrrown State Zip Code Date of r>spedion
D. System Information (cont.)
Type (`� '�►n-t-�/l T���vrs S7�
❑ leaching pits number.
❑ leaching chambers number.
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/altemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Joy/ C�Gea,� �n �✓
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
!Sins•I 1/10
Tide 5 Official Inspection fnrm Subsuriare Sav age Disposal System•Pnge 13 of 17
Commonwealth of Massachusetts
12Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner
information is
Owner's Name
Name
information
required for every (i e
page. Cityfrown State Zip Code Date of 1 spedion
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i5ins•I Wo -
i••Ih 5 0lriri.d Inspection Form Subsurlare Sn NG oispo .I System•page 14 of 17
Commonwealth of Massachusetts
Titre 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is
required for every r"er^�✓(/t f QoZ(,��
page. City/Town State Zip Code Date of I spe i n
D. System Information (cunt.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
drawing attached separately
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15ins• 11/10
'Ile 5 Official Inspection Form.Suhsurface Sevmge Disposal Sy:,1em•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
-+ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V
Property Address /! /
Owner 6� er's Name G/
information is required for every e
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells ` "'e--
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:
LA
A C_-%1 4 14 11� 4-0 X/0 e��o 11 -1 C 6_�
vC C_ e
S0 "vim (0W
Jio 1 ----
Before filing this Inspection Weport, please see Report Completeness Checklist on next page.
15ins•11110
F-ie 5 OlGdal Inspect—Fnrm:Suhsuirace Se npe Disposal SyJem-Page 164 17
Commonwealth of Massachusetts
- Form
• Inspection Title � Official Inspec
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
` 9�7
Property Address
Owner Owner's Narne
information is C�v��P✓Vl
required for every State Zip Code Date of I pedion
page. City/To In
E. Report Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
[] Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
�s m Information— Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
rile 5 tidal Inspection F—:Subswface Sevsge oisposal S"em•Page 17 of 17
15,ns•11110
LOCATION 7(5 ' SEWAGE PERMIT NO. E
VILLAGE
INSTALLER'S NAME&ADDRESS
�6 BUILDER OR OWNER ,
DATE PERMIT ISSUED
`7Ae----
DATE COMPLIANCE ISSUEIJ
i
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0
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No.:.i�Z�91 Fps . .......
THE COMMONWEALTH OF MAS,SACHUSETTS
BOARD* OF HEALTH
........... . ..
.........OF........
Appliration for 0hiposal Works .Tonstrurtion Frrmit
Application is hereby made fdr a Permit to Construct-Q%QLor Repair an Individual Sewage Disposal
System at: rl F7 1 _S-
t C'Mish, . -
....................... ... ........................ ... ..... .�7
7
Location Address or Lot No.
Owner Address
14 ............................................................ .......C?..IL nr&.....i Z w L vj�A,1,r 0< Y5-
I I Installer Address
Type of Building Size Lot...- ......Sq. feet
U
Dwelling—.No. of Bedrooms---. ..............Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
04 Other fixtures .........................
S*,S' -----*----*................................. ..........
Design Flow............................................gallons per person-per day. Total daily flow ...............gallons.
Septic Tank—Liquid capacityJ`-5F!gallons Length._<k-.-.!1K.. Width;.��.�� &a.'r...e.t.e..r................... Depth:!EJ��-
Disposal Trench—No..................... Width_._.---.............Total Length....-............... Total leaching area....................sq. ft.
Seepage Pit No..orb�.. Diameter..!! �.. Depth below inlet.�.'�Frr...-Total leaching area... ...sq. ft.
Other Distribution box Dosing tank ( )
P-.4 Percolation Test =�� (IRS
Results Performed by..........P,...J=14�� Z02 -y- ............. Date... .........
Test Pit No. I...<.Zn..minutes per inch Depth of Test Pit....!3........ Depth to ground water...k4!?:!t4R....
44 Test Pit No. 2..............minutes per inch Depth of Test Pit..... Depth t6,ground water...
......................................................................................................................................................
I C�CL C. t-r_
0 Description of Soil.......9�... 3.............................. ........
W :sc. ........
QleOnv" MCA ............ ... ......... .
----------------—--------
........................ .......................A-
U Nature of Repairs or Alterations—Answer when applicable—.—....—.-- la-.. .................
....................................................................................................................................................................................................
Agreement:
The. uncle i ed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provision of I'ALZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation u til if liance has been issued by the board of health.
n e d..fl 41 '7
.................................................... . . . ..........
i'�.......................... ............
Date
pplition v ... ...... ..... ...............0........ ...... ... ...... Q_-_r
Date
Applicati isapproved for the following reasons:.................................................................................................................
........................................................................................................................................................................................................
Date
PermitNo........................:.......----------------------- Issued-......................................................
Date
NFEB........ ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0F..... _Z...................................... ...........
Appliration for Disposal Works TonstrWion thrrAft
Application is hereby made for a Permit to Construct (� or Repair an Individual Sewage Disposal
System at: C-f A -If .
L_j Al
Location-Address YN
(� or Lot No.
pt, -T,),6 Ax�vAllIc'..1h........................ ... .................. . . ....... ................
Owner Address
rWa T-7 (L A
.................................................................................................. ..................................... ......
Installer Address 5'
Type of Building Size Lot....:=1..SZ>......Sq. feet
Dwelling—No. of Bedrooms_.....!.. az ..............Expansion Attic ( ) Garbage Grinder
Other—Type of Building _...._...I................... No. of persons............................ Showers Cafeteria
aOther fixtures .........:........................
-7*.................................................................................................................
Design Flow_._...._._..S-71E.5-;........................gallons per person per day. Total daily flow...............>-3....................gallons.
Septic Tank—Liquid capacity.!s7:gallons Length..<lt-..55L. Width;..S�.'E Diameter................ DepthA-..c�
Disposal Trench—No..................... Width............._...... Total Length....................
Total leaching area....................sq. ft.
Seepage"Pit No..25.7�^ �.. Diameter..! .. Depth below inlet�^.'� .-Total leaching area.2-9.n.-A...sq. f t.
Other Distribution box Dosing tank
---' -. `/`e�, �;>�-= - Date...
Percolation Test Results Performed by............._... ......:.................... .............
Test Pit No. 1...! -:..minutes per inch Depth of Test Pit.... Depth to ground water...
LZq Test Pit No. 2..................minutes per inch Depth of Test Pit.`:►Z.:...... Depth to ground water...
pt —tit
.....................................................................................................................................................
0 Description of Soil....... lj� S,
..................
U .......... .................................�..O,L:
k.AA51t3... ....... ...............
.................... .....
U Nature of Repairs or Alterations—Answer when applicable...........
..................................o......................................................................................................................................................................
Agreement:
The unders/i_g6ed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisiot /of A.IILZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until- C rtifi to of Corfipliance has been issued by the board of health.
Signed..!�� ............/
.... ....................................... .... .......
Date
Application v ......... ...... C-0 ........................ ..... ............
---------------------------* . .................. ... .... ......
1;;1, Date' �
Applicatip isapproved for the following reasons:................................................................................................................
.....................................................................................................................................................................................................
Date
PermitNo........................................................ Issued.......................................................
DaU
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Terfifirate Lit (Somphiturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
I , %VZ
by..................... .............::.�....................................................................................................................................................
a
at.................. ...... ................ ...............!Z�, t/
...........................................................................................
has been installed in accordance with the provisions of TITLP- 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N-..-.,............ ..q .............. dated..........'A'k-?... ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL F NCTION SATISFACTORY.
DATE.............. ( h�,k�
......... ......... ,....................... Inspector....'....".:......:..........••--•----•-•-•---•-----•-----------..................
- - - - -- - - - - - - - - - - - -- - --- --- - - - - - -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............OF.....................................................................................
Fim........................
Disposal Works Tonstrudion Prrutit
Permission is hereby granted...........R.�- ................................................................................................
to Construct (X or Repair an Individual Sewage Disposal System
atNoZ.2,...... .....................................................................................................................
Street
T'5 as shown on the application for Disposal Works Construction Permit No.......... ...`.j. D a t e d.......�1;
...................................
.............................................................. ..................................
Board of Health
DATE..--_..._. .......�>
........ ... ................................
1 Y.
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Ham,a -•s�.cr;.aw+-k-.•—" i
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TION - S j ACE
—SEPTIC TANK- "D" Ij0:
WASHED STC�'a_
`t 1
IN OUT IN OUT IN
_ ( SEPTIC
ELEV. ELEV. ELEV. ELEV. ') i
ELEV. ELEV.
WASHEDSTONE --
T MOLE ..LOG
tom= q-:�•� �
t
)ATE _-- -- _ = wlrNEss - DESIGN � - BEDROOM HOUSE
T.H. « 1 T.H. 2 1
ELEV. ,_.�� ELEV. NO
DISPOSER ( J'SPOSER
- 4 �- PERC RATE �G MIN/IN. I L
jFLOW RATE =`,—jGAL./DAY I \
SEPTIC TAN-K
- REQ'r SEPTIC TANK SIZE E '—
LEACH FACILITY ,
1 SIDE WALL G'D. !
BOTTOM "��+ _ I I I s --- G rn
TOTAL
USE: `fir L LEACHING
f WATER ENCOUNTERED I
1
TES: (UNLESS OTHERWISE NOTED)
TUM(MSL)-TAKEN FROM . -- .GJADRANGLE MAP
7 V r�
rf
d•�
NICtCAL:•ATER...•----_— ..� __.--. —.AVAILAELC
E P1TC1-'. =P FOOT
SIGN LOP ^.G FOR ALL PRE-CAST UNITS: AASHO ._ � ARINf
u.GROUND COVER OVER ALL SEWAGE FACILITIE: ;1; FT.
It v
E JOINTS SHALL BE MADE WATER TIGHT
NSTRUCTION DETAILS TO BE ACCORDANCE WITH COt,k!.OF MASS. /,, o-• v4 <•J"� t ` +
TE ENVIRONMENTAL CODE TITLE 5