HomeMy WebLinkAbout0132 NOBADEER ROAD - Health 132 NO$ADEER ROAD
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Commonwealth of Massachusetts
re Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c �
� fit
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name ,
information is
required for every Centerville gjfto f� MA 02632 8/14/19
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.
A. Inspector Information 1/09��
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 r
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based,on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
8/14/19
Inspector,06nalM 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 DER The original form should be sent to the system owner and copies sent to
the buyer, if applicable,and the approving authority.
)//Al
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
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
n� 132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2 System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N _ ❑ ND (Explain below):
F
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
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. CityrTown 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.-
El 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,
r safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*"This system passes if the well water analysis; performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
El ® clogged SAS or cesspool
El ® 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
5
Commonwealth of Massachusetts
,P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. CityrFown 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 Y2 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
El ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead'Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page.5 of 18
Commonwealth of Massachusetts
�. ,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
tl/
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ 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
IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form :Not for Voluntary Assessments
o 132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. Citylrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Description:
3 bedroom permit on file
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: March 2019
Date
t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: No pump history given
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1983 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 24"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
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
IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
n� 132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is ,
required for every Centerville MA 02632 8/14/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) "
6. Septic Tank(locate on site plan):
Depth below grade: 18"feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g
4"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle >12
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle >2"
Distance from bottom of scum to bottom of outlet tee or baffle >2
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
,ig Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•� 132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. Cityfrown 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:
s ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
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.):
i
_ I
*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 was video inspected, no adverse conditions observed
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
r
* 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: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville . MA 02632 8/14/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The leach pit was excavated, it is 3' below grade, damp at this time, stain line is 2' below the invert,
no indication of past hydraulic failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth &Wssachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•�e 132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. City(rown State 'Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: -
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc:):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14119
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing.attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•� 132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. Cityrrown 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: >13
feet
i
Please indicate all methods used to determine the high ground water elevation: i
® 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:
4'seperation per compliance on file
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Site is at 70'msl and nearby surface water is at 28'msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. City(rown 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
4 (Failure Criteria) and 6(Checklist)completed
t
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
i
For 15: Explanation of estimated depth to high groundwater included
f
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
if CATION ti , r� SEWAGE PERMIT NO.
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Ue5S4'� 'V tl �
INSTALLER'S NAME A ADDRESS
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D U I L D E R OR OWNER
DATE PERMIT ISSUED
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DATE COMPLIANCE ISSUED
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INSTALLER'S NAME A A0DNESS
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DATE PERMIT ISSUED
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Commonwealth of Massachusetts
- Title 5 Off
fclal Inseco®n Form
r° Subsurface Sewage Disposal System Form-Not for Voluntary AssessmentsI
132 Nobadeer Rd. "
rod
Property Address
On
yd - --
Owner Owner's Name w^
information is
required for every Centerville MA. 02632 r
page- City/Tawn _ 8/14/19
State Zip,Code Date of Inspection, >
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information
Frank Nunes III
Name of inspector —
saa
Company Name
Box 841
Company Address
East Falmouth MA
City/Town 02536
State Zip Code
508-272.6433 13010
Telephone Number
License Number- -
B. Certification -
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected listed above; the information reported below:is the sewage disposal system at the property address
true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems:After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspector n re 8/14/19Date
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 address how the system wilt perform
in the future under the same or different conditions of use.
t5insp.doc•rev.72612o16
Titte 5 official Inspection Form:Subsurface Sewage Disposal system; Page 1.of 18
Commonwealth of Massachusetts
y =;? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address - - --
Hyde
Owner Owner's Name — — —
information is
required for every Centerville MA 02632 8/14/19
page. Citylrown _ 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 wl-ich 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.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18
Commonwealth of.Massachusetts
�m T itle 5 Official
Ins
pection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville . MA 02632 8/14/19
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):
El obstruction is removed ❑ Y ❑ N • ❑ ND (Explain below)
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below)
❑ The system required pumping more than4 times a;year due to broken or obstructed pipe(s). The
system will pass inspeetion'if(with approval of the Board of Health):
broken pipe(s) are replaced 0 Y ❑ N ❑ ND (Explain below),:
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
� t-
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
16.303(1)(b)that the system is not functioning.in ..manner which will protect public,health,. .
safety and the environment: .
t5 nsp.doc-rev.7126l2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3.of 18.
Commonwealth of Massachusetts
is3 Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address --
Owner ode
information is Owner's Name _
required for every Centerville MA 02632 8/14/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
❑ 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 wall".
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 t-ie presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no ether failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts }`
Title 5 Off ic.i.a-l;-T;�lin-s'P�eclti,on dorm
Subsurface Sewage,Disposal System Form Not for Voluntary Assessments
132 Nobadeer Rd
Property Address.
Hyde
Owner Owner's Name
information is
required for-every Centerville „ MA 02632 8/1,/.1.4/19
_.
Page City/Town State Zip Code Date of Inspection
C. InspectionYSumrnary (cont.)
4) System Failure Criteria Applicable to'AlI Systems •,(cont.)
Yes No
El Iz
Static liquid level in the distribution box above outlet invert due fo an;overloaded
or clogged SAS or cesspool
Liq"ud depth in cesspool is less than 6" below invert or available volume is'less
than%Aay flow,", ,
FT
Required pumping.more than 4 times in the last Year NOT d,ue to clogged or.
obstructed pipe(s).`Number of times pumped:,
Any portion of the.SAS, cesspool ci'privy is below high ground water elevation..
Any portion of cesspool or privy,is within 1.00 feet.of a surface water supply or
® .. ..
tributary to-a surface water supply.
Any portion of ti cesspool.or privy is.within'a Zone 1 of a public water supply
well.
s Any portion of a cesspool or privy is Within.50 feet of-a private water supply,well.
0 IZ 'Any portion.of a'cesspool or privy'is less than 100 feet but greater tharr;50 feet
fram a private water supply well with no acceptable water quality.analysis:,[This'
'system passes if well water analysis, performed at'a DER 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 theanalysis
and chain of•custody must be attached to this form.] '
The system is a cesspool servinga facilitywith 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 sc deribed in 310 CMR 15.303,therefore the system fails.'The
system owner should contact the`Board of Health to.determine`whatwill be
necessary to correct the failure.
5) Large Systems: To be considered a large.system the system must serve a facility,with
design flow`bf'10,000�•gpd to.`15 000Ygpd:
For large,systems,'.you.must indicate either"yes"or no to each of the following, in addition to the
questions, in,Sectioon C.4.
Yes No =..
El [ the system is within 400 feet of al surface drinking water supplyD El `
the system,,ismithin 200 fleet of Oributary to a §urfac6,drinking water�supply:
the system is.located in a nitrogen.sensitive,area (Interim Wellhead Protection
Area IWP.A) or a mapped Zone it of a public water supply welt``
,_
t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurtace:Sewage'Disposal System Page 5 of 18
Commonwealth of Massachusetts
-I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•�, 132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. City(Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section C.4 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 d stance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
,Y P Title 5 Official. Inspection' Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Owner Hyde
information is Owner's Name
required for every Centerville MA 02632 8/14/19
page. Cityfrown 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:
3 bedroom permit on file
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? El Yes 0. 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 0 No
Seasonal use? ❑ Yes M No
Water meter readings, if available(last_2 years usage(gpd)):
Detail
Sump pump? T ❑ Yes E No.
Last date of occupancy: March 2019
Date
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address -
Hyde _
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. CitylTown 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): Canons per day tgpol
Basis of design flow(seats/persons/sq.ft., etc.): -
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: --...... --- — - -
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: No pump history given
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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
132 Nobadeer Rd:
Property Address
Hyde ,
Owner Owner's Name
information is `
required for every Centerville MA -02632 8/14/19
page. CityrFown State Zip Code Date of Inspection
D. System Information,(cont:j
4. Type of System:
® Septic tank, distribution box soil absorption system
El Single cesspool
FT Overflow cesspool w
❑ Privy
El Shared system (yes or no) (if yes, attach previous inspection records; if.anyEl )
Innovative/Alternative technology:Attach.a copy of the current operatioh and:
maintenance contract(to be obtained from system owner)and a copy of latest*
inspection of the'l/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:
1983 per BOH record' '
Were sewage odors-detected when arriving at the site?: El Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below, 24
grade: feet
Material of construction:
❑ cast iron [Z 40 PVC ❑'other(explain):
Distance from.private.water supply.well or suction line: >10'
feet
Comments (on Condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7126/2018 Title 5 Official inspection Form:Subsurtace Sewage Disposal System•Page 9 of 18 '
Commonwealth of Massachusetts `
l Title 5 Official Inspection Form
__ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14119 page. Cityfrown State Zip Code Date of Inspection _
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 18
feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g �
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle >12 -
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle ----
Distance from bottom of scum to bottom of outlet tee or baffle >2„
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of'Massachusetts
Title 5 Official Inspection Form
1;
Subsurface Sewage Disposal System Form -=Not for.Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner s Name
information is
required for every Centerville i MA 02632 8/14119
page. Cityrrown State Zip Code Date of Inspection
D. System Information. (co it)
7. Grease Trap (locate on site plan):
Depth below grade` feet
Material of construction:
El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑•other(explain)::
Dimensions:
Scum thickness
Distance from top of scum totop of outlet tee or baffle
Distance from bottom of scum to bottom.of outlet tee or baffle
Date of last pumping; date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity;
liquid levels as related to outlet invert,'evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan
Depth below grade:
Material of construction: -
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
'gallons
Design Flow:
gallons per day..
t5insp.doc•rev.7/26/2018 Title 5 Official_Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
- F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. Cityrrown 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 was video inspected, no adverse conditions observed
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 16
Commonwealth of Massachusetts
_ _- IIP Title 5 Official Inspection Form
i Subsurface Sewage Disposal-System Form - Not for Voluntary Assessments
132 Nobadeer Rd.
Property.Address
Hyde ..
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
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'. 1
❑ leaching chambers number:
❑ leaching galleries number'.
❑ leaching trenches number,length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
El 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
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
YQ Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8114/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.,
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The leach pit was excavated, it is 3' be ow grade, damp at this time, stain line is 2' below the invert,
no indication of past hydraulic failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration -- -
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool -- -
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of'8
Commonwealth of Massachusetts
1�? Titre 5 Official Inspection Form i_
,° Subsurface Sewage_Disposal System,,Form - Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
.Hyde _ r
Owner Owner's Name.
information is '
required for every Centerville MA ' 02632 8/1`4/19
page. Citylrown 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 Official Inspection Form:Subsurface Sewage Disposal System-Page,15 of 18
Commonwealth of Massachusetts
it? Title 5 Official Inspection Form
= Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
information is Owner Owner's Name
nfor
required for every Centerville MA 02632 8114/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate aL 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
�0"36
t5insp.doc•rev.712612018 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
' Commonwealth of Massachusetts
- Title 5 Official Inspection Form
I Subsurface Sewage Disposal System,Form Notfor Voluntary Assessments
132 Nobadeer Rd.
Property Address
Owner HydeOwner's Name' _
information is
required for every Centerville MA 02632 8/14/19
page. Cityrrown 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: >13'
feet
Please indicate all.methods used,to.determine'the high ground water elevation:
1z Obtained from system design plans on record
If checked, date of design plan reviewed`: n/a
Date
❑ Observed site.(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
4' seperation per compliance.on fife
Checked with local excavators, installers -:(attach documentation)
Accessed USGS-,database=explain:
Site is at Vmsl and nearby surface water is at 28'msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist onnext,page.
t5 nsp.doc•rev,7126/2018 Title 5 Official.Inspection Form:.Subsurface Sewage Disposal System•Page 1j of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
132 Nobadeer Rd.
Property Address
Hyde
Owner Owner's Name
information is
required for every Centerville MA 02632 8/14/19
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
Z B. Certification: Signed& Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 8
0?3
No...do /_ P ,r Fmc..........60.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
W.Ta. n..............OF........... file---------------------------------
Aliptiration for UiipusFal Workii Tomitrnrtion ranfit
Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal
n_�Systesn at
`Q ...........Z_.411.----A Q.......---. ------------------ .... -____. ...�C,..??!1`. .._......-..-------•----
Locat n-Address or Lot
Ow er Address
a •................G ! ..4 e0 4-le"l i_A00 2...C.9.• ....................
/ Installer Address
d Type of Building Size Lot_._ ���7¢___Sq. feet
U Dwelling—No. of Bedrooms............. _.__.Expansion Attic ( ) Garbage Grinder ( )
'04 4 Other—Type of Building ................. No. of persons.................•.......... Showers — Cafeteria
04
Other fixtures --------------------------- -------•----------------•---.---------------------------------------•------------------------------_-•----••---------•..
W Design Flow...................X.5 ......_........gallons per person per�dV. Total daily flow...................3 ...............gallons.
W Septic Tank—Liquid capacity/AAAgallons Length... 4!.� Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........../........ Diameter----lO.-4,... Depth below inlet....-.5_-Q..... Total leaching area3/-.TtP..1..sq. ft.
Z Other Distribution box (,-j Dosing tank ( ) //
Percolation Test Results Performed by...-�Jr' 'G_ ..!•f� 4_.4.� Date......`-�l-! 8 ............
as Test Pit No. l.....4 --.minutes per inch Depth of Test Pit------/L'....... Depth to ground water-___ oryk -.
fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................-.......
O Description of Soil-------------------.4?�"-,Z...... ,�hAV.-----i 2- 17....- ......................
x
UNature of Repairs or Alterations—Answer when applicable._..............................................................................................
--------------------•------•---•----------•---------------•-----------•---• ---------------------------------------------------------------------•-------------...---•-•---•--•.......••.....---•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI,t. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed....................................................................................... at••••-••-•---D .e.........
Date __.._.. ..
ApplicationApproved By...................... .........................................................................
Date
Application Disapproved for the following reasons-----------------------•-----•---------....------------••------------------------•----------••--••--••----•••••--
.............••------•----•----------•---•-----.....----------------------•----------•--.....--------------••••--•••-•-•--••------••------•••---•••-•----•----•--------...-----••-----•-----•-•....-•---
Date
PermitNo......................................................... Issued_.......................................................
Date
No...... .............. Fizz..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
................... ..._.................OF...........
...........
Appliration for Di-qVaiittl Works Tomitrnrttun frrufit
Application is hereby made for a Permit to Construct (,j'or Re r an Individual Sewage Disposal
System at: �.
Locat' n-Address or Lot 1jo.
/,/
// ow er Address
a �/C/���I c�_.I :��L./ T/Gl Go /Gr 7y/S
/ Installer Address
Q Type of Building Size Lot... .....Sq. feet
U Dwelling—No. of Bedrooms............. _.........................Expansion Attic ( ) Garbage Grinder ( )
'_l Other—Type T e of Building No. of ersons____________________________ Showers
� YP g --------•---------•-----•--- P ( ) — Cafeteria ( )
QOther fixtures ------------------------------------•-----------------•••••••••-----------••------•••------••--•-•--.....----------------•-•-•...-----•-•...•----•••.
W Design Flow...................
......t.................gallons per person per day. Total daily flow_.__._._____.____. _`% '_________.__.._gallons.
R: Septic Tank—Liquid capacity lrl _gallons Length._. . Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..--------- Diameter_.__ ?= 'p.__ Depth below inlet-----_`-_o_----- Total leaching areal/s_l'2..sq. ft.
z Other Distribution box (✓) Dosing tank
'-' Percolation Test Results Performed by___ J'------------"l .:' .. Date..... j_ ..
1 Test Pit No. 1.....!�.3___._minutes per inch Depth of Test Pit..... ......... Depth to ground water..... =f
GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' ...................................................................
O Description of Soil-•-----------•-•-•. `= �j �......................�,� "�='----!' ' �= -----` === -•-----•--•----•-•---
x
---- ------------- �------------•- 1. ._.
w
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------•-----------------------------------------•-------------_-_..__.......-•••--...-----•-••-•---•••----•••-----------•-••--•------••••----•----••-----•-----••-••---•.....••••.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed........................................................................•-•........•-- ................................
Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons----.............................................................................................................
.........................................................................................................
Date
PermitNo.......................................................- Issued.................... ................................
Dattee
THE COMMONWEALTH OF MASSACHUSETTS
BOARD �FHEALL'TH
OF....... ................................ .....................................
�rr�gf gr��p ,af fP�nnt�li�nr.�
THIS IS TO C Th e dividual Sewage Disposal System constructed ( ) or Repaired ( )
by fCe1_A_
'00
i;•."......... t� i.1' .._ ✓ } -- ---------------------------------------•---••--------------------------
at -•--
has been installed in accordance with the provisions of TI`� ~• r he State Sanitary Co s dgscribed in the
f }'
application for Disposal Works Construction Permit No---------____`._ __.__._____._ dated--------- .._ __ ________._________
THE ISSUANCE 9F THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM VIAL FUN ION SATISFACTORY.
z DATE.. . . : -----------------------------
Iy �.... r_.... Insector
p
THE COMMONWEALTH OF MASSACHUSETTS
- BOARD F
1 ....................................
V
No._..-•- •--..__..... H TH
FEE - -`.".�
•"••`-_._....
�rk n ,��rnnr�irrn rrntit
Permission is hereby granted-------- ---------•-•---••----• -•-•--------•--•--•••-------------•-•----•---•-•-••-•--•••-.._._......_._..........._....
to Co t r ) �n Indlyid ewa
................._........ _•--•- -- --••-•• ---------- -- --
Street
as shown on the a li ion.for Disposal Works Construction Permit _7�r Dated_ � �� --�
..............•• •. ------ f--- .............................
rd of He
DATE----11----- - ...........................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS '
a,:..- ai...'"Y rp. a-.,Y.,n, a..•:. .u^.fi-. .Y t -. A:?--., ,.Y.'E.+Xa x. .-;-.._.k_::. _/L... _. .., 'ac,:... 'e`sq J. h^'ts': a>... e 6 'yp4 ��' .. .;a„_ '-q. •yf•...A st` :,n!', :n �..MC.^a.:' f�r s„dam=
�__�n-"k.,'• o.. . ...,._..� ,.. - ,.,.«'^ f. F3' .. .._- _, ,. -. .: . r�?k!' ya:`K .. _ - _. 'S -'ii" ,K. y, .'k..g". _ � v.. ;:,:�ra.,,t'� . ..FCC
SITE PL A 11/ l YPICAL PROFIL E
SCALE NOT TO SCALE
--- -
i� STD. LT NGT C.I. MH r:(''VE''
G3
k
4„C/ PPE
4 ?; F bF.q P/F,E ,,,`;h'T ")IN TS t
i OUTLE' LEVE'
._. _ FI W L!.Vf �� ._ _.� - TO F!F'T JO/NTH
--- - DWELLING aiYo I_a !� �_ O
C.I. TEE G 2 9
C. Tf
_ STANDAh ) - j4,�,�rECA.�; --I'
70 ; CONCRE�`F f.P,wAC LON I -I
I .A 10 �
SEPTIC BOX A N K e„ D/S RIB!''ION
TO BE INSTALL ED ON
LEVEL , S1-4HLF BASE.
SEPTIC TANK
TO BE INS TA L L EC' ON
L.FVEL , 5T49:_E BASE
2 - //8 TO I/2 WASHED' f E,', " t' LEACH!,"IG PIT
pro,��ecc.ga r �a+ic ALL AROUND FREE OF IRONS ggSF TO HEE I'EL
' F
/ ANC � U`'T /.N PLACE
2�,z.;'¢ P 2 e, 7¢ /` '�. BRICK 8 MORTAR COJRES 314 TO I-I/2 WASH£D CRUSHE,:
AS KEOUIREO TO BRING
' I COVER TO GRA!'E. 24"C I. MH COVER STONE ALL ARQUNp FREE n F
sry o �,�ar / /' =np 4j /ROAi• , FINES A N!� DUST /N : L ACE
A.ND FRAME _
s9r�c x k Q
,� e�7
o =a
�� wL �T � t 4„ ---1______ 4 C R'fi FLOW r_lNE - -- — -- ----— ——� L E ACHING Pl T SEC RON—
------ -- ---
_ __ _
PIPE
- ITT _ I. CONCRETE TO BE 4000 PSI 28 DAYS
�{ 2. REINFORCED WITH 6'' x 6" N0. 6 GA W.W.M.
3. 2' AND 4' SECTIONS ARE AVAILAR,LE FOR GREATER
I DEPTH REQUIREMENTS.
3xo 1 s d Q, j OPENING WITH 4-1/8 i 4. NUMBER OF PITS REQUIRED
U ' I , OUTER DIAMETER B 2.a
�.; b � I i � � � NOTE EXCAVATE TO ELEVATION �—OR LONER A�
I-3/4 INSIDE DIAMETER ,
h REQUIRED TO REMOVE ALL LOAM AND CLAY BENEATH
PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN
I .
I GRAVEL TO DESIGNED GRADE ,
R o 4'_o
`•q MIN. !
�•'" � EFFECTIVE DIAMETER
(NO T TO EXCEED 3 TIMES EFFEC T/VE DEPTH)
-U' WATER 7481-E A14WE
.5'0'L A X0, 1� F C 04 T4 --- GENERA NO TES
RERC. RA , E < z MIN, /IN .
� -'' NO HEAVY EQUIPMENT TO RUN OVER SYSTEM
SEPTIC TANK, DISTRIBUTION BOX , LEACHING PITS TO BE STANDARD
TEST BY: ___ ��-!� _ __—____— PRECAST REINFORCEC CONCRETE UNITS
WITNESSED BY. _4/_l4C0eVL__ _"- 14 ____ ._ ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE ,
TEST PIT GR EL. G3.S DATE _ .5 G ��_�_ MINIMUM REOUIREMENTS FOR THE SUBSUFACE DISPOSAL_ OF
TEST PIT NO. I TEST PIT NO 2 SANITARY SENAGE EFFECTIVE I JULY 1977.
0" -- 0"-- -- ---------' ANY CHANGES TO THIS PLAN MUS . BE APPROVEC BY THE
TOP t.� o�G BOARD OF HEALTH '
2
AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILLING, HE
/Y1E� SANG BGLARD OF HEALTH SHALL BE NOTIFIED FUR INSPECTION.
+ PITCH ALL SEWER LINES 1/4" / FT. UNLESS INDICATED
---------- � OTHERWISE.
D":_51611 DA T4
BEDROOMS,_3 ___ DISPOSAL
EST. TOTAL DAILY EFF. ___ __t3Q._—GALS,
s n SEPTIC TANK.__j o _ 'AL
AEI l0 - _ -----
-- SIDEWALL AREA FT.
EXISTING GRADE BOTTOM AREA FT,.____1...,Q___�GAL./SQ.
LEACHING REQUIRED Z 45,- S0.FT.
ZONE FINISHED GRADE
AC`,AL LEACHING AREA _ 24AP-Z_SQ.FT.
INVERT ELEVATION
DOMESTIC WATER SOURCE.____
PROPERTY LINE
PLAN REFERENCE -_`•Le_ 91 ff"� 2— ------- -.------ -- SCALE: AS INDICATED DATE ��-/L ---__
MEAN HIGH WATER,
BENCH MARK DATUM __ r13G,3 �L3Z_ f�/�5_ _ �T - ---- MARsti AVM. M W.4fy'WICH 9 ASSOCIATE>
'1► NORTH FAL lI o 'TH
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.s' IF•...': :,! ?'"!: .t�,,Yt... 'a_: ..._.3,::? .Y ': $,'. J -,. ': ..:+.,,.. }
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