HomeMy WebLinkAbout0073 MOORING DRIVE - Health \ \ \\ \ \4\ �\rive\\
a PF \\ \ 2
\ } «
a
! .
I
i
Commonwealth of MassEi husetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for .Voluntary Assessments (� ,
73 Mooring Drive
Property Address �M
Marilyn MacAdam & Mary Jean Fryar rti�
Owner Owner's Name
information is it MA 02635 1/19/1 t ou5
required for every C ;�.�.
page. City/Town State t !a Zip Code Date of Inspection
,l
Inspection results must be submitted on this form.;Inspection forms may not be altered in any r
way. Please see completeness checklist at the end o�the form.
Important:When filling out forms A. General Information
F .
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford
use the return Name of Inspector
key.
Company Name l
P.O. Box 49
Company Address
P Y
Osterville - MA 02655
City/Town a State Zip Code
508- 62-9400 `'S 124 2
8 8
Telephone Number 6'License Number
i
i
B. Certification '
M
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and comple:�e as of the time of the inspection. The inspection
was performed based on my training and experience in,the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
j
Needs Further luation by the Local Approving Authority I
AAA
' a 1/15/15 _
Inspecror
re a ! Date
The spector shall submit a copy of this inspection report to the Approving Authority(Board
of HeP)within 30 days of completing thisinspection. 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.jhe original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
r:**This report only describes e•onditions at the time of inspection and under the conditions of use
at that time.This inspecticii does not address h'ow the system will perform in the future under
IS the same or different conditions of use.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
1 F
:t
Commonwealth of Massachusetts I
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
73 Mooring Drive
Property Address
Marilyn MacAdam &Mary Jean Fryar
Owner Owner's Name t li
information is 1, !}
required for every Cotuit MA 02635 1/19/15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always,yomplete all of Section D
A) System Passes: "I
® I have not found any information which indicates!that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist:Any failure criteria not evaluated are
indicated below.
Comments:
,
t y�
i
it
t r
`t
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. 4
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 exfiltratioh 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 pas's 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 i❑ ND (Explain below:' ,
' a
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
�i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not 0 Voluntary Assessments
�M 73 Mooring Drive
Property Address
Marilyn MacAdam & Mary Jean Fryar
Owner Owner's Name
information is required for every Cotuit MA 02635 1/19/15
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B System Conditional) 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 Jt❑ Y ❑ N ❑ ND (Explain below):
it
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box i,s leveled or replaced, 3❑ 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 ❑ YI ❑ N ❑ ND (Explain below):
11
❑ obstruction is removed 's ❑ Y ❑ N ❑ ND (Explain below):
i
� .a
C) Further Evaluation is Required by the Board;of Health:
% i
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of:a urface water
❑ Cesspool or privy is within 50 feet of,,a'jbordering vegetated wetland or a salt marsh
a '1
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
r ;.
I tl . .. -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
73 Mooring Drive `
Property Address
Marilyn MacAdam &Mar Jean Fr ar
Y Y
Owner Owner's Name
information is it MA 02635 1/19/15
required for every Cotu :{
page. City/Town State t Zip Code Date of Inspection
B. Certification (cont.)
,F
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning i!n'a manner that protects the public health,
safety and environment:,,, .
i .
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface:water.supply or tributary'to`:a surface water supply.
El 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:
ij.
**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:
j,
e ,
I.
D) System Failure Criteria Applicable to All Systems:
a
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 i'
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official; Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 73 Mooring Drive
Property Address
Marilyn MacAdam & Mary Jean Fryar
Owner
Owner's Name
information is f,
required for every Cotuit MA 02635 1/19/15
page. City/Town State . Zip Code Date of Inspection
B. Certification (cont.)
Yes No 1 ;
❑ ® Required pumping more than 4 times in`the last year NOT due to clogged or
obstructed pipe(s). Number Qf limes 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 asurface water supply.
❑ ® Any portion of a cesspool or;privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or�privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or;privy•is less than 100 feet but greater than 50 feet
from a;private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for 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 ke attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000gpd-
® 10,000;d. ; I;
❑ ® The system fails. I have dd°termined that one or more of the above failure
criteria,exist as described in:310 CMR 15.303, therefore the system fails. The
systen' g6ershould conta let 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""ora no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the sy�'te'm is within 400 feet of a surface drinking water supply
j`
a
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El E] the syte,m 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 Seoti'on 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 3M0 CMR 15.304.The system owner should contact the appropriate
regional office of the Department. t `a
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
f..
49
I :I
! ;I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form -Not for\ oluntary Assessments
M 73 Mooring Drive
Property Address
Marilyn MacAdam &Mary Jean Fryar
Owner Owner's-Name i
information is
required for every Cotuit . MA 02635 . 1/19/15
page. City/Town State ' i Zip Code Date of Inspection
C.-Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
I
Yes No ,i
I )
I I,
® ❑ Pumping information was provid1. `bd by the owner, occupant, or Board of Health
I
❑ ® Were any of the system components pumped out in the previous two weeks?
El ® Has thesystem received normal flows in the previous two week period?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® El available
as built plans of the system obtained and examined? (If they were not
available note as N/A)
. r
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of breakout?
® ❑ 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 oflthe baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
a
® 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 drmined based on:
, i
® ❑ Existing information. For example, a plan at the Board of Health.
® El approximation
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:
i
Number of bedrooms(design): 3 t Number of bedrooms (actual): 3
i,
DESIGN flow based on 310' 1VIR 15.203(for example: 110 gpd x#of bedrooms): 330
I
t
:Il
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage;Disposal System•Page 6 of 17
i'
Commonwealth of Massachusetts
Title 5 Officiat Inspection Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
7
73 Mooring Drive I
Property Address
Marilyn MacAdam & Mary Jean Fryar
Owner Owner's Name
information is it MA 02635 1/19/15
required for every Cotu I`
page. Cityrrown State , ;, Zip Code Date of Inspection
D. System Informatioh a '
Description: a
r !)
0
Number of current residents!% j
_ 1
Does residence have a garbage grinder? { ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report:)
Laundry system inspected? ' ❑ Yes ® No
i'
Seasonal use? ! El Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail: I ��
unavailable
4 F
r '
{Y3Y3f
:3
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
Date
Commercial/industrial Flovi.Ibondltlons:
Type of Establishment:
i
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
e
Basis of design flow(seats/persons/sq.ft., etc.): i.
Grease trap present? 1 ; ElYes ❑ No
i
i�
Industrial waste holding tank"present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 sys#eh ? El Yes El No
Water meter readings, if available:
L
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
1
Commonwealth of Massachusetts
wI-IF Title 5 Official Inspection Form
_ Subsurface Sewage Disposal Pystem Form - Not for Voluntary Assessments
M 73 Mooring Drive
Property Address
Marilyn MacAdam & Mary Jean Fryar
Owner Owner's Name
information is required for every Cotuit MA = 02635• 1/19/15
page. Citylrown 'State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: '
Date
Other(describe below):
:,I
General Information
Pumping Records: {
Source of information: ldnnown
� I?
Was system.pumped as part'of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping: "
Type of System: .
}
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
F ;
❑ 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.
P Plt
❑ Other(describe): t
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
P
Commonwealth of Mass4zhusetts
Title 5 Official: Inspection Form
Subsurface Sewage Disposal :system Form- Not for Voluntary Assessments
M 73 Mooring Drive
Property Address
Marilyn MwAdam & Mary Jean Fryar
Owner Owner's Name
information is required for every Cotuit MA 02635 1/19/15
-
page. City/Town State ' Zip Code Date of Inspection
D. System Information (cont)
Approximate age of all components, date installed(if known)and source of information:
installed in 4/14/80-per as built j
p
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on=.ite plan):
.r
Depth below grade:
feet
Material of construction: ;
❑ cast iron ® 40 PUP, ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of j6iots, venting, evidence'of leakage, etc.):
x
Septic Tank(locate on site plan): .
Depth below grade: fe e et 1 t
Material of construction: N
® concrete ❑ metal ❑fibe(glass ❑ polyethylene ❑ other(explain)
t
1 F !Y
If tank is metal, list age: A!
years
Is age confirmed by a Certificate of Compliance? (a#tach a copy of certificate) ❑ Yes ❑ No
1000 gal.
Dimensions:
' 2
Sludge depth:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 73 Mooring Drive
Property Address li a
Marilyn MacAdam & Mary Jean Fryar
Owner Owner's Name
information is Cotuit MA 02635 1/19/15
required for every
page. Cityrrown State ; Zip Code Date of Inspection
D. System Informatioh (cant.)
,a
Septic Tank(cont.)
i
27
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness i 2
Distance from top of scum to. top of outlet tee or baffle 6
} Distance from bottom of scum to bottom of outlet(ee or baffle 15
How were dimensions determined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of I4akage, etc.):
The tees were present.There was no sign of leakage.
. a
j
1
Grease Trap (locate on site plan): r
i t
Depth below grade: n/a
i.
feet
Material of construction:
❑ concrete ❑ metf ❑fiber glass El polyethylene El other(explain):
Dimensions:
Scum thickness f
Distance from top of scum to top of outlet tee or baffle
,i
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: t;
Date
it
t5ins-3/13 tTille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
;V
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a
�M 73 Mooring Drive
Property Address
Marilyn MacAdam & Mary Jean Fryar ?
Owner Owner's Name
information is Cotuit MA 02635 1/19/15
required for every __�
page. City/Town State .: Zip Code Date of Inspection
D. System Informatiop (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.):
i
it
Tight or Holding Tank(tank must be pumped at,time of inspection) (locate on site plan):
Depth below grade: f.
Material of construction:
• F
❑ concrete ❑ met`l ❑fiberglass ❑ polyethylene ❑ other(explain):
•N/a
Dimensions:
Capacity: .,i
1( gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
i�
Alarm level: f j Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
I
Comments (condition of alarn:and float switches; etc.):
a
;i
Attach,copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
i-
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
i
t ai
Commonwealth of Massachusetts i
Title 5 Official. Inspectidn Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 73 Mooring Drive I
Property Address . t
Marilyn MacAdam &Mary Jean Fryar ('
Owner Owner's Name
information is required for every Cotuit MA 02635 1/19/15
page. Cityfrown j State - Zip Code Date of Inspection
D. System Informatiol;n (cont.)
Distribution Box(if present:.must be opened)(locate on site plan):
Depth.of liquid level above outlet invert `; even
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The D-Box was normal
b
S
k
\ j
y.
i
Pump Chamber(locate on site plan):
Pumps in working order: , M ❑ Yes ❑ No"
Alarms in working order: El Yes . ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/a
R
a
If pumps or alarms are not'in.working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why: it
r. r;
t
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
F
:s
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form -Not fors.sVoluntary Assessments
M ,•'' 73 Mooring Drive
Property Address
Marilyn MacAdam &Mary Jean Fr ar
Owner Owner's Name 1
information is required for every Cotuit MA 02635 1/19/15
page. Cityrrown State,, Zip Code Date of Inspection
D. System Information (cont.)
Type: ;
® leaching pits f number: 1-1000 gal. with
2' stone
❑ leaching chambers , 'j number:
❑ leaching galleries number:
t
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The pit was dry. The bottom to grade was 9'.The cover was 24" below.The pit is under the fence.
There was no sign of failure.,'
• i;
"r
i
'4
t
Cesspools (cesspool must be,pumped as part of inspection)(locate on site plan):
i'
Number and configuration
I I
Depth—top of liquid to inlet invert .
Depth of solids layer ;
Depth of scum layer },
Dimensions of cesspool I�
Materials of construction i
Indication of groundwater inflo;�.i El Yes ❑ No
t5ins•3/13 Titl9 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
Commonwealth of Mass�.chusetts
t.
W Title 5 Official inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 73 Mooring Drive d
Property Address
Marilyn MacAdam & Mary Jean Fryar
Owner Owners Name
information is
required for every Cotuit MA 02635 1/19/15
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
!i
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.):
N/a
i
. 4
I
d
t
it
S 'I
i
t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
° Commonwealth of Massachusetts '
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 73 Mooring Drive
Property Address
Marilyn MacAdam & Mary Jean Fryar
Owner Owner's Name
information is
required for every Cotuit MA . 02635 1/19/15
page. City/Town State ;{ Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a viel of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
I
A ` /3
1 :a o
.i
30
i a ys�
a a9
w T
c.Ae_L
3 3a 49
M
,1
y y
•
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official` Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 73 Mooring Drive j
Property Address
Marilyn MacAdam & Mary Jean Fryar
Owner Owners Name
information is ,
required for every Cotuit MA 02635 1/19115
page. Cityrrown State 3 Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 40'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
� 9
If checked, date:of design plan reviewei :
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Topo and water contours map
i
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:',
You must describe how you,established the high ground water elevation:
see above
I
: s
i
• .:f -
.1
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r 4
3.
f �1
t
Commonwealth of Massachusetts
W Title 5 Official, Inspection Form -
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L.
73 Mooring Drive
Property Address
Marilyn MacAdam & Mary Jean Fryar
Owner Owner's Name
information is required for every Cotuit MA > 02635 1/19/15
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
" r .
t +
f
1 I
i
R�
• 4, I
'P>
t5ins•3/13 fitle!5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
k13
' LOC � INN ZL&�tw I- � � SEWAGE PERMIT N0.
r'
VILLAGE
INSTA LLER'S NA E i ADDRESS
r
BUILDER OR OWNER
eel,
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ,/�y
, . ,
�� __ _ _
.�
.� v\
If
� �
� J
l.r,
!�
No.......» ........... Fes$.. .... .
THE COMMONWEALTH OF MASSACHUSE17S
3 / BOAR® OF HEALTH
oF.....
....................................
ApPrtt#tlan for Disposal Works Toustrurttun Prrutit
Application is hereby made for a Permit to Construct (,s<) or Repair ( ) an Individual Sewage Disposal
Systemt:��. ... .... ... .0�..4 ._.. ... ........• •-----••-••••-••.................
.»».. .... ........ .
er — d7
(� ttA��
Installer Address
U Type of Building Size Lot... feet
Dwelling—No. of Bedrooms............. ........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons..... Showers ( ) — Cafeteria ( )
Q' Other fixtures -----------•--•-•••---••--•-••-
W Design Flow........ 7_'T...............gallons per person per day. Total daily flow.........rc2't�Q 0...................gallons.
WSeptic Tank—Liquid capacity./r�..gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length g.......... Total leaching area............__..._.-s . ft.
x / g �
Seepage Pit No------------- ---- Diameter------- . .--•-- Depth below inlet---. .- .... Total leaching area:...S �s
Z Other Distribution box DosingpNef.
Percolation Test Results Performed by ?Plet'✓ ......... --- Date--- ��� --------------
a
,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.__... _ . . ._. .
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...
x ---•-
r�
0 Description of Soil -
W -------------- ------------------ .... %'1 n I. ----------------------...----------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-------•-•-•-----------------------••-----------------------........------------------------..----•----•--•--•-•-----------•----•-•-•---•-•------•--------------•------------------•---•------....------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITLE 5 of the State Sanitary Code— he u ersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee sued b oar of health.
S'Oned•. --- --.... - -------• --------------------• ����. ....
Date
Application Approved By...... I�_.... ................................. .. 2
Date
Application Disapproved for the following reasons--------------- ---------•------ --•----•----••---•-----------------------------•------•-•••...--------
------------------------------------------•--------•-•--•----------------•----•--------------•---....--••'-----•----------------•------•----•-•--••-•--•-•------------•---•---•--------------------•-...
Date
PermitNo......................................................... Issued. a....----.........._..-•--
Date
No..----..°..'..._....... Fims., .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for UiipAiiai Works Tonstrnrtiun Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
cyst:/� .......... .....±� ................:.... .. ....�'��--=--.._. ................... ..... .•--..
e yy✓nar ress
...
��/-------------;1 -------------------------
Installer Address
Type of Building Size Lot--- t /Sq. feet
�. Dwelling—No. of Bedrooms.................'�:::......_._________._Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building fin. No. of persons----�/.................. Showers ( ) — Cafeteria ( )
a' Other fixtures. J......
W Design Flow________: __________________gallons per person per day. Total daily flow_________ ...................gallons.
WSeptic Tank—Liquid capacityAgallons Length................ Width................ Diameter................ Depth................
x Disposal Trench'—No_ ____________________ Width.................... Total Length.........._____..... Total leaching area....................sq. ft.
3 ___ Diameter....... Depth below inlet___. .._.?.. . Total leaching
Seepage Pit No'_____________�_ p ! g
Z Other Distribution box V Dosing nk ( )
'-' Percolation Test Results Performed by..__ - �'- :?�' _. �z l R ....��i�S/
a Date - .__:_ ----------------
Test Pit No. 1________________minutes per inch Depth of Test Pit._.______.._.._____. Depth to ground water_._.%
f34 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_. ....................
W' ..........=...................................................................................................................
O Description of Soil..... �___.�' .. ���`'f r
�"
UW •------------------------------- ==�--- ------•--s _ -. -__-----------------------•----•----------------•----•-------------------•--•-•-----------•------------
Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
-••-----•-----•------•------•------------------------------•---------._.._..--------•••---•--_--•..._.......----•-•--•------•-......--------....--------•-•-...........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI:'L- 5 of the State Sanitary Code— The u ersigned further agrees not to place the system in
operation until a Certificate of Compliance has been"ssued b boar of health.
S• ned_,:._: ... 1..... '... _
• � Date
Application Approved By..... -_ .................................... ....../~--- 2- ....
Date
Application Disapproved for the following reasons--------------• ••--------•-----•----------------•-•-•-------•••-•---•••----•--•--••---------------------.._.._
... ..•-------•---•••-----------•••-•----•--•...._._..--••-----------------•--•--------•----------•------- --•--•-••------------ -•••••--•--_-•---
Date
PermitNo.................................=-------•------------_. Issued.................. ................................
Datete
THE COMMONWEALTH OF MASSACHUSETTS
�— BOARD OF HEALTH
T ..........................................� .
...............O F.... .. ................ ......._.-.....
f Trr#ifiratr of Toutpliattrr
TH "�"ISSO C IFY, hat the- ndividual Sewage Disposal System constructed (A or Repaired•------•-• .._...by..- r tlprov Installer/! *Y .[-__-- J ( -, :.
has been installed in accordance with isions of of The State Sanitary Code as described in the
.G dated._-./ . ���application for Disposal Works Construction Permit No___ ___________________________________
THE ISSUANCE OF THIS CERTIFICATE SHALL,NOT'BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Ins ector....................................................................................
4 �..
_ ....w..,....+:._++e..ek>.+:..�a...`" • -•,ra,ue.., .'.emu... �a:�_"s.rsc�:u:.GxiamWi_4:�.w�:x,5n}'.M• 'r t _ _ -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH/
OF............. :
.2 _...----••..................... ........_........
v FEE.
Permission is hereby granted-_.................... )_....
to Construct (X or Repair ( ) an Individual Sewage Disposal System
as shown' on,the applCitcaltio>'rfor Disposal Works Construction Pe No_________ ______ ` ted___/�_�~__ ..----.----..
.; -.......................
d
DATE...---`•-•�`---'�-----�-4 Board of Health
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS t .
;a
;F
R :
F.FL. ELEV.=
-- FINISH GRADE .L FINISH GRADE FINISH GRADE—
TOP Of FOUND, OVER TANK = _ �l l x� OVER PIT ��Y �__ _1
!
ELEV. = x v
a„ C.I. ^--'-. '. , . , M _ \,\ CHIMNEY BLOCK BACKf±I 3 PEAS TONE
VOWELWNG .� WHERE NEE DEG
CELLAR FLOOR )00 0 GAL LON -�- • • • •-� [ a• T � � o O O 3° 1 �i
ELEV. _ _ {! REINFORCED GONG. �, J 0 p o ° T
O O o � ° � CRUSHED
i-iED STONE
��+.°—•-ram�' s.i i J h d 0 C) 0 p
DIST. BOX ' o 0 o o a e �t
-- -� �� oa el ' o p 0 p 0
SEPTIC TANK rG `�` LEVEL tip 7 1f p 0 (� Q p o BOTTOM OF PIT
AND STABLE ) ° 1 o O 0 O o ° ° 4 ELEV. = x
SYSTEM PROFILE - - t i
NOT TO SCA. E, , f - --- -- -
LEACHING _PIT
DES! CN CRITERIA
�. ZT jn0j S
hiMB£R OF RE b R 0 OM S = _.-_ ------- ---- —-- ___._._�_. Y'"4 ' ' X
GALLONS PER DAY ___ _. � _ —. `J N
jvJ
GARBAGE GRINDER ata IL..
TOTAL DAILY FLOW
LEACHING AREA PROVIDED =��.�`,;�a_`�r-F>t__ i f
A.ZZ *• tic 11K4,X-?,- t Z-5 4-sust�»:a�� \At. -0�� c4Z �I.0 -
�J C Ptd. G r �5 T pt% ` ' Y1 �` 12'
O
T/►N K.
SOILS LOG 1-- - - -.
O"
1
X
LOT
-:. :_. _•: E - _ PROPOSED SEWAGE
f
DISPOSAL SYSTEM
t� , � � � � PROPOSED DWELLING
INSPECTED BYE �'"Jt�`�►�-•-�Y.1�,1.�'���-''- �vlc?gc,,, �t.�, f��..�TF{ -- -- --- --- .__-----------z :�_.:�:-_ - ---
DATE !a MASS.
(PERCOLATION RATE ��-.__�-_..MINJINCH SCy/AL�F(_ QAS/ NOTED --_-DATE
L.!'EVA►'"! �C3�.�'�r �,��,7 MSL i✓'.�T )I./t A� NORM t T1�LJ L:�E)'`JTR�.k 'F, nr1 Lak: :�
LrdT '54 LGvWhi 0" PLA►�� T� 1PE:� I�7 `-��'[.ET i.I�� , � $ : '3 N I 24- Gr-IE,�T
NORMAN GROSSMAN PE, RL S
PICO M L_',/w ze. 10NA► � 226 HOLLY POINT Roa ;
CENTERVILLE, MASS .