HomeMy WebLinkAbout0074 MOORING DRIVE - Health 74 Mooring Lane
Cotuit
A= 024-104
i
J
Commonwealth of Massachusetts
Title 5 OffciaI hns,pecto=n Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i
74 Mgoring Lane, Cotuit, Ma.
Property Address
David Peteasko _
Owner Owner's N"ame
information is. 15 Gallagher Drive,Marstons Mills Ma. 0264.8 July 27, 2012
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results Imust be submitted on this form.•Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General information
filling out forms
on the computer,
use only the tab 1. 1n3,peCtOr:
key to move your
cursor-do not Dan,A. Speakman
use the return Name of Inspector
key..
Company Name
15 Speak Way
Company Address
No Harwich Ma. 02645
Cltyfrown State Zip Code
508-4:342 5565 637 _
Telephone Number License Number
B. Certtiflcatlon
l certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true accurate and complete as of the time of the inspection. The inspection
was performed based on my tratning.'and experience in the proper function and maintenance of on site
sewage.d sposal:syste'm.'s. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR_.15.00.0). The' ystem:'
® Passes ❑ Conditiorially Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
July 27, 2012
:tors Ign ture Date
The system inspector,shall submit a copy of this inspection report to the Approving Authontys(Board
of Health or DEP)within k days of.cor- pleting this inspection. If the system i64a'shared system c8
has a design flow,of 10,000 gpd or greater, th•e inspector and the system own
erlshall sut�rit they;;
report to the appropriate regional office of the DEP. The original should be sent to the sy?tem owner
and'copies sentto the buyer, if applicable, and the approving authority. ,
*,*`*This report only describes cond!itions;at the lme of>mspection and under the COWitio of use
at that time.This on,,does not address-how the system will perform in thb futu under
the same or`different conditions'of use;
Sewage Di posal Sy
t5ins-11110 Title 5 Official Inspecli Fo Subsurface tem-Page 1 of 17
Commonwealth of Massachusetts
Ttlo 5 Official hnfspecton Form
SUbsU At Sewage Disposal System Form-'Not for Voluntary Assessments
74 Mooring Lane, Cotuit; Ma.
Property Address
-David Petrasko ' r
Owner. owner's Name
information is 15 Gallagh:er,Drive Marstons Mills Ma, 02648 July 27, 2012
required for every
page. CO, own,,, , State Zip code Date of Inspection
B. Certifica Jib n:(cone.)
Inspection Summary Check A,B,C,D or E/always complete all of Section D
A) System Passes:
Ir"Ih e not found.any information which indicates that any of the failure criteria.described
in 310 CM R 16.'36 grin 310 CMR 16.304 exist.Any failure criteria not evaluated are
ihdi7 dated-below.
Comrr►ehis:
B) System Cohditionally Passes .
:.
❑ One or more syste components as":describ ed in t
mhe `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 he box,for ,yes", "no' or"not determined"(Y, N, ND) for the following statements. if"not
determined,"pleas."e explain.,
The-septic tank is metal and,.over;: 0 years old* or the septic tank(whether metal or not) is structurally
unsound exhibits substantial infiitrat�on or exfiltratlon or tank failure is imminent. System will pass
inspection if-the ew 1i tank is replaced:with a.complying septic tank as approved by the Board of
Health:.
Am et8I 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 yews old is available.
❑ Y ❑ N . ❑ NOD(Exp am below): E
t5ins-11110 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Ti-tle5 Official Inespecton Form
Subsurface Sewage Disposa(System Form -Not for Voluntary Assessments
74.Moonng Lane, Cotuit; Ma.
Property Address
David Petrasko
owner Owner's Name
information is 15•Gallagher Drive,Marstons Mills Ma: 02648 July 27, 2012
required for-every
gtylTown State Zip Code Date of Inspection
page. ._,.
B Certification (cont)'
B) System Conditionally Passes(cunt.): "
❑ 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 inspecion if(with approval of Board of Health):
broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
ill .
obstruction is rernoved ❑ Y ❑ N ❑ ND (Explain below):
distribution box Is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
_ .
i
❑ The system required pumping:more than 4,tmes ayear due to broken or obstructed pipe(s). The
system wilt pass Inspection (with approval of the.Board of Health):
broken.pipe(s) are rephaced ❑ Y ❑ N E] ND (Explain below):
obstruction"is removed. ❑ Y ❑ N El ND (Explain.below):
C) ?FurtherEvaluatlon is Regwred bythe Board of Health:
❑ C.onditions 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 340 CMR ti
15 303(,1)(b)that the system is A. unctioning in a manner which will protect public health, `
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I'M.,y,/,..
Commonwealth Of Massachusetts
Tstle S -0 ffici'a I�nsp�ect -on Form
Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments
74 Mooring Lane; Cotuit, Ma:
Property Addtbss'. ._
David Pefrasko
Owner Owner's Name
tnfom atlon is 15.Galldi her Driye,Marstons Mills Ma. . 02t 48 July 27, 2012
required fore'ery
page. CitylTovirn` State Zip Code Date of Inspection
B. Certification ( -ont:j10M .
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system,is functioning,in a`manner that protects the public health,
safety and environment:
The system has a septic tank and soil absorption,system (SAS) and the SAS is within
166.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 septic1. tank and SAS and the SAS is within 50 feet of a private water
supply well.
El 'The system has a septic t6iri SAS and the SAS is less than 100 feet but 50 feet or
more from a pnvate,water supply well**.
Method used'tg`determine distance:
This system passes m.1 a well.water analysis; performed at a DEP certified laboratory, for fecal
coN#orn bacteria indicates;absentand;the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided tf'at no,other failure critena'are triggered. A copy of the analysis must
be attached to this form': j
3. Other: '.
1 II
D) System Failure Criteria Applicable to All Systems:.
You must indicate"Yes";or"No"to each ofahe 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.a,n overloaded or,clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
El 131/l/
than%day flow
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official lnspecto-n Form
Subsurface SeArage"Disposal $ystem`Form -Not for Voluntary Assessments
74 MoorJnb Lane..,Cotuit Ma:
Property Address
David Petrasko , '
Owner owner's Name —
information is . 15 Gallagh er Drive Marstons Mi sll Ma. 02648 July 27, 2012
required for every
page. CitylTown, state Zip Code Date of Inspection
B "Certification;(cont.)
Yes No
Required pumping more:than 4 times in the last year NOT due to clogged or
Ee
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.
El Eo 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 tf the well water analysis, performed at a DEP certified
labe atorya for fecal col fgrm 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 foam.] t
The'system is a cesspool serving a facility with a design flow of 2000gpd-
The system fads I have determined that one or more of the above failure
criteria exist,As; 'bed_in 3.10'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:
d ' , l 1To b
a s sE Lar e,S stems e cons1,deredajar " t' m`the system must serve a facility with a
eg f 0000 god to 1&000Vpdsignfowo For'large systems,you must indicate either"yes"or no to each of the following, in addition to the
questions in Section;D.
Yes No
0 • the system.is within400 feet of a surface drinking water supply
0 the'system is within 200 feet of a tributary to a surface drinking water supply
the system is located in"a nitrogen sensitive area (Interim Wellhead Protection
Area_IWPA)or a;mapped Zone II of a public water supply well
If you have answered yes"to any question in Section E the system is considered a significant threat,
or answered°yes" in Section D above the large system has failed. The owner or operator of any large '
system considered a signifcant threat
;under Section E or failed under Section D shall upgrade the
system in.accordance with.310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
_ Title 5 officia Inspection Form
Subsurface Sewage 3isposal System Form Not for Voluntary Assessments
74 Mooring Lane, Co#piit, Ma:
._ Property Address
David.Petrasko.
i .Owner Owners Name
Information is 15.Gallagher Drive Ma�stons Mlis 'Ma. 02648 July 27, 2012
q
re ulred forevery Cltyr
-page rown State. Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes" or"no" as to each of the following:
Yes No
El Pumping information wasprovided by the owner, occupant, or Board of Health
P g
Were any of th'system components pumped out in the previous two weeks?
El [[']� Has the system received normal flows in the previous two week period?
L
Have large volumes of water been introduced to the system recently or as part of
this inspections
Were as buih 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 siteinspected for signs of break out?
El ".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 he condition of the`baffles or tees, material of construction,
dimensions, dep.'th of liquid, depth of sludge and depth of scum?
aWas the facility owner(an d'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
"' r xim i r ` f i n e is unacceptable) 1 1 app o. at o o d sta c [3 0 CMR 5.302(5)]
f
D. System Information
Residential Flow Conditions
Number of bedrooms(design) 3 Number of bedrooms(actual): 3
330
DESIGN flow based on 310 CMR 1'5.20.3(for example: 110 gpd x#of bedrooms):
l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusia is
To. 5 Official Inspection Form
Subsurface'Sevuage Dispo al System,Form -Not for Voluntary Assessments
i
74-Mooring Lane, Cotuit, Ma.
Property Address..
David Petrasko
Owner Owner's Name
Information is 15-Gallagher Drive,MarStons Milis Ma. 02648 July 27, 2012
required or every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description;
Number of current residents:
Y/es -,,No
Does residence have a "garbage Tinder. I� ❑
9 9 9
Is laundry'on a separate sewage system? [if yes separate inspection required) ❑ Yes L� No
laundry system inspected? ❑ Yes ❑ No
Seasonal uses ❑ Yes [�No
Water mE'40t readings, if available{last 2,years usage(gpd)):
Detail:
i
Sump pump? El Yes La No
7 •
Last date of occupancy: / Date
Commercial/Industrial Flow Conditions: N r
Type of Establishment
Design flow;(based on 31 Q CMR 15.203): Gallons Per day(9Pd)
Bass'of design flow(seats/persons/sq'ft. etc):
Grease trap presents ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
on
Off
waste discharged to the`Titte,5 system? ❑ Yes ❑ No
Water meter readings, if available:
l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
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i
Commonwealth of Massachusetts
Title `5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Mooring Lane,'Cotuit, Ma.
Property Address
David Petrasko
Owner
Owner s Name .
Inforrhation is
required for every 15 GaI1140 �Qrive,Marstons Mills Ma. _ 02648 July 27, 2012
page. City/Town: State Zip Code Date of Inspection
D.'System Information (cost:)
Last date of occupancy/use: Date
Other(describe below):
s
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes I� No
If yes,volume pumped:
gallons
How was quantity pumped determined? -
Reason for pumpirig:
TYpe of S: stem;
Septic tank, distribution box, soil absorption system
Single cesspool
El Overflow cesspool"
Ej Privy
s
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 fhe l/Asysteim by system operator under contract
Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
do .. .. ,r;
Commonwealth of Massachusetts
Title 5 offi cti 0h Form
Subsurface Sewage t)isposal System Form -Not for Voluntary Assessments
74-Mooring Lane, Cotvit, Ma.
Property Address
David Petrasko.
Owner Owners Name
information is 150911agher Drive,Marstons Mills Ma: 02648 July 27, 2012
required for every
page. City/Town State. Zip Code Date of Inspection
D. System Information (cost:)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
Building`Sewer(locate on site plan):
DePfh'below,grade:_ feet
Material.of construction;
❑cast iron 40 PVC ❑ other(explain):
Distance from p ivate water supply;well or sucfion line: feet
Comments(on condition of points,venting, evidence of leakage, etc.):
nk to on site lan . s
.Septic Ta_ ,( Cate p , )
P L
Depth belowgrade: f2 T
feet
Material ofconstruction:
concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank.is metal,list age:
years
Is age confirmed.by aCertificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth: -
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
{`
Commonwealth of Massachusetts
Tittle: 5 Officia}I Intspecton Form
Subsurtace Sewage Disposal System Form Not for Voluntary Assessments
74 Mooring Lane; Cotuit, Ma.'
Property Address
David Petrasko
Owner Owner's Name
information. is 15 Galla tier Drive MarstonsMills Ma._ 02648 July 27, 2012
required for every 9
page. CityTTY own State Zip Code Date of Inspection
D. S. stem Information (cost:)
Septic Tank(cost.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to.top of outlet tee or baffle
Distance from bottom.of scum to bottom of outlet tee or baffle L.
How were dimensions deterrnin 'd. S
Comments(on.pumping recommendatiohs, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of ieakage, etc.):
Grease Trap(locate on site plan):
Depth,belowgrade: feet
Material of construction:
❑concrete ❑ metal El fiberglass El polyethylene El 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
t5ins•11110 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposa System Form Not for Voluntary Assessments
74.Mooring Lane; Cotuit, Ma.
Property Address
David P,etrasko
Owner Owners Name ;
information
re uired .for every is 15 Gallagher Drite,Marstons Mills Ma. 02648 July 27, 2012
q
page. CitylTown... State Zip Code Date of Inspection
D System Lnformattlon
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t
Ti f9r Holding Tank(tank must;be pumped at time of inspection) (locate on site plan): ,L7 4
Depth below grade:
Material of construction:
❑ concrete` ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain):
Dimensions;
Capacity: gallons
I
Design Flow: gallons per day
Alarm present: ❑ Yes El No
Alarm level:. Alarm in working order: ❑ Yes ❑ No
Date'of lastpumping date
Comments (condition of?alarm and float switches, etc,):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
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Comimonwealth of Massachusetts
Title 5 .Official hnspecton Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Mooring Lane, Cotuit, Ma. _
Prop Y a Address
DaVad Retrasko
Owner Owner's Name
information is 15 Galladher
required for every DriveMarstons Mills . Ma. . 02648 July 27, 2012
page. City(Town. .: State Zip Code Date of Inspection
D. System Information (writ)
Dritributidn Box'(if present rmst be opened) (locate on site plan):
Depth of liquid level above outlet invert
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
;): s
Q— Z —
S/ afi F" tG. lz .
Pump Chaer(locate on site pian
Chamber ): Al
Pump's in working order: ❑ Yes ❑ No
Alarms in working order._ El Yes El No
Comments{note condition:of pump chamber;condition of pumps and appurtenances, etc.):
Soil Absorption System,(SAS) (locate on site plan, excavation not required):
If SAS not located, explain wh.y:
G/ /aJ
t5ins•1 MCI Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth.of Massachusetts
!�bewagitle 5 Offcia linspecti:on Form
e'Disposal System Form Not for Voluntary Assessments
74 Mooring Lane Cotuit, Ma.'
Property Add
David Petrasko
Owner owners Name
informations 15.Gallagher Drive,Marstons Mills Ma. 02648 July 27, 2012
required for every
page. Gity/Town ;: State Zip Code Date of Inspection
D. System 10 rma, ion (cunt)
Type:
lea phin9 pits number:
El leaching chambers` number:
❑ leaching galleries number: —
❑ leaching trenches : n' number, length:
leaching fields number, dimensions:
El overflow cesspool number:
innovative/alternative system
Type/name of tech'nology:
Cor rm6hts'(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation,e,c.
Cessp oois (cesspool must be pumped as part of inspection) (locate on site plan):
Number.and configuration
Depth top of liquid to inlet Invert
D"epth of solids layer
Depth of scum layer
Dimensions of cesspool —
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Ttl`e 5 Official lnspectorn Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Mooring Lane, Cotuit, Ma.
Property Add
David Petrasko..
Owner Owner's Name
Information is 15 Gallagher Drive,Marstons Miils W 02648 July 27, 2012
required for every
page.. Cityffown,, state Zip Code Date of Inspection
DO System Information (coat:)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate.on site plan):. w`
Materials of construction:
Dimensions
Depth of solids
Comments(note condltion'.of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
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commonwealth of;Massachusetts
t
,{ _ tT tie 5 Off ciarl Inspectibh Form
yZs: Subsurface Sewage Disposal System Form Not for Voluntary Assessments
74.Mooring Lane;Cotuit; Ma
f
f�s David Petrasko
Owner Owner s Name }
s lnforniatlon�s 15,Gallagher DnV.e'W t' Mills Ma 02648 July 27, 2012 .
s regwred for every
page. CitylTown State Zip Code Date of Inspection 3"
-D-System Information bht )
k. Sketch Of Sewage Disposal System Provide a view of the sewage disposal system, including ties to
ri
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
❑ deawing'attached separately J.
.x
.P
e
13ut7p OJiCE Title Oflidr Yupeclgn corm.SuGwrfsq 9,w+ge DlrperW S Yuan•Peps is or
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
a.
Commonwealth Of Massachusetts.
Title 5 Official In4specton Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Mooring Lane;Cotuit, Ma.
Property Address
.David Petralsko
Owner Owner s Name
information is
required for every 15 Gallagher Drive,Marstons Mills Ma. ' 02648 July 27, 2012
page. City/Town" State Zip Code Date of Inspection
D. System Inform6 Jon ( -ont,j
Site Exam:
❑ Check Slope
Surface water
❑ Check cellar -
Shallow wells
Estimated depth to high ground water: Z cii T )0/7
feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from'system design plans on record
ff._checked, date of design plan reviewed: date
Observed site`(abutting propertylobseryation hole within 150 feet of SAS)
❑ Checked with local Board of He
6ith
-explain:
Checked with local.excavators, installers-(attach documentation)
.Accessed USES database explain:
You:In describe how you established the'high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
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Commonwealth of Massachusetts
Title 5 Official i, ect on Form
p
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Moorin` Lane Cotulf Ma: _
9
Property Address
David_Petrasko
Owner owners-Name.
information is
required for every 15 Gallagher Drive,Marstons Mills Ma. 02648 July 27, 2012
page. city/Town State Zip Code Date of Inspection
. . .. . - ..
E. Re'porf Colmpleteness Checklist
Inspection Summary: A, B, C, D, or E checked
spection Summary D (Syste'm Failure Criteria Applicable to All Systems)completed
�ystem Information—'Estimated depth to high groundwater
etch of Sewage Disposal,System either drawn on page 15 or attached in separate file
r ,
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
fft
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
C T v tr -`�/ ---
Property Address
gLGIEL..i°ETlz�/ 1'fro 
Owner Ow ers Name
information is
-� - --
required for I to - _ -- —.....-
every page.. Cityrrown - - State Zip Code Date of.lnspedion
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:When filling out A. General Information
) '
forms on the
computer.use 1. Inspector.
only the tab key
to move your
cursor-do not
Name of Inspector
use the return
key. ----- ---...- ...-- ------- -------------- —
Company Name
Company Address
New ��'
nrn City/Town�// -' ..__ State —.. Zip Code —--- -
Telephone Number License Number
B. Certification
I certify that I have.personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 �iOR 15.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
Needs,Further Evaluation by the Local Approving Authority
V..
spectors Signature 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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer .if_appl cable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This Inspection does not address how the system will perform in the future under
the same o�j ltrer
.6 V t conditions of use.
� !
snap•03108 Title 5 Official Inspection Form:Subsurface Sewa;e Disposal System•Pape I of 15
Commonwealth of Massachusetts
Tale 5 Official Inspection Form
I
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
rnoorri-g nr, tic t
PropertyAddress
Owner Owners Name
information is
required for
every page. City/Town State Zip Code Date f Ins Ion
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes
al-h--ave 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:
B) System Conditionally Passes: /f
❑ 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.
Answer yes, no or not determined(Y, N, ND)in the ❑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.
ND Explain:
❑ 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
❑ obstruction is removed
t5insp,030 Title 5 Offiusl Inspection Form:Subsurface Sewage Disposal System Pape 2 of 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y h(1 oo ►- 10ri'ye, C,
Property Addres
Owner owner's Name
information is L,� y��, I'�C
required for —[L'4�
every page. Cityfrown State Zip Code Date o Insp ion
B. Certification (cont.)
B) System Conditionally Passes (cont.): AJ
E distribution box is leveled or replaced
ND Explain:
❑ 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
❑ obstruction is removed
ND Explain:
C) Further Evaluation
n is Required b the Board of He
alth:
oU vt
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
14 loTitle 5 Official Inspection Form
w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
U _74 Mmi- &),U rylo-
PMpe ZAdd
-ta I- T , , Pr
Owner owner's Name
inforrnation is
required for h'-\a U
�' -�- o { --- - - - oZ -) b
every page. Cityfrown� state Zip Code Date 6f lnspdctlon
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.): AJ�T
❑ 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 coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ �/ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cessp
ool
pooI
❑ [2,- Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ [a,-- Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Er 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.
t5insp•DUN TiU&s Official Inspection
. pection Form:Subsurface Sewage DispCsel System•Page 4 W 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
IVI Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
r� I Cy�,.> . y,�.r p x
Owner Owner's Name
information is
" "ton
required for S r t l a� C a
every page. Cityrrown State Zip Code Date 6f lnsp6ction
B. Certification cont.
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ 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.
❑ E] 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.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ L_t' The system falls. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large sy lem the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd. �j
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ -the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate _
regional office of the Department.
t5insp-0301 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address r ^ f
I I PY'la ko I S l� a �[v_�? !�-�" �►�
Owner Owners Name �,��.�
information is t �. r r L 6 1.L
required for
every page. CityrTown state Zip Code Dawbf-1nsp6cWn
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
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?
O 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?
LS ❑ 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:
lam' ❑ 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))
i5lncp.03M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of Is
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
s` t.s
Owner Owner's Name
information is tn� J ,r ,l} 2 p
required for +wn _L!L
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): — Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 3 0
Number of current residents:
Does residence have a garbage grinder? es ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes B--fTo-
Laundry system inspected? ❑ Yes 0-1510
Seasonal use? ❑ Yes g- o
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes 0-�o
Last date of occupancy:
Date
CommerciaUlndustrial Flow Conditions: x)
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
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):
15insp•0301 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Ivi --)(4Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
oor' r"I C ► tq
Property Address
b] i�& IS-
Owner Owner's Nam--jje
information
requ red fora trJTtTr\S rn► 01 S
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: -
Was system pumped as part of the inspection? ❑ Yes No
If yes,volume pumped: -
gallons
How was quantity pumped determined? --- — -- --- --
Reason for pumping:. -
Type of 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:
Were sewage odors detected when arriving at the site? ❑ Yes No
l5insp-03M Title 5 Official Inspection Form:subsurface sewn"oisposai system•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal f System Form-Not for Voluntary Assessments
f ��I, • 1
� YY10 6 r' 'rP n�'► U•G �* �,1- '
Prop6rty Address
M I'WW e cltn�4 k 0
Owner Owners Name
information is VT m �� j�y�}
required for (C� t —
every page. City/Town State Zip Code Date o Inspedlon
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑cast iron 40 PVC ❑other(explain):
• /Cr7 't
Distance from private water supply well or suction line: feet
Comments (on condition of joints, .venting, evidence of leakage, etc.):
/0�1 � o c�U c.�dv�. r-7 0•J
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
K
Sludge depth:
f
Distance from top of sludge to bottom of outlet tee or baffle 2 8
3� t
Scum thickness
G
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle fO c
How were dimensions determined? u'e CQ t
t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Addre
Owner Owner's Name V
required on is
required for T�
every page. Cityfrown State Zip Code Date/of Inspfiction
D. System Information(cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan): ^J �1
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: gate - - --
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: -- -- -
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
15insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Dispos,sl System•Page 10 01 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Add
Owner owner's Name
information is �yr
required for tt '6'�r'" e
oa
every page. Citylrown State Zip Code Date df Insp ion
D. System Information (cont.)
Tight or Holding Tank (cont.)
C 1 vl
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present:, ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
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.):
odo <:!:c'Av0/ ��a� �o SiG"J
bF . ��►� � y t2E
Pump Chamber(locate on site plan): AJ
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp-WO Title 5 Official Inspection forth:Subsurface Sewage Disposal system-Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 L1 m o o r r• no Ple-0'V't' C+ f rn a
Property Add
Owner Owners r/
information is f f f Y o L. `tP' I a, l 0
required for every page. Cky/Town State Zip Code Date—�f Ins—pe ion
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
leaching pits number: ---- ---
❑ leaching chambers number: -------
❑ leaching galleries number: --- ---
❑ 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.):
t5insp-03I08 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
rno
` Property Addres
ey
Owner awnef s Name
information is _^ f i �114. M/1_ 0 Z�V � ,t� � p
required for .1-►�A-Y'" I'L1
every page. Cityrrown State Zip Code Date df Ins ion
D. System Information (cont.)
` Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): A
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.):
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.03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address -.._._..._. —__.....__f—.._..__.....----- ------
a"r/Zo f5� a G /t. �r•
----Owner .._.L. - - - --_.._. ...----.......---
Owners Ne II
information is Y�f r 1.J
squired for —
every page. Cityfrown state Zip Code Date f Ins , ion
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch 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.
Y A-
/ , o -c7 o
- r
Q 71- ��� fA
�9 . 41 -
tsu+w•OJiOE • _ - - Titb S Of st UUWIion Form.SubWAaq S m�W OiMoja Syu.m.P.p0 14 of 15
t Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
UV
Property Address ✓1
Owner owners Na e
information is
required for
every page. Cityfrown State Zip Code DaW of Insf ction
t ,
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
El Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
t5insp•03I08 Title 5 Official Inspection Form:SubsurfaceSewage Disposal system-Pa
ge 15 of 15
y 9/9/01
DATE ; -------- -- -
PROPERTY ADDRESS:7 4 ,_Mooring _Drive _-----
' Cotuit,Mass __
S �3
On tho obova date, i Inapeoled the eeptlo oylte'M at the abova address.
Thls ays(em conal3l5 of the lollowing
1 . 1 -1000 gallon septic tank. '3 . 1 -1000 gallon c R rec . Pr
p �� 11jymp i t
2. 1 -Distribution box. 6 x10
eased on my Inipecllon, I comity the following oondliloi a;
3 . This is a title five septic system. ( 78 Code j OCT 0 9 2001
4. The septic system is in proper working order
at the present time. �OWHEALTHD� a�l.a;
5. Pumped the septic tank at time of inspection.
Heavy scum & solds layers were present.
¢- Waste water is. 57" below the invert ppippe .
of the leaching pit. SfaNATURl;'t./ _.
s 6 •
Company.:�JOe • Qh P _ N•comb•r_6 Son ,' Inc .
•Addre � a ;_ Box 66-� ��__�__ '
_ Cent tryillsL_He , 0 32-0066
Phone 508 _775,-- 77)8 __-„_
Tri1S CERTIFICATION OOCS HOY COHSTITVTe A OVARAKTY OR WARRANTY
C
Pr MA00M8ER & SON, INC,+nki=Q ,�pool�rL ,h"""Pumped L InitillsdTown Sewer ConnµlIO2s6S2-0066 6776.))3 iOe '776.6412
t
COMMONWEALTH OF MASSACHUSETTS
r EXECUTFVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 74, Mooring Drive
o ui ,Mass
Owner's Name: Mary Reardon
Owner's Address: 18 Robertso,a Road_
Worrest_er,Macc Q160
Date of Inspection: cl /n 1 '
Name of Inspector: (please print) Joseph P.Macomber Jr.
Company Name: J.P.Macomber & Son Inc.*
Mailing Address: Box 66
Centerld 1 1 e, Mass..02632•
Telephone Number: 908-77g-33I8
CERTIFICATION STATEMENT
l certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
:� Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authoriry
Fa' s
g
InsP ector's Signature: l Date:
The system inspector shall mit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Y Notes and Comments
****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.
Title 5 Inspection Form 6/I5/2000 page I
Page 2 of 1 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS_
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
,
Property Address: 74 Mooring Drive
o ui ass. ,
Owner: Mary Reardon
Date of Inspection: 979/01
Inspection Summary: Cbeck•A,B,C,D or E/ALWAYS complete all of Section D
A System Passes:
. 1 have not found any in rrriation_s'yhich 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:
The septic system is in proper working order at the
Present time.
B. System Conditionally Passes:
WO 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.
Answer yes,no or not determined(Y,N,ND) in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
'OU1 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
obstruction is removed
ND explain:
2
r, Page 3 of 1. l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:. 741 Mooring Drive ,
Co uit,Mass.
Owner: Mary Reardon
Date of Inspection: 9 01
C. Further Evaluation,is Required by the Board of Health:
—420 Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning in a manner that
Y g protects the public health,safety and environment:
,V6 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.
4)6 The system has a septic tank and SAS and the SAS is within a Zone I 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.
4)f) The system has a septic tank and SAS and the.SAS is less than 100 feet but V 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A.copy of the analysis must be attached to this form.
3. Other:
i ..
3
I
' Page 4 of l 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM_.INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 74 Mooring Drive ;
Cotuit,Mass.
Owner: Mary Reardon
Date of Inspection: , 9 0
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections`.
Yes No
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
1/ D ischarge 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, above outlet invert due to an overloaded or clogged SAS or
J cesspool ;-kdidod
_ ✓ squid depth in-cssspeel is less than 6"below invert or available volume isless than day flow
: Required pumping more than 4 times in the last year NOT due to clo ed or d6is ruc'ted pipe(s).Number
of times pumped .
Any portion of the SAS,cesspool or privy is bs)ow 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.
_ v�y portion of a cesspool or privy is within a Zone 1 of a public well.
!/ y portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _t/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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)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.
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•
You must indicate either"yes or"no"to each of the follow g:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
d th 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
_ Y g (_ PP
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
`'yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner.should contact the appropriate regional office of the Department.
4
a Page 5 of I 1
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 74 Mooring Drive
o ui ,Mass. _
Owner: Mary Reardon
Date of Inspection: 977701
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
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?
_ as 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 fans of the system obtained and examine w p y d.,(Ifthey 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: .
Yes no
' Existing information. For example,a plan at the Board of Health.
'/ _ Determined in the field if an of the failure criteria related to Part C is at issue approximation of distance
( Y PP
is unacceptable){310 CMR 15.302(3)(b)]
. 5
Page 6ofII
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 74 Mooring Drive
7 a_ntColrt 1te,Mass.
Owner: Mary Reardon
Date of Inspection: 9 01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design) Number of bedrooms(actual):
DESIGN flow based on 310 C 15.203 (for example: 110 gpd x# of bedrooms): /6• ffeem
Number of current residents: �/
Does residence have a garbage grinder(yes or no): s,
Is laundry on a separate sewage system (yes or no):.l. [if yes separate.inspection required]
Laundry system inspected es or no):15
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)): /9
Sump pump(yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL -
Type'of establishment: JQ
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no): `
Non-sanitary waste discharged to the Title 5 system(yes or no):,m
Water meter readings, if available: !�
Last date of occupancy/use: tbf
OTHER-(describe): 110
GENERAL INFORMATION
Pumping Records i
Source of information: e
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: gallons--Hov�a qu ntity umped determined?Xy /&/
Reason for pumping:
TYP OF SYSTEM
t�Septic tank,distribution box, soil absorption.system
41p 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)
Tight tank /-4-Attach a copy of the DEP approval
Other(describe): .
Approximate a2e of all components, date installed(if known)and source of information:
Tom_
Were sewage odors detected when arriving at the site(yes or no):,(,�p
6 �
. Page 7 of 1 1
t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 74 Mooring Drive
Cotui ,Mass.
Owner:Mary Reardon
Date of Inspection: 9 01
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: Cast iron . 40 PVCAbother(explain):
Distance from private water supply well or suction line: /-
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of leakage system is vented
through the house vent.
SEPTIC TANK: (locate on site plan) 1Md ��
Depth below grade:
Material of construction: Vconcrete d/d metal VP fiberglass,0dAolyethylehe
Other(explain) AID
If tank is metal list age:AA2 is age confirmed by a Certificate of Compliance (yes or no),V( (attach a copy of
certificate) 4//Z11 Dimensions: Nxoxw
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_ 0
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to boom of outlet tee or baffle:
How were dimensions determined: i=Qd ZZ7-';9ff9
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of.leakage, etc.):
Pump the septic tank annually.Garbage disposal is prpGPnt
Inlet & outlet tees are in nlaeP_The tank is structura117
sound and shows' no evidence of leakage.
GREASE TRAP4&(Iocate on site plan)
Depth below grade: 109
Material of construction:aI concrete gU metalef. fiberglass 4 polyethylene&other
(explain): ,Uo
Dimensions: AJ
Scum thickness: A,14
Distance from top of scum to top of outlet tee or baffle: �/r9
Distance from bottom of scum to bottom of outlet tee or baffle: _
Date of last pumping: A,),4 _
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present. ,
7
Page 8 of l I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued;
Property Address: 74 Mooring Drive
Cotuit,Mass.
Owner: Mary Reardon
Date of Inspection: . 9/9/01
TIGHT or HOLDING TANKXA (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: /•'�
Material of construct concrete 40 metalt/i9 fiberglass�_�olyethylene,40 other(explain):
Dimensions:
Capacity: A114 gallons
Design Flow: gallons/day
Alarm present(yes or no):_41,f
Alarm level: _1 Alarm in working order(yes or no):41W
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOX:A--, of present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Ald
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.):
Distribution box has one lateral.No evidence of solids
rarr_y over-No evidence of leakage into or out of the ox
PUMP CHAMBER4�_(locate on site plan)
Pumps in working order(yes or'no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
Ptimn chainher is not present. '
j
s � `
8
'• Page 9 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: -74 Mooring_ Drive
Cotuit,Mass.
Owner: mar_v Reardon • .
Date of Inspection: 9 01
SOIL ABSORPTION SYSTEM (SAS): Z ocate on site plan,excavation not required)
If SAS not located explain why:
.Located
Type
leaching pits, number:
.vd leaching chambers, number: Q
leaching galleries,number: O
leaching trenches,number, length:
leaching fields;number, dimensions: d
/ overflow cesspool, number:
,20 innovative/alternative system Type/name of technology:' j��
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to fine sand.No signs of hydraulic failure or
_ponding.Soils are dry Ve etation is normal.Waste water is
57" below the invert pipe.
CESSPOOLS9,6f,'p-(cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer: A
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
Cesspools are not present
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.):
Privy i s; not nrpgpnt
9
1% Page 10 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:74 Mooring Drive
Cotuit,Mass.
Owner: Mary Reardon
Date of Inspections 9 01 —
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
tr
k
3.
10
,^ Page 1 1 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddress:74 Mooring Drive
o ui ,Mass.
Owner: Mary ear on
Date of Inspection: 01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 04 feet
Please indicate (check)all methods used to determine the high ground water elevation:
f '
Obtained from system design plans on record - If checked, date of design plan reviewed:
_Observed site(abutting property/observation hole within 150 feet of SAS)
_Checked with local Board of Health-explain:
_Checked with local excavators, installers-(attacFi documentation)
Accessed USGS database-explain:
You must describe how you established the high groundwater elevation:
Used; Gahrety & Miller Model,
U.S Geological Survey 92-0001 Plate#2
USGS Observation Well Data For Ji,ntm 1992
Top of Ground -
Leaching
Pit gj. ;eet
n
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom .
of the leaching pit and the adjusted groundwater table
•feet.
' 11
>•mnrn.-tSt'iTr-r7— rnrinr•nretrr+s-'rrrt tT*T•iTR:'.T't':Tf/Pl1R*.t'rtm l7trR14t T.`L"R►tOS1R1.
arnstable B
TOWN OF BOARD OF HEALTII
SUBSURFACR 9FWA F DISPOSAL SYSTEM INSPECTION FORM - PART D CERTIFICATION I
•••TSB(�T'•.••• —T.ti►�.-.rr{:rtr.Tf'R.•.rt rtlras'rPan'rn:r—!.'t*'itmf7arnlR'T�RR'v=R terfannftrTR'Itr7 tsntn ..•nrrr•Tr-1r+•..^
-TYPL OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRES$ 74 Mooring Drive Cotuit,Mass. '
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Mary Reardon
,mom.
PART D CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Inc•:- '
COMPANY ADDRESS Box66 Centerville,Mass. 02632
,. Street - Town or City State LIP
COMPANY TELEPHONE ( 508 I 775 3338 FAX ( 508 1 790 _ 1578
CERTIFICATION STATEMENT. y
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of -inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
Systeui PASSED h _
The inspection which I have conducted has -not found any information
which. indicates that the system fails to adequately protect public
health or, the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not .evaluate'd are as stated' in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection. which I have con acted has found that the system fails to
Protect the public health and the environment in accordance with Title
6 , 31.0 CMR 15., 303 , and as specifically noted on' PART C - FAILURE
CRITERIA of this inspection fo m .
Inspector Signature Date
O( ne
copy of this ification must be provided to the OWNER, the BUYER
where applicable ) and the I30ARD OF HEALTH.
* If the inspection FAILED, the owner or 'o� erator shall upgrade
pgrade ' the ayetem
within one year of the date of the inspection, unless allowed or required
otherwise as provided- in 3.10 CHR 16 . 305
partd .doc
LOCATION SEWAGE PERMIT NO.
O - 3
VILLAGE
INSTA LLER'S NA.ME i ADDRESS
3 U I l D E R OR OWNER
DATE PERMIT ISSUED -7_f�_ �
DATE COMPLIANCE ISSUED
�-�3
'�- � �
� �
O
U'� o
� �
'�
�� � �
' ''1 / �
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._____-1........ ...............
f. THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
® ......................OF.....- 4-� D
Appliration for Disposal Works Tonstrurtinn Vamit
Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal
System at: , �
....... . , ...... �... ..... . -- •:•-. -.-• ..••••-.••-•-•..............•................_
..._._.••L�- Location
- �
�drd.o'
- �
....................••-•-
Wa� On
� �
•--- � --•--'
. ------•----•-- ----•------••-----......................
--•-•----.. ____________________________________•-------__
Installer_... Address � ��
d Type of Building Size Lot__4__�__________--------Sq. feet
Dwelling—No. of Bedroo _______ __ _ ______________________Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Buildings ..... No. of persons........L................ Showers ( ) — Cafeteria ( )
a' Other fixtures ___________________________________
d --•----•..._.....--.-----•-- ----•--••----•----•••-•-•-•--•••-----------------------------------------------------
W Design Flow.............. ...................gallons per person per day. Total daily flow.........3-3®.....................gallons.
WSeptic Tank—Liquid'capacity./_gallons Length_Y.__ta`_-__. Width__�_L____. Diameter________________ Depth................
Disposal Trench—No ____________________ Width.................... Total Length._.__.__.._o..___ Total leaching area re sq, ft.
Seepage Pit No........./--------- Diameter_______ ________ Depth below inlet-_�_J. _..._ Total leaching area..................sq. ft.
Z Other Distribution box (/) Dosing t lI ( )
'-' Percolation Test Results Performed by.._._ /l`( t {'�-
a Date �.. �
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water----_..J,_-_,y_�.�..
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..................
x -
O Description of Soil....0._-.. _.._. . . ''�.___..:..
x (ra.. .
U -• ------.............. .....
-----------------------------3•Q--�-ly----------- r, __-...............................................................................................
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 TITLE 5 of the State Sanitary Code— The undersigns urther agrees not to place the syste in
operation until a Certificate of Compliance has been is ed by the boar health.
at
S• d ------ ---�/ ........ ........... .. ��
Application Approved BY 4 ..... ..
----- ---1�
--- -- --------..... ....
Date
Application Disapproved for the following reasons___________________________________________________________---••--------------------•---__ .__.....__._._
........--•-•------------------------•--••---•---•-----------.....--•--•---------•--...---...-------...--•---------------------------•-------------••-•-•-----------------•••----------------------•-••-
2.7-dQ�
�q Date
Permit No. ........... - Issued =1 --------.............................
Date
r
i {
1 .
THE COMMONWEALTH OF MASSACHUSETTS
,.- BOARD OF HEAfLTH
----//�1/✓./U..................OF......�f ......................
Allplira#ion for Disposal lVarkii Tontitrur#inn runfit
Application is hereby made for a Permit to Construct (� ) or Repair ( ) an Individual Sewage Disposal
System at•
Locationye Addr�iess ' or Lot No. /
.........•• ••••• r .................
•• ,,.��,+,}, � / ,� � Add �' v
� .H)f etP}i',, �f, ress ._........_
a .......................................................� .....------------.........._..............•••• -•-•••••---....._.._•--•••--••••••••........---
/ Installer Address rr��
Type of Building Size Lot....
d:t2j.. . ® a...............Sq. feet
Dwelling—No. of Bedrooms............... 3.......................Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building/�i r"' �'i`�....... No. of persons (.................. Showers .
Pa YP g...----='----=----•--- P - ( ) — Cafeteria ( )
a' Other fixtures ............................
W Design Flow................. ....................gallons per person per day. Total daily flow......... ' ..........................gallons.,
WSeptic Tank—Liquid capacity./C/L.gallons Length.Z..�,�'_.. Width.0 X':.`.... Diameter................ Depth................
Disposal Trench—No..................... Width.... Total Length.................... Total leaching area.......--_-_::- sq. ft.
Seepage Pit,'No.........Z---------- Diameter.......7......... Depth below inlet._2."_1...... Total leaching area.................. q..._..s ft.
Z Other Distribution box (/ ) Dosing tank
Percolation"Test Results Performed by...._f/__ _ ' r x-... �`:*:.��:/� ..._..... Date...._ ...�` r��
,.a X'e O "'
Test:;Pit No. I................minutes per inch Depth of Test Pit.................... Depth to groundwater..__.._ ...............
(x, Test 'Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------------------------•--------•----•-------....---•-------------------•--..._--••••......•••............................................................
D Description of Soil... .'._^_._...........%(,qr 1."t_' .x ..--•-•-----------------------------------------------------------------------------
-••-------•------------.....------------------------
yh
- ------------------•------------------••••---------....---••-.........--------••-•--•--...---...---
� .............................-. ...---�-'..��� J/�1�------......:,�t�------------------------------------------------------••---------.........-•-----•--•-----.......
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 LITIL 5 of the State Sanitary Code— The undersignedfurther agrees not to place the system in
_ operation until a Certificate of Compliance has been issued by the board of health.A Ile
----•.................... .�
f Date
Application Approved By--tt"
Date
Application Disapproved for}the following reasons-------------•-•--•------•-------....------------------------...........-•-•---------•--• . ------.........._
•---....--•---•------•--------------•....---•------•-----•--•----....4_--------------.......--------•------------------•-------------•---------.....----•-------------•--•--•---•-------•-•---......••-
Date
PermitNo...............................-----------------•----•--- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA
LTH
"1.. /lJ.............OF..........''C...,t:t!!..J`......f...:f..................._................
Tntifirab of f ampliFanrr
THIS,IS TO CERTIFY, That the Ind vldual Sewage Disposal Sysfem...constructed ( ) or Repaired ( )
by.........:t:).:i.-- f/1 !(...................
Installer
J J ..:..
at........... ---•---.-—----••-----•-•------------------------------
----- *.-• .-----•--. -•----
has been installed in accordance with the provisions of ) of The State Sanitary Code a escr e m the
application for Disposal Works Construction Permit No. .._._ �_'r,................, dated-_ .__.�_.._..._....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILk FUNCTION SACTORY. �;`
f,:
y
DATE.. ......: ----- --•...................... ' Inspector. idlr ---.....:--------------
THE
COMMONWEALTH OF MASSACHUSETTS
// BOARD OF HEALTH y
....../''6 L'?L...............OF...... 1� fir.'
3�- .................•----......_..._................--•-•....
.............�....... FEE.........._.............
Disposal lVarkii Tnns#rnduan jhrutit
Permission is hereby granted----..�(-`•/.'/sL_ ' -= '- 1 f! • s!':.
to Construct ( E ) or Repair ( ) an Individual Sewage Disposal System f_ f` f
at No.----.../-' ' �; f tt,1`st-7.e.)Zfn /_'�,f if /-" e,_Ie" •l/t
fr -------, -------------------------•---- --
/ _ 'Street
as shown on the application for Disposal Works Construction Per ...........
Sd'
`' ' r of Health
_ '
FORM 1255 HO.BBS & WARREN. INC.. PUBLISHERS �'�,
Y
i7
ol
h
F.FL ELEV.=74+
FINISH GRADE = 72t50 FINISH GRADE FINISH GRADE----
TOO OF FOUND. I OVER TANK = OVER PIT = I_If0
ELEV. •f!"z `
'•
5��
'"
1C CHIMNEY BLOGK „
4° C.I. Tl
__ 4" WHERE NEEDED SACKFII_L 3 PEASTONE
W L IN6 - _4 V.C. v.CJ = - - -_- --_
4_€.4.__ --- - --- _
f ,
\ 1 -- fo ++` o a a I:
CELLAR FLOOR= ) QUO GALLON I' �74+ �� °_ �. • �; , b+ ( o O O i o 3/4" TO 1-112"
ELEV. ; L�'�' REINFORCED GONG. o O r) O 0 i CRUSHED STONE
� . - •_L � ° •�� DIST. BOX o a � o
SEPTIC TANK �" (TO BE LEVEL a a n O O o 1.� Q� BOTTOM OF PIT
AND STABLE ) l� Q o O O C o ° 4 S
—L� o - -. —
SYSTEM PROFILE
( NOT TO SCALE)
LEACHING PIT
DESIGN CRITERIA N
dwJ
kWOER OF BEDROOMS
ry (o0.0c7 1O
GALLONS PER DAY
GARBAGE GRINDER
w ,
1 x
TOTAL DAILY FLOW = __.. 1 to�Le =' ,
LEACHfNG AREA PROVIDED = S6
C.
�'/ •� tom. � � 2 �* �aao c.
SOILS LOG
l �
ON ELfV. : 7o+cj .1 9 --Ir
7
G ,40.y 47'
c�
.GCS -7- `17- 2. I +►1 "
36
PROPOSED SEWAGE
144. 4-0=7 DISPOSAL SYSTEM
PROPOSED DWELLING
INSPECTED BY:
DATE _r otu►T) MASS.
av
PERCOLATION RATE "IN./INCH SCALE_ AS NOTED DATE
i1fD7`"ES' tH MA,g
X. Of q y AWNED_�Y__ Y T'2 U 5Z
S c/ cul>A, A.0 V.-E P_
S'11-1v4' �,v Dt 41V -rut3E /67 S.S� -e-i- Z• o� NORMAN 24 C�F�/4T f=�� C:? I�i� + �J �
2. Z,�7.0V E o 6ROSSM N '� . �/h�MC.X.JTI
�va'T ��✓ .�-L 4aTi �GrO�/Y " 127 ---
Ey�jS'-1 NORMAN GROSSMAN PE, R L S
f�AC:'1G1� �Lt✓ .o'�� 6 �,\��. 1126 POLLY POINT ROArl
I Or.6.►. �y ;FN"ERVIL`E • PA4
f.w.a...ewti'-..Ewa+...wsrer.+.•..+..r....e.«...aur.rew....�k,i.
Lim
14