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HomeMy WebLinkAbout0263 OXFORD DRIVE - Health r263-Oxf6rd Drive - --- - j Cotuit .,,A ..021 —.-033 I s —_J Commonwealth of Massachusetts Dal- 033 9TM ,=_,P Title 5 Official Inspection Form — I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments { 263 OXFORD DRIVE t Property Address SANDRA& JEFFREY KUNZ-89 HOLLINGSWO_R_TH AVE BR_AINT_REE MA 02184 Owner Owner's Name information is ' required for every COTUIT ✓_ ___ _ _ MA _ 02635 5/24/2021 a page. City/Town State Zip Code Date of Inspection r.J Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information _5 14 Sys on the computer, Trevor Kellett use only the tab key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return Company Name key. 350 Main Company rrb Company Address W Yarmouth _ _ MA 02673 City/Town State Zip Code srmo _508-775-2825 _ SI-1_3744 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/27/2021 Inspector's 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I Commonwealth of Massachusetts Y Title 5 Official Inspection Form V �ii; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 OXFORD DRIVE Property Address SANDRA& JEFFREY KUNZ - 89 HOLLINGSWORTH AVE BRAINT_REE MA 02184 Owner Owner's Name v� information is required for every COTUIT MA 02635 5/24/2021 _ __ _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1). System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310,CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM IS IN WORKING CONDITION 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or.not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts was....\ Title 5 Official Inspection For - i! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 OXFORD DRIVE Property Address SANDRA& JEFFREY K_U_ NZ- 89 HOLLINGSWORTH AVE_BRAINTREE MA 02184 Owner Owner's Name information is COTUIT _ _ M_A _ 02635 _ 5/24/2021 required for every _ _ — _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipes) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts -Y=, Title 5 Official Inspection Form ' __ l) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 OXFORD DRIVE Property Address SANDR_A& JEFFREY KUNZ- 89 HOLL_INGSWORTH AVE BRAINTREE MA 02184 Owner Owner's Name information is required for every C_OT_UIT _ _ _ _ MA 026_35' __ 5/24/2021 _ _ _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.ddc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts `title 5 Official Inspection Form _ 4 1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ 263 OXFORD DRIVE Property Address -------- -- ----_---- ---- SANDRA & JEFFREY KUNZ-89 HOLLINGSWORTH AVE BRAINTREE MA 02184 Owner Owner's Name information is COTUIT MA 02635 5/24/2021 required for every _ __- ____ _. page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but,greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEEP certified laboratory, for fecal coliform,bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26.12018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systen•Page 5 of 18 Commonwealth of Massachusetts 6 Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 OXFORD DRIVE Property Address SANDRA& JEFFREY KUNZ- 89 HOLLINGSWOR_TH AVE BRAINTREE MA 02184 Owner Owner's Name information is required for every COTUIT _MA 02635 5/24/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the systern in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of.the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health, N ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.712 612 01 8 Title 5 Of-icial Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form �i1'1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2_63 OXFORD DRIVE Property Address — — S_ANDRA & JEFFREY KUNZ- 89 HOLLINGSWORTH AVE BRAINTREE MA 02184 Owner Owner's Name -- �------------ ---- -----�- --- information is COTUIT _ MA__ 02_635 5/24/2021 required for every ---- _._. _ _ _ page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 — Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: SEASONAL Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: -- Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water.meter readings, if available (last 2 years usage (gpd)): '20 - 197 GPD '19 -208 GPD Detail: Sump pump? ® Yes ❑ No Last date of occupancy: SEASONAL Date t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systen•Page 7 of 18 f ` Commonwealth of Massachusetts Title 5 0fTicial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 OXFORD DRIVE Property Address SANDRA& JEFFREY KUNZ- 89 HOLLINGSWORTH AVE BRAINTREE MA 02184 Owner Owner's Name information is required for every COTUIT MA 02635 5/24/2021------ --------------------------- _.._ _.._..--- ------------ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: = Design flow(based on 310 CMR 15.203): Gallons per day(gpaN Basis of design flow (seats/persons/sq.ft., etc.): -- — Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: --- --- -- Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use:, Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume.pumped: gallons How was quantity pumped determined? Reason for pumping: — t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form — ri Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 OXFORD DRIVE _ Property Address SANDRA& JEFFREY KUNZ-89 HOLLINGSWORTH AVE BRAINTREE MA 02184 Owner Owner's Name information is required for every POT UIT_ _ _ _ _ __ MA 02635 5/24/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool r ❑ 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: 1984 PER ASBUILT CARD ON FILE AT BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1811 feet ~ Material of construction: - ❑ cast iron ® 40 PVC ❑ other(explain): - Distance from private water supply well or suction line: 10'+ — feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments :. 263 OXFORD DRIVE Property Address SANDRA & JEFFREY KUNZ - 89 HOLLIN_G_SWOR_ TH AVE BRAINTREE MA 02184 _ Owner Owner's Name information is COTUIT _ MA _ 02635 5/24/2021 required for every --------- ----- -_...----_--__—.—. __ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 8"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: 1000 GALLON - Sludge depth: 5 — Distance from top of sludge to bottom of outlet tee or baffle — 0" Scum thickness — -- Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle - How were dimensions determined? ESTIMATED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 8" BELOW GRADE t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts - ;p Title 5 Official Inspection Form =1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 OXFORD DRIVE Property Address SANDRA& JEFFREY KUNZ- 89 HOLLINGSWORTH AVE BRAINTREE MA 02184 Owner Owner's Name -------- require tifor a COTUIT _MA_ _02635 5/24/202.1 required for every . _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. -Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: -- -- --- Scum thickness --- Distance from top of scum to top of outlet tee or baffle -- Distance from bottom of scum to bottom of outlet tee or baffle -- Date of last pumping: - Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related-to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site olan): Depth below grade: -- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ---- ---- — Capacity: -- - - gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Forrin '\ -- 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t % 263 OXFORD DRIVE Property Address SA_NDRA& JEFFREY KUNZ- 89 HOLLINGSWORTH AVE BRAINTREE MA 02184 Owner Owner's Name_. ------ ----------- ----- ----- information is COTUIT MA 02635 5/24/2021 required for every _-_--- -----------,..-- --------- ---------- -- page. City/Town Stae Zip Code Date of Inspection ®. .System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: -- Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): DISTRIBUTION BOX LEVEL AND WATERTIGHT t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments — 263 OXFORD DRIVE Property Address SANDRA& JEFFREY_ KUNZ- 89 HO_LL_IN_GSWORTH AVE BRA_INTR_E_E_MA 02184 Owner Owner's Name information is COTUIT MA 02635 5/24/2021 required for every — _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.). 10. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6'X6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: — ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — --- — ----- -- — t5insp.doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 263 OXFORD DRIVE Property Address SANDRA & JEFFREY KUNZ- 89 HOLLINGSWORTH AVE BRAINTREE MA 02184 Owner Owner's Name information is required for every COTUIT MA 02635 5/24/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS,'. (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-6'X6' PIT FOUND DRY DURING INSPECTION WITH NO EVIDENT STAINING. COVER IS 21 -BELOW GRADE 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configurdtion 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 0 Yes El No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): —----------- t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,ti Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 OXFORD DRIVE Property Address ---------- ---------- ------------- SANDRA & JEFFREY KUNZ- 89 HOLLINGSWORTH AVE BRAINTREE MA 02184 Owner Owner's Name information is COTUIT— MA 02635 5/24/2021 required for every _ ___ __--._.__.__-____—__ ____. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions -- Depth of solids — --- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): + t5insp doc•rev.7/26/2018 Title Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 I - '°�`' Commonwealth of Massachusetts 11 Title 5 Off dciai Inspection Form ,.,-__�:. •mil � ,f 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - ' 263 OXFORD DRIVE Property Address — SANDRA & JEFFREY KUNZ- 89 HOLLINGSWORTH AVE BRAINTREE MA 02184 ----- --------- _-- _ - ..._- _—..__.._......- --- Owner Owner's Name `---- ----- information is COTUIT required for every MA 02635 5/24/2021 City/Town __.._.... — ---..._ page. Y/Town State Zip Code Date of Inspection _ D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i I I 15insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsuiiace Sewage Disposal System•Page 16 of 18 f ` { Commonwealth of Massachusetts �P Title 5 Official Ins ection Form y1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2_63 OXFORD DRIVE Property Address SANDRA& JEFFREY KUNZ- 89 HOLLING_ SW0_R_T_H AVE BRAINTREE MA 02184 Owner Owner's Name information is required for every COTUIT MA 02635 5/24/2021_...._ — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +12'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked'with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high groundwater elevation: HAND AUGER PERFORMED ONSITE AT TIME OF INSPECTION TO 12' ENCOUNTERED NO GROUNDWATER. BOTTOM OF SAS AT 8' Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 C Commonwealth of Massachusetts ;ra Title 5 Official Inspection Porm _ "I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 OXFORD DRIVE Property Address SANDRA & JEFFREY KUNZ-89 HOLLINGSWORTH AVE BRAINTREE MA 02184 Owner Owner's Name information is COTUIT MA 02635 5/24/2021 requiredfor every -----...-----_—..-----_.---------_..----_--------- --._.. _..---- ----------- -- -- page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of:- ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included l51nsp doc•rev 7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI DEPARTMENT OF ENVIRONMENTAL PROTEC 81 A ONE WINTER STREET, BOSTON CIA 02108 (617) 292-5500 �plus TP-9t 6 9 %�RUDY_C, XE 0� .0 0,�. Q See, taty ARGEO PAUL CELLUCCI VID BJS UHS Governor Co sinner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ti4. CERTIFICATION f '/ Z T Property Address:,X S 0)C FOR Name of Owner ERIA Got 64 Address of Owner: /r Date of Inspection: �'Co' Name of Inspector:(Please Print)EJwAR6 C,(Loos Fi cL.D I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) v Company Name: 1 O76WARD C, US06 C0 Mailing Address: WOO E ,'94AA w 1 N► , 0a563, Telephone Number Sf>$ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: XPasses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature _ Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS �/100 ,4lLo� SC �C f -F14tuK UCiE'�/ �� S�L�D,S revised 9/2/98 Pagel of11 40 Printed on Recycled Paper I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART A CERTIFICATION(continued) Property Address Owner:jERIto G o&U Date of Inspection:3-6-Mcl INSPECTION SUMMARY: Check A B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: 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. Indicate yes,no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A c CERTIFICATION (continued) Property Address 063 ©�r X D DR, Owner: ENV Ga<DcN Date of Inspection: 3-61—ffO C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER a revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:�6 3 OXFORD DR, Owner: (`91fi)GoCOE21 Date of Inspection: D. SYSTEM FAILS: C7 1 You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone'I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No i 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. j revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: S Q x,rokA DR, Owner: (`R1lu GOLDEN Date of Inspection: Check if the following have been done:You must indicate either "Yes" or "No"'as to each of the following: s No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. x _ The site was inspected for signs of breakout. All system components,ex have been located on the site. The septic tank manholes were uncovered, opened,and the interior of the septic,tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)] The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. 1 revised 9/2/98 Page 5of11 ' { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:A3 fi Owner: epltu Date of Inspection:7Jf_1l pqq t� 1 ^ FLOW CONDITIONS RESIDENTIAL: Design flow: ',SW g.p.d./bedroom. Number of bedrooms(design)-3— Number of bedrooms(actual): Total DESIGN flow g' Number of current residents: Garbage grinder(yes or49):ff Laundry(separate system) (yes or 69):AQs If yes,separate inspection required ' Laundry system inspected (yes or no) Seasonal use(yes or(a):/ Water meter readings,if�ayva�ilable(last two year's usage(gpd): :• Sump Pump(yes or a:rvv _ Last date of occupancy: 5T7Q accu pt lo, COMMERCIAL/INDUSTRIAL: Type of establishment: ` Design flow: gpd ( Based on 15.203) Basis of design flow ` 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)_ ' Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and ource of information: System pumped as part of inspection: (yes or<Q WO w If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM 4.. Septic tank/distribution box/soil absorption system Single cesspool ; f Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information:. Sewage odors detected when arriving at the site: (yes or no) , revised 9/2/98 Page 6of11 • R�#'tY 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION!continued) Property Address: 3 01"CaD 1 Owner: Lire lV 60LOCAJ �j Date of Inspection: /' 7 7. BUILDING SEWER: t� ) (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) Depth below grade:-LOWNS Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list ages_ Is age confirmed by Certificate of Compliance (Yes/No) Dimensions:c�`e LX I J©r�rA! w Sludge depth: t Distance from top of sludge to bottom of outlet tee or,baffler ► � Z vUs� �L���� Scum thickness: ® LEEKS /11�.o e, Distance from top of scum to top of outlet tee or-baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) o CDiIlOf77FJ UC TEC / 7- corUGRC-TL7 ao -1- ' oun fL J UO- CC,E00;T iNi26'e= Wnnles GREASE TRAP: (locate on site plan) Depth below grade:_ - Material of construction: concrete_metal Fiberglass _Polyethylene_other(explain) Dimensions t 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: Comments: ," r (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc:) a revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:'26 3 o X FORD Q D Owner: ERIN (,acheN I Date of Inspection: -3;.i6-1q 1q TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:4 (locate on site plan) Depth of liquid level above outlet invert:� W/"'M �� PI PC Com ments: evidence of leakage into or out of box, etc.) evidence of solids carryover, ion is a ual e9 (note if level and distribution q fVc) Sou S G 01V6- - iE PIPE dU j D ►�Rf2YC�i Pig �n� rsrr PUMP CHAMBER:_ (locate on site plan) r r 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.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION(continued) Property Address:_Z3 (OX1=040.5 Owner: 6RW C--oLOEN Date of Inspection: —6_11Nq SOIL ABSORPTION SYSTEM(SAS); (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: g ��E S UC leaching pits, number: FOOT /000 G ALCOl1/ leaching chambers,number:_ leaching galleries,number:_ leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level ponding, damp soil, condition of vegetation, etc.) ` 0/7700 a CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: F Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) 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.) revised 9/2/98 Page 9of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: :26 3 Q kFOP p Ro Owner: Eiew 60a)CA1 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) • L revised 9/2/98 Page 10of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:20 ®XFo" gD, Owner: ER1N v0c,oEw Date of Inspection: 3 /_/ 7 qq? NRCS Report name �j Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) GRouruDWATE2 M6P/TYPO Mlip revised 9/2/98 Page 11of11 t ' 0 A BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEW�AGEI DISPOSAL SYSTEM INSPECTION FORM Address Of Property Owner's Name s' ��tf�Z Date Of Inspection PART A CHECKLIST Check if the following have been done: y Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large columes of water have not been introduced into the system recently or as part of this inspection. As-Built plans have been obtained and examined. Note if they are not avail- able with N/A. ti The facility or dwelling was insp ected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on exist- ing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLAW CONDITIONS If residential number of bedrooms z number of current residents ,A/0 garbage grinder, yes or no r'6 laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: C 49'r4 T Last date of occupancy GENERAL INFORMATION Pumping records and source of information: 1661 System pumped as part of inspection, yes or no if yes, volume pumped 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) Other (.explain) Approximate age of all components. Date installed, if known. Source of informati n: r ) Sewage odors detectecYwhen arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION Cl7NTINUED SEPTIC TANK: Z (locate on site plan) depth below grade: material. of construction: j/eoncrete metal FRP other(explain dimensions: sludge depth 3 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 bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) /000 C� " LOs 12d DISTRIBUTION BOX:_ (locate on site plan) . 141E depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation fro re irs, etc. ) S ri�2A�}9n vx Le)alS Q/6 0 0 Ov v PUMP CHAMBEM: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump. chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION CONTINUED SOIL ABSORPTION SYSTEM SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type pits and number 14 ;6;�J j Vt 4ecle? I YT l leaching chambers and number leaching galleries and number leaching trenches, .number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) • �� Q /� ion ��c::G] �� Q.� �s v� Uee- � ---�/� CESSPOOLS (Locate on site plan) : /t)d 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 (cesspool must be pumped as part of. inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) PRIVY: N (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, recommendations for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION CONTINUED SKE= OF SEWAGE DISPOSAL SYSTEM; include ties to at least two permanent references landmarks or benchmarks locate.all wells within 100' 96 0 /(a3 DEPTH TO GROUNDWATER I depth to groundwater method of determination or approximation: SUBSURFACE .SEWAGE,DISPOSAL.SYSTR4 INSPECTION FORM PART C FAILURE CRIMUA Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6" below invert or available volume 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped IV Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? L- Is any portion of the SAS, cesspool or privy, below the high groundwater elevation? A/ Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Al Within a Zone I of .a public well? Within 50 feet of a private water supply well? _ Within 50 feet of a bordering vegetated wetland or salt marsh (cess pools pools and privies only, net the SAS)? Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, amonia nitrogen .and nitrate nitrogen. f r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D C Yrf-FICATION Name of Inspector: Company Name : &r4o/ww- �()r��S k6cC V`1 /I Company Address : Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete 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: V/ I have 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 evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined .that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determinimation is provided in the FAILURE CRITERIA section of this form. Inspector's Signature Date Original to System Owner Copies to: Buyer (If applicable) Approving authority fi :� 6)Al — 033 LOCATION 'S -2&� SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME L ADDRESS Toss-Ph Duftrt* /Aj,!�a S I� /14e11S /4ft7. B U I L D E R OR OWNER lc �#,vim U 6 llc, DATE PERMIT ISSUED - I DAT E COMPLIANCE ISSUED r DO �� No... .`1_ ,/a G 6 F�s......Sa.� ... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i 2 -------------------- ................... OF.......................................................................................... T� Appliration for DhipogFal Works (foustrn.rtion ranfit tPY Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........., .. .��........ . ...... '�................ ............................................ ---.......---..............------------. . . Locatio Address or Lot N . Owne Address a _ ..:.....�.c ....... ?.5 __ _...l 2 ..................................... Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms-----3............. .....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building .... No. of persons............................ Showers — Cafeteria aOther fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow......J 3.;.......................gallons. WSeptic Tank—Liquid capacity,l_PPP..gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.--......---.--...-- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 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------.................. n+ -•-----------------------------------------------•-------------------...............---•----•--•--....--•--•---------------••------------•........--••.••---- ODescription of Soil........................................................................................................................................................................ x U ------------------------ •--------------- ---------------------------------•------------------------------------------------------------------------------------------------••-------------- W VNature of Repairs or Alterations—Answer when applicable................................................................................................ ...---...-•----------•-----•...............•-----•---------------------------------................----•---------------------------------------------------........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the board of health. Signed-----. � ................................... '^ ate Application Approved BY D -•--•.-----p '--- --•-•-. Date Application Disapproved for the following reasons-----------------•--- ---------------------------------------•-------------------------------•--------------- ....................••-••....----•-----•----•--------•-------....---•-----•••-----•--•--•--•---.....•--•----------------------•-------•-----•-----•------------•-------•-•---••-------•--•-••---------.. Date PermitNo--------------------------------------------------------- Issued_....................................................... Date :THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..................................... ............. Appliration for Btovosal Works Tonotrurtion ami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: I 9. 1l Locatipr Address or Lot No.. ,y ,r /1--'----•------------------------- rl�'. ,e( da. ..��........ /.................. Own(I ( j Addres3 a ----•......_m. 15__:......L}_ `! �,..... t C>alb__ .... 1'a.., t2,7/7.---....--"•----""-•'--••-----.... Installer A ddress Type of Building. Size Lot............................Sq. feet U Dwelling No. of Bedrooms..._ .................Ex anion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ----------------------------------•-•.........•----------•-••••------•-----•----•----------------------------------------------------•--•......--_.. w Design Flow............................................gallons per person per day. Total daily flow...... .......................gallons. 1:4 Septic Tank—Liquid capacity/A ..gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No..................... Width.................... Total Length_................. Total leaching area....................sq. ft. Seepage Pit No.................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .................................................•-•-------.........--------.....-•--'----•'•------......--•-'--'...........---•--•-•----'"-.___...---....-- 0 Description of Soil........................................................................................................................................................................ x c, ..............................................-----------------------------------...-------------•--'---------•--••---•-•--'•--•-------------•.....----------........-----...._..."'------•'---'•------ w VNature of Repairs or Alterations—Answer when applicable............................................................................................... --------- ---------------------•-••-----------....---------------------.....------•"-•---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI..L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been sued by the board of health. Signed----I .... ti!_��'�'--� ....................... Date Application Approved By...-'-- ............. ........ !1�,`,� Date Application Disapproved for the following reasons:...................... -------------------------------•-------------------•------•-•--•------••........._ .................•---•---••-••-•--'•----......---'•----------............-------•--•-'-'•----...........-.....................---'--------•------•--------------....------------••-----------•--•-'...... Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF......................................I.............................................. At urdif iratr of Tomplittnrr THIS IS TO CERFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---•---------•-----_- =cC..s .....�............'--Installer-------'--•-------------------•---•••--.......--'-'-'-•---'---............._......_...........�Tj + `- - at.. - =--. ,` - -------- % ?=`_'1....................%".�Y�--•-------------------•------••-----------•--------------- has been installed in accordance with the "rovi5io' n of TITLE of The Stat Sanitary Code as described in the P 5 y application for Disposal Works Construction.Permit No......... 'e c _t 2 dated................................................ TIME ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.-•-•-•--•-•-•-•--•-•---•...........................^� .�-�••....... Inspector................. --------------------------------..-.----------------•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F...................................................................................... �� No......................... FEE...5...---............ Disposal ork Tontr ion rantit Permission is hereby granted............. ----------------------------------------------------------------------------- to Construct ( ) or Repair ) an Individual Sewage Disposal System atNo...............................•-••-•----.. Z -" C'�''�< .._._r.__r................ ............... .... ..................... ............ Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... DATE-----------------••-----••---:_.�------...._•---- Z Board of Health FORM 1255 A. M. 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